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Neurology > Primary and Secondary Headache > Flashcards

Primary and Secondary Headache Flashcards

1
Q

important questions in headache history?

A

what happened before the headache?
any strange symptoms as headache was developing?
how did it evolve? (getting worse or better or changing)
how suddenly did it arise?
exacerbating/relieving factors? (posture, behaviours etc)
severity?
PMH
FH (esp migraine)
DH
SH
headache diary

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2
Q

headache when lying down which is relieved by standing up, what may be the cause?

A

raised ICP

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3
Q

name 5 red flags?

A 
new onset headache in >55
known/previous malignancy
immunosuppressed
early morning headache
exacerbation by valsalva
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4
Q

who is migraine most common in?

A

young females

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5
Q

most migraine sufferers have how many attacks per month?

A

around 1

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6
Q

does migraine always have aura?

A

no, 80% don’t have any aura

aura can by anything really

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7
Q

criteria for migraine without aura?

A 
at least 5 attacks lasting 4-72 hours
2 of:
- mod/severe
- unilateral
-throbbing pain
- worse on movement
1 of
- autonomic features
- photophobia/photophonia
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8
Q

cluster headaches vs migraine?

A

cluster headache patients prefer to be up and about, almost banging head off wall
migraine prefer to be still

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9
Q

peak ages in women for migraine?

A

early teenage years
around menopausal years
(hormonally driven)

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10
Q

pathophysiology of migraine?

A

vascular and neural influences in susceptible individuals
stress triggers changes in brain which cause serotonin to be released
blood vessels then constrict and dilate (constrict early on in aura phase)
chemical pain substances (including substance P) are released which irritate nerves and blood vessels causing pain

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11
Q

pathway in migraine with aura?

A

cortical spreading depolarization > activation of trigeminal vascular system > dilation of cranial blood vessels > release of substance P, neurokinin, CGRP (pain chemicals)

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12
Q

features of migraine with aura?

A

aura = fully reversible visual, sensory, motor or language symptom (usually visual)
aura lasts 20-60 mins
headache follows <1 hr later but aura can occur simultaneously

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13
Q

types of visual aura?

A 
central scotoma (blurred centre)
central fortification (distorted centre)
hemianopic visual loss (loss of left/right field)
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14
Q

what can trigger migraine?

A 
sleep
dietary (chocolate, cheese)
stress
hormonal
physical exertion
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15
Q

non-pharmacological treatments for migraine?

A

set realistic goals
education - avoid triggers
headache diary
relaxation/stress management

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16
Q

pharmacological management of migraine?

A

acute

prophylaxis

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17
Q

acute migraine management?

A

stepwise approach
NSAID +/- antiemetic
- 900mg aspirin/250mg naproxen/400mg ibuprofen
triptans (5-HT agonist)

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18
Q

how are triptans used?

A

oral/sublingual/SC
treat at start of headache
efficacy similar to NSAID

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19
Q

types of triptan?

A

rizatriptan = eletriptan > sumatriptan

frovatriptan for sustained relief

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20
Q

when is prophylaxis considered for migraine?

A

more than 3 attacks per month

each method is trialled for min 3 months

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21
Q

non-pharmacological prophylaxis?

A

acupuncture
relaxation
exercises

22
Q

pharmacological prophylaxis of migraine?

A 
amitriptyline (10-25mg, 75mg max)
propanalol (80-240mg)
topiramate (25-100mg) (CA inhibitor)
gabapentin
pizotifen
Na valproate
botox
anti-calcitonin gene related toxin Ab
23
Q

adverse effects of amitriptyline?

A

dry mouth
postural hypotension
sedation

24
Q

propanalol adverse effects?

A 
PVD
nightmares
avoid in asthma
heart failure
raynauds
25
Q

side effects of topiramate?

A 
weight loss
depression
paraesthesia
impaired concentration
enzyme inducer
26
Q

Na valproate can only be used in which people?

