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Neurology > Primary and Secondary headache syndromes > Flashcards

Primary and Secondary headache syndromes Flashcards

1
Q

What is included in a headache history?

A

Onset/peak

  • acute vs subacute vs gradual

Relieving features

  • posture, headache behaviour

​Exacerbating

  • Posture, valsalva (sneezing, couging, straining). Diurnal variation.

Associated features

  • autonomic features (N+V), photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
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2
Q

What are the headache red flags?

A
  • new onset headache >55
  • known/previous malignancy
  • immuno-suppressed
  • early morning headache
  • exacerbation by valsalva
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3
Q

What proportions of migraines have aura?

A

20%

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4
Q

What are the IHS criteria for migraine without aura?

A
  • At least 5 attacks
  • duration 4-72 hours
  • 2 of: moderate/severe, unilateral, throbbing, pain, worse on movement
  • 1 of: autonomic features, photophobia/phonophobia
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5
Q

What is the pathophysiology of migraine?

A

Both vascular and neural influences cause migraines in susceptible individauls

Stress triggers changes in the brain, these changes cause serotonin to be released.

Blood vessels constrict and dilate.

Chemicals including substance P irritate nerves and blood vessels causing pain.

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6
Q

What is the neurophysiology of migraine with aura

A
  1. Cortical spreading depolarisation
  2. activation trigeminal vascular system- dilatation of cranial blood cessels
  3. release of substance P, neurokinin A, CGRP
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7
Q

What is aura

A

Fully reversible visual, sensory, motor or language symptom

Aura duration 20-60 minutes

Visual is most common (positive symptoms usually monochromatic)

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8
Q

What is the typical pattern of migraine with aura?

A

headach follows aura <1 hour later but can occur simultaneously

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9
Q

What are some examples of a visual aura

A

Central Scotoma

Central fortification

Hemianopic loss

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10
Q

What are some triggers of migraine?

A
  • sleep
  • dietary
  • stress
  • hormonal
  • physical exertion
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11
Q

What is the non-pharmacological treatment for migraine?

A

Set realistic goals

Education- avoid triggers

Headache diary

Relaxation/stress management

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12
Q

What is the pharmacological treatment for migraine?

A

Acute- NSAID, triptans

Phrophylactic- amitriptyline, propanolol, topiramate, gabapentin, pizotifen, Na valproate, botulinum toxin, anti calcitoning gene related peptide Ab

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13
Q

Describe use of NSAIDs for abortive treatment of migraines?

A

Aspirin 900mg

Naproxen 250mg

Ibuprofen 400mg

+/-

anti-emetic

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14
Q

Describe the use of triptans for abortive migraine treatment?

A

Given: oral, sublingual, subcutaenous- depending on N&V

Treat at start of headache

Rizatriptan = eletriptan > sumatriptan

Frovatriptan for sustained relief

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15
Q

What are triptans?

A

5-HT agonists

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16
Q

When should migraine prophylaxis be considered?

A

More than 3 attacks a month or very severe attack

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17
Q

What is the aim of migraine prophylaxis?

A

Titrate drug as tolerated to achieve efficacy at the lowest dose possibile

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18
Q

How long must migraine prophylaxis be trialed?

A

Trial all methods for 3 months minimum

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19
Q

What non-pharmacological prophylaxis can be trialed?

A

Acupuncture

Relaxation exercises

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20
Q

What dose of amitriptyline is used for migraine prophylaxis?

A

10-25mg (max 75mg)

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21
Q

What are the adverse effects of amitriptyline

A

Dry mouth, postural hypotension, sedation

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22
Q

What dose of propanolol should be used for migraine prophylaxis?

A

80-240mg

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23
Q

Which patients cannot use propanolol for migraine prophylaxis?

A

Patients with; Asthma, PVD, HF

24
Q

What dose of topiramate can be used for migraine prophylaxis?

A

25mg-100mg

25
Q

What class of drug is topiramate?

What are the adverse effect?

A

Carbonic anhydrase inhibitor (Na/GABA)

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

26
Q

What lifestle changes should be encouraged in migraine sufferers?

