Headaches

Question 1

What is the etiology of migraines?

Answer 1

1. irritations of CNS structures
2. Activation of Trigeminal n. (release of neuropeptides)
3. sensitization (neurones get increasingly responsive to stimuli)

Question 2

Drugs used to abort migraine

Answer 2

NSAID (aspirin, NAPROXEN, Ibuprofen) (reduction by 60% in 2hrs)

-TRIPTANS (5ht agonist) —RIZATRIPTAN and ELEtriptan

Question 3

When is prophylactic rx given for migraine?

Answer 3

• if you have more than 3 ATTACKS in a month

- or very debilitating

Question 4

S.E of sumatriptan?

Answer 4

• raises BP

- C.I in CAD and Prinzmetal’s Angina

Question 5

Which drug can be given as a migraine prophylaxis and is a tricyclic antidepressant?

Answer 5

AMITRIPTYLINE

• s.e: dry mouth, postural hypotension, sedation

Question 6

Name other prophylactic drugs for migraines.

Answer 6

1. Propanolol (reduces freq. of migraines in 60-80% of pts)
2. TOPIRAMATE (^ GABA)
3. Valproate

Question 7

What is the AIM of prophylaxis?

Answer 7

• titrate drug as tolerated to achieve efficacy at the LOWEST dose

(start low and keep on)

Question 8

Which drug used for prophylaxis in migrain has a POOR s.e profile?

Answer 8

• TOPIRAMATE

weight LOSS, paraesthesia, impaired conc, enzyme inducer,

Question 9

Which prophylactic drug causes stones in the kidney?

Answer 9

• TOPIRAMATE

- because it a carbonic anhydrase inhibitor (MORE Calcium in the urine)

Question 10

Valproate is ALSO used as a prophylaxis for Migraine. What are its S.E?

Answer 10

• tremor
• hepatootoxicity
• NTD
• wgt gain
• GI distress

Question 11

What is SEEN in migraines and is NOT seen in tension headaches?

Answer 11

• those with migraines may experience N & V

- photo-/phonophobia

Question 12

How to manage Tension headache?

Answer 12

• relaxation physiotherapy
• antidepressant ( Amitriptyline) for 3 MONTHS
• reassure

Question 13

Cluster headaches are often in _____

Answer 13

men and SMOKERS

Question 14

What is key about cluster headache?

Answer 14

• ipsilateral cranial AUTONOMIC fts are seen

Question 15

What are the 4 types of trigeminal autonomic cephalgias?

Answer 15

1. cluster
2. paroxysmal hemicrania
3. hemicrania continua
4. SUNCT

Question 16

When does a cluster headache strike?

Answer 16

• around sleep
• seasonal variation
• same time EVERY day

Question 17

What are the distinct fts of a cluster headache?

Answer 17

• EXCRUTIATING unilateral headache
• last 15mins to several hrs
• as freq. as one EVERY other day to 8 per day

Question 18

How to treat cluster headache?

Answer 18

• HIGH flow oxygen (100% for 20 mins)
• sub. cutaneous sumatriptan 6mg

-PROPHYLAXIS verapamil & prednisolone (reduce over 2 weeks)

Question 19

What is SUNCT?

Answer 19

• Short-lived (12-120s)
• Unilateral
• Neuralgiaforme headache
• Conjunctival injections
• Tearing

Question 20

What is the diff. between SUNCT and the others?

Answer 20

SHORT-LIVED

—the pain can occur 3-200 times a DAY !

Question 21

How to treat SUNCT?

Answer 21

D.t to activation of autonomic nervous system in the Trigeminal nerve—-so …
Gabapentin
Lamotigrine

Question 22

Who is prone to paroxsymal hemicrania?

Answer 22

• women in their 50s-60s

Question 23

How long does paroxysmal hemicrania last?

Answer 23

2-45mins

freq: 1-40 a day

Question 24

How to treat paroxysmal hemicrania?

Answer 24

• Indomethicin

shorter and more frequent than cluster

Question 25

Those with NEW onset unilateral cranial fts require what?

Answer 25

Imaging of the brain

MRI or MR angiogram

Question 26

Idiopathic intracranial hypertension is commonly seen in which demographic gr.?

Answer 26

• Females

- OBESE

Question 27

How does IIH present as?

Answer 27

• Throbbing headache; WORSE in the MORNING, coughing or STRAINING
• morning N and V
• day time
• feeling sick, sleepy, irrtable
• –vision maybe DARK or GREYED out for a few seconds

Question 28

What are the findings for IIH in MRI and CSF ?

Answer 28

MRI = normal

CSF: elevated pressure and NORMAL constituents

Question 29

How to manage IIH?

Answer 29

• weight loss
• ACETAZOLAMIDE
• diuretics
• Ventricular-atrial SHUNT
• lumbar peritoneal shunt
• monitor visual fields and CSF pressure

Question 30

Who gets trigeminal neuralgia?

Answer 30

• > 60y.o WOMEN

Question 31

How does Trigeminal neuralgia present as?

Answer 31

• severe STABBING unilateral pain— made worse by CHEWING and SPEAKING
• lasts 1s-90s
• freq. of 10-100/day

Question 32

How to treat trigeminal neuralgia ?

Answer 32

• PHENYTOIN/ GABAPENTIN/ CARBAMAZEPINE/ BACLOFEN

Question 33

How to manage trigeminal neuralgia?

Answer 33

by decompression or ablation

Question 34

Why is Ergotamine no longer given as rx?

Answer 34

• causes gangrene and overuse headache

Question 35

Management of migraines?

Answer 35

offer simple analgesia

2. offer triptans ALONE or with PCM (or another NSAID)
   - —sumatriptan is FIRST line
3. offer anti-emetic even in the absence of N &V

Question 36

What are said to be triggers for migraines?

Answer 36

CHeese
OCP
Caffeine
AlcohOL
Anxiety
Travel 
Exercise 

chocolate—atonym

Question 37

Causes of IIH?

Answer 37

• subdural hematoma
• brain tumor
• iron def. anemia
• OBESE or overweight
• LUPUS
• CKD
• hormone problems: CUSHING’S, hypoparathyroidism. hyper-/ hypo- thyroid
• meds: some antibiotic, COCP, steroids

Question 38

How to go about investigating IIH?

Answer 38

• neurological examinations (muscle strength/ balance/ reflexes)
• assessment of eyes and vision
• CT
• MRI
• LP