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Neurology (personal) > Primary and Secondary Headache Syndromes > Flashcards

Primary and Secondary Headache Syndromes Flashcards

1
Q

Red flags in patient presenting with headache

A
  1. New onset headache >55
  2. Previous tumour/malignancy
  3. Exacerbation - early morning (raised ICP)
  4. Exacerbation - valsalva (raised ICP)
  5. Immunosuppression
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2
Q

Demography and incidence of migraine

A

More common in females (1:25)
1 year prevalence
Age: <40 yo/
Aura - 20%; without aura - 80%

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3
Q

Pathophysiology of migraine headache

A

Vascular & neural causes in susceptible individuals

  1. Stress triggers changes in the brain
  2. Serotonin is released
  3. Blood vessels constrict in aura phase and then dilate
  4. Release of pain substances
  5. Irritation of nerves and BV –> PAIN
Genetic influences (+ve family history) 
Hormonal influences (preponderance in women, correlation with menstrual cycle)
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4
Q

Pathophysiology of migraine aura

A

D/t dysfunction of ion channels –> cortical front of depolarisation (excitiation) spreads –> hyperpolarization (depression of electrical activity)

This occurs at 3mm/minute which corresponds with the spread of the symptoms of aura

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5
Q

List the triggers of a migraine (5)

A 
Sleep
Dietary - cheese, chocolate, alcohol, excercise 
Stress
Hormonal
Physical exertion
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6
Q

Method to identify triggers of a migraine?

A

Headache diary

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7
Q

Clinical features of classical migraine

A

SYMPTOM TRIAD:

  1. Headache - paroxysmal, unilateral (hemicranial)
  2. N & V
  3. Aura - reversible; visual (most common), sensory, motor or language symptoms lasting 20-60 minutes
  4. General malaise/irritability (just before aura)
  5. Photophobia
  6. Transient aphasia (if dominant hemisphere involved)
  7. limb weakness (hemiplegic migraine)
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8
Q

Clinical features of common migraine

A

NO AURA
At least 5 attacks
Duration: 4-72hrs
2 of: moderate/severe headache, unilateral, throbbing pain, worse on movement
1 of: autonomic features, photo/phonophobia,

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9
Q

What are the relieving factors of classical migraine?

A

dark room
Silence
Sleep

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10
Q

Common visual symptom of aura?

A

Zig-zig lines march across visual field

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11
Q

Non-pharmacologic treatment options for migraines

A

Set realistic goals
Education - avoid triggers
Headache diary
Lifestyle - avoid alcohol, regular excercise, reduce stress, increase hydration

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12
Q

Treatment for acute episode of migraine

A

Abortive NSAID +/ - anti emetic

NSAID - Aspirin(900mg), ibuprofen (400mg), naproxen (250mg)

Anti-emetic (NICE - consider administering this even in the absence of N and V) - metoclopramide, domperidone

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13
Q

Treatment for severe migraine

A

TRIPTAN (alone or in combination with NSAID/paracetamol)

1st line = sumatriptan
Rizatriptan = elatriptan > sumatriptan

Note: consider route of administration in patients with N & V (non-oral forms to be used)

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14
Q

What is the MOA of triptans?

A

Vasoconstrictors of extra-cranial arteries

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15
Q

What should patients be advised on regarding efficacy of medications?

A
  1. Acute medication to be taken when the pain is mild
  2. If aura is present, triptan should be taken at start of headache and not the start of aura (unless the two occur simultaneously)
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16
Q

Indications for prophylactic management of migraine

A

If >3 attacks/month or very severe

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17
Q

List the drug classes to be used in migraine prophylaxis

A
  1. Tricyclic - amitriptyline (postural HTN, dry mouth, sedation)
  2. Beta-blocker - propranolol (CI in asthma, PVD, HF)
  3. Carbonic anhydrase inhibitor - topiramate (weight loss, paraesthesia, impaired concentration, enzyme inducer)
  4. Others: gabapentin, botulinum toxin, anti-calcitonin, pizotifen, Na valproate
18
Q

Which migraine prophylactic drug causes dependency?

A

Gabapentin

19
Q

Which migraine prophylactic drug is contraindicated in pregnancy?

A

Na valproate - teratogenicity

20
Q

What is the side effect of pizotifen?

