Headache

Question 1

Migraine tends to occur in whom?

Answer 1

Young females.

Question 2

What features may be associated with headaches?

Answer 2

• Photophobia.
• Phonophobia.
• Positive visual symptoms.
• Ptosis, miosis.
• Nasal stuffiness.
• Autonomic features e.g. n+v.

Question 3

Red flags in headaches?

Answer 3

• New onset >55 y/o.
• Known/previous malignancy.
• Immuno-suppressed.
• Early morning headache.
• Exacerbated by valsalva/coughing/sneezing (which raise ICP).

Question 4

Are most migraines with or without aura?

Answer 4

Without- 80%.

Question 5

IHS criteria for migraine without aura.

Answer 5

• At least 5 attacks.
• Duration of 4-72 hours.
• 2 of: moderate/severe pain, unilateral pain, throbbing pain, pain worse on movement.
• 1 of: autonomic features, photophobia or phonophobia.

Question 6

How may migraines be induced by stress?

Answer 6

• Serotonin release in the brain causes constriction and dilation of blood vessels.
• Chemicals e.g. substance P irritate nerves and blood vessels to cause pain.

Question 7

How long does aura last in migraine?

Answer 7

20-60 minutes.

Question 8

Do migraine and aura always occur simultaneously?

Answer 8

No.

Aura may occur an hour before headache onset or simultaneously.

Question 9

What types of aura are associated with migraine?

Answer 9

• Visual.
• Sensory.
• Motor.
• Language symptoms.

Question 10

Describe visual aura of migraine.

Answer 10

• Central scotoma.
• Central fortification.
• Hemianopic loss.

Question 11

Migraine may be triggered by?

Answer 11

Sleep, diet, stress, hormones, physical exertion.

Question 12

Non-pharmacological treatment of migraine?

Answer 12

• Set realistic goals.
• Avoid triggers.
• Headache diary.
• Relaxation/stress management.

Question 13

Pharmacological treatment of acute migraine?

Answer 13

• Acute: NSAID (aspirin, naproxen, ibuprofen, triptans ASAP +/- anti-emetic if gastroparesis.

Question 14

Dose of aspirin in acute migraine?

Answer 14

ASAP 900mg +/- anti-emetic if gastroparesis.

Question 15

Dose of Naproxen in acute migraine?

Answer 15

ASAP 250mg +/- anti-emetic if gastroparesis.

Question 16

Dose of ibuprofen in acute migraine?

Answer 16

ASAP 400mg +/- anti-emetic if gastroparesis.

Question 17

Pharmacological prophylaxis of migraine should be considered when?

Answer 17

If more than 3 attacks per month or if very severe.

Question 18

What is the aim of migraine prophylaxis?

Answer 18

To titrate drug as tolerated to achieve efficacy at lowest dose possible.

Question 19

How long must migraine prophylaxis drugs be trialed?

Answer 19

A minimum of 4 months each.

Question 20

Which beta-blocker reduces migraine frequency in 60-80% of patients?

Answer 20

Propranolol.

Question 21

Daily dose of propranolol to reduce migraine frequency?

Answer 21

80-240mg.

Question 22

When should propranolol be avoided?

Answer 22

Asthma, PVD, heart failure.

Question 23

What is topiramate?

Answer 23

Carbonic anhydrase inhibitor (Na+/GABA).

Question 24

Daily dose of topiramate in prevention of migraine?

Answer 24

25-100mg.

Question 25

Adverse effects of Topiramate?

Answer 25

- Weight loss, paraesthesia, impaired concentration, enzyme inducer.

Question 26

Side effects of amitriptyline?

Answer 26

Dry mouth, postural hypotension, sedation.

Question 27

Describe a tension type headache.

Answer 27

- Pressing tingling quality. - Mild to moderate pain. - Bilateral. - Absence of N+V. - Absence of photophobia/phonophobia. - Episodic or chronic nature.

Question 28

Management of tension type headache?

Answer 28

- Relaxation physiotherapy. - Anti-depressant (dothiepin or amitriptyline) for 3 months. - Reassurance.

