Management of HA's

Question 1

Prevalence of HA’s

Answer 1

Globally: 50% in the past year
Any HA = 79%
F> M

Question 2

Types of primary HA?

Answer 2

1. Migraines
2. Tension type (TTH)
3. Trigeminal autonomic cephalagia
4. Other

Question 3

5 phases of Migraine

Answer 3

1. Premonitory symptoms - affects 60%
Aura - affects 20%
Headache - affects 80%
Termination – end of HA
Postdrome – after effects

Question 4

What are Premonitory symptoms?

Answer 4

Psychological symptoms:
depression, euphoria, mental slowness, hyperactivity
Neurologic: photophobia, phonophobia
nausea / vomiting
General:coldness, loss of appetite, food cravings

Question 5

Features of Migraine Aura?

Answer 5

Develops over 5- 20 mins
lasts <60 mins, prolonged upto 1 week
Symptoms: visual/auditory numbness, tingling, ophthalmoplegia/hemiplegia

Question 6

Migraine Visual Aura features?

Answer 6

Binocular confined to one hemifield
Fortification spectra that starts centrally and expands out
coloured fringes at edged
scintillating scotoma 
Teichopsia 
Rarely total vision loss

Question 7

Migraine HA features?

Answer 7

60 mins after aura finishes, lasts 4- 72 hrs
moderate to severe pulsating unilateral pain made worse by movement

assoc. with photo/phonophobia/poor conc. nausea & vomiting

Question 8

Non - migraine HA aura features ?

Answer 8

no longer than 1 hr, completely reversible, absence of HA
visual/sensory/speech problems
In older px refer for TIA

Question 9

Migraine pathophysiology?

Answer 9

Vasoconstriction corresponds with aura
vasodilation corresponds with HA - pain from intra - cranial and extra cerebral vessels

Genetics 
idiopathic 
External trigger: tiredness, foods, drink fatigue
Glare, flicker - flashlights/tv
Patterns - text

Question 10

Migraine management

Answer 10

Refer to GP
reassurance - not life threatening, assoc. with serious illness, check hormones for women on the pill, write HA diary
Meds: Pain relief for acute attack, preventative if >5 per month

Question 11

TTH features

Answer 11

Episodic/ chronic: 30 mins - 7 days
Bilateral - extends from back of the neck occipital/parietal/posterior neck)
tight pressing not pulsating pain
mild to mod. (won't stop daily activities)
assoc. with photo/phonophobia)
NO NAUSEA/VOMITING
assoc. with sleeplessness stress
DD = MIGRAINE

Question 12

Pathophysiology TTH

Answer 12

muscle contraction, psychological problems, stress

Question 13

TTH referral

Answer 13

routine to GP

Question 14

Trigeminal autonomic cephalgias features?

Answer 14

A.K.A Cluster HA
pain on one side of head in trigeminal nerve area
starts around one eye/cheek, spreads across head
Peaks in few mins, lasts 30 mins to few hrs
intense pain, may wake px
1- 8 attacks over days/weeks
Assoc. with facial flushing, conjunctival injection, lid oedema, rhinorrea, pupil constriction, partial ptosis
6 x more likely in M>F

Question 15

Cluster HA pathophysiology ?

Answer 15

unknown cause, fMRI

Question 16

Cluster HA management

Answer 16

routine referral to GP, prophylactic meds, analgesics

Question 17

Temporal Arteritis features

Answer 17

Secondary HA
A.K.A GCA 
normally over 60s 
F>M
Constant HA with gradual onset which develops into severe aching 
Temporal scalp tenderness
Jaw claudication
Worse at night/cold 
Systemic assoc. fever/anemia, weight loss, polymalagia rheumatica

Question 18

TA pathophysiology

Answer 18

arteritis affecting external carotid and ophthalmic arteries

elevated ESR

Question 19

TA ocular signs

Answer 19

AION - partial/total infarction of ONH, occlusion of PCA
Arteritis - inferior altitudinal hemianopia
CRAO
Amaurosis Fugax

Question 20

TA management

Answer 20

Emergency referral 
risk of sight loss in other eye (70% in 10 days)
Risk of cerebral vascular accident
Temporal artery biopsy
MRI and Doppler study
Erythrocyte sedimentation rate (ESR)
C-reactive protein levels
Treated with high doses of oral steroids
Visual acuity does not recover

Question 21

Aneurysm

Features?

Answer 21

Sudden, excruciating headache
stiff neck
vomiting
focal lesions
3rd CNP if PCA affected
hemiparesis if MCA affected

Question 22

Aneurysm referral

Answer 22

emergency

Question 23

Arteriovenous Malformation

Answer 23

Specific recurring headache
Ruptured AVM or fistula
sudden severe headache
stiff neck
Homonymous field defect typical  of occipital AVM

Question 24

AVM referral?

Answer 24

Emergency

Question 25

Raised ICP HA features

Answer 25

intermittent, non - specific, dull pain
worse after exercise
transient HA on coughing
HA may be absent with ICP

Question 26

Papilloedema features

Answer 26

Disc swelling and  hyperaemia
Nasal margins affected 1st
Venous engorgement
Blurring of disc margins and  peripapillary RNFL
Loss of spontaneous venous  pulsation

Question 27

Papilloedema management

Answer 27

emergency 24 hrs

Question 28

HA assoc. with eye disorders

Answer 28

acute glaucoma
refractive error
heterophoria or heterotropia
ocular motor nerve palsies
ocular inflammatory disorder
corneal lesions, anterior uveitis, optic neuritis

Question 29

Trigeminal neuralgia features

Answer 29

Affects trigeminal nerve 
Over mandibular and maxillary region 
intense repetitive jabs of pain
>50 YO 
routine referral