Headache

Question 1

What are some red flag features of a headache?

Answer 1

New onset headache > 55 y/o
Known/previous malignancy
Immune-suppressed
Early morning headache
Exacerbation by valsalva e.g. coughing, sneezing

Question 2

What percentage of migraines have aura?

Answer 2

Migraines with aura = 20%

Migraines without aura = 80%

Question 3

Criteria for migraine without aura:
At least 3 attacks
Duration 1-4 hours
2 of; moderate/severe, unilateral, throbbing pain, worse on movement
1 of; autonomic features, photophobia/photophobia
True or false?

Answer 3

False - partly

Criteria for migraine without aura:
At least 5 attacks
Duration 4-72 hours
2 of; moderate/severe, unilateral, throbbing pain, worse on movement
1 of; autonomic features, photophobia/photophobia

Question 4

What is the pathophysiology behind migraines?

Answer 4

Both vascular and neural influences cause migraines in susceptible individuals
Stress triggers changes in the brain, these changes cause serotonin to be released. This causes the blood vessels in the brain to constrict and dilate.
Chemicals including substance P are released and then irritate nerves and blood vessels causing pain

Question 5

What is the typical duration of aura in migraine with aura?

Answer 5

Usually 20-60 minutes. Headache follows <1 hour later but aura can occur simultaneously. Visual aura is the most common but sensory, motor or language aura can occur

Question 6

NSAIDs are used in headache. Which NSAIDs are used and how effective are they?

Answer 6

Aspirin (900mg), naproxen (250mg) and ibuprofen (400mg) +/- antiemetic
60% significant reduction in headache at 2 hours - only 25% complete pain relief
If gastroparesis consider anti-emetic

Question 7

Name a serotonin agonist class of drugs that are used in headaches

Answer 7

Triptans
Oral, sublingual, SC - consider method in those with N+V
Treat at start of headache
Rizatriptan or frovatriptan for sustained relief

Question 8

When would you consider prophylactic treatment in a migraine patient?

Answer 8

More than 3 attacks per month or very severe attacks
Consider non-pharmacological methods such as acupuncture, relaxation exercises
Aim is to titrate drug as tolerated to achieve efficacy at the lowest possible dose

Question 9

How effective is propranolol in migraine prophylaxis and when should it be avoided?

Answer 9

Reduction in migraine frequency in around 60-80% of patients. Avoid in asthma, peripheral vascular disease and HF

Question 10

What carbonic anhydrase inhibitor is used as migraine prophylaxis and has a poor side effect profile so must be started slowly?

Answer 10

Topiramate

Adverse effects - weight loss, paraesthesia, impaired concentration, enzyme inducer

Question 11

Name some migraine prophylactic drugs (other than propranolol and topiramate)

Answer 11

Amitriptyline, gabapentin, botulinum toxin, sodium valproate, pizotifen

Question 12

What are the features of a tension type headache?

Answer 12

Pressing tingling quality, bilateral, mild-moderate, absence of N+V, absence of photophobia or phonophobia

Question 13

How is a tension type headache treated?

Answer 13

Relaxation physio therapy, antidepressant e.g. dothiepin or amitriptyline for 3 months
Reassure

Question 14

What are the trigeminal autonomic cephalgias (TACs)?

Answer 14

A group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features

Question 15

What are ipsilateral cranial autonomic features?

Answer 15

Ptosis, miosis, nasal stuffiness, nausea/vomiting, tearing, eye lid oedema

Question 16

What are the 4 main types of trigeminal autonomic cephalgics?

Answer 16

Cluster, paroxysmal hemicrania, hemicrania continua, SUNCT

Question 17

Who typically gets cluster headaches?

Answer 17

Young (30-40y/o) men>women

Usually occurs around sleep and has a seasonal variation

Question 18

What are the features of cluster headache?

Answer 18

Severe unilateral headache lasting 45-90 minutes
1-8 times per day
Cluster bout may last from a few weeks to months

Question 19

How do you treat cluster headaches?

Answer 19

High flow oxygen 100% for 20 mins
SC sumatriptan 6mg
Steroids - reducing courser over 2 weeks
Verapamil for prophylaxis

Question 20

Who tends to get paroxysmal hemicrania?

Answer 20

Older (50-60y/o) women>men

Question 21

What are the features of paroxysmal hemicrania?

Answer 21

Severe unilateral headache, unilateral autonomic features
Duration 10-30mins
Frequency 1-40 per day
I.e. shorter duration and more frequent than cluster

Question 22

What is the treatment for paroxysmal hemicrania?

Answer 22

Absolute response to indomethicin

Question 23

What does SUNCT stand for?

Answer 23

S = short lived (15-120 seconds)
U = unilateral
N = neuralgiaform headache
C = conjunctival injections 
T = tearing

Question 24

What is the treatment for SUNCT?

Answer 24

Lamotrigine, gabapentin

Question 25

What investigations are used with new onset unilateral cranial autonomic features?

Answer 25

MRI brain and MR angiogram

Question 26

Name some features of idiopathic intracranial hypertension (IIH)

Answer 26

Females > males
Obesity is a huge risk factor
Headaches - diurnal variation with morning N+V
Visual loss

Question 27

What investigations are done for IIH and what would the typical results be?

Answer 27

MRI brain - normal
CSF - elevated pressure and normal constituents
Visual fields

Question 28

How is IIH treated?

Answer 28

Weight loss
Acetazolamide
Ventricular atrial/lunar peritoneal shunt
Monitor visual fields and CSF pressure

Question 29

Who tends to get trigeminal neuralgia and how is it triggered?

Answer 29

Older women > men

Triggered by touch, usually V2/3

Question 30

What are the features of trigeminal neuralgia?

Answer 30

Severe stabbing unilateral pain
Duration 1-90 seconds
Frequency 10-100 per day
Bouts pain may last from a few weeks to months before remission

Question 31

How is trigeminal neuralgia treated?

Answer 31

Medical treatment - carbamazepine, gabapentin, phenytoin, baclofen
Surgical - ablation, decompression
Investigations - MRI brain