A

Weight gain

21
Q

What is the most common type of headache?

A

Tension type

22
Q

Pathophysiology of tension headache

A

Emotional stress or anxiety
Anxiety about the headache worsens the symptoms
Patients are convinced of a serious underlying condition

23
Q

Clinical features of tension headache

A 
Bilateral
Radiating from occiput
Constant and generalised
Character - 'dull', 'tight', 'like a pressure' 
More troublesome as the day goes on
Less noticeable when patient is occupied

Negative association - photo/phonophobia, nausea and vomiting

24
Q

Management of tension-type headache

A

Reassure patient - no serious underlying pathology
Simple analgesia - paracetamol, aspirin, NSAID
Relaxation physiotherapy + stress management
Low dose antidepressant (amoxicillin or dothiapin, 3 months)

25
Q

What is the umbrella term for headache syndromes with unilateral trigeminal distribution pain?

A

Trigeminal autonomic cephalgia

26
Q

Which feature do all autonomic cephalgias have in common?

A

Unilateral trigeminal distribution pain

27
Q

List the 4 autonomic cephalgias

A
  1. Cluster headache
  2. Paroxysmal hemicrania
  3. SUNCT
  4. Hemicrania continua
28
Q

Epidemiology of cluster headace

A

Age: younger
Gender: M>F
More common in heavy smokers and higher than usual alcohol consumption

29
Q

Clinical features of cluster headache

A

Headache: periodic, severe, unilateral
Unilateral peri-orbital pain + unilateral lacrimation, nasal congestion, conjunctival infection
Duration: 45-90mins, striking circadian (about to sleep) or seasonal variation
Pain score: 10/11
Frequency: 1 to 8/day

Cluster bout may last from a few weeks to months followed by a respite for a number of months before another cluster occurs.

30
Q

Treatment of cluster headache

A

ACUTE
High flow oxygen (100%) for 20 mins
Subcut sumitriptan (6mg)

PROPHYLAXIS
Steroids reducing course over 2 weeks
Verapamil

31
Q

Epidemiology of paroxysmal hemicrania

A

Elderly (50-60 y/o)

Women >men

32
Q

Clinical features of paroxysmal hemicrania

A

Severe unilateral headache
Unilateral autonomic features
Duration: 10 to 30 mins
Frequency: 1 to 4/day

33
Q

Investigations & treatment for paroxysmal hemicrania

A

MRI brain and MR angiogram for new onset unilateral cranial autonomic features

Absolute response to indomethacin

34
Q

Clinical features and treatment of SUNCT

A 
S - short-lived
U - unilateral
N - neuralgia from headache
C - conjunctival infections
T- tearing

Treatment: carbamazepine, lamotrigine

35
Q

Clinical features of idiopathic cranial HTN

A

Obese
F>M
Headache - diurnal variation, N & V
Visual loss

36
Q

Investigations for idopathic cranial HTN

A

MRI with MRV sequence - normal
CSF - elevated pressure, normal constituents
Visual fields

37
Q

Management of idiopathic cranial HTN

A

Weight loss
Acetolazamide
Ventricular atrial/lumbar peritoneal shunt
Monitor visual field & CSF pressure

38
Q

Epidemiology of trigeminal neuralgia

A

Elderly (>60)

Women > men

39
Q

Pathophysiology of trigeminal neuralgia

A

Aberrant loop of cerebellar arteries compress on trigminal nerve as it enters brainstem
Other compressive lesions (usually benign)
In MS - plaques of demyelination in the trigeminal root entry zone

40
Q

Clinical features of trigeminal neuralgia

A

Pain - lancinating pain in 2nd and 3rd division of CN V (severe, brief, repetitivel unilateral
Precipitated by touching trigger zones - (cold wind on face, eating)
Causes patient to flinch as with motor tic
Duration - 1 to 90 s
Frequency - 1-100/day
High tendency of relapse and remission

41
Q

Management of trigeminal neuralgia

A

• Carbamazepine: 1200mg daily
- Start with low dose and increase gradually
• Gabapentin: In those who cannot tolerate carbamazepine
• Phenytoin
• Baclofen
• Surgical: ablation, decompression
• Investigations: MRI brain

Neurology (personal) (2 decks)

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