Headaches

Question 1

Patient gets headache every time they stand up. Diagnosis?

Answer 1

intracranial hypotension

Question 2

What kind of problem does waking up every day with a headache suggest?

Answer 2

raised pressure problem

Question 3

What are red flag symptoms of headaches?

Answer 3

New onset headache age >55
Known/previous malignancy
Immunosuppressed 
Early morning headache 
Exacerbation of valsalva (coughing, sneezing, raise in ICP)

Question 4

Is it more common to have migraine with or without aura?

Answer 4

without (80%), with aura 20%

Question 5

What is the criteria for diagnosing migraine without aura?

Answer 5

At least 5 attacks
2 of: moderate/severe, unilateral, throbbing pain - worse on movement.
1 of: autonomic features, photophobia/phonophobia

Question 6

Vascular and neural influences cause migraine in susceptible individuals. Describe blood vessels during migraine.

Answer 6

during aura = constrict

dilate during migraine

Question 7

What causes pain in migraine?

Answer 7

chemicals including substance P irritate nerves and blood vessels causing pain.

Question 8

Dopamine is released by stress triggers causing migraine. True or false?

Answer 8

false - serotonin released in response to stress triggers in brain

Question 9

Which areas in brain comprise the migraine centre in the brain?

Answer 9

dorsal raphe nucleus

locus coeruleus

Question 10

Migraine without aura last longer than migraine with aura.

True or False?

Answer 10

ture
without –> 4-72hrs
with aura –> 20-60 mins

Question 11

What is the most common type of migraine aura? Give examples.

Answer 11

visual
central scotoma
central fortification
hemianopic loss

Question 12

What can trigger a migraine with aura?

Answer 12

sleep
dietary (dark choc & cheese)
stress
hormonal 
physical exertion

Question 13

What drugs can be given acutely in migraine?

Answer 13

NSAIDs

Triptans - 5hT agonists

Question 14

Give examples of acute drugs SPECIFIC to migraine.

Answer 14

RIZATRIPTAN - wafer form - dissolves in mouth, ~30 mins to work.
FROVATRIPTAN - for sustained relief

Question 15

Patient with 4 migraine attacks in last month. What sort of medication would you consider starting?

Answer 15

Prophylaxis since >3/month;
consider non-pharmacological methods e.g. acupuncture, relaxation exercises.
Must trial each for minimum of 3 months

Question 16

What is the aim of migraine prophylaxis medication?

Answer 16

titrate drug as tolerated to achieve efficacy at lowest dose possible.
go slow and keep low

Question 17

What dose of amitriptyline would you give as migraine prophylaxis? What are the side effects to warn about?

Answer 17

10-25mg

dry mouth, postural hypotension, sedation

Question 18

A beta-blocker which reduces migraine frequency in ~60-80%… what is its dose and when to avoid it?

Answer 18

Propranolol 80-240mg

Avoid in asthma, PVD, heart failure.

Question 19

Name a carbonic anhydrase inhibitor that is used in migraine prophylaxis.

Answer 19

Topiramate 25-100mg

Question 20

Which migraine prophylactic causes bradycardia and nightmares?

Answer 20

propranolol

Question 21

Which migraine prophylactic causes weight loss, paraesthesia and impaired concentration?

Answer 21

Topiramate

Question 22

Patient has a mild bilateral headache or pressing/tingling nature. No photophobia or nausea.

Answer 22

tension type headache

Question 23

Treatments for tension type headaches?

Answer 23

relaxation & physiotherapy

antidepressant (dothiepin or amitriptyline) for 3 months - reassure

Question 24

What are trigeminal autonomic cephalgia’s (TACs)?

Answer 24

a group of primary headache disorders characterised by UNILATERAL trigeminal distribution pain that occurs in association with prominent IPSILATERAL cranial autonomic features.

Question 25

Examples of autonomic features?

Answer 25

ptosis, mitosis, nasal stuffiness, N&V, tearing and eyelid oedema

Question 26

What are the 4 main types of TACs?

Answer 26

cluster
paroxysmal hemicrania
hemicrania continua
SUNCT

Question 27

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.

Answer 27

cluster headache

Question 28

How would you treat a cluster headache?

Answer 28

high flow O2 100% for 20 mins
MRI if in hospital
SC sumatriptan 6mg
40mg prednisolone - reduce course over 2 weeks

Question 29

What is the essential difference between a cluster headache and a paroxysmal hemicranial?

Answer 29

paroxysmal hemicrania is shorter duration and more frequent than cluster

Question 30

Duration and frequency of paroxysmal hemicrania?

Answer 30

10-30 mins duration

1-40/day

Question 31

Which type of trigeminal autonomic cephalgia responds absolutely to indomethacin?

Answer 31

paroxysmal hemicrania

Question 32

Condition with constant severe unilateral headache, unilateral autonomic features and responds to indomethacin?

Answer 32

hemicrania continua

Question 33

SUNCT

Answer 33

Short lived; 15-120s
Unilateral
Neuralgiform headache
Conjunctival injections
Tearing

Question 34

Treatment for SUNCT

Answer 34

lamotrigine

gabapentin

Question 35

1st line investigations for anyone with new onset unilateral cranial autonomic features ?

Answer 35

MRI brain and MR angiogram

Question 36

Obese female with nausea and vomiting in mornings, complains of diplopia.
Investigations and findings?

Answer 36

MRI brain with MRV sequence - normal
CSF - elevated pressure, normal constituents, NO LUMBAR PUNCTURE
VF - large blind spot

Question 37

Describe the pathway for treating IIH.

Answer 37

weight loss > acetazolamide > ventricular/lumbar peritoneal shunt

Question 38

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.

Answer 38

Trigeminal neuralgia
touch of V2/3 trigger
frequency 10-100/day
1-90s duration

Question 39

Treatments for trigeminal neuralgia?

Answer 39

carbamazepine
gabapentin
baclofen
phenytoin