Headache & Migraine

Question 1

What are the three classes of primary headaches?

Answer 1

Tension-Type Headache (TTH), Migraine and Cluster Headache

Question 2

What are the key symptoms of Tension-Type Headache (TTH)?

Answer 2

• Non-throbbing, bilateral pain
• No nausea or vomiting
• Photophobia or phonophobia, but not both

Question 3

What is the recommended treatment for TTH?

Answer 3

OTC analgesics: Paracetamol, aspirin, NSAIDs
Limit use to avoid medication-overuse headache (MOH)

Question 4

What is medication-overuse headache (MOH)?

Answer 4

A headache caused by excessive use of painkillers, occurring >15 days/month for simple analgesics or >10 days/month for triptans/opioids.

Question 5

What are the typical symptoms of a migraine?

Answer 5

• Throbbing, unilateral pain lasting 4-72 hours.
• Moderate to severe intensity.
• Nausea, vomiting, photophobia, or phonophobia.
• May occur with or without aura

Question 6

What is an aura in the context of migraine?

Answer 6

A focal neurological disturbance, often visual (e.g., scintillating scotomas), that precedes or accompanies the headache in ~15% of patients.

Question 7

What is cortical spreading depression (CSD)?

Answer 7

A wave of neuronal depolarisation across the cortex, linked to aura and local blood flow reduction in migraines.

Question 8

What are three theories of migraine pathophysiology?

Answer 8

1. Vascular Theory: Vasoconstriction followed by vasodilation.
2. Neuronal Theory: Involves cortical spreading depression (CSD).
3. Inflammation Theory: Activation of trigeminal nerve terminals causing neurogenic inflammation.

Question 9

What is the trigeminovascular pathway?

Answer 9

A pathway involving the trigeminal ganglion and intracranial vessels, central to the neurovascular model of migraine.

Question 10

What are triptans, and how do they work?

Answer 10

Selective 5-HT_1B/1D receptor agonists that:

• 5-HT 1B: Cause vasoconstriction of cranial blood vessels
• 5-HT_1D: Block release of vasoactive peptides from trigeminal nerves.

Question 11

Name some examples of triptans

Answer 11

Sumatriptan, Almotriptan, Naratriptan, Eletriptan, Rizatriptan, Zolmitriptan.

Question 12

What are the available formulations of triptans?

Answer 12

Tablets, subcutaneous injections, nasal sprays, and orally dissolving tablets (rapid-melt)

Question 13

What are ditans?

Answer 13

Selective 5-HT_1F agonists (e.g., Lasmiditan) used for migraine without vasoconstrictive effects.

Question 14

What is the role of CGRP in migraines?

Answer 14

CGRP (Calcitonin Gene-Related Peptide) is released during migraines, causing vasodilation and inflammation in the trigeminovascular pathway.

Question 15

Name three CGRP monoclonal antibodies approved for migraine prevention.

Answer 15

Fremanezumab (Ajovy), Erenumab (Aimovig), Galcanezumab (Emgality).

Question 16

What is the WHO pain ladder for headache management?

Answer 16

Mild Pain: NSAIDs (e.g., aspirin, ibuprofen).

Moderate Pain: Weak Opioids (e.g., codeine, buprenorphine).

Severe Pain: Strong opioids (e.g., morphine, fentanyl)

Question 17

What are the prophylactic treatments for migraines?

Answer 17

Beta-blockers (e.g., propranolol), tricyclic antidepressants (e.g., amitriptyline), antiepileptics (e.g, topiramate), and CGRP monoclonal antibodies.

Question 18

What emerging treatments target migraine sensitisation mechanisms?

Answer 18

• TRPV1 antagonists.
• Nitric oxide synthase inhibitors
• Prostanoid receptors blockers

Question 19

What is cluster headache, and how is it treated?

Answer 19

A severe, unilateral headache autonomic symptoms. Treated with Verampil (off-label)

Question 20

What are the main side effects of triptans?

Answer 20

Flushing, tingling, chest pressure, and rare vasoconstrictive complications.