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Neurology > Primary and Secondary Headache Syndromes > Flashcards

Primary and Secondary Headache Syndromes Flashcards

1
Q

What are some important features of the history of a patient with a headache?

A

Onset/peak = acute, subacute or gradual
Relieving features = posture, headache behaviour
Exacerbating features = posture, sneezing, coughing
Family history of migraine

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2
Q

What are some potential associated features of headaches?

A

Nausea and vomiting, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness

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3
Q

What are the red flags in a patient with a headache?

A 
New onset headache in patient >55
Known or previous malignancy
Immunosuppression
Early morning headache
Exacerbated by valsalva
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4
Q

What are some features of migraines?

A

More common in women

Most people have 1 attack per month = 20% have aura, 80% do not

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5
Q

What is the criteria for diagnosing a migraine without an aura?

A

At least 5 attacks = duration 4-72 hours
2 from = moderate/severe, unilateral, throbbing, worse on movement
1 from = autonomic features, photophobia, phonophobia

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6
Q

What causes migraines in susceptible individuals?

A

Both vascular and neural influences

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7
Q

How does stress trigger migraines?

A

Stress triggers changes in brain = serotonin release

Chemicals like substance P irritate nerves and blood vessels causing pain

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8
Q

What is the migraine centre of the brain?

A

Dorsal raphe nucleus and locus coeruleus

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9
Q

What is the flow of depolarisation that occurs in a migraine?

A

Cortical spreading depolarisation - activation of trigeminal vascular system causing cranial vessel dilation - release of substance P, neurokinin A and CGRP

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10
Q

What are some features of migraines with auras?

A

Reversible visual, sensory, motor or language symptoms
Duration 20-60 minutes
headache follows <1hr later but aura can occur simultaneously

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11
Q

What are the most common type of aura?

A

Visual auras = central scotomata, central fortification, hemianopic loss

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12
Q

What are some triggers of migraines?

A

Headache diary may help identify triggers = sleep, diet, stress, hormonal, physical exertion

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13
Q

What are some drugs used to treat migraines acutely?

A

NSAIDs and triptans

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14
Q

What are some features of using NSAIDs to treat migraines?

A

Analgesia = aspirin 900mg, naproxen 250mg, ibuprofen 400mg, may give anti-emetic
Take as early as possible = 60% have significant reduction in headache at 2hours
Consider anti-emetic if gastroparesis present

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15
Q

What are some features of using triptans to treat migraines?

A

5-HT agonists = oral, sublingual or subcutaneous
Treat at start of headache
Rizatriptan best option but give frovatriptan for sustained relief

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16
Q

When should you consider prophylaxis for migraines?

A

If more than three attacks per month or very severe = aim is to titrate drug as tolerated to achieve efficacy at lowest dose possible

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17
Q

How long must you trial prophylactic migraine drugs for?

A

3 months

18
Q

What are some drugs given for migraine prophylaxis?

A

Amitriptyline, propanolol and topiramate mainly

Others = gabapentin, pizotifen, botox, anti-calcitonin gene related peptide antibody

19
Q

What are some features of using amitriptyline as migraine prophylaxis?

A

10-25 mg = max is 75mg

May cause dry mouth, sedation or postural hypotension

20
Q

What are some features of using propanolol as migraine prophylaxis?

A

80mg given daily
Reduces migraine frequency in 60-80%
Avoid in asthma, PVD or heart failure

21
Q

What are some features of using topiramate as migraine prophylaxis?

A

Carbonic anhydrase inhibitor = 25-100mg daily

Start slowly as poor side effect profile = weight loss, paraesthesiae, impaired concentration

22
Q

What are some lifestyle changes that may help migraines?

A

Healthy diet, decrease caffeine, 2L of water per day, decrease stress, regular exercise

23
Q

What are migraines?

A

Common unilateral headaches of the young

24
Q

What are some examples of more complicated migraines?

A

Acephalic = aura without headache

Basilar, retinal/ophthalmic. hemiplegic, abdominal

25
Q

What are some features of tension type headaches?

A

Episodic or chronic = may be mild or moderate

Pressing tingling quality, bilateral, no nausea/vomiting, absence of photophobia or phonophobia

26
Q

How are tension type headaches treated?

A

Relaxation physiotherapy, dothiepin or amitriptyline for three months

27
Q

What are the types of trigeminal autonomic cephalgias?

A

Cluster, paroxysmal hemicrania, hemicrania continua. SUNCT

28
Q

What are the ipsilateral cranial autonomic features of trigeminal autonomic cephalgias?

A

Ptosis, miosis, nasal stuffiness, nausea and vomiting, tearing, eye lid oedema

29
Q

What are some features of cluster headaches?

A

More common in men aged 30-40
Striking circadian and seasonal variation
Severe unilateral headache = 45-90mins, 1-8x daily
Cluster bout may last from few weeks-months

30
Q

How are cluster headaches treated?

A

High flow 100% oxygen for 20mins
Subcutaneous sumatriptan 6mg
Steroids for 2 weeks
Verapamil for prophylaxis

31
Q

What are some features of paroxysmal hemicrania?

A

More common in women aged 50-60
Shorter duration and more frequent than cluster type
Severe unilateral headache = 10-30min duration, 1-40x a day, unilateral autonomic features

32
Q

How is paroxysmal hemicrania treated?

A

Absolute response to indomethicin

33
Q

What is SUNCT?

A

Short lived = 15-20s
Unilateral Neuralgiaform headache
Conjunctival injections and Tearing

34
Q

How is SUNCT treated?

A

Lamotrigine or gabapentin

35
Q

What investigations should any patient with a new onset unilateral cranial autonomic feature get?

A

Brain MRI and MR angiogram

36
Q

What are some features of idiopathic intracranial hypertension?

A

More common in women
Headache with morning nausea/vomiting and visual loss = shows diurnal variation
Empty sella and flattened optic disc

37
Q

What investigations may be done for idiopathic intracranial hypertension?

A

Normal MRI brain with MRV sequence

CSF = normal constituents, elevated pressure

38
Q

How is idiopathic intracranial hypertension treated?

A

Weight loss, acetazolamide, ventricular atrial or lumbar peritoneal shunt

39
Q

What are some features of trigeminal neuralgia?

A

More common in women aged >60
Triggered by touch = usually V2 or V3
Investigate with MRI of brain

40
Q

What is the character of the pain felt in trigeminal neuralgia?

A

Severe stabbing unilateral pain = duration of 1-90s, occurs 10-100 times a day
Pain bouts may last from few weeks to months

41
Q

What is the treatment for trigeminal neuralgia?

A 
Drugs = carbamazepine, gabapentin, phenytoin, baclofen
Surgery = ablation, decompression
42
Q

What is the first line treatment for uncomplicated migraines?

A

Symptomatic over the counter medication

Neurology (48 decks)

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