Migraines Flashcards
Primary headaches = no known cause
Secondary headaches = have a known cause
Which of these is more common?
- primary
What is the most common type of primary headache?
1 - migraines
2 - thunderclap
3 - tension type
4 - cluster
3 - tension type
- migraine is the 2nd most common form of primary headache
- incidence of 0.5-5%
- difficult to identify exact incidence
What is the most common debilitating headache?
1 - tension headache
2 - thunderclap headache
3 - Migraine
4 - Cluster headaches
3 - Migraine
- also 2nd most common type of primary headaches
- 7th highest cause disability globally
- 2.9% of years of life lost to disability
- twice as likely in women
Can migraines be pulsatile in nature?
- yes
Pulsatile may suggest increases BP or increased intracranial pressure
What is the incidence of migraines?
1 - 50/100,000
2 - 500/100,000
3 - 5000/100,000
4 - 50,000/100,000
3 - 5000/100,000
At what time do migraines generally start and begin to decline?
1 - starts at puberty and declines around 20y/o
2 - starts at puberty and declines around 40y/o
3 - starts at puberty and declines around 60y/o
4 - starts at puberty and declines around 80y/o
2 - starts at puberty and declines around 40y/o
- 2% have chronic migraines, causing medication overuse
Are migraines more common in men or women?
- women
- 3x more likely
Menstrual migraines can occur in women. When would these generally occur?
1 - days 1-2
2 - days 2-3
3 - days 5-7
2 - days 2-3
- before the period of during the period
Are patients with comorbid psychiatric disorders such as anxiety & depression more or less likely to experience medication overuse headaches?
- more likely
The trigeminal nerve (CN5) is derived from the 1st pharyngeal arch and is the largest of all the cranial nerves. What functions does this cranial nerve have?
1 - sensory only of the face
2 - motor only of mastication muscles
3 - both of the above
4 - none of the above
3 - both of the above
What is the trigeminocervico complex?
1 - CN V (5) meets cervical vertebrae 1
2 - CN V (5) synapses in same nucleus as cervical vertebrae 1
3 - CN V (5) synapses in same nucleus as cervical vertebrae 1 and 2
4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3
4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3
- sensory only from CV V (5)
- this essentially means any sensory information from cervical vertebrae 1-3 can revert pain to the head causing a headache
- region of the brain receives nociceptive stimulus
The trigeminocervico complex is a nucleus where CN V (5) synapses in same nucleus as cervical vertebrae 1-3 for sensory receptors only. Where is this located?
1 - cerebellum
2 - brain stem
3 - pons
4 - medulla oblongata and upper cervical spine
4 - medulla oblongata and upper cervical spine
Which of the following is not part of the trigeminal nerve?
1 - ophthalmic
2 - maxillary
3 - accessory
4 - mandibular
3 - accessory
The spinal trigeminal nucleus is a nucleus in the medulla that receives information about deep/crude touch, pain, and temperature from the ipsilateral (same side) face. Which of the following is important for pain and temperature sensations?
1 - Pars oralis
2 - Pars interpolaris
3 - Pars caudalis
3 - Pars caudalis
Which of the following are typical triggers for developing a migraine?
1 - tiredness, stress, dehydration
2 - alcohol
3 - combined oral contraceptive pill
4 - cheese, chocolate, red wines, citrus fruits
5 - menstruation
6 - bright lights
7 - all of the above
7 - all of the above
Remember the mnemonic CHOCOLATE:
C = chocolate
H = hangovers
O = orgasms
C = cheese/caffeine
O = oral contraceptive
L = lie-ins
A = alcohol
T = travel
E = exercise
Migraines are a form of primary headaches, which essentially means the cause is unknown. Do migraines typically present unilaterally or bilaterally?
- unilaterally
Which of the following locations would the main symptom of a migraine be felt?
1 - on one side of the face
2 - around the eye on one side of the face
3 - across the top of the forehead
4 - all of the above
1 - on one side of the face
Migraines are a form of primary headaches, which essentially means the cause is unknown. Which of the following do migraines NOT typically present with?
