Headache and Migraine

Question 1

Primary headache

Answer 1

Diagnosis made on history in absence of physical signs

Treating headache, not thing that may be causing it

Question 2

Secondary headache

Answer 2

Diagnosis made on history in presence of physical signs

Underlying cause treated

Question 3

Primary headache types

Answer 3

Tension type
Migraine
Cluster

Question 4

Tension-type headache facts

Answer 4

80% primary headaches

F>M

Question 5

Migraine facts

Answer 5

15% primary headaches

F>M

Question 6

Cluster headache facts

Answer 6

0.2-0.3% primary headaches

M>F

Question 7

Tension type headache

Answer 7

Disappear soon after noxious stimulus stops
Band-like, bilateral
Tightness, pressure, dull ache
Mild to moderate
Not aggravated by movement
Treatment- acute, prophylactic

Question 8

Cluster headache

Answer 8

Treatment- high flow O2- constricts blood vessels
6-8 weeks
Extreme pain
Unilateral
30 mins --> several hours
Usually couple of hours after go to sleep
No cure
Strong link to smoking

Question 9

Migraine without aura diagnostic criteria

Answer 9

At least 5 attacks fulfilling:

• Headaches 4-72 hours
• Headache 2/4 characteristics of: unilateral, pulsating, moderate/severe pain, aggravated by physical activity
• During headache at least one of: nausea and/or vom, photophobia + phonphobia

Question 10

Migraine diagnostic

Answer 10

Light bothers you
Headaches limit ability to work/study
Feel nauseated or sick
--> 2 positive answers- 93%
--> 3 positive answers- 98%

Question 11

Migraine pathophysiology

Answer 11

Triggers –> (Cortical spreading depression –> aura –> ) Activation/sensitisation of TGVS –> headache

Question 12

Types of migraine

Answer 12

Without aura: 70-80%

With aura: 20-30%

Question 13

Migraine aura

Answer 13

Visual 99%
Gradual development
Duration of each symptom typically 20-30 mins
Complete reversibility
Typically resolves before onset of headache
No motor weakness

Question 14

When does migraine start

Answer 14

Chemical changes start 24 hours before headache - Premonitory phase

Question 15

5HT

Answer 15

Monoamine neurotransmitter
Vasoconstrictor and/or vasodilator
Increase during migraine
Drugs that deplete serotonin trigger migraine
Serotonin infusions help relieve migraine

Question 16

Triptans

Answer 16

Acute

5HT 1d/b agonists

Question 17

Methysergide

Answer 17

Prophylactic

5HT2b antagonist

Question 18

Reserpine

Answer 18

Depletes serotonin

–> triggers migraine

Question 19

Aura

Answer 19

Originates from visual cortex
Still persists when eyes closed
Unilateral
May resolve before onset of headache
Less than an hour
Consequence of CSD
Gets bigger as CSD spreads across cortex

Question 20

Cortical spreading depression

Answer 20

A transient and local suppression of spontaneous electrical activity in cortex with moves slowly across the brain
3mm a minute
Aura is consequence of CSD
Thought to be caused by constriction of BVs by serotonin, reducing blood flow

Question 21

Serotonin effects

Answer 21

Causes meninges on outside of brain to dilate

Once dilated, release of other inflammatory neuropeptides- CGRP

Question 22

CGRP

Answer 22

37 AA neuropeptide
Potent vasodilator
Widely distributed in CNS + PNS
Levels rise spontaneously during migraine attacks
Decreases after triptans
CGRP infusions trigger migraine

Question 23

Trigeminal ganglion (in roof of mouth)

Answer 23

Neuropeptides activate nerve pathways
Nerves send pain signals to trigeminal ganglion
Trigeminal ganglion transmits pain impulses to trigeminal nucleus caudalis in brainstem
Relays pain to thalamus
Thalamus –> cerebral cortex

Question 24

Triptans

Answer 24

5HT 1d/b agonists
Acute treatment
Sumatriptan
Zolmitriptan
Naratriptan

Question 25

CGRP monoclonal antibodies

Answer 25

Prevention
Erenumab
Fremanezumab
Eptinezumab