Neurology - Headaches

Question 1

Discuss the triggers for migraine

Answer 1

• Stress
• Physical activity
• Poor sleep
• Fatigue
• Alcohol use
• Chocolate
• Cheese
• MSG
• Aspartame
• Caffeine
• Nuts
• Nitrates

Question 2

Discuss the treatment for migraines

Answer 2

Acute - Mid to Moderate
- NSAID Ibuprofen 400mg Q4-6H
- antiemetic
Acute - Moderate to Severe
- Triptans
- Ergotamines
- Prochlorperazine 5-10mg IM/IV
- Antiemetics
- Fluids

Question 3

Discuss the prevention options for migraines

Answer 3

Beta Blocker First Line
- Propranolol 40-240mg/day
Calcium channel blocker
- verampamil 240-320mg/day
Anticonvulsants
- Topiramate 25-100mg/day
TCA
- Amitriptyline 50-150mg/day

Question 4

Discuss the diagnostic criteria for migraine without aura

Answer 4

At least 5 attack fulfilling 2-4 criteria
Headache attackes lasting 4-72hrs
Headache has at least 2 of the following
- unilateral
- pulsating quality
- moderate to severe pain intensity
- aggravation by or causing avoidance of routine physical activity
During headache have at least one of
- nausea/vomiting
- photophobia and phonophobia

Question 5

Discuss the diagnostic criteria for migraine with aura

Answer 5

At least two attack fulfulling 2 and 3
One or more of the following fully reversible aura symptoms
- visual
- sensory
- speech and/or language
- motor
- brainstem
- retinal
At least 3 of the following
- at least one aura symptom spreads gradually over >5 minutes
- two or more symptoms occur in succession
- each individual symptom lasts 5-60 minutes
- at least one aura is unilateral
- at least one aura symptom is positive
- aura is accompanied or followed within 60 minutes by headache

Question 6

Discuss the diagnosis of cluster headaches

Answer 6

At least 5 attacks
Attacks are severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes
One or both of the following
- at least one of the following ipsilateral to the headache
- conjunctival injection/lacrimation
- nasal congestion and/or rhinorrhea
- eyelid edema
- forehead and facial swelling
- miosis and/or ptosis
- sense of restlessness or agitation
Frequency of one every other day to eight per day

Question 7

Discuss the triggers, treatment and prevention of cluster headaches

Answer 7

Trigger
- alcohol
Acute Treatment
- 100% O2 first line
- sumatriptan 6mg SC
- Lidocaine 1mL 4% intranasal
- Octreotide 100mg SC
Prevention
- Prednisone 40-80mg x7 days then taper over 5 days
- Verapamil 120-360md/day

Question 8

Discuss the diagnosis of tension headaches

Answer 8

At least two of the following
- bilateral location (fronto-occipital)
- pressing or tightening quality (band-like, contracted neck muscles)
- mild to moderate intensity
- not aggravated by routine physical activity
Both of
- no nausea or vomiting
- no more than one of photophobia or phonophobia

Question 9

Discuss the triggers, treatment and prevention of tension headaches

Answer 9

Triggers
- Stress
Acute Treatment
- rest and relaxation
- NSAID or acetaminophen
Prevention
- physical activity
- rest
- biofeedback

Question 10

Discuss the diagnosis of medication overuse headaches

Answer 10

Episodic headache disorder occuring 15 or more days per month
- develop due to regular overuse of acute or symptomatic headache medication for more than 3 months

Question 11

Discuss the triggers and treatment for medication overuse headaches

Answer 11

Triggers
- >=10 days per month for >3 months of ergotamines, triptans, opioids or combination analgesics
Treatment
- withdrawal of overused medication

Question 12

Discuss the red flag headaches

Answer 12

New Headache >50
- temporal arteritis (ESR, CRP)
- Mass lesion (CT)
Sudden Onset
- Subarachnoid hemorrhage (thunderclap - CT or LP)
- Carotid/vertebral artery dissection
- Mass lesion
Increasing Frequency and Severit
- Mass Lesion
- Subdural Hematoma
- Medication overuse
Headache with Signs of Systemic Illness
- Meningitis
- Encephalitis (Lyme)
- Systemic infection
- Collagen vascular disease
Focal Neurological Symptoms
- Mass lesion
- vascular malformation
- stroke
- collagen vascular disease
Papilledema
- mass lesion
Head Trauma
- Intracranial hemorrhea
- Subdural hematoma
- Epidural hematoma
- Post-traumatic headache
Red eye, cloudy cornea, mid fixed dilated pupil
- Acute angle closure glaucoma

Question 13

List the criteria for a CT head in those with headache

Answer 13

Red Flags
- Onset after age of 50
- Sudden onset headache
- Headache with change of increased frequency or severity
- New onset headache in high risk population
- Headache with systemic illness
- Focal neurological deficits, confusion, LOS
- papilledema
- head trauma
- headache during pregnancy
Worsening headache despite therapy
Onset with exertion, cough, sexual activity
Orbital bruit
Family Hx of structural lesion