1 - severe, bilateral, throbbing headache
2 - nausea, photophobia (sensitive to light) and phonophobia (fear of sound)
3 - can last up to 72h
4 - patients typically stay in dark and quiet rooms
5 - auras maybe present
6 - stiff neck
7 - vary 1-2/month or 1/year
1 - chronic, bilateral, throbbing headache
- typically migraines are unilateral
A migraine aura is something that you experience when having a migraine. which of the following is true?
1 - can be visual only
2 - can be auditory only
3 - can be motor or sensory
4 - all of the above
4 - all of the above
- most common is visual, and it is completely reversible
- builds up over time and can last up to 60 minutes
- more common in older patients, but no headaches
An aura is when there are visual changes that are associated with migraines. What visual symptoms can be experienced in an aura?
1 - Sparks in vision
2 - Blurring vision
3 - Lines across vision
4 - Loss of different visual fields
5 - all of the above
5 - all of the above
Auras typically occur prior to a migraine and can include visual (most common), auditory, motor and sensory aspects. Typically how long can the auras last for?
1 - <10 minutes
2 - <40 minutes
3 - <60 minutes
4 - <2 hours
3 - <60 minutes
How long do migraines typically last?
1 - 4-72 hours
2 - 15-180 minutes
3 - 30 minutes to 1 week
4 - >1week
1 - 4-72 hours
When migraines are present are they continuous or episodic?
- episodic
- typically throbbing unilaterally, but can be bilateral
- feels like someone is drilling on the side of your head
Is the pain experienced during a migraine typically severe or moderate?
- Can range from moderate to severe
Overuse of medication can present in a similar way to migraines. Which of the following are present in migraines that helps distinguish migraines from medication overuse in headaches?
1 - occurrence of headache
2 - duration of the migraine
3 - nausea and vomiting
4 - gender
3 - nausea and vomiting
- both are present in migraines
When performing a history on a patient with a headache, if there is an increase in headache symptoms when performing a Valsalva manoeuvre bad?
- Yes
Indicates a space occupying lesion in cranial cavity
Causes an increased intracranial pressure
When performing a history on a patient with a headache, which of the following is NOT typically a red flag?
1 - patient wakes up with headache
2 - change in character
3 - age of onset
4 - sudden onset (thunderclap)
5 - focal neurological deficits
6 - constitutional symptoms (fever, meningism, rash, weight loss)
1 - patient wakes up with headache
A RED FLAG here would be if the headache wakes the patient whilst they are asleep
When examining a patient, all of the following are RED FLAGS except which one?
1 - patient appears sick-appearing, skin changes
2 - evidence of trauma
3 - altered cognitive state
4 - ocular: hyphema, pupil non-reactivity, optic disc swelling, proptosis, restricted eye movements
5 - meningism
6 - weight gain
7 - focal neurological findings (eg limb weakness)
6 - weight gain
Weight loss is a red flag as it could be caused by malignancy
Of the following, which is most likely to trigger a migraine?
1 - dehydration and stress
2 - food and weather
3 - cigarettes and alcohol
4 - medications
2 - food and weather
When diagnosing a migraine if the patient has no aura, how many migraines lasting 4-72h should a patient have had?
1 - >3
2 - >5
3 - >8
4 - >12
2 - >5
When diagnosing a migraine if the patient has no aura, patients should have >5 migraines lasting 4-72h with nausea or vomiting. They should also have how many of the following?
- unilateral pain
- pulsing pain
- impairs ADL
- photophobia/phonophobia
1 - >2
2 - >3
3 - all 4
1 - >2
In addition to aura, which of the following occurring would suggest that the patient is having a migraine over tension headaches and cluster headaches?
1 - ipsilateral (same side) autonomic features
2 - no features at all (including aura)
3 - aura, vomiting and nausea
4 - none of the above
3 - aura, vomiting and nausea
Following a migraine, which of the following symptoms are unlikely to occur?
1 - fatigue
2 - tired
3 - lacrimation and ptosis
4 - difficulty concentrating
5 - stiff neck
3 - lacrimation and ptosis
- this commonly occurs in cluster headaches
What is typically the 1st line treatment patients with migraines are given as part of abortive approach?
1 - paracetamol
2 - lifestyle advice
3 - NSAIDs
4 - Triptan (serotonin agonist)
2 - lifestyle advice
- adequate sleep, hydration, exercise, cognitive behavioural therapy, biofeedback and avoiding triggers
Patients may also be asked to complete a migraine diary
If lifestyle advice fails in patients with migraines, which of the following can then be prescribed next as part of abortive approach?
