Headache

Question 1

first line treatment of tension headache ?

Answer 1

paracetamol, aspirin or NSAID

Question 2

prophylaxis treatment for tension headache ?

Answer 2

up to 10 sessions of acupuncture over 5-8 weeks

Question 3

red flag signs of headache ?

Answer 3

substantial change in characteristics of headache
age < 20 with history of malignancy
previous history of malignancy in the brain
sudden onset headache reaching maximum intesnsity in < 5 mins
orthostatic headache
vomiting
worse with valsavla
worsening headache with fever
signs of GCA or acute angle closure glaucoma
new onset neurological dysfunction
new onset cognitive dysfunction
impaired level of consciousness compromised immunity i.e. HIV, immunosuppressive drugs
change in personality

Question 4

definition of chronic tension type headache ?

Answer 4

tension-type headache which occurs > 15 times each month

Question 5

1st line treatment for migraine ?

Answer 5

triptans

Question 6

what is prophylactic management for migraines ?

Answer 6

1st line: propanolol or topiramate

2nd line: switch to either propranolol or topiramate

if both fail to prevent migraines - up to 10 sessions of acupuncture over 5-8 sessions

Question 7

atypical signs of aura that warrant further investigations ?

Answer 7

double vision 
visual disturbance that only affects one eye 
loss of consciousness 
motor weakness 
poor balance

Question 8

features of aura ?

Answer 8

onset about 5 minutes
last approx 5- 60 mins
fully reversible

visual;

• transient hemianopia
• scintillating scotoma (‘black spot’, ‘zig-zag’, ‘twinkling blur’)

Question 9

diagnostic criteria for migraine ?

Answer 9

x5 headaches with the following;

headache with at least 2 of the following;

• unilateral
• pulsating
• moderate/severe intensity
• aggregated by activity / prevents you doing activity

during headache at least one of the following;

• nausea and/or vomiting
• photophobia and phonophobia

not attributed to another disorder (not a secondary headache)

Question 10

contraindication for triptans ?

Answer 10

hx or significant risk factor for ischaemic heart disease

should be avoided in pregnancy (as with all opioids)

Question 11

contraindication for propranolol ?

Answer 11

asthma

Question 12

contraindication for topiramate ?

Answer 12

women of child bearing age due to it being teratogenic

Question 13

treatment of migraine during pregnancy ?

Answer 13

1st line: 1g paracetamol
2nd line: NSAIDS in 1st and 2nd trimester

avoid opioids (triptans) and aspirin during pregnancy

Question 14

is it safe to take the COCP and HRT with a history of migraine ?

Answer 14

history of migraine with aura is an absolute contraindication to the COCP

it is safe to start HRT if history of migraine but it may make headaches worse

Question 15

what is recommended for treatment of migraine during menstruation ?

Answer 15

migraines tend to get worse during time of menstruation

recommended women are treated with mifenamic acid or a combination of paracetamol, NSAIDS and caffeine
triptans can also be used in the acute situation

Question 16

side effects of triptans ?

Answer 16

triptan sensations - tingling, tightening, pressure, heat

Question 17

action of triptan ?

Answer 17

5-HT1b and 5-HT1d agonist

serotonin receptors

Question 18

1st line line treatment for acute attack of cluster headache ?

Answer 18

100% oxygen via non-rebreathe

subcutaneous triptan e.g. sumatriptan

Question 19

prophylaxis management for cluster headache ?

Answer 19

verapamil

Question 20

describe features of cluster headaches.

Answer 20

occur in bouts lasting 4-12 weeks, headaches typically occur 1/2 times per day
each cluster occurs

severe unilateral headache
sharp stabbing
lacrimation, orbital oedema

Question 21

what can trigger a cluster headache ?

Answer 21

alcohol

increased risk in male and smokers

Question 22

red flag signs of trigeminal neuralgia ?

Answer 22

onset < 40yrs 
family history of MS 
optic neuritis 
deafness / other ear problems 
pain only in the ophthalmic division
history of skin or oral lesions that could spread perineurally

Question 23

1st line treatment of trigeminal neuralgia ?

Answer 23

carbamazepine

Question 24

2nd line treatment of trigeminal neuralgia ?

Answer 24

TN I: microvascular decompression

TN II: ablative surgery

• radio frequency ablation
• gangliolysis
• balloon compression