Headaches and Migraines Flashcards
List the red flags that could indicate something more severe.
New onset headaches >35 History or present malignancy Immunosuppression Early morning headache Worsened by valsalva manoeuvre
Describe the frequency of migraines without an aura.
At least 5 attacks with a duration of 4-72 hours
Describe migraine without an aura?
Moderate to severe unilateral throbbing which is worse on movement.
Can be accompanied by photophobia or phonophobia
What is the pathophysiology of migraines?
Both vascular and nueronal causes
Stress causes seretonin release
Blood vessels constrict or dilate
Substance P is released which irritates vessels and nerves causing pain
What is an aura?
A fully reversible sensory motor or language symptom
How long do auras related to a migraine last?
20-60 mins
Do auras usually precede or follow a migraine?
Usually occur one hour prior to migraine onset.
Describe some common visual auras?
Central scotoma - central fuzziness
Hemianopia loss
What regions of the brain are linked to migraines?
Dorsal raphe nucleus
Locus Coeruleus
What chemicals have been linked to triggering a migraine?
Substance P
Neurokinin A
CGRP
What system when activated is thought to trigger a migraine with aura?
Trigeminal Vascular system
List some causes of migraines with aura?
Sleep deprivation Diet Stress Hormones Physical exertion
What are some non pharmacological treatments for migraines?
Prevention
Education on triggers e.g. diet sleep relaxation etc
What are some pharmacological treatments for migraines once they have started?
NSAIDs Aspirin Naproxene Ibuprofen
Triptans- Fovatriptan
What are Triptans?
5HT seretonin agonists
How are triptans administered and when?
Orally, Sublingually or subcutaneously
Start of the headache for sustained relief
In order to be put on migraine prophylaxis what must the patient present with?
More than three attacks per month
Very severe migraines
What is the rule in terms of pharmacological treatment of migraines?
Start low go slow
What tricyclic can be used for migraine prophylaxis?
Amitriptyline 10-25mg
What are some common side effects of amitriptyline?
Dry mouth
Postural hypertension
What is first line in migraine prophylaxis?
Propanolol 80mg
What are some common side effects of propanolol?
Avoid in asthma
Peripheral vascular disease
If beta blockers are unsuitable what can be given for migraine prophylaxis ?
Topiramate 25-100mg
What is Topiramate?
Carbonic anhydrase inhibitor
What are some of the side effects with Topiramate?
AVOID if looking to conceive
Weight loss
Paraesthesia
Impaired concentration
List some other drugs which can be used for migraine prophylaxis?
Gabapentin
Sodium Valproate
Botulinum Toxin
How long should prophylaxis be used for before determining whether or not it is effective?
3 months at maximum dosage
What lifestyles factors should be altered in someone complaining of chronic migraines?
Healthy diet Increase water to >2L Reduce caffeine Regular exercise Reduce stress
What class of drug should be taken alongside the acute migraine treatment?
Anti emetic - Metoclopramide Hydroxychloride
What is a Acephalgic Migraine?
Aura without the headache/migraine
What is a basilar migraine?
Vertigo and severe N+V
What is a retinal migraine?
Visual aura
What is a hemiplegic migraine?
Familial or sporadic
Self resolving weakness down one side for 1-2 weeks
Give a list of acephalic migraines.
Basilar
Hemiplegic
Retinal
What are tension type headaches ?
Normal everyday headache
Describe a tension type headache.
Bilateral mild to moderate pain
Photo/Phonophobia
Absence of Nausea + Vomiting
What are some non pharmacological treatments for a tension type headache?
Physiotherapy
Relaxation
Sleep
Hydration
What is the mainstay of pharmacological treatment for tension type headaches?
Amitriptyline
3 months
List some Trigeminal Autonomic Cephalgias
Cluster
Paroxysmal Hemicrania
Hemicrania continua
SUNCT
What are some autonomic features related to Trigeminal Autonomic Cephalgias?
Ptosis Miosis Nasal Stiffness N+V Eye lid oedema
Who is affected by cluster headaches?
M>F
30-40s
Describe when someone is likely to be affected by a cluster headache?
Around sleep (Circadian rhythm) Seasonal variation
Describe cluster headaches.
Sever unilateral headache
1-8 a day
Clusters last weeks to months
What is the acute treatment for a cluster headache?
High flow O2
Sub cutaneous Sumatriptan
Reducing course of steroids
What is the dosage of the 5HT serotonin agonist used in cluster headache treatment. Subcutaneous injection
Sumatriptan 6mg
What is first line prophylaxis in cluster migraines?
Verapamil
Who is affected in paroxysmal Hemicrania?
F>M
50-60s
Describe Paroxysmal Hemicrania.
Severe unilateral pain
Unilateral Autonomic features
Describe the course of Paroxysmal Hemicrania.
Lasts 10-30 mins
1 to 4x a day
What is used in the treatment of Paroxysmal Hemicrania?
Absolute response to Idomethacin
SUNCT
Short Lasting - 15/120s Unilateral Neuralgiaform Conjunctival injections Tearing
What is the treatment for SUNCT?
Lamotragine
Gabapentine
Epidemiology of Idiopathic Intracranial Hypertension
F>M
Obese
Female of chid bearing age
How does someone with idiopathic intracranial hypertension present?
Diurnal variation headaches Morning D+V Visual Loss Bilateral Papilloedema Tinnitus
What could be seen on the MRI of a patient with Idiopathic Intracranial Hypertension.
Flattened optic discs Empty Sella (Pituitary fossa)
If a CSF sample was taken of someone with Idiopathic Intracranial Hypertension what would you expect to find?
Normal make up
Raised pressure
What is an affective method of monitoring Idiopathic Intracranial Hypertension?
Visual Field
Take a base line and track progression
What is the first line treatment for Idiopathic Intracranial Hypertension?
Weight Loss
Acetazolamide
If Idiopathic Intracranial Hypertension continues to progress despite pharmacological treatment and lifestyle changes what is considered?
Lumbar peritoneal shunt
Epidemiology of Trigeminal Neuralgia
F>M
>60 years
How does someone with Trigeminal Neuralgia present?
Severe stabbing unilateral stabbing pain that lasts for up to 90s
Bouts of pain may recur for 100 days before remission
What nerves are involved in Trigeminal Neuralgia?
CN V2 / V3
What investigations are undertaken in trigeminal Neuralgia?
MRI
In a patient with Trigeminal Neuralgia what could be seen on MRI?
Usually a vessel touching and irritating a cranial nerve
What is the treatment for Trigeminal Neuralgia?
Carbezamapine
Gabapentine
Surgical ablation
