Week 4 - J - Headaches - Migraines, Tension, Cluster, Trigeminal Autonomic Cephalgias (4), Trigeminal Neuraglia, Idiopathic INtracranial hypertension

Question 1

In general terms, “if a diagnosis or

differential diagnosis cannot be formulated

after the history…start again”

What are important questions to ask when taking a headace history?

(basically Socrates - remember which questions to ask for each letter of socrates )

Answer 1

• Site - where in the head does the pain occur
• Onset - when does it come on, is it gradual or acute
• Character - stabbing or dull pain
• Radiating - does the sore head spread anywhere
• Associated symptoms - photphobia, phonophobia neck stiffness, visual symptoms
• Time (duration) - how long does the headache last
• Exacerbating factors- posture, valsalva, time of day
• Severity - rate the pain on a scale form 1-10

Question 2

In a patient presenting with a headache, what would the red flags be?

A red flag for headache is when the HA is exacerbated by valsalva - what does this mean?

Answer 2

• New onset headache in patient greater than 55 years of age
• Known/previous malignancy
• Immunosuppressed individual
• If the headaches is worse in the morning/wakes them from their sleep
• If the headaches is exacerbated by valsalva - eg coughing, sneezing - things that raise ICP

Question 3

If thinking a headache may be due to a space occupying lesion, why might the headache be worse in the mornings?

Why might sneezing and coughing cause increased headache?

Answer 3

Early morning headache/wakes you up from sleep - worse because the CSF doesnt drain as well when lying flat and therefore this cause a build up can cause a further rise in ICP if there was a SOL - leading to bad headache

Sneezing and coughing (valsalva) increase the ICP and therefore can worsen headaches

Question 4

It is important to consider the demographic with whom you are speaking when taking a history.

Which person may a migraine be relatively common in?

Answer 4

Common in young women

Question 5

Headache history

• PMHx - beware previous carcinoma, predisposition to thrombosis
• FHx of migraine
• DH also

What is a migraine?
What is the symtpoms of a migraine associated with?

Answer 5

A migriane is usually a moderate a severe headache felt as a throbbing on one side of the head that gets worse when you move and prevents you from carrying out normal activities.

The main symptom of a migraine is usually an intense headache on one side of the head.

Symptoms include: photophobia, phonophobia, (Autonomic features) nausea and vomiting

Question 6

Migraines are commoner in women than in men and on average there is one attack per month

Migraines can occur with aura (20%) or without aura (80%)
What is aura?

What are the symptoms of aura?

Answer 6

Aura is the typical warning signs that precede the headache by minutes

Usually get visual changes - seeing flashy lights or dots, as well as paraesthesia (pins and needles), numbness in hands and feeling dizy

Question 7

Describe each of the 4 stages of migraine

• Prodromal stage
• Aura stage
• Headache stage
• Resolution stage

Answer 7

Prodromal stage - precedes headache by days - yawning/cravings, mood/sleep change

Aura stage - precedes the migraine by minutes and may persist during it - vision problems - blurry light and dots, numbness and paraesthesia in limbs

Headache stage - unilateral moderate/severe throbbing headache with vomiting&nausea , photophobia/ phonophobia

Resolution stage - the headache lessens

Question 8

Is migrain with or without aura more common?

Answer 8

80% of cases have migraine without aura

20% of cases have migraine with aura

Question 9

Migraine without aura is more common but has criteria for its diagnosis by the International Headache Society

What is required for diagnosis of migraine without aura? (there are three categories for diagnosis)

Answer 9

At least 5 attacks, each lasting between 4and72 hours in length

+ 2 of

Moderate/severe, unilateral, throbbing/pulsating, worse on movement

+ 1 of

Autonomic features (nausea/vomiting), photphobia/phonophobi

Question 10

Both vascular and neural influences cause migraines in susceptible individuals

What is the pathophysiology of migraine without aura?

Answer 10

Stress triggers changes in the brain resulting in serotonin to be released

This causes blood vessels to constrict and dilate

Chemicals including substance p is also released and this irritates nerves and blood vessels causing pain

The migraine centre is now activated

Question 11

What are some partial triggers of migraines that are seen in 50% of patients

The aconym CHOCOLATE is used to remember this

Answer 11

• Chocolate
• Hangovers
• Orgasms
• Cheese
• Oral contraceptives (combined pill)
• Lie-ins
• Alcohol
• Tumult - loud noise
• Exercise

Question 12

WHat is the diagnostic criteria for migraine without aura?
What is the pathophysiology for igraine in general?
What is partial risk factors?

