Headache

Question 1

what aspects in the Hx are important in a PC of headache

Answer 1

Onset/ Peak:
Acute Vs Sub-acute Vs Gradual

Relieving features:
Posture, headache behaviour

Exacerbating:
Posture, valsalva (sneezing, coughing, straining etc). Diurnal variation.

Demographic

Associated features:
N+V, photophobia, phonophobia, positive visual symptoms, ptosis, miosis (constriction of pupils)

Question 2

what are red flags for headaches

Answer 2

New onset headache >55
Known/previous malignancy
Immuno-suppressed
Early morning headache
Exacerbation by valsalva (coughing, sneezing, raised ICP)

Question 3

what features in the PMH should be acquired in a headache Hx

Answer 3

previous cancer

predisposition to thrombosis

Question 4

what are the demographics of migraines

Answer 4

commoner in women
on average 1 attack per month
20% with aura
80% without aura

Question 5

Sx of migraine

Answer 5

• visual or other aura
• unilateral, throbbing headache
• often premenstrual
• N+V
• photophobia, phonophobia
• allodynia

Question 6

what is the criteria for migraine without aura

Answer 6

at least 5 attacks: 4-72 hours

2 of: Moderate/ severe, unilateral, throbbing pain, worst movement.

1 of: Autonomic features, photophobia/ phonophobia

Question 7

what is the pathophysiology of migraines

Answer 7

vascular and neural influences cause migraines in susceptible individuals

Stress triggers changes in the brain, these changes cause serotonin to be released

Blood vessels constrict and dilate

Chemicals including substance P irritate nerves and blood vessels causing pain.

Question 8

what is aura

Answer 8

fully reversible visual, sensory, motor or language symptoms

duration 20-60 minutes

headache follows < 1 hour later and can occur simultaneously

Question 9

what Tx can be used in an acute migraine

Answer 9

NSAID
- aspirin, naproxen, ibuprofen

Triptans
- Rizatriptan, frovatriptain

Question 10

what class of drugs is triptans

Answer 10

5HT agonist

Question 11

when should a triptan be given

Answer 11

at start of the headache

Question 12

when is frovatriptan given

Answer 12

for sustained relief

Question 13

when is prophylaxis given in cases of migraine

Answer 13

More than 3 attacks month or very severe attacks

Question 14

what are drugs used in prophylaxis in migraines

Answer 14

Propranolol (beta blocker)
Topiramate (carbonic anhydrase inhibitor)
Amitriptyline

Question 15

when should propranolol be avoided

Answer 15

in asthma, PVD, heart failure

Question 16

what are SE of topiramate

Answer 16

weight loss
paraesthesia
impaired concentration

Question 17

side effects of Amitriptyline

Answer 17

dry mouth
postural hypotension
sedation

Question 18

what else could be used if amitriptyline was not suitable in migraines

Answer 18

gabapentin
pizotifen
sodium valproate

Question 19

what lifestyle changes can decrease the risk of a migraine

Answer 19

Diet- regular intake, avoid triggers, healthy balanced diet

Hydration- at least 2 litres day, decrease caffeine

Stress- decrease

Regular exercise

Question 20

what are trigeminal autonomic cephalgias (TACs)

Answer 20

group of primary headache disorders

characterised by unilateral trigeminal distribution pain

occurs in association with prominent ipsilateral cranial autonomic features.

Question 21

what are ipsilateral cranial autonomic features

Answer 21

Ptosis  
Miosis
Nasal Stuffiness  
Nausea/ vomiting  
Tearing
Eye lid oedema

Question 22

what are the 4 types of TCA

Answer 22

cluster
paroxsymal hemicrania
hemicrania continua
SUNCT

Question 23

what is features of a cluster headache

Answer 23

30-40s 
Men more than women
can last 20-120 mins
can have up to 8 a day
often nocturnal

Question 24

Sx of cluster headaches

Answer 24

rapid onset of severe unilateral headache
excruciating pain around one eye 
bloodshot, watery eye 
lid swelling, lacrimation
facial flushing, rhinorrhoea
miosis +/- ptosis

Question 25

what is the acute treatment of a cluster headache

Answer 25

High flow oxygen 100% for 20mins

sumatriptan 6mg sc

steroids - reducing course over 2 weeks

Question 26

what is prophylactic treatment for cluster headaches

Answer 26

verapamil

Question 27

who gets Paroxysmal hemicrania

Answer 27

Elderly (50s-60s)

women> men

Question 28

symptoms of Paroxysmal hemicrania

Answer 28

• severe unilateral headache
• unilateral autonomic features
• multiple severe, yet short, headache attacks affecting only one side

Question 29

features of Paroxysmal hemicrania

Answer 29

2 mins-45 hours

1 to 40 a day

Question 30

Tx of Paroxysmal hemicrania

Answer 30

Indomethicin

- absolute response

Question 31

what does SUNCT stand for

Answer 31

S= Short lived (15-120 secs)
U=unilateral
N= neuralgiaform headache
C= conjunctival injections
T= Tearing

Question 32

what does conjuntival injection meaning

Answer 32

bloodshot eyes

Question 33

Tx for SUNCT

Answer 33

Lamotrigine

Gabapentin

Question 34

who with headaches require investigation

Answer 34

new onset unilateral cranial autonomic features

Question 35

what Ix should be done in the cases of new onset unilateral cranial autonomic features

Answer 35

MRI brain

MR angiogram

Question 36

who gets trigeminal neuralgia

Answer 36

> 60y/o
women > men
triggered by touch often
1-90s 
10 to 100 days

Question 37

Sx of trigeminal neuralgia

Answer 37

severe stabbing unilateral pain in the trigeminal nerve distribution

Question 38

what is first line Tx for Trigeminal neuralgia

Answer 38

Carbamazepine 100mg

Question 39

what is used if Carbamazepine isn’t working for trigeminal neuralgia

Answer 39

Gabapentin
Phenytoin
Lamotrigine

Question 40

what Tx is used if patient is not responsive to anti-convulsant treatment in trigeminal neuralgia

Answer 40

Baclofen

Question 41

what options are there if drug treatment doesn’t work in trigeminal neuralgia

Answer 41

surgical abalation

surgical decompression