* Headache

Question 1

What are the primary headache types?

Answer 1

1) Migraine
2) Tension-type
3) Cluster headache

Question 2

What are the cranial nerves carrying brain fibres?

Answer 2

5, 7 9 & 10

Question 3

What are the most common causes of headache?

Answer 3

1) Migraine
2) Tension-type
3) Cluster
4) Intracranial mass lesion
5) Low intracranial pressure
6) Meningitis, SAH
7) Temporal arteritis, intracranial vasculitis?

Question 4

What is the mechanism of a migraine?

Answer 4

• Dilation and inflammation
• of intracranial and extracranial arteries
• Neurally induced

Question 5

What is the mechanism of a cluster headache?

Answer 5

• Inflammation and edema
• in Internal carotid artery
• Neuronally induced

Question 6

What is the mechanism of an intracranial mass lesion in causing a headcahe?

Answer 6

• eg Brain tumors, hydrocephalus
• Displaces pain-sensitive vessels

Question 7

What is the mechanism of low intracranial pressure in causing a headache?

Answer 7

• eg Post-lumbar puncture
• Traction through brain
• Causes sagging on dural attachments
• Intracranial vasodilation

Question 8

What is the mechanism of meningitis and SAH in causing a headache?

Answer 8

• Inflammation of vessels
• in Meninges and perivascular area

Question 9

What is the mechanism of temporal arteritis and intracranial vasculitis in causing headache?

Answer 9

• Inflammation
• of Scalp and intracranial vessels

Question 10

What are some danger signs of a headache?

Answer 10

• Abrupt onset that is unusually severe
• Associated with neurological symptoms
• Progressive headache over days to months
• Associated with N/V and fever
• Change in character or response to treatment of pre-existing headache
• New onset headache in adult life
• Associated with paroxysmal hypertension (episodic and volatile high blood pressure)
• Systemic symptoms of fever, weight loss and myalgia
• Associated with nocturnal occurrence and morning awakening

Question 11

What are the investigations for headache and when are they done?

Answer 11

When presentation of the patient has atypical features

1) Blood tests
2) Imaging
- Especially for patients with high-risk features

3) Lumbar puncture
- To diagnose CNS infections and exclude SAH

4) Biopsy
- of Temporal artery and meningeal artery

Question 12

How to diagnose headaches?

Answer 12

1) Presence of papilledema
- To rule out mass legions

2) Presence of Nuchal rigidity/neck stiffness
- Meningeal irritation seen in meningitis, SAH or intraparenchymal hemorrhage

Question 13

How to diagnose a migraine Without Aura / common migraine?

Answer 13

> 5 attacks fulfilling these criteria
- Lasts 4-72 hours and unsuccessfully treated
- At least 2 of these:
~ Unilateral location
~ Pulsating
~ Moderate or severe intensity
~ Pain aggravated by exertion

Attack should have at least 1:
- N/V
- Photophobia
- Phonophobia

No other disease that may cause headaches

Question 14

How to diagnose migraine with aura/Classic migraine?

Answer 14

• Typically precedes headache and lasts 20-30 min
  ~ Clears before headache begins
• Mostly visual aura
• Criteria is the same as for common migraine BUT +++ symptoms of neurologic function occurring before/during the attack

Question 15

What are the common types of migraine aura?

Answer 15

1) Visual
- See scintillating saw-tooth crescents of light
- Photopsias )glistening points of light)
- Shimmering heat-wave-like obscuration

2) Sensory
- Tingling/numbness
- Originates in mouth or hand

3) Others
- Mono/hemiparesis
- Dysphagia
- Cognitive changes

Question 16

What are the common triggers for migraines?

Answer 16

1) Hormones

2) Diet
- Alcohol, MSG, chocolate, aged cheese, artificial sweetener

2) Psychological

4) Sleep

5) Drugs
- Nitroglycerine, histamine, reserpine, hydralazine, ranitidine

6) Physical-environmental

Question 17

Migraine vs Tension-type vs Cluster

• Gender
• Location
• Frequency
• Severity and duration
• Pain characteristics
• Misc

Answer 17

• More common in females except for Cluster
• M: One side, T: Band-like, C: Peri-orbital
• M: 1-4/month, T: 1-30/month, C: 1-4/day for 3-12 months
• M: Mod-severe for 4-72 hours, T: Mild-moderate for variable time, C: Extremely severe for 15 min - 3hrs
• M: Throbbing and pulsating, T: Dull and boring, C: Sharp
• M has most family history
• M has aura
• C has autonomic features
• M has NN/V/, photopsia and exacerbation by movement

Question 18

What is the treatment for migraines?

Answer 18

1) NSAIDs
- NAPROXEN, IBUPROFEN

2) Mixed barbiturate analgesics
- ASPIRIN, ACETAMINOPHEN, Codeine-containing compounds

3) Triptans
- SUMATRIPTAN, ZOLMITRIPTAN/Zomig

4) Anti-emetics
- PROMETHAZINE, PROCHLORPERAZINE, METOCLOPRAMIDE

Question 19

What are the prophylaxis for migraines?

Answer 19

1) Beta-blockers

2) Calcium antagonists
- FLUNARIZINE
3) Anticonvulsants
- VALPROATE

4) NSAIDs
- NAPROXEN

5) Tricyclic antidepressants
- AMITRIPTYLLINE

Question 20

What are the main side effects for each migraine prophylactic?

Answer 20

1) B-blocker
- Weight gain, depression, cold extremities

2) Calcium antagonists
- Sedation, weight gain, depression, constipation

3) Anticonvulsants
- Tremor, weight gain, hair loss

4) NSAIDs
- Dyspepsia, peptic ulcers

5) Tricyclic antidepressants
- Sedation, dry mouth, weight gain

Question 21

When is migraine prophylaxis started?

Answer 21

• > 2 attacks/month
• Significant disability that lasts >3 days
• Ineffectiveness of symptomatic medications
• Use of abortive medications >2x/week
• For rare migraine variants (hemiplegic migraine, migraines producing profound disruption or neurological injury)

Question 22

What is medication overuse and rebound in migraines?

Answer 22

• Due to regular use oof acute, symptomatic medication for headaches (>15 days/month)
• eg Simple analgesics >5 days/week, Triptans >3 days/week, Opioids >2 days /week

Question 23

What is the MIDAS questionnaire?

Answer 23

• Self-administered Migraine Disability Assessment
• Assess headache over a 3 month period
• If score >6 days, see doc