Headaches

Question 1

Headache red flags

Answer 1

> 55 yrs new onset headache (consider malignancy)
Known/ previous malignancy (consider recurrence/ mets)
Immunosuppressed
Early morning headache
Exacerbated by valsalva

Question 2

Medications for migraines

Answer 2

1st line for acute;

• 900mg aspirin
• take as early as possible and add an anti-emetic if necessary
• Triptans can be used at the start of the headache

Prophylaxis options;

• Propranolol
• Amitryptyline
• Gapabepentin
• Botulinum toxin scalp injections
• Topiramate

Question 3

Clinical features of tension headaches and management

Answer 3

Mild to moderate pain (usually not as severe as migraines)
Bilateral
Tingling sensation and pressure (like a tight band around the head)

Management; relaxation physio + anti-depressants (e.g amitriptyline)

Question 4

Which types of headaches are typically unilateral?

Answer 4

Migraine 
Cluster headaches 
SUNCT 
Paroxysmal hemicrania 
Trigeminal neuralgia

Question 5

Which type of headache is typically bilateral?

Answer 5

Tension headache

Question 6

What are the four types of trigeminal autonomic cephalgias?

Answer 6

Cluster headaches
Paroxysmal hemicrania
Hemicrania continua
SUNCT

Question 7

Clinical features of cluster headaches and management

Answer 7

Young patients
Severe unilateral headache lasting 20 mins to hours
Several per day

Management;
High flow 02
Subcutaneous sumatriptan
Steroids - reducing course over 2 weeks

Prophylaxis;
Verapamil

Question 8

Clinical features of paroxysmal hemicrania headaches and management

Answer 8

Severe unilateral headache lasting for 10-30 minutes
Many per day
(shower duration and more frequent than cluster headaches)

Management;
Indomethacin

Question 9

Clinical features of SUNCT headaches and management

Answer 9

Short lived (15-20 seconds) 
Unilateral 
Neuralgiaform headache 
Conjunctival injections 
Tearing 

Management;
Lamotrigine/ Gabapentin

Question 10

Clinical features of idiopathic intracranial hypertension and management plan

Answer 10

Almost always obese patients
Visual loss
Headache
N&V

Management;
Weight loss
Acetazolamide
Shunts

Question 11

Clinical features and management of trigeminal neuralgia

Answer 11

Triggered by touch
Severe stabbing unilateral pain
Lasts for seconds to minutes (may last weeks to months before remission)

Management;
Carbamazepine/ gabapentin etc
Surgical ablation/ decompression

Question 12

Topiramate is a medication which can be used in the management of migraines. To what drug class does it belong?

Answer 12

Carbonic anhydrase inhibitor