Headaches - 1

Question 1

What is a primary headache?

Answer 1

No underlying medical cause
Tension type headache, migraine and cluster headache

Question 2

What is a secondary headache?

Answer 2

Has identifiable structural or biochemical cause
Tumour, meningitis, vascular disorders, systemic infection, head injury and drug-induced

Question 3

Describe the pathophysiology of a primary headache

Answer 3

Sensitisation of normal pain pathways
Involves brainstem, cortical structures and trigemino-vascular system
Calcitonin gene related peptide a key transmitter

Question 4

What is used for management for primary headache?

Answer 4

Modifiable lifestyle triggers - sleep, dehydration, stress
Abortive treatment
Transitional treatment
Preventative treatment

Question 5

What is the aim of preventative treatment?

Answer 5

Adjust threshold for developing headache - reduce sensitivity

Question 6

What is the identifiable structural or biochemical cause of secondary headache?

Answer 6

Headache occurring for first time in close temporal relation to another disorder known to cause headache
Pre-existing primary headache becoming significantly worse in close temporal relationship another disorder known to cause

Question 7

What are the specific headache features that give clues to diagnosis of secondary headache?

Answer 7

Thunderclap in SAH
Postural headache in low pressure headache
Biology is mainly migraine and migrainous features

Question 8

What is the investigations for headaches?

Answer 8

Primary - look for underlying cause, usually need no investigation but can have MRI or CT
Secondary - CT and CT angiogram, MRI

Question 9

Describe a tension type headache

Answer 9

Most frequent primary headache
Not disabling
Is mild, bilateral headache with pressing or tightening quality
Aggravated by routine exercise

Question 10

What is the treatment for tension type headache?

Answer 10

Acute - paracetamol or NSAIDs
Preventative - Tricyclic antidepressants (Amitriptyline)

Question 11

Describe a migraine

Answer 11

Most disabling primary headache
A chronic disorder with episodic attacks and complex changes in brain

Question 12

What are the symptoms of a migraine?

Answer 12

During - headache, nausea, vomiting, phonophobia, photophobia and functional disability
In between attacks - anticipatory anxiety

Question 13

Describe the course of a migraine

Answer 13

Premonitory - mood changes, fatigue, cognitive changes, muscle pain and food craving
Aura
Early headache - dull, muscle pain and nasal congestion
Advanced headache - unilateral, throbbing, nausea
Postdrome - fatigue and cognitive changes

Question 14

Describe aura in migraines

Answer 14

Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve sensory, visual, motor or speech systems
Is a slow evolution of symptoms
Duration - 15 to 60 mins
Can be confused with transient ischaemic attack

Question 15

Describe chronic migraine

Answer 15

Headache more than 15 days a month of which more than 8 days are migraine, for more than 3 months
Transformation can occur with or without escalation of medication use

Question 16

What is a transformed migraine?

Answer 16

History of episodic migraine, increasing frequency of headache over weeks/months, migraine symptoms become less frequent and severe

Question 17

Describe medication overuse headache

Answer 17

Headache present more than 15 days a month which have developed or worsened whilst taking regular symptomatic medication
Can occur in primary headache

Question 18

What can medication overuse headache be caused from?

Answer 18

Use of triptans, ergots, opioids and combination analgesics more than 10 days a month
Use of simple analgesics more than 15 days a month
Caffeine overuse

Question 19

What are some modifiable lifestyle triggers for a migraine?

Answer 19

Dehydration, diet, environmental stimuli, changes in oestrogen in women, stress, hunger and sleep disturbance

Question 20

What is used for acute treatment of migraines?

Answer 20

Aspirin and NSAIDs
Triptans
Limit to 10 days per month

Question 21

What is used for prophylactic treatment for migraines?

Answer 21

Propranolol, Candesartan
Anti-epileptics - topiramate and valproate
Tricyclic antidepressants
Flunarizine
Botox
CGRP monoclonal antibodies

Question 22

What is the treatment for medication overuse headache?

Answer 22

Prevention - limit treatment to 2 days a week
Abrupt withdrawal of medication
Best strategy is not clear

Question 23

What are specific headache issues in women?

Answer 23

Migraine without aura is better in pregnancy and with doesn’t change
First migraine can occur in pregnancy
Combined OCP is contraindicated if migraine with aura
Avoid anti-epileptics in women of child bearing age

Question 24

What is the treatment of migraine is women is pregnant?

Answer 24

Acute attack - paracetamol, triptans and NSAID
Preventative - propranolol and amitriptyline

Question 25

Describe new daily persistent headache

Answer 25

Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24hrs
Medication overuse is common
Diagnosis and exclusion of secondary cause

Question 26

What are the clinical features of primary new daily persistent headache?

Answer 26

2 subtypes
Self-limiting - usually resolves within months even without therapy
Refractory - resistant to aggressive treatment
Headache can resemble chronic migraine or chronic tension type headache