1 - paracetamol
2 - aspirin
3 - NSAIDs
4 - Triptan (serotonin agonist)
1 - paracetamol
- then it would be aspirin and NSAIDs
- if these fail then we can use:
+ Triptan (eg sumatriptan, zolmitriptan)
+ Dopamine agonists (metoclopramide, prochlorperazine)
+ Monoclonal antibodies
+ Nerve block injections
Which of the following can be prescribed as a one off dose for migraines?
1 - gabapentin
2 - tramadol
3 - sumatriptan
4 - prochlorperazine
3 - sumatriptan
Dose of 50-100mg
<6/day and prescribe no more than 6/month
Sumatriptan is typically the 1st line management for patients with migraines. Is this used as a prophylaxis to stop migraines, or given at the onset of the migraine?
- given at the onset of the migraines
Should opioids ever be prescribed for the acute management of patients with migraines?
- no
What is typically the 1st line treatment patients with migraines are given as part of a preventative approach?
1 - Amitriptyline
2 - Lifestyle advice
3 - Propranolol
4 - Topiramate
2 - Lifestyle advice
If lifestyle advice fails in patients with migraines, all of the following can be prescribed, EXCEPT which one?
1 - Amitriptyline
2 - Morphine sulphate
3 - Beta blockers
4 - Topiramate
2 - Morphine sulphate
Never use opioids in migraines
Topiramate = GABA agonist and AMPA antagonist
Block neuronal excitability that is causing migraines
Which of the following would be a suitable differential for a patient with suspected migraine?
1 - cluster/tension headache
2 - cervical spondylosis
3 - intracranial pathology
4 - increased BP
5 - TIAs
6 - sinusitis/otitis media
7 - all of the above
7 - all of the above
Patients who are menstruating may experience a menstruating migraine. Typically this last 2-3 days of the menstrual cycle, and occurs in 2/3 of cycles. Which 2 of the following medications can be used to prevent menstruating migraines?
1 - fovatriptan (inhibit cranial vasodilation)
2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation)
3 - verapamil (induces vascular vasodilation)
4 - B-blockers (slows heart rate and reduces brain oxygen requirements)
1 - fovatriptan (inhibit cranial vasodilation)
2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation)
Is it ok to prescribe the combined oral contraceptive (COC) pill in women who are experiencing migraines with aura?
- No
This is a 4 on the Mec guidelines
COC can increase the risk of stroke
Medication-overuse headache are caused by taking painkillers too often for tension headaches . The body responds to this by increasing the number of pain receptors in the head. Which of the following is NOT typically linked to causing medication overuse headaches?
1 - codeine
2 - cyclizine
3 - triptans
4 - NSAIDs
2 - cyclizine
All others are pain medications, except triptan which is specific for headaches
Migraines = feature full headaches
Tension like headaches = featureless headaches
This essentially means there are specific features associated with Migraines (aura, vomiting, photophobia etc..
When thinking about red flags, which of the following is most likely to cause a new severe or unexpected headache?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - subdural bleed
4 - giant cell arteritis
2 - sub-arachnoid haemorrhage
Also described as a thunderclap headache
When thinking about red flags, which of the following is most likely to follow a head trauma?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - subdural bleed
4 - giant cell arteritis
3 - subdural bleed
When thinking about red flags, which of the following is most likely to cause a headache in an immunocompromised patient?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - subdural bleed
4 - giant cell arteritis
1 - malignancy
When thinking about red flags, which of the following is most likely to cause a persistent headache that then changes drastically?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - subdural bleed
4 - giant cell arteritis
1 - malignancy
This is very common in >50s
When thinking about red flags, which of the following is most likely to cause a headache in a current or recent pregnancy?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - pre-eclampsia
4 - giant cell arteritis
3 - pre-eclampsia
When thinking about red flags, which of the following is most likely to cause a headache that is associated with pain, specifically in the temporal region?
1 - malignancy
2 - sub-arachnoid haemorrhage
3 - pre-eclampsia
4 - giant cell arteritis
4 - giant cell arteritis