A

menopausal

only if no possibility of pregnancy

27
Q

what is anti-calcitonin gene related peptide Ab?

A

monoclonal antibody newly liscened

28
Q

what lifestyle factors can help migraines?

A

diet (regular intake, avoid triggers)
hydration (2L day, decrease caffeine)
stress relief
regular exercise

29
Q

fancy types of migraine?

A

acephalgic (speech, vision, nausea)
basilar (vertigo, unsteady, incapacitated)
retinal
ophthalmic
hemiplegic (familial/sporadic, channelopathy, stroke like features, lasts days-weeks, encephalopathic, drowsy/unresponsive)
abdominal (abdo pain, common in kids)

30
Q

how does tension headache present?

A 
episodic or chronic
pressing, tingling quality
mild-mod
bilateral
no nausea/vomiting
no photophobia/phonophobia
31
Q

management of tension headache?

A

relaxation therapy
antidepressant
reassure

32
Q

migraine relates syndrome which aren’t migraine?

A

trigeminal autonomic cephalgias
- group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features

33
Q

trigeminal autonimic cephalgias features?

A 
partial ptosis (often have smaller pupil on same side)
miosis
nasal stuffiness
nausea/vomiting
tearing
eye lid oedema
34
Q

what are the 4 main types of trigeminal autonomic cephalgia?

A

cluster
paroxysmal hemicrania
hemicrania continua
SUNCT

35
Q

who is cluster headache most common in?

A

men 30s-40s

36
Q

features of cluster headache?

A

striking circadian (around sleep) with seasonal variation
severe unilateral headache lasting 45-90 mins
frequency 1-8 days
cluster bout may last from few weeks to months

37
Q

how can cluster headache be managed?

A

high flow oxygen (100% for 20 mins)
S/C sumatriptan 6mg
steroids (reducing course over 2 weeks beginning at start of cluster bout)
verapamil for prophylaxis

38
Q

who is paroxysmal hemicrania most common in?

A

elderly women

39
Q

features of paroxysmal hemicrania?

A 
severe unilateral headache
unilateral autonomic features
lasting 10-30 mins
frequency = 1-40 per day
shorter duration and more frequent than cluster
normal scan
40
Q

management of paroxysmal hemicrania?

A

absolute response to indomethacin

41
Q

features of SUNCT?

A

SUNCT

  • short lived (15-120 secs)
  • unilateral
  • neuralgiaform headache
  • conjunctival injections
  • tearing
42
Q

treatment of SUNCT?

A

lamotrigine

gabapentin

43
Q

how is headache investigated?

A

new onset unilateral cranial autonomic features require imaging
MRI brain and MR angiogram

44
Q

what is idiopathic intracranial hypertension?

A

high pressure in spaces that surround brain and spinal cord
associated with hypertension and obesity
causes diurnal headache, visual loss and morning N & V

45
Q

what is seen on fundoscopy in IIH?

A

loss of disc margin

papilloedema

46
Q

how is IIH investigated?

A

MRI brain with MRV sequence (will be normal)
CSF sample (elevated pressure, normal constituents)
- only do in raised ICP if IIH suspected and scan is normal (must be scanned first)
visual fields

47
Q

management of IIH?

A

weight loss
acetazolamide (CA inhibitor)
ventricular atrial/lumbar peritoneal shunt (not first line, if weight loss fails etc, only done to save vision)
monitor visual fields and CSF pressure

48
Q

who gets trigeminal neuralgia?

A

elderly women

49
Q

features of trigeminal neuralgia?

A

triggered by touch, chewing, swallowing etc, usually V2/3
severe, sharp, stabbing
unilateral nerve pain lasting 1 sec-90secs
frequency = 10-100 per day
bouts of pain may last from a few weeks to months before remission

50
Q

how is trigeminal neuralgia managed?

A 
investigate = MRI
carbamazepine (1st?)
gabapentin
phenytoin
baclofen
surgical in few cases (ablation/decompression)

Neurology (53 decks)

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