Headaches Flashcards
Patient gets headache every time they stand up. Diagnosis?
intracranial hypotension
What kind of problem does waking up every day with a headache suggest?
raised pressure problem
What are red flag symptoms of headaches?
New onset headache age >55 Known/previous malignancy Immunosuppressed Early morning headache Exacerbation of valsalva (coughing, sneezing, raise in ICP)
Is it more common to have migraine with or without aura?
without (80%), with aura 20%
What is the criteria for diagnosing migraine without aura?
At least 5 attacks
2 of: moderate/severe, unilateral, throbbing pain - worse on movement.
1 of: autonomic features, photophobia/phonophobia
Vascular and neural influences cause migraine in susceptible individuals. Describe blood vessels during migraine.
during aura = constrict
dilate during migraine
What causes pain in migraine?
chemicals including substance P irritate nerves and blood vessels causing pain.
Dopamine is released by stress triggers causing migraine. True or false?
false - serotonin released in response to stress triggers in brain
Which areas in brain comprise the migraine centre in the brain?
dorsal raphe nucleus
locus coeruleus
Migraine without aura last longer than migraine with aura.
True or False?
ture
without –> 4-72hrs
with aura –> 20-60 mins
What is the most common type of migraine aura? Give examples.
visual
central scotoma
central fortification
hemianopic loss
What can trigger a migraine with aura?
sleep dietary (dark choc & cheese) stress hormonal physical exertion
What drugs can be given acutely in migraine?
NSAIDs
Triptans - 5hT agonists
Give examples of acute drugs SPECIFIC to migraine.
RIZATRIPTAN - wafer form - dissolves in mouth, ~30 mins to work.
FROVATRIPTAN - for sustained relief
Patient with 4 migraine attacks in last month. What sort of medication would you consider starting?
Prophylaxis since >3/month;
consider non-pharmacological methods e.g. acupuncture, relaxation exercises.
Must trial each for minimum of 3 months
What is the aim of migraine prophylaxis medication?
titrate drug as tolerated to achieve efficacy at lowest dose possible.
go slow and keep low
What dose of amitriptyline would you give as migraine prophylaxis? What are the side effects to warn about?
10-25mg
dry mouth, postural hypotension, sedation
A beta-blocker which reduces migraine frequency in ~60-80%… what is its dose and when to avoid it?
Propranolol 80-240mg
Avoid in asthma, PVD, heart failure.
Name a carbonic anhydrase inhibitor that is used in migraine prophylaxis.
Topiramate 25-100mg
Which migraine prophylactic causes bradycardia and nightmares?
propranolol
Which migraine prophylactic causes weight loss, paraesthesia and impaired concentration?
Topiramate
Patient has a mild bilateral headache or pressing/tingling nature. No photophobia or nausea.
tension type headache
Treatments for tension type headaches?
relaxation & physiotherapy
antidepressant (dothiepin or amitriptyline) for 3 months - reassure
What are trigeminal autonomic cephalgia’s (TACs)?
a group of primary headache disorders characterised by UNILATERAL trigeminal distribution pain that occurs in association with prominent IPSILATERAL cranial autonomic features.
Examples of autonomic features?
ptosis, mitosis, nasal stuffiness, N&V, tearing and eyelid oedema
What are the 4 main types of TACs?
cluster
paroxysmal hemicrania
hemicrania continua
SUNCT
35 y/o male with severe unilateral headache that comes and goes. Lasts for 45 mins or more and can get them up to 8 times a day. Describes pain as 11/10 intensity.
cluster headache
How would you treat a cluster headache?
high flow O2 100% for 20 mins
MRI if in hospital
SC sumatriptan 6mg
40mg prednisolone - reduce course over 2 weeks
What is the essential difference between a cluster headache and a paroxysmal hemicranial?
paroxysmal hemicrania is shorter duration and more frequent than cluster
Duration and frequency of paroxysmal hemicrania?
10-30 mins duration
1-40/day
Which type of trigeminal autonomic cephalgia responds absolutely to indomethacin?
paroxysmal hemicrania
Condition with constant severe unilateral headache, unilateral autonomic features and responds to indomethacin?
hemicrania continua
SUNCT
Short lived; 15-120s Unilateral Neuralgiform headache Conjunctival injections Tearing
Treatment for SUNCT
lamotrigine
gabapentin
1st line investigations for anyone with new onset unilateral cranial autonomic features ?
MRI brain and MR angiogram
Obese female with nausea and vomiting in mornings, complains of diplopia.
Investigations and findings?
MRI brain with MRV sequence - normal
CSF - elevated pressure, normal constituents, NO LUMBAR PUNCTURE
VF - large blind spot
Describe the pathway for treating IIH.
weight loss > acetazolamide > ventricular/lumbar peritoneal shunt
Elderly female patient complains of frequent severe stabbing unilateral pain lasting ~1min and thinks it is linked with putting on makeup and drinking cups of tea.
Trigeminal neuralgia
touch of V2/3 trigger
frequency 10-100/day
1-90s duration
Treatments for trigeminal neuralgia?
carbamazepine
gabapentin
baclofen
phenytoin
