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Neurology > Primary and Secondary Headache Syndromes > Flashcards

Primary and Secondary Headache Syndromes Flashcards

1
Q

What are important facts to elicit in the history of a headache?

A

Onset/ peak: acute vs subacute
Relieving features: posture, headache
Exacerbating features: posture, valsalva, diurnal variation
Assoc features; autonomic, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
Consider demographic

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2
Q

What are the red flags in terms of headaches?

A 
New onset headache >55yrs
Known/ previous malignancy
Immunosuppressed; think about intracranial infection 
Early morning headache
Exacerbation by valsalva
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3
Q

What is the demographics of a migraine?

A

Commoner in women
Most will have an attack once a month
Migraine without aura: 80%
Migraine with aura: 20%

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4
Q

What is the IHS criteria for a migraine without aura?

A

At least 5 attacks of duration 4-72 hours
2 of: moderate/severe pain, unilateral, throbbing, worse with movement
1 of: autonomic features, photophobia, phonophobia, N+V

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5
Q

What is the pathophysiology of migraines?

A

Vascular and neural influences
Stress will trigger changes in the brain resulting in the release of serotonin
Blood vessels constrict and dilate
Chemicals including substance P, neurokinin A and CGRP irritate nerves and blood vessels resulting in pain

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6
Q

In what stages of a migraine will the blood vessels constrict and dilate?

A

Constrict: aura phase
Dilate: headache phase

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7
Q

What are common triggers of migraines?

A 
Lack of sleep
Dietary; dark chocolate, cheese, alcohol, hangovers
Stress
Hormonal; menstrual cycle
Physical exertion
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8
Q

What are the non-pharma treatments of migraines?

A 
Set realistic goals
Education; avoid triggers
CHOCOLATE: 
Chocolate
Hangovers 
Orgasms 
Cheese/ caffeine
OCP 
Lie-ins
Alcohol 
Travel 
Exercise 
Headache diary
Relaxation/ stress management
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9
Q

What are the pharmacological principles to treating migraines?

A

Acute treatment

Prophylactic treatment

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10
Q

What drugs are used in the acute management of a migraine?

A

NSAID; 900mg aspirin, 350mg naproxen, 400mg ibuprofen
+/- antiemetic
Triptans - selective 5-HT agonists

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11
Q

Do NSAIDs help with migraine pain?

A

60% significant reduction in headache at 2 hours

Only 25% to complete pain relief

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12
Q

What are triptans?

A

5-HT agonist

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13
Q

When should triptans be give?

A

At the start of the headache; similar efficacy to NSAIDs

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14
Q

What are examples of triptans?

A

Rizatriptan
Eletriptan
Sumatriptan
Fovatriptan

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15
Q

How can triptans be given?

A

Oral
Sub-lingual
Subcut

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16
Q

When should you consider prophylaxis for migraines?

A

More than 3 attacks a month or very severe

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17
Q

What is the aim with prophylaxis?

A

Titrate drug as tolerated to achieve efficacy at the lowest dose possible
Must trial each for a minimum of 3 months
GO SLOW AND KEEP LOW

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18
Q

What are examples of migraine prophylaxis?

A 
Amitriptyline
Propranolol
Topiramate
Gabapentin
Pizotifen
Sodium valproate
Botulinum toxin 
Anti calcitonin gene related peptide (CGRP) Ab
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19
Q

What dose of amitriptyline is given in migraine prophylaxis and what are the adverse effects?

A

10-25 mg - max 75mg

Adverse: dry mouth, postural hypotension, sedation: Anticholinergic effects

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20
Q

What dose is given on propranolol in migraine prophylaxis and what are the contraindications?

A

80-240 mg daily

Avoid in asthma, PVD

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21
Q

What mechanism of action of topiramate?

A

Carbonic anhydrase inhibitor

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22
Q

What dosage of topiramate is given in migraine prophylaxis and what are the adverse effects?

A

25-100mg

Adverse: weight loss, paraesthesia, impaired concentration, enzyme inducer, teratogenic

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23
Q

Should you give sodium valproate in young women?

A

No - highly teratogenic

Give in menopausal women

24
Q

What lifestyle factors can be used as prophylaxis of migraines?

