Migraine

Question 1

What causes a headache?

Answer 1

Structures:

• Trigeminovascular system
• Meninges
• CSF containing structures
• Muscles
• Nerves

Processes:

• ‘Neurogenic’ inflammation
• Inflammation
• Infection
• Pressure
• Obstruction

Question 2

What is a primary headache?

Answer 2

No known underlying pathology

Question 3

What is a secondary headache?

Answer 3

Potentially serious underling disease mechanism

Question 4

What are the most consistent indicators of a secondary headache?

Answer 4

• Thunderclap (sudden onset)
• Associated focal neurological deficit
• Associated systemic features
• Patients > 50yrs

Question 5

What is the hypothesised pathophysiology of a migraine?

Answer 5

• Cortical spreading depression (CSD) may be initiated by a slowly propagated wave of depolarisation in neurones and glial cells from the occipital pole.
• This is followed by a sustained suppression of spontaneous neuronal activity
• This suppression has been shown to occur alongside complex changes in brain blood flow, through alterations in vascular size
• CSD can activate the trigeminal nucleus caudalis (TNC), which is known to be associated with headache symptoms

Question 6

What is an aura?

Answer 6

Transient neurological features which precede a headache or occur at headache onset

Question 7

What kind of symptoms would an aura produce?

Answer 7

Visual

Sensory

Question 8

What are the known triggers of a migraine?

Answer 8

• Foods containing tyramine
• Menstruation
• Relaxing after stress
• Flickering lights
• Jet lag
• OCP

CHOCOLATE

C - Chocolate
H - Hangovers
O - Orgasms
C - Cheese
O - OCP
L - Lie-ins
A - Alcohol
T - Travel
E - Exercise

Question 9

What is an episodic TTH?

Answer 9

< 15 days per month

Question 10

What is a chronic TTH?

Answer 10

≥ 15 days per month for > 3 months

Question 11

What is an episodic migraine?

Answer 11

< 15 days per month

Question 12

What is a chronic migraine?

Answer 12

≥ 15 days per month for > 3 months

Question 13

What is an episodic cluster headache?

Answer 13

1 every other day to 8 per day with remission > 1 month

Question 14

What is a chronic cluster headache?

Answer 14

1 every other day to 8 per day, with a continuous remission < 1 month in a 12-month period

Question 15

What type of headache does medication overuse cause?

Answer 15

Migraine or TTH

Question 16

What drugs cause a medication overuse headache?

Answer 16

• Triptans
• Opioids
• OCP
• Paracetamol
• Aspirin
• NSAIDs

Question 17

What would you advise for a medication overuse headache?

Answer 17

• Restrict acute headache medications to no more than 2 days/week
• Encourage prophylactic treatments
• Stop triptan for 2-3 months
• Stop analgesic for 3 months

Question 18

What is the management of a migraine with or without aura?

Answer 18

• Headache diary
• Triptan +/- NSAID/paracetamol (1st dose when HEADACHE STARTS, take 2nd if relapse)
  Sumatriptan 100mg

Question 19

If oral treatment for a migraine is not working, what wold you do?

Answer 19

- Non-oral triptan
      Subcutaneous sumatriptan 6mg
      Intranasal sumatriptan 10-20mg
- Non-oral Anti-emetic
      Metoclopramide 10mg or prochlorperzine 10mg

Question 20

If treatment for a migraine with or without aura is not working, what would you do?

Answer 20

Change triptan

Question 21

When would you offer prophylactic treatment for a migraine with or without aura?

Answer 21

• QoL/business duties/ school attendance is severely affected
• 2 + attacks a month
• Migraine attacks do not response to acute drug treatment
• Frequent, very long or uncomfortable auras occur

Question 22

What prophylactic treatment would you offer for a migraine with or without aura?

Answer 22

o Topiramate
o Propranolol
o Low-dose amitriptyline

Question 23

What acute treatment would you offer for a TTH?

Answer 23

Oral paracetamol or aspirin

Question 24

What prophylactic treatment would you offer for a TTH?

Answer 24

Amitriptyline

Question 25

What treatment would you offer for a cluster headache?

Answer 25

• Oxygen at 100% at 12-15 litres/minute for 15-20 minutes

- Subcutaneous/nasal triptan

Question 26

What is the mechanism of action of triptans?

Answer 26

Serotonin (5-HT) receptor agonist causing:

• Smooth muscle in arteries to cause vasoconstriction
• Peripheral pain receptors to inhibit activation of pain receptors
• Reduce neuronal activity in CNS

Question 27

What is the mechanism of action of amlodipine?

Answer 27

Calcium channel blocker with high affinity for peripheral blood vessels.
Causes vasodilation

Question 28

What is the mechanism of action of propanolol?

Answer 28

Nonselective β-adrenergic receptor antagonist

Question 29

What is the mechanism of action of topiramate?

Answer 29

Anti-epileptic drug

- Increases GABA activity and inhibits glutamate activity, blocking neuronal excitability

Question 30

What is the mechanism of action of Prochlorperazine?

Answer 30

First-generation antipsychotic drug that is used for the treatment of severe nausea and vomiting
- Blocks the D2 dopamine receptors in the brain

Question 31

What is the mechanism of action of Metoclopramide?

Answer 31

Dopamine antagonist used to treat nausea and vomiting
- Increased lower oesophageal sphincter (LES) and gastric tone, accelerating gastric emptying and transit through the gut

Question 32

What is the second-line medication for migraines?

Answer 32

• Sodium valproate
• Topiramate
• ACE-i
• ARB
• Calcium channel blockers