A
  • Diet- regular intake, avoid triggers, healthy balanced diet
  • Hydration- at least 2 litres a day, decrease caffeine
  • Stress- decrease
  • Regular exercise
27
Q

What are the atypical types of migraine?

A
  • acephalgic
  • basilar
  • retinal
  • ophthalmic
  • hemiplegic (familial sporadic)
  • abdominal
28
Q

What are the two variations of tension type headach

A

Episodic vs chronic

29
Q

What are the characteristics of a tension type headache?

A

Presssing tingling quality

Mild to moderate

Bilateral

Absence of N&V
Absence of photophobia or phonophobia

30
Q

What are the treatments for tension type headache?

A
  • relaxation physiotherapy
  • antidepressant
  • sothiepin or amitriptyline 3 months Rx*
  • -* reassurance
31
Q

What are trigeminal autonomic cephalgias?

A

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

32
Q

What are the prominent ipsilateral cranial autonomic features?

A

Ptosis

Miosis

Nasal Stuffiness

N&V

Tearing

Eye lid oedema

33
Q

What are the 4 main types of trigeminal autonomic cephalgias?

A

Cluster

Paroxysmal hemicrania

Hemicrania continua

SUNCT

34
Q

Who gets cluster headaches?

A

Young people 30s-40s

Men > Women

35
Q

When to cluster headaches occur?

A

Circadian and seasonal variation

36
Q

What are the features of cluster headaches?

A
  • severe unilateral headache, duration: 45-90mins (20 mins-3 hours)
  • Frequency: 1 to 8 day
  • Cluster bout may last from a few weeks to months
37
Q

What is the treatment for cluster headaches?

A
  • High flow oxygen 100% for 20 mins
  • Subcutaenous sumatriptan 6mg
  • Steroids- reducing course over 2 weeks
  • Verapamil for prophylaxis
38
Q

Who suffers from paroxysmal hemicrania?

A

Elderly 50s-60s

Women>men

39
Q

What are the features of paroxysmal hemicrania?

A
  • severe unilateral headache, unilateral autonomic features
  • duration: 10-30minutes (2 mins-45hours)
  • Frequency 1 to 40 a day
40
Q

What is the treatment for paroxysmal hemicrania?

A

Absolute response to indomethicin

41
Q

What differentiates paroxysmal hemicrania from cluster headaches

A

Shorter duration and more frequent

42
Q

What is SUNCT?

A

S= short lived (15-120 seconds)

U= unilateral

N= neuralgiaform headache

C= conjunctival injections

T= tearing

43
Q

What is the treatment for SUNCT?

A

Lamotrigine, gabapentin

44
Q

What do those with new onset unilateral cranial autonomic features require?

A

MRI brain and MR angiogram

45
Q

Who is affected by idiopathic intracranial hypertension?

A

F>M

obese

46
Q

Describe the presentation of idiopathic intracranial hypertension?

A

Headache

  • diurnal variation
  • morning N&V

Visual loss

47
Q

What abnormalities will be found in idiopathic intracranial hypertension?

A

Elevated pressure of CSF

48
Q

What is the treatment for idiopathic intracranial hypertension?

A
  • weight loss
  • acetazolamide
  • ventricular atrial/lumbar peritoneal shunt
  • monitor visual fields and CSF pressure
49
Q

Who is affected by trigeminal neuralgia?

A

Elderly >60

Women> Men

50
Q

What triggers trigeminal neuralgia?

A

Touch, usually V2/V3

51
Q

What are the features of trigeminal neuralgia?

A

Severe stabbing unilateral pain

Duration: 1 second to 90 seconds

Frequency: 10 to 100 day

Bouts of pain may last from a few weeks to months before remission.

52
Q

What is the medical treatment for trigeminal neuralgia?

A

Carbamazepine, gabapentin, phenytoin, baclofen

53
Q

What is the surgical treatment for trigeminal neuralgia?

A

Ablation

Decompression

54
Q

What are the investigations for trigeminal neuralgia?

A

MRI brain

55
Q

What should be taken into consideration when there is facial pain?

A

Non-neurological structures e.g. eyes, ears, sinuses, teeth, TMJ

Neurology (41 decks)

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