A

Diet; regular intake, avoid triggers, healthy balanced diet
Hydration; at least 2 L/ day, decrease caffeine
Stress - decrease
Regular exercise

25
Q

What are the rare subtypes of migraines?

A

Basilar
Retinal/ ophthalmic
Hemiplegic
Abdominal

26
Q

What is a tension type headache?

A 
Episodic vs chronic
Pressing tingling quality
Mild to mod
Bilateral
Absence of N+V 
Absence of photophobic or phonophobia
27
Q

What is the treatment for tension type headaches?

A

Relaxation physiotherapy
Antidepressant; dothiepin or amitriptyline
Reassure

28
Q

What are trigeminal autonomic cephalgias (TAC)

A

Primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in assoc with prominent ipsilateral cranial autonomic features

29
Q

What are ipsilateral cranial autonomic features?

A 
Ptosis
Miosis
Excess lacrimation 
Injection of conjuntiva 
Nasal stuffiness
N+V 
Eye lid oedema
30
Q

What are the 4 main types of TACs?

A

Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT

31
Q

What is the demographic of cluster headaches?

A

Young - 30s/40s

Men more than women

32
Q

When will people get cluster headaches?

A

Striking circadian and seasonal variation

33
Q

What are the features of cluster headaches?

A

Severe unilateral headache
Duration of 45-90 mins
Frequency of 1-8 a day
Cluster bout can last from a few weeks to months

34
Q

What is the treatment of cluster headaches?

A

High flow oxygen 100% for 20mins
Subcut sumatriptan 6mg
Steroids; reducing course over 2 weeks
Verapamil for prophylaxis

35
Q

What is the demographic of paroxysamal hemicrania headaches?

A

Elderly 50s/60s

Women more than men

36
Q

What are the features of paroxysmal hemicrania headaches?

A

Severe unilateral headache, unilateral autonomic features
Duration of 10-30 mins
Frequency of 1-40 a day

37
Q

What is the treatment for paroxysmal hemicrania headaches?

A

ABSOLUTE RESPONSE to indomethacin

38
Q

What does SUNCT stand for?

A 
Short lived 
Unilateral
Neuralgioaform headache
Conjunctival injections
Tearing
39
Q

What is the treatment for SUNCT?

A

Lamotrigine

Gabapentin

40
Q

Describe the duration of all headaches

A

Migraine: hours
Cluster: 45-90 mins
Paroxysmal hemicrania: 10-30 mins
SUNCT: seconds

41
Q

What are the indications for imaging in headaches?

A

ALL those with new onset unilateral cranial autonomic features requires imaging; MRI brain or MRA

42
Q

Who is likely to get idiopathic intracranial hypertension?

A

Females

Obese

43
Q

What are the symptoms of idiopathic intracranial hypertension?

A

Diurnal variation
Morning N+V
Visual loss`

44
Q

Why will all those with idiopathic intracranial hypertension get a scan?

A

To ensure not tumour or obstructive hydrocephalus

45
Q

What will be seen in fundoscopy of IIH?

A

Papilloedema

46
Q

What will be seen on LP in IIH?

A

Increased pressure

Normal constituents; white cells, protein and glucose

47
Q

What investigations should be done in IIH?

A

MRI brain with MRV sequence
LP
Visual fields

48
Q

Do you do an LP in increased ICP?

A

NO: UNLESS CT SCAN IS NEGATIVE

49
Q

What is the treatment for IIH?

A

Wt loss
Acetazolamide
Ventricular atrial/ lulmbar peritoneal shunt only if going blid

50
Q

What is the demographic of trigeminal neuralgia?

A

Elderly (>60yrs)

Women more than men

51
Q

What can trigger trigeminal neuralgia?

A

Touch in V2/3
Chewing
Eating
Swallowing

52
Q

What are the features of trigeminal neuralgia?

A

Severe stabbing unilateral pain
Duration: 1 to 90 secs
Frequency: 10-100 day
Bouts pain may last from a few weeks to months before remission

53
Q

What are the medical treatments of trigeminal neuralgia?

A

Carbamezapine
Gabapentin
Phenytoin
Baclofen

54
Q

What are the surgical treatments of trigeminal neuralgia?

A

Ablation

Decompression

55
Q

What investigations should be done in trigeminal neuralgia?

A

MRI brain

Neurology (48 decks)

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