Headaches

Question 1

Definitions of episodic and chronic migraine

Answer 1

Episodic migraine - occurs on less than 15 days per month
Subdivided into:
- Low frequency (1–9 days per month)
- High frequency (10–14 days per month).

Chronic- headache occurring on at least 15 days per month
Need migraine features on at least 8 of these days.
Needs to be for more than 3 months.

Question 2

How long do migraines last

Answer 2

4-72h
Usually get pre and post phases. Pre (called premonitory) can be unusual stiff like thirst/ increased frequency of urination/ yawning.
Post is usually tiredness

Question 3

Which nerve is thought to be affected in migraines

Answer 3

1st division trigeminal sensory neurons

Question 4

What does migraine increase your risk of

Answer 4

Both ischaemic and hemorrhagic stroke.

Question 5

How is migraine with and without aura diagnosed

Answer 5

Migraine without aura - need at least 5 attacks meeting the criteria e.g. lasts 4-72h, unilateral, pulsating, sound aversion

Migraine with Aura - Need at least 2 attacks filling the criteria

Question 6

When to suspect menstrual migraine

Answer 6

When migraines occur between 2 days before and 3 days after the start of menstruation for at least 2 out of 3 consecutive cycles.

Question 7

What is a medication overuse headache

Answer 7

Can get this if you use simple analgesics on 15 or more days of the month

Or if you use triptans for 10 or more days

Question 8

Acute migraine tx for adults and when to follow up

Answer 8

400-600mg ibuprofen OR 900mg aspirin OR 1g paracetamol

50-100mg sumatriptan.
If vomiting restricts PO use then could try intranasal

Consider px anti sickness - metoclopramide 10mg or prochlorperazine 10mg but not regularly

NICE says Triptan + NSAID with a long half-life e.g. naproxen may be most effective.

Should follow up within 2-8 weeks.

Question 9

When should a patient take acute migraