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Neurology > Primary and Secondary Headaches > Flashcards

Primary and Secondary Headaches Flashcards

1
Q

what are the red flags of a headache?

A

new onset headache >55

known / previous malignancy

immunosuppressed

early morning headache

exacerbated by valsalva (coughing, sneezing - raises ICP)

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2
Q

what should you be aware of in terms of past medical history when someone has headache?

A

cancer - predisposition to thrombosis

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3
Q

what is family history particularly important in?

A

migraine

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4
Q

what gender is migraine more common in?

A

women

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5
Q

on average, most migraine sufferers have how many attacks per month?

A

1

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6
Q

what % of migraines are those with aura (specific warning signs)?

A

20

80% are without aura

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7
Q

how do you diagnose migraine without aura by IHS criteria?

A

at least 5 attacks (duration 4-72 hours)

2 of: moderate / severe, unilateral, throbbing pain, worst movement

1 of: autonomic features, photophobia / phonophobia

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8
Q

what is the pathophysiology of a migraine?

A

both vascular and neural influences cause migraines in susceptible individuals

stress - serotonin released

blood vessels constrict and dilate

chemicals inc substance P irritate nerves and vessels causing pain

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9
Q

what areas in brain are known as migraine centre?

A

dorsal raphe nucleus

locus coeruleus

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10
Q

what is “aura”?

A

fully reversible visual, sensory, motor or language symptoms

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11
Q

what is the duration of aura and when does this occur in relation to headache?

A

aura duration 20-60 mins

headache follows <1 hour later but aura can occur simultaneously

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12
Q

what is most common aura symptom?

A

visual (positive symptoms usually monochromatic)

eg central scotomata, central fortification, hemianopic loss

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13
Q

what tends to trigger a migraine?

A 
sleep 
diet 
stress
hormonal 
physical exertion
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14
Q

what may help patient to identify triggers?

A

headache diary

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15
Q

what are types of non-pharmacological management of migraine?

A 
realistic goals 
avoid trigger 
balanced diet and hydration 
avoid caffeine 
relaxation / stress management
regular exercise
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16
Q

what are two types of pharmacological management of migraine?

A

acute

prophylaxis

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17
Q

what 2 types of medications can be given as abortive treatment of migraine?

A

NSAIDs

Triptans (5HT agonist)

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18
Q

what types of NSAIDs can be given as migraine abortive treatment?

A

aspirin 900mg
naproxen 250mg
ibuprofen 400mg

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19
Q

when should NSAIDs be taken for a migraine?

A

as early as possible

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20
Q

when should anti emetic be considered when giving NSAIDs?

A

if gastroparesis

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21
Q

how can triptans be administered?

A

oral, sublingual and subcutaneous

consider method of administration in those with N&V

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22
Q

when should triptans be given for migraine?

A

at start of headache

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23
Q

what is name of triptans given for migraine?

A

rizatriptan, eletriptan, sumatriptan

frovatriptan for sustained relief

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24
Q

when should you consider prophylaxis for migraine?

A

more than 3 attacks per month or very severe

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25
Q

how long must you trial each prophylaxis drug for?

A

minimum of 3 months

aim is to titrate drug as tolerated to achieve efficacy at lowest dose possible

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26
Q

what non-pharmacological methods of prophylaxis should you consider?

A

acupuncture

relaxation exercises

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27
Q

what are the main medications that can be given for migraine prophylaxis?

A

amitriptyline
propranolol
topiramate

28
Q

how much amitriptyline should be given for migraine prophylaxis?

A

10-25mg (max 75mg)

29
Q

what are the adverse effects of amitriptyline?

A

dry mouth
postural hypotension
sedation

30
Q

how much propranolol should be given for migraine prophylaxis?

A

80-240mg daily

31
Q

when should propranolol be avoided?

A

asthma
peripheral vascular disease
heart failure

32
Q

what class of drug is topiramate?

A

carbonic anhydrase inhibitor

33
Q

how much topiramate should be given for migraine prophylaxis?

A

25mg - 100mg daily

start slowly due to poor side effect profile

34
Q

what are the adverse effects of topiramate?

