Headaches

Question 1

Primary vs secondary headache

Answer 1

Primary - migraine, tension, cluster
Secondary - precipitated by another condition/disorder local or systemic. Serious causes uncommon.

Question 2

Long lasting primary headache

Answer 2

Migraine, tension-type headache, medication overuse headache

Question 3

Short lasting primary headache

Answer 3

Trigeminal autonomic cephalalgia -> cluster headache

Question 4

Threshold for long lasting headache (how many hours)

Answer 4

Over 4

Question 5

Differentiating between primary and secondary after history and examination

Answer 5

No red flag -> primary
Red flag -> secondary -> diagnostic tests
History is key for differentiation

Question 6

4 key red flags suggesting secondary headache

Answer 6

Age - New onset or different headaches in a person >50yrs
Onset - Sudden, abrupt onset of a severe headache (thunderclap headache)
Systemic symptoms - Fever, neck stiffness, rash, weight loss
Neurological signs - Confusion, impaired consciousness, focal neurology, swollen optic discs

Question 7

Migraine pathophysiology

Answer 7

Abnormal cortical hyperexcitability
(­Ca++, ­Glu, ¯Mg++)
Abnormal brain stem function
Excitation of brain stem, PAG (periaqueductal gray), etc.
Cortical Spreading Depression - aura
Activation of TGVS (trigeminovascular system) - headache pain
CGRP from activation - Vasodilation, Neurogenic Inflammation (pain perpetuation)
Activation causes central sensitisation

Question 8

Migraine characteristics

Answer 8

Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
Last hours and sometimes days!
Usually one or more of:
Nausea and/or Vomiting
Photophobia and/or Phonophobia
+/- auras

Question 9

What is migraine aura

Answer 9

Complex array of symptoms reflecting focal cortical or brainstem dysfunction
Gradual evolution: 5-30minutes (<60minutes)
Usually before headache

Question 10

Types of migraine aura

Answer 10

Expanding C’s
Elemental visual disturbance

Question 11

Migraine phases

Answer 11

Premonitory: yawning, polyuria, mood change, irritable, light sensitive, neck pain, concentration difficulty
Aura: Visual, sensory (numbness/paraesthesia), weakness, speech arrest
Headache: Head and body pain, nausea, photophobia
Resolution: rest and sleep
Recovery: mood disturbed, food intolerance, feeling hungover
Can take up to 48 hours

Question 12

Aspects of migraine management

Answer 12

Lifestyle
Pharmacological therapy
Acute/abortive
Long term preventative

Question 13

Migraine lifestyle management

Answer 13

avoid triggers, diet, sleep, exercise, mindfulness

Question 14

Migraine acute management

Answer 14

Hard and fast! Paracetamol, NSAIDs (high dose soluble), Prokinetics, Triptans (5-HT1B/1D/1F receptor agonists)

Question 15

Migraine long term management

Answer 15

Long term preventative: >5 days/month
“low and slow” with doses until at optimal dose

Question 16

Tension-type headache characteristics

Answer 16

Patients usually say its feels like:
Tight muscles around head and neck, as though head is in a vice.
Lasts 30mins (but can be hours long):
Bilateral
Mild or moderate
Not aggravated by movement
No added features typically
No nausea or vomiting
No photophobia or phonophobia

Question 17

Tension-type headache treatment

Answer 17

Reassurance may suffice in the majority of patients.
Individual attacks can be treated with simple analgesics such as Aspirin or Paracetamol.
Preventative medications rarely required

Question 18

Cluster headache characteristics

Answer 18

Severe unilateral pain
Last 15-180 minutes if untreated.
At least one of the following, ipsilaterally:
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea
Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Not associated with a brain lesion on MRI

Question 19

Cluster headache acute treatment

Answer 19

Triptan. Nasal or subcutaneous route
High flow oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex

Question 20

Cluster headache preventative treatment

Answer 20

Verapamil (Calcium channel inhibitor)
Get an ECG first!
Greater occipital nerve block

Question 21

Cluster headache frequency

Answer 21

1-3 per day (up to 8).
Usually occurs daily for 2-3 months at a time