YearClub 2026 Neurology session (headache) Flashcards
Are migraines typically recurring?
Yes, typically recurring and lasts 4-72 hours.
What is the underlying pathophysiology of a migraine headache?
Cortical spreading of depolarisation In the dorsal raphe nucleus and locus coeruleus, causing activation of trigeminal vascular system and vasodilation of blood vessels which then causes pain.
Common triggers of migraine headache?
- Stress
- Skipping meals
- Menstrual cycle
- Certain foods
- Lack of sleep
Clinical presentation of migraine headache?
Unilateral (one sided) throbbing headache
“Aura” occurs after onset of pain in migraine headache. True/false?
False. ‘aura’ before the onset of pain, and can be visual, auditory, sensory or motor (GI pain is typical in children).
Associated symptoms with migraine headaches?
Increased pain on movement, photophobia, nausea and vomiting.
How is diagnosis of migraine headache made?
Mainly clinical however CT scan can be used to rule out stroke.
Acute management of migraine headache?
NSAID’s or triptans (+/- antiemetics)
Examples of triptans include:
Sumatriptan.
Zolmitriptan.
Frovatriptan.
If occurring more than 3x per month. What is the preventative treatment of these migraine headaches?
Propanolol or topiramate and AVOID TRIGGERS
What are tension headaches associated with and what could it be triggered by?
Strongly linked to depression and anxiety, and often triggered by stress.
Possibly due to a stiffening of the muscles of the face and neck
What does a tension headache feel like?
Headache ‘like a tight band of pressure’ and possible tingling sensation in this distribution.
Treatment of tension headache?
Reassurance, relaxation therapy/ CBT, amitriptyline if refractory pain
What is a cluster headache?
Type of Trigeminal autonomic cephalgia – a headache which has autonomic facial features in the distribution of the trigeminal nerve
Who does cluster headaches mainly affect and what is the general feeling?
Men > women. Unilateral periorbital pain. “worst headache ever experienced”, can’t sit still
Clinical features of autonomic cephalgia - cluster headaches?
Ptosis, miosis (excessive constriction of pupil in eye), nasal stuffiness, eye tearing, eyelid oedema
How do cluster headaches present?
Headaches last 15 min- 3 hours but occur in “clusters” of 4-12 weeks
Imaging used for a cluster headache?
Need to use MRI and MRI angiogram imaging (to rule out secondary causes)
Treatments for cluster headaches?
Acute: high flow O2 and subcutaneous or oral triptan +/- 2 week reducing course steroids
Prophylaxis: verapamil
What is idiopathic intracranial hypertension (IIH)?
Unknown cause of chronically raised ICP, due to chronically raised CSF pressures.
What is IIH associated with and what are the symptoms?
High association with obese young women
Headache – worst in morning/ coughing, relieved when standing
Nausea and vomiting
Blurred vision (papilloedema)
Nausea and vomiting
What investigations are used for IIH and what do they show?
Fundoscopy: bilateral papilloedema, enlarged blind spot
CT/MRI: “slit like ventricles”
Lumbar puncture: raised opening pressure
Treatment for idiopathic intracranial hypertension?
Ace
WEIGHT LOSS
Tazolamide
shunt CSF from ventricles to peritoneum
What is trigeminal neuralgia?
Chronic neuropathic pain in distribution of CN V (cranial nerve 5)
Causes of trigeminal neuralgia?
Compression from superior cerebellar artery
AVM (arteriovenous malformation - tangle of blood vessels that irregularly connects arteries and veins, disrupting blood flow and oxygen).
Tumours
MS (multiple sclerosis)
Injury to the nerve (eg stroke or trauma)
What does the patient present with in trigeminal neuralgia?
Severe pain when chewing and talking, pain on contact (eg shaving, washing face) with psychological consequences
What imaging is used for trigeminal neuralgia?
MRI to rule out MS or tumour
Treatment of trigeminal neuralgia?
Pain relief (carbamazapine or amitriptyline)
Possible surgical treatment of trigeminal neuralgia?
Microvascular decompression (a surgery to relieve abnormal compression of a cranial nerve)
Balloon compression
Radiofrequency ablation
Worst headache ever, feels like a hit to the back of the head. What is it?
Subarachnoid haemorrhage
Headache + paralysis, weakness on 1 side of body and face, slurred speech. What is it?
Stroke
Headache + fever, stiff neck, mental confusion, seizures, double vision. What is it?
Meningism (shares same symptoms as meningitis but without meningeal inflammation).
CSF pressure may be elevated but CSF is normal.
Headache “behind the eye” and other neuro complications. What is it and what condition is it associated with?
Optic neuritis - inflammation of the optic nerve. Strong association with MS.
New headache which wakes you +/- vomiting. What is it?
Brain tumour - RED FLAG
What type of drug are triptans?
Serotonin receptor agonists
Mechanism of triptans?
In acute attacks, triptan binds to the specific serotonin receptors causing intracranial vasoconstriction leading to decreased blood flow causing the attack to calm.
Triptans are usually used first line in combination with NSAID or paracetamol. true/false?
True
Contraindications of triptans?
Patient with history or significant risk factors of, ischaemic heart disease or cerebrovascular disease.
For migraine with aura, some patients report beginning of onset 48 hours before headache. True/false?
True
In migraine with aura, what phase occurs before the headache?
Prodromal phase
Features of prodromal phase of migraine with aura?
Severe visual symptoms occurring 60 mins before headache appearance
Irritability
Depression
Frequent yawning
Hyperexcitability
What can migraine with aura be referred to as?
Classic migraine
For migraine with aura, what visual symptoms can occur before headache (around 60 mins before)?
Flashes of light (photopsia)
Wavy linear patterns on visual field (fortification spectra)
Migrating scotoma
Blurred vision
Characteristic of migraine with aura?
Headache itself usually described as pulsatile or throbbing
Typically duration of migraine with aura headache?
4-72 hours
Migraine with aura will show abnormal MRI. True/false?
False
MRI will be normal
Common symptoms occurring alongside headache with classic migraine?
Nausea
Vomiting
Photophobia (light sensitivity)
Phonophobia (sound sensitivity)
Irritability
Malaise
What is first-line prophylaxis (prevention) for migraine?
Propranolol
If propranolol is contraindicated, what is second line prophylaxis for migraine?
Topiramate
What are some signs that could be present in meningitis?
Kernig’s sign
Nuchal rigidity
Brudzinski’s sign
What is Kernig’s sign?
Positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance).
This may indicate subarachnoid hemorrhage or meningitis.
What is nuchal rigidity?
The inability to flex the neck forward due to rigidity of the neck muscles; if flexion of the neck is painful but full range of motion is present, nuchal rigidity is absent.
What is a positive Brudzinski’s sign?
Is positive when the forced flexion of the neck elicits a reflex flexion of the hips, with the patient lying supine.
Basically when lying down and neck flexed forward, hips flex and knees come up