A

weight loss
paraesthesia
impaired concentration
enzyme inducer

35
Q

what types of “fancy” migraine can you get?

A 
acephalgic 
basilar 
retinal 
ophthalmic 
hemiplegic (familial / sporadic)
abdominal
36
Q

what is difference in symptoms of tension type headache and migraine?

A

tension type is bilateral

absence of N&V, photophobia and phonophobia

37
Q

what type of pain is tension type headache?

A

pressing tingling quality

38
Q

how sore is a tension type headache?

A

mild to moderate

39
Q

how can tension type headache be treated?

A

relaxation physiotherapy

reassure

antidepressant - 3 months of dothiepin or amitryptyline

40
Q

what is trigeminal autonomic cephalgias (TACs)?

A

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

41
Q

give examples of ipsilateral cranial autonomic features seen in TACs?

A 
ptosis 
miosis 
nasal stuffiness 
nausea / vomiting 
tearing 
eye lid oedema
42
Q

what are the 4 main types of trigeminal autonomic cephalgias (TACs)?

A

cluster
paroxysmal hemicrania
hemicrania continua
SUNCT

43
Q

who gets a cluster headache?

A

young (30-40s)

men > women

44
Q

when do cluster headaches often occur?

A

striking circadian (around sleep) and seasonal variation

45
Q

what are the features of a cluster headache?

A

severe unilateral headache

duration: 45-90 mins
frequency: 1 to 8 per day

cluster bout may last from few weeks to months

46
Q

what is the treatment for a cluster headache?

A

high flow oxygen 100% for 20 mins

sub cut sumatriptan 6mg

steroids - reducing course over 2 weeks

verapamil for prophylaxis

47
Q

who gets paroxysmal hemicrania?

A

elderly (50s-60s)

women > men

48
Q

what are the features of paroxysmal hemicrania?

A

severe unilateral headache, unilateral autonomic features

duration: 10-30 mins
frequency: 1 to 40 per day

ie shorter duration and more frequent than cluster

49
Q

what is treatment of paroxysmal hemicrania?

A

indomethicin

50
Q

what are features of SUNCT headache?

A 
short lived (15-120 secs)
unilateral 
neuralgiaform headache 
conjunctival injections 
tearing
51
Q

what is treatment of SUNCT headache?

A

lamotrigine, gabapentin

52
Q

what patients that present with headache require imaging?

A

those with new onset unilateral cranial autonomic features

53
Q

what imaging is carried out for these patients?

A

MRI brain and MR angiogram

54
Q

who is more likely to be affected by idiopathic intracranial hypertension?

A

F > M

obese

55
Q

what are symptoms of IIH?

A

headache - diurnal variation
morning N & V
visual loss

56
Q

what investigations should take place in IIH?

A

MRI brain with MRV sequence - normal

CSF - elevated pressure, normal constituents

visual field

57
Q

how should IIH be treated?

A

weight loss

acetazolamide

ventricular atrial / lumbar peritoneal shunt

monitor visual fields & CSF pressure

58
Q

who gets trigeminal neuralgia?

A

elderly (>60)

women > men

59
Q

when does trigeminal neuralgia occur?

A

triggered by touch, usually V2/3

60
Q

what are features of trigeminal neuralgia?

A

severe stabbing unilateral pain

duration: 1 sec to 90 secs
frequency: 10 per day to 100 per day

bouts pain may last from a few weeks to months before remission

61
Q

what investigation should take place in trigeminal neuralgia?

A

MRI brain

62
Q

what is medical and surgical treatment options for trigeminal neuralgia?

A

medical - carbamazepine, gabapentin, phenytoin, baclofen

surgical: ablation or decompression

63
Q

when someone presents with facial pain, you must consider non-neurological structures such as what?

A 
eyes 
ears
sinuses
teeth 
TMJ etc
64
Q

how is diagnosis of primary headache syndromes (inc TCA) established?

A

clinically based on demographics, duration, frequency and triggers

65
Q

what is 1st line for uncomplicated migraine?

A

symptomatic OTC medication

Neurology (32 decks)

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