Question 29

What are trigeminal autonomic cephalgias (TACs)?

Answer 29

Primary headache disorders characterised by pain in a unilateral trigeminal distribution in association with prominent ipsilateral cranial autonomic features.

Question 30

Name the ipsilateral cranial autonomic features associated with trigeminal autonomic cephalgias (TACs).

Answer 30

- Ptosis. - Miosis. - Nasal stuffiness. - Nausea/vomiting. - Tearing. - Eye lid oedema.

Question 31

What are the four main types of trigeminal autonomic cephalgias (TACs)?

Answer 31

- Cluster headaches. - Paroxysmal hemicrania. - Hemicrania continua. - Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT).

Question 32

Cluster headache is most common in who?

Answer 32

Men in their 30s-40s.

Question 33

When do cluster headaches typically occur?

Answer 33

- Striking circadian (around sleep). | - Seasonal variation.

Question 34

Features of a cluster headache?

Answer 34

Severe unilateral headache lasting 45-90 mins and occurring 1-8x a day. A cluster bout may last from weeks to months.

Question 35

Management of cluster headaches?

Answer 35

- High flow 100% oxygen for 20 mins. - Sub/cut Sumatriptan 6mg. - Steroids: reduce course over 2 weeks. - Prophylactic Verapamil.

Question 36

Paroxysmal hemicrania is most common in who?

Answer 36

Woman in their 50s-60s.

Question 37

Features of paroxysmal hemicrania?

Answer 37

- Severe unilateral headache. - Unilateral autonomic features. - Last 10-30 mins 1-40x a day.

Question 38

Management of paroxysmal hemicrania?

Answer 38

Indomethicin. If it don't respond to indomethicin, it ain't paroxysmal hemicrania.

Question 39

SUNCT stands for?

Answer 39

- Short lived. - Unilateral. - Neuralgiaform headache. - Conjunctival injections. - Tearing.

Question 40

Management of SUNCT?

Answer 40

- Lamotrigine, Gabapentin.

Question 41

Who requires investigation for headache?

Answer 41

New onset unilateral cranial autonomic features.

Question 42

What is the imaging used in investigating new onset unilateral cranial autonomic features?

Answer 42

- MRI brain. | - MR angiogram.

Question 43

Who is idiopathic intracranial hypertension most common in?

Answer 43

Obese females.

Question 44

How does idiopathic intracranial hypertension?

Answer 44

- Diurnal variation. - Morning n+v. - Visual loss.

Question 45

What will MRI brain with MRV sequence show in idiopathic intracranial hypertension?

Answer 45

Normal.

Question 46

What will CSF show in idiopathic intracranial hypertension?

Answer 46

Elevated pressure but normal constituents.

Question 47

Management of idiopathic intracranial hypertension?

Answer 47

- Weight loss. - Acetazolamide. - Ventricular atrial/lumbar peritoneal shunt. - Monitor visual fields and CSF pressure.

Question 48

Apart from imaging and CSF tap what should be tested in idiopathic intracranial hypertension?

Answer 48

Visual fields.

Question 49

Trigeminal neuralgia is more common in?

Answer 49

Elder women (>60 y/o).

Question 50

Trigeminal neuralgia is triggered by?

Answer 50

Touch usually in V2/3 dermatome.

Question 51

Features of trigeminal neuralgia?

Answer 51

- Severe stabbing unilateral pain. - Lasting 1-90 seconds 10-100x a day. - Bouts of pain may last weeks to months before remission.

Question 52

Medical management of trigeminal neuralgia?

Answer 52

Carbamazepine, Gabapentin, Phenytoin, Baclofen.

Question 53

Surgical management of trigeminal neuralgia?

Answer 53

Ablation, decompression.

Question 54

Investigation of trigeminal neuralgia?

Answer 54

MRI brain.

Question 55

What other non-neurological structures should be considered in headaches with facial pain?

Answer 55

- Eyes. - Ears. - Sinuses. - Teeth. - TMJ.