Answer 12

5 headaches each lasting 4-72 hours, +2 of Unilateral, pulsating/throbbing, moderate to severe, worse on movement +1 of Autonomic features (N+V), photophobia/phonophobia

Stress triggers changes in the brain causing the release of serotonin, this causes blood vessels to constrict and dilate. Chemical substance P also irritates nerves and blood vessels activating the migrain centre complex

Chocolate, Hangovers, Orgasms, Cheese, OCP, Lie-ines, Alcohol, Tumult (noise), Excercise

Question 13

In migraine with aura, what part of the pathophysiology caauses the aura symptoms?

Answer 13

This would be the constricting and dilating of blood cells

Aura - vision problems - flashes, dots

Numbness and tingling in limbs etc

Question 14

Migraine with aura

• 20% of all cases
• Aura fully reversible visual, sensory, motor or

language symptom
How long dose the aura tend to last?
When is the headache said to occur due to the aura?

Answer 14

Aura tends to last 15-30 minutes but can last up to one hour

The headache begins within one hours of onset of aura but the aura symptoms can occur simultaneously

Question 15

Visual symptoms are the most common aura symptoms

What visual symptoms can occur?

Answer 15

Visual symptoms are the most common

Can have flashing lights, dots

Central scotoma, hemianopia

Question 16

Potential triggers for migraine have already been discused, try and rename then?

Treatment can be both non-pharmacological and pharamcological (acute + prophylaxis for both)

What are non-pharmacological treatments?

Answer 16

Chocolate, Hangovers, Orgasms, Cheese, OCP, Lie-ins, Alcohol, Tumult, Exercise

Non pharamcological treatments - avoid triggers, keep a headache diary that helps you to note down what the triggers are, attempt to stay relaxed and stress free

Question 17

If opting for a pharmacological approach of treating the acute migraine,

What is given? 1st and 2nd line When should the treatments be taken?

Answer 17

1st line - Offer triptan (can be given alone or in combination with paracetamol or NSAID)

For people preferring monotherapy, can give NSAID (ibuprogen, aspirin or naproxen) or paracetamol or triptans

(generally NSAIDs are given+/- anti-emetics if the patient has gastroparesis)take as early as possible

Triptans should be taken at the start of headaches

Question 18

What is the first line treatment of migraines in a pregnant patient?

Answer 18

Pregnancy - 1st line would be paracetamol

Question 19

Abortive- NSAID

• • Step wise approach Vs stratified management
• • NSAID- Aspirin, naproxen, ibuprofen
• • Take as early as possible
• • 60% significant reduction in headache at 2 hours

(only 25% complete pain relief)

• • If gastroparesis consider antiemetic - name the ones that are usually given?
• How do triptans work? Name one triptan? How can they be given?

Answer 19

Consider offering an anti-emetic (such as metoclopramide 10mg or prochlorperazine 10mg) in addition to other acute medication even in the absence of nausea and vomiting.

Triptans are 5HT1 agonists

• Oral sumatriptan (50–100 mg) is first choice — other triptans should be offered if sumatriptan fails eg rizatriptan
• They can be given orally, sublingually and subcut - important to consider in a patient with nausea and vomiting

Question 20

NSAIDs are much less expensive than triptans and they are therefore preferred, the efficacy of the two drugs is also almost the same

What can overuse of triptans cause?

Answer 20

They can cause triptan induced headaches

Question 21

When is prophylaxis to migraines given?

How long must each prophylactic trial drug be given before considering changing drug?

Answer 21

Pophylaxis is given if there is 3or more migraine attacks monthly or very severe attacks

Each porphylactic drug must be trialled for at least 4 months

Question 22

What are drugs that can be given as prophylaxis for the migraine? (name 3)

Remember trigger avoidance whilst taking the drugs is still key

Answer 22

Beta blockers - propanolol - usually given 1st

Anti-convulsants - topiramte - avoid in pregnant

Tri-cyclics - amitryptiline

Question 23

When should adminstration of beta blockers not be used?

How does topiramte work?

What are the side effects?

Answer 23

Beta blockers- do not give if the patient has asthma, peripheral vacular disease or heart failure

• Topirmate works by inhibiting carbonic anydase (also acts on voltage activated sodium and GABA channels)
• Topirmate can cause wight loss, parasthesisia, impaired concentration and is an enzyme inducer
• It also starts slowly

Question 24

What is the aim of the prophylaxis of migraines?

How long must each drug be trialled for before changing?

Answer 24

Aim of prophylaxis is to titrate drug as tolerated to achieve efficacy at the lowest possible dose

Each drug should be trialled for a minimum of 4 months

Question 25

What lifestyle factors should be changed in migraine?

Answer 25

Diet - avoid triggers and have a healthy diet ## Footnote Stay hydrated - 2 lites daily and avoid caffeine Decrease stress and exercise

Question 26

Migraine common unilateral headache of young * Infrequent treat symptomatically * Consider prophylaxis for those more than 3 attacks per month * Consider non pharmacological treatment * For typical migraine no investigations required When might imaging be required in amigriane?

Answer 26

If the person is late onset \>55, there is a known malignany or acephalgic migraine (no headaches) - basically acephalgic means there is aura but no migriane

Question 27

What is the difference between a tension headache and a migraine? (describe how tension headaches presents and what features it does not exhibit that migraines do)

Answer 27

Tension type headache is a mild-moderate bilateral headache which is a non-pulsatile pain in the absence of autonomic features (nausea+vomiting) and in the absence of photphobia and phonophobia ## Footnote Tension headaches are not sensitive to head movement also Migraine - unilateral, moderate to severe, throbbing/pulsating, worse on movement headache associated with autonomic features and photo/phonopobia

Question 28

How long do tension headaches tend to last?

Answer 28

Typically lasts hours to days

Question 29

Tension headache * Stress and mental tension are common triggers. * Symptoms include dull, non-pulsatile, bilateral, constricting pain (not severe); pericranial tenderness is common. * Unlike migraine, there is no significant nausea, no vomiting, and a lack of aggravation by routine physical activity. What is the usual treatment of this headache? WHat can be used for preventative measures?

Answer 29

Stress relief and relaxation is a good non-pharamcological method Simple analgesia usually solves the tension headache problem - paracetamol or aspirin ## Footnote If the tension headache is not episodic and instead is chronic (ie greater than 7 to 9 per month) then can give tri-cyclic antidepressants such as amtryptiline

Question 30

# Define trigeminal autonomic cephalgias (TACs)? Remember acephalgic migraine means the migraine has the aura symptoms without the headache - just a clue for what cephalgic means here

Answer 30

These are a group of primary headaches disordered characterised by a unilateral trigeminal distribution pain that occurs in association with prominent ipsitlateral cranial autonomic features

Question 31

Migraine and tension headaches are the bog standard headaches, the trigeminal autonomic cephalgias are the headaches associated with cranial autonomic features What are the cranial autonomic features?

Answer 31

* Ptosis - drooping eyelid * Miosis -constricted pupil * Nasal stuffiness * Neausea/vomiting * Tearing * Eye lid oedema

Question 32

Name the cranial autonomic features again? What are the four different TAC?

Answer 32

Cranial autonomic features - ptosis, miosis, nose stuffiness, nausea and vomiting, tearing, eye lid oedema TAC types: * Cluster headache * Paroxysmal hemicrania * Hemicrania continuia * SUNCT (sudden unilateral, neuralgiaform headache, conjunctival injections, tearing) Migraines only occur couple times monthly, these occur frequently through the day unless treated

Question 33

Describe a cluster headache? ## Footnote What is the hypothesisied cause of cluster headaches? What age group does it affect?

Answer 33

A cluster headache is a primary headache disorder that causes severe unilateral trigeminal nerve pain around one eye that may cause ipsilateral cranial autonomic features as well and tends to recur over a period of several weeks. ## Footnote Thought it may be potentially due to superficial temporary artery smooth muscle hyperactivity due to 5HT Affects men usually in their 30s-40s

Question 34

* How long to cluster headaches tend to last? * How often does it occur daily and when? * How long do the cluster bouts last? The cluster bouts are followed by pain free periods of months and even years before the next attack

Answer 34

The headaches tend to last anywhere from 15 minutes to 3 hours They usually occur around twice a day but can be up to 8 times daily and are more common to occur at night The bouts lasts usually from a few weeks to months (4-12 weeks)

Question 35

WHat is given as the treatment for cluster headaches? What can be given for prophlaxis of this type of TAC?

Answer 35

* High flow oxygen 100% in a non rebreather mask for 20 minutes is recommended * 6mg subcut sumatriptan at onset * and * Steroid injections - start at beginning of bout and continue over 2 weeks (40mg reducing course) Verapamil can be given for prophylaxis

Question 36

Describe cluster headaches in full?

Answer 36

* Severe unilateral headache in trigeminal distribution with associated ipsilateral cranial autonomic features * Usually last 15mins-3hours and occur once to 8times daily, usually occur at night time * Bouts lasts for 4-12 weeks with long periods between bouts Tx * High flow (100%) oxygen given for 20 mins, 6mg subcut sumitriptan,Steroids - 40mg with reducing dose over 2 weeks * Prophylaxis - verapmil

Question 37

Paroxysmal hemicranias - they are similar to cluster headaches in presentation How do they differ however? (gender, age, duration, fequency)

Answer 37

Similar - both severe unilateral headache with unilateral cranial autonomic features ## Footnote They occur more commonly in women ages 50-60s Duration is shorter (2 minutes to 45 minutes this time) and they are more frequent - 1to40 times per day

Question 38

Paroxysmal hemicrania - shorter duration and more frequent than cluster headaches What is the difference in duration and frequency in both? What is the treatment for paroxysaml hemicrania?

Answer 38

Cluster headache * Duration - 15 mins to 3 hours * Frequency - once to 8 times per day * Paroxysmal hemicrania * Duration - 2 minutes to 45 minutes * Frequency - one to 40 times per day Treatment - absolute response to indomethacin

Question 39

Hemicrania continua is The following diagnostic criteria are given for hemicrania continua: * Headache for more than 3 months fulfilling other 3 criteria: * Unilateral pain that is continous (no pain free peridos) and has sometimes exacerbations of severe pain pain * At least one ipsilateral cranial autonomic feature and completely responds to one specific drug. What is this drug?

Answer 39

The factor that allows hemicrania continua and its exacerbations to be differentiated from migraine and cluster headache is that hemicrania continua is completely responsive to indomethacin ## Footnote Triptans have no effect whatsoever

Question 40

What does the trigeminal autonomic cephalgia, SUNCT stand for?

Answer 40

* Short lived * Unilateral * Neuralgiaform headache * Conjunctival injections * Tearing

Question 41

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome), is a rare headache disorder that belongs to the group of headaches called trigeminal autonomic cephalalgia (TACs) * What are conjunctival injections? * How short lasting is this headache? * How is the condition different from paroxysmal hemicrania? * What is the treatment options?

Answer 41

* Conjunctival injections is redness of the eye * The symptoms usually last 15-120 seconds * Cluster headaches tend to last far longer (up to 3hours) and are less frequent (up to 8 times daily) * Paroxysmal hemicranias occur just as often, only last slightly longer (2-45 minutes) but SUNCT is unresponsive to indemethacin Treatment options include lamotrigine and gabapentin

Question 42

How do lamatorigine and gabapentin work?

Answer 42

Lamotrigine - this is anticonvulsant medication * It appears to increase the action of gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter in the central nervous system and decrease voltage-sensitive sodium channels Gabpentin - a gabapentoid - acts by inhibiting certain calcium channels.

Question 43

What investigations are done into patients with new onset unilateral cranial autonomic features?

Answer 43

MRI brain and MR angiogram ## Footnote Normal in primary headaches

Question 44

What is idiopathic intracranial hypertension and who does it affect (include presentation here)?

Answer 44

This is usually thought of in patients who present as if there were a mass but none is found (papilloedema, increased ICP and headache) Typical presentation is in obese women with narrowed visual fields due to papilloedema (bilateral optic disc swelling) and blurred vision

Question 45

Idipathic intracranial hypertension * Mostly overweight females * Headache - diurnal variation, morning nausea and vomiting * Visual loss * Headache probably due to raised ICP causing papillodema also hence the visual loss * How is the diagnosis of this condition made? * How is the condition treated?

Answer 45

* Visual fields test * Fundoscopy * MRI to excluse any brain mass Treatment - weight loss, acetaolzamide (carbonic annyhdrase inhibiitor), can try furosemide

Question 46

What patients are trigeminal neuralgia more common in? ## Footnote What trigeminal dvisions does it usually affect? What are the symptoms? How many per day and how long do they last?

Answer 46

More common in elderly patients \>60, more common in females ## Footnote Usually symptoms are triggered by touch normally in CNV2and3 regions Features - severe sharp stabbing unilateral pain Patients can have 10-100 recurrences per day which last from one second to 90 seconds

Question 47

What is the treatment for trigeminal nerualgia? (which group of drugs is first line) If pharmacological treatments dont work, what can be carried out? What is carried out first?

Answer 47

Anti-convulsants are first line * Carbamezapine, lamtroigine, phenyotin or gabapentin * If anticonvulsants dont work then baclofen (activates GABA receptors) Carry out MRI before surgery: ablation or microvascular decompression