Headache

Question 1

What are the trigeminal autonomic cephalagias?

Answer 1

Group of primary headache disorders characterised by unilateral trigeminal distribution pain and prominent ipsilateral autonomic features

Cluster headaches
Paroxysmal hemicrania
Hemicrania continua
SUNCT

Question 2

Those with new onset unilateral and cranial autonomic features require

Answer 2

imaging MRI brain and MR angiogram to rule out aneurysm

Question 3

List some headache red flags?

Answer 3

Any new onset headache in someone over age 55
Anyone with known/ previous malignancy
Immuno-suppressed
Early morning headache
Exacerbation by valsava (suggests increased ICP)
Headache that wakes you up

Question 4

What is the most common cause of episodic headache?

Answer 4

Migraine

Question 5

Pathophysiology of migraines?

Answer 5

it’s neurologic and basically results in waves of depolarisation across cortex that activate trigeminal pain receptors

Question 6

Who are migraines more common in?

Answer 6

women

Question 7

Criteria for diagnosis of migraine?

Answer 7

• Criteria for migraine without aura: at least five attacks lasting 4-72 hours with
2 of: moderate/ severe, unilateral, throbbing pain, worse with movement
1 of: autonomic features, photophobia, or phonophobia

Question 8

25% of migraine sufferers have

Answer 8

auras

Question 9

Describe migraine auras?

Answer 9

can be visual which is most common e.g. scotomas, central fortification, hemianopia
also get sensory and motor auras
these auras usually last 20-60 mins and are followed by the headache phase

Question 10

Describe some triggers for migraines?

Answer 10

sleep deprivation, skipping meals, alcohol, hormones (oestrogen), physical exertion

Question 11

Describe some non pharmacologic treatment of migraines?

Answer 11

headache diary, education on avoiding triggers, relaxation, stress management

Question 12

Describe some acute abortive treatments for migraines?

Answer 12

NSAIDs or triptans (however shouldn’t overuse as can get medication overuse headaches)

Question 13

Describe prophylactic drugs for migraines?

Answer 13

1st line > amitriptyline
2nd line > propranolol
3rd line > topiramate

Question 14

What type of headache is the classic everyday headache one might complain of?

Answer 14

tension headache

Question 15

Describe the features of tension headaches?

Answer 15

Mild to moderate pain, bilateral, tight band sensations, pressure behind the eyes, bursting sensation (absence of photophobia, photophobia, nausea and vomiting)

Question 16

Treatment of tension headaches?

Answer 16

simple analgesics effective but should avoid overuse
physio to relax the scalp, relaxation, massage and ice packs
tricyclics may be useful for chronic cases

Question 17

Who are cluster headaches most common in?

Answer 17

males in 20s-40s

Question 18

Describe the features of a cluster headache?

Answer 18

excruciating unilateral headache with parasympathetic autonomic activation in the same eye causing redness or tearing, nasal congestion or even transient Horner’s syndrome
frequency is about 1-8 a day, lasting 45-90 mins, with bouts lasting 1-2 months

Question 19

Attacks of cluster headache are most common at ____

Answer 19

night

Question 20

Describe when bouts of cluster headache occur?

Answer 20

usually recur a year or more later after a previous bout and often at the same time of year

Question 21

Describe treatment of cluster headaches?

Answer 21

ACUTE: high flow 100% oxygen, sub cutaneous sumatriptan (only drug that works fast enough)
OTHER TREATMENT: verapamil or steroids may terminate a bout of cluster headaches

Question 22

Who does paroxysmal hemicranial and hemicrania continua occur in

Answer 22

often elderly women

Question 23

Compare frequency and duration of attacks in hemicrania cluster headaches?

Answer 23

hemicrania attacks are shorter (10-30 mins) than cluster headaches (45-90 mins)
hemicrania attacks are more frequent (1-40 a day) than cluster headaches (1-8 a day)

Question 24

Describe treatment of paroxysmal hemicrania and hemicrania continua?

Answer 24

rapid and complete response to indometacin

Question 25

If a headache responds completely to indomethacin it is likely?

Answer 25

hemicrania

Question 26

Describe SUNCT?

Answer 26

S= short lived
U= unilateral
N= neuralgiaform headache 
C= conjunctival injections 
T= tearing 
attacks very short, 5 secs to 2 mins and often occur in bouts

Question 27

Treatment of SUNCT?

Answer 27

lamotrigine or gabapentin

Question 28

Who does idiopathic intracranial hypertension commonly occur in?

Answer 28

younger, overweight females, many have PCOS

Question 29

Describe features of idiopathic intracranial hypertension?

Answer 29

headache with red flags, worse in the morning, get nausea and vomiting, often headache with transient visual obscurations due to papilloedema

Question 30

Describe investigations for idiopathic intracranial hypertension?

Answer 30

MRI is normal

Lumbar puncture shows elevated CSF pressure but normal constituents

Question 31

Treatment of idiopathic intracranial hypertension?

Answer 31

monitor visual fields, weight loss, acetazolamide, ventricular atrial or lumbar peritoneal shunt may be necessary to protect vision

Question 32

Who is trigeminal neuralgia most common in and what is the main risk factor?

Answer 32

elderly

hypertension

Question 33

What is often the cause of trigeminal neuralgia?

Answer 33

Often due to compression of the trigeminal nerve at or near the pons by an ecstatic vascular loop which can be seen on high resolution MRI (can also be caused by MS)

Question 34

Describe clinical features of trigeminal neuralgia?

Answer 34

severe, sharp, stabbing, unilateral pain in the 5th neve distribution, lasts seconds but there are 10-100 attacks a day
may be caused by trivial stimuli e.g. washing, shaving or chewing
bouts of pain may last weeks to months

Question 35

Describe treatment of trigeminal neuralgia?

Answer 35

carbamazepine reduces the severity of attacks, may do ablation or decompression of blood vessel if very severe