Primary & Secondary headache syndrome

Question 1

How does subarachnoid hemorrhage present

Answer 1

Instant peak in pain

Question 2

What are some red flags for headache?

Answer 2

• New onset >55 y/o
• Known/previous malignancy
• Immunosuppressed
• Early morning headache
• Exacerbated by valsava

Question 3

How often do migraine attacks generally occur?

Answer 3

once a month

Question 4

Is a migraine with aura effecting both or one eye?

Answer 4

Both

Question 5

How likely is it that a migraine has ‘aura’ (visual involvement)?

Answer 5

20%

Question 6

What is the criteria for a migraine with aura?

Answer 6

• At least 5 attacks
• Last 4-72hrs
• 2 of: Moderate/severe, unilateral, throbbing pain, worse movement
• 1of: autonomic features, photophobia/phonophobia

Question 7

What is the biggest trigger for migraines?

Answer 7

Stress

Question 8

How does stress cause migraine?

Answer 8

• Stress triggers changes in the brain leading to serotonin release
• Blood vessels constrict and dilate
• Chemicals including substance P irritate nerves and blood vessels causing pain

Question 9

Where is the migraine center?

Answer 9

Dorsal raphe nuclei & Locus coeruleus

Question 10

How is migraine treated non-pharmacologically?

Answer 10

• setting goals
• avoid triggers
• headache diary
• Relaxation/stress management

Question 11

How is migraine treated pharmacologically?

Answer 11

Acute
- NSAID (aspirin, naproxen, ibuprofen) +/- Anti-emetic
- Triptans (rizatriptan, fovatriptan)
Prophylaxis
- Amitriptyline (10-25mg normally)
- Propranolol (80-240mg)
- Topiramate (25-100mg)

Question 12

When is prophylaxis considered for migraine?

Answer 12

> 3 attacks a month
OR
Very severe attack

Question 13

How long does each method of prophylaxis need to be trialed for in migraine?

Answer 13

at least 3 months

Question 14

What are some contraindications to propranolol use in migraine?

Answer 14

Asthma
PVD
Heart failure

Question 15

What are adverse effects of amitriptyline?

Answer 15

• Dry mouth
• Postural hypotension
• Sedation

Question 16

What are some adverse effects of topiramate?

Answer 16

• Weight loss
• Paresthesia
• Impaired concentration
• Enzyme inducer

Question 17

What does CGRP do?

Answer 17

Triggers receptors which open up pain pathways to start migraine attacks

Question 18

When can anti-CGRP be given to a patient?

Answer 18

After three prior prophylactics

Question 19

Name some ‘Atypical’ migraines

Answer 19

Acephalgic
Basilar
Retinal
Ophthalmic
Hemiplegic (familial/sporadic)
Abdominal

Question 20

When are abdominal migraines common?

Answer 20

Kids

Question 21

Are migraines unilateral or bilateral headaches?

Answer 21

Unilateral

Question 22

Are tension type headaches unilateral or bilateral?

Answer 22

Bilateral

Question 23

How are tension headaches managed?

Answer 23

Relaxation physio
Anti-depressants
- Dothiepin or Amitriptyline
- 3 months

Question 24

What are trigeminal autonomic cephalgia’s (TACs)?

Answer 24

Primary headache disorders characterized by unilateral trigeminal distribution of pain with ipsilateral autonomic features

Question 25

What are the types of trigeminal autonomic cephalgia's?

Answer 25

Cluster headache Hemicrania

Question 26

What age do cluster headaches usually occur?

Answer 26

30-40

Question 27

When do cluster headaches occur?

Answer 27

Around sleep Tends to be seasonal

Question 28

How does cluster headache present?

Answer 28

Severe unilateral headache Lasts 45-90 mins Every 1-8 days

Question 29

How are cluster headaches treated?

Answer 29

High flow oxygen Sub cut sumatriptan 6mg Steroids Verapamil (prophylaxis)

Question 30

What age do hemicrania normally present at?

Answer 30

50-60s

Question 31

How does hemicrania present

Answer 31

Severe unilateral headache Unilateral autonomic features 10-30 mins

Question 32

How often do hemicrania happen?

Answer 32

Every 1 to 40 days

Question 33

How is hemicrania treated?

Answer 33

Indomethacin

Question 34

How does idiopathic intracranial hypertension present?

Answer 34

- Obese - Headache - Visual loss

Question 35

What investigations are there for idiopathic itracranial hypertension?

Answer 35

MRI brain with MRV sequence CSF - Increased pressure Visual field

Question 36

How is idiopathic intracranial hypertension managed?

Answer 36

- Weight loss - Acetazolamide - Ventricular atrial / Lumbar peritoneal shunt - Monitor visual field & CSF pressure

Question 37

What age does trigeminal neuralgia present at?

Answer 37

>60

Question 38

How does trigeminal neuralgia present?

Answer 38

Severe stabbing unilateral pai in distribution of trigeminal nerve

Question 39

How is trigeminal neuralgia treated medically?

Answer 39

- Carbamazepine - Gabapentin - Phenytoin - Baclofen

Question 40

How is trigeminal neuralgia treated surgically?

Answer 40

Ablation decompression

Question 41

Is giant cell arteritis a secondary or primary headache?

Answer 41

Secondary

Question 42

How does GCA present?

Answer 42

- Temporal headache - Jaw claudication - Elevated CRP/Plasma viscosity

Question 43

How is GCA treated?

Answer 43

Steroids