Headache II

Question 1

What are the 3 most common types of headaches?

Answer 1

Migraine
Tension
Cluster

Question 2

What is a Migraine?

Answer 2

A headache disorder - repeated attacks of stereotypes headaches
Usually hemicranial - persistent unilateral headache
Triggered

Common features - easily hungover, visual vertigo and motion sickness

Question 3

What are the 3 attack forms of a migraine?

Answer 3

Pain
Focal symptoms - speech arrest, aphasia, pins and needles and weakness
Pain and focal symptoms

Question 4

What are the 5 phases of a migraine?

Answer 4

1. Prodome
2. Aura
3. Headache
4. Resolution
5. Recovery

Question 5

How do these 5 phases of a migraine present and progress?

1. Prodome
2. Aura
3. Headache
4. Resolution
5. Recovery

Answer 5

1. Prodome - changes in mood, urination, fluid retention, food craving (cheese, chocolate), yawning
2. Aura - visual, sensory (numbness / paraesthesia), weakness (hemiplegic migraine - looks like they have had a stroke), speech arrest (difficulty finding and speaking words)
3. Headache - head and body pain, nausea, photophobia, phonophobia
4. Resolution - lighter / softer pain allowing patient to rest and sleep
5. Recovery - mood disturbed, food intolerance, feeling hungover

Question 6

How long is the cycle?

Answer 6

Avg = 48hrs

Range from 1-5 days

Question 7

What are the 2 types of symptoms for migraine auras?

Give examples for each.

Answer 7

Positive or negative symptoms

Positive = flashes, zigzags, bright starbusts 
Negative = blackness, loss of vision

Question 8

What happens if positive and negative symptoms of a migraine aura combine?

Answer 8

Scintillations
Blindspots

Shimmering border with centre of darkness in their vision
Small blindspot slowly getting larger

Question 9

Why doe the scintillations and blindspots expand? What causes a migraine?

Answer 9

Spreading electrical depression across the cerebral cortex, as it goes across visual cortex = expansion of visual image

Question 10

What is the treatment for acute migraine attacks?

Answer 10

Aspirin/ibuprofen and paracetamol

Anti-emetic - e.g. metoclopramide (stimulates peristalsis, gut slows down during migraines, hence helps nausea symptoms and absorption of other medications)
Soluble preparations to aid absorption

Triptans-tablets (painkillers for migraines - treat the headache not aura): melts, nasal sprays, s/c injections
Act as vasoconstrictors and synergise with NSAIDS
Take it as soon as headache starts - doesn’t work if the headache has progressed too far

Opiates - although have analgesic abuse potential

A short nap

TMS - interrupts complex networks that trigger and perpetuate migraine, which is caused by spreading electrical depression across the cerebral cortex

Question 11

Why do migraine sufferers get recurrent headaches?

Answer 11

Genetic pre-disposition - sensitive head

Trigger - overreaction to stimulation

Question 12

What long term treatment options are there for migraine sufferers?

Answer 12

Lifestyle adjustments -

Look for triggers and avoid them:
dietary, environmental, hormonal, weather, dehydration, stress, alcohol (esp. containing sulphites)

Drink 2 litres water/day

Avoid caffeinated drinks

Don’t skip meals. Fresh food. Avoid ready meals & take-aways

Don’t oversleep or have late nights, keep electronics downstairs

Analgesic abuse

Question 13

How are chronic migraines classified clinically?

Answer 13

> 14 headaches / month

Question 14

What medications (migraine prophylaxis) are given to chronic migraine sufferers?

Answer 14

Over-the-counter preparations: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide

Tricyclic antidepressants (TCAs): amitriptyline 7pm

Beta-blockers - Propranolol, Atenolol
Serotonin antagonists: pizotifen, methysergide

Calcium channel blockers: flunarazine, verapamil

Anticonvulsants: valproate, topiramate, gabapentin (must not get pregnant while taking this medication)

Greater occipital nerve blocks

Botox: crown of thorns

Suppress ovulation - POP or implant/injection (not OCP as oestrogen content may trigger migraine)

Question 15

Why are there so many different medications for chronic migraines?

Answer 15

Depends on biochemistry of patient - some have issues with sodium channels, others with potassium, others with calcium etc,

Question 16

What is Erenumab?

How does it work?

Answer 16

A new migraine treatment - injectable drug erenumab (Aimovig) given monthly

Cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month, and reduces severity so worth trying for sufferers of episodic migraine, chronic migraine, or cluster headache

Monoclonal antibody
disables calcitonin gene-related peptide or its receptor (CGRP mAbs)

Question 17

What is a tension type headache?

Answer 17

Tight muscles around the head and neck bilaterally, as though head is in a vice
Soreness on head and neck

Question 18

How can tension type headaches be treated?

When prone to tension headaches, what treatments may be given?

Answer 18

NSAID’s preferred - ibuprofen, naproxen, diclofenac
Paracetamol

Tricyclic antidepressants:-
Amitriptyline 50-75mg daily
30-60% derive some symptomatic relief
SSRI’s probably less effective
Biofeedback and relaxation although unproven

Question 19

What are cluster headaches?

What are they classified as?

Which CN is affected?

Answer 19

Severe unilateral pain lasting around 15-180 mins untreated

Classified as a trigeminal autonomic cephalgia - pain mainly in CN V1
Phantom of the opera mask pain

At least one of the following, ipsilaterally:
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea (runny nose)
Eyelid oedema

Forehead and facial sweating

Miosis and/or ptosis (constriction / dilation of pupil), drooping of eyelid

A sense of restlessness or agitation

Frequency between one on alternate days to 8 per day.

Not associated with a brain lesion on MRI

Question 20

What is the treatment for acute cluster headaches?

Answer 20

Advise patients to attend A&E for inhaled oxygen. If it works, GP can prescribe oxygen cylinder for use at home
Oxygen inhibits neuronal activation in the trigeminocervical complex

S/C (subcutaneous injection) or Nasal Sumatriptan

Question 21

What is the treatment to limit / prevent further cluster headaches?

Answer 21

Verapamil
Prednisolone 
Lithium 
Valproate
Gabapentin
Topiramate
Pizotifen

Question 22

What are the differences between migraines and cluster headaches in terms of:

Distribution 
Duration 
Frequency
Remission
Nausea
Pain
Symptoms
Activity

Answer 22

Migraine VS Cluster

Distribution: 33% M, 67% F || 90% M, 10% F

Duration: 3-12 hours || 45-180 mins

Frequency: 1-8 attacks monthly || 1-3 attacks daily (often at night)

Remission: Long remissions unusual || Long remissions common

Nausea: nausea and vomiting frequent || Nausea rare

Pain: pulsating and hemicranial pain || steady, exceptionally severe, well localised pain, unilateral in each cluster

Symptoms: visual or sensory auras seen || eyes watery, nose blocked, ptosis etc.

Activity: patient lies in the dark || patients pace about