Headaches

Question 1

What are the important features in a headache Hx?(9)

-what are the red flags? (5)

Answer 1

onset/peak (acute.subacute/gradual)
reliving features 
(posture, behaviour)
Exacerbating
(posture, valsalva, diurnal variation)
Assoc features
(autonomic features, photophobia, positive visual symptoms, Ptosis, miosis, nasal stuffiness)
demographics should be considered 
PMH
(previous CA, predisposition to thrombus)
Fam Hx
(Migraine)
Drug Hx
(OTC)
Social Hx 

-new onset >55
Known, prev malignancy 
immunosuppressed
early morning headache
exacerbation by valsalva

Question 2

Migraine

• types?
• Features of type 1.?
• what criteria must be met for type 2.? (4)
• pathophysiology?
• what 3 visual changes can occur?
• triggers? (5)
• treatment? (non-pharmo and pharmo)
• when should prophylaxis be considered?
• examples of prophylaxis (5)
• lifestyle changes? (4)
• inv?
• name the 6 more unusual migraine types?

Answer 2

• 1. with aura
     
     2. without aura

-aura fully reversible, sensory, motor or language
deteriorates fater 20-60 mins
headache follows > 1 hr later
visual most common

-at least 5 attacks
duration 4-72 hrs
2 of: moderate/severe unilateral throbbing pain, worst on movement
1 of: autonomic features, photophobia/phonophobia

-Both vascular and neural influences cause migraines
stress triggers a change in the brain and causes serration to be released
Blood vessels constrict and dilate
Chemicals including substance P irritate blood vessels and cause pain

In migraine with aura:
get activation of trigeminal vascular system- dilation cranial blood vessels
release of substance P, neurokinin A, CGRP

-central scotoma
central fortification
Hemianopia loss

-Sleep
dietary
Dress
Hormonal 
Physical exertion 

-Educate to avoid triggers
headache diary
relaxation & stress management

Acute:
NSAID-Aspirin, Naproxen, Ibuprofen +/- anti-emetic

Triptans- 5HT agonist
e.g. Rizatriptan, Frovatriptan (for sustained relief)
use at start of headache

-more than 3 attacks per month or very severe
must trial for min 4 months
e.g. Propranolol (B-Blocker) 80-240mg/day
Topiramate (carbonic anhydrase inhibitor), 25-100mg/day
Others: amitriptyline, gaba[entin, pizotifen, Na valproate

-regular intake, avoid triggers
hydration & reduce caffeine
Stress
Regular exercise

-imaging if late onset >55, known malignancy or acephalgic

-Acephalic (aura, no headache)
Basilar (vertigo, N&V)
Retinal (visual fortification)
Ophthalmic 
Hemiplegic (stroke like episode, severe with weakness)
Abdominal (in kids)

Question 3

Trigeminal autonomic cephalgia

• what are they?
• give the 4 main types?
• investigations?

Answer 3

-group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features

-Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT

-MRI brain and MR angiogram for new unset unilateral cranial autonomic features

Question 4

What are ipsilateral cranial autonomic features? (6)

Answer 4

Ptosis
Miosis
Nasal stuffiness
Nausea/vomiting
Tearing
Eye lid oedema

Question 5

Cluster headache

• who?
• when does it occur?
• features?(location, frequency) (3)
• treatment? (3)
• prophylaxis?

Answer 5

• young, more common in men
• around sleep and with seasonal variation

-severe unilateral headache for 45-90 mins
1 to 8 occur a day
cluster bout may last from weeks to months

-high flow O2
Subcut sumatriptan 6mg
steroids

-Verapamil

Question 6

Paroxysmal hemicrania

• who?
• features (location, frequency)
• treatment?

Answer 6

-elderly, more in women

-severe unilateral headache with unilateral autonomic features
last 10-30 mins
can have 1-40 a day

-respond to indomethicin

Question 7

SUNCT

• stands for what?
• treatment?

Answer 7

• Short lived, unilateral, nebralgiaform headache, conjunctival injections, tearing
• Lamotrigine, gabapentin

Question 8

Trigeminal neuralgia

• in who?
• when?
• features? (4)
• treatment(pharmo-4, surgical-2)?
• investigations?

Answer 8

• elderly
• triggered by touch

-severe stabbing unilateral pain
for 1-2 secs
10 -100 times a day
bouts of pain may last form weeks to months

-Carbamazepine
gabapentin
phenytoin
baclofen

Ablation Vs décompression

-MRI if examination findings, atypical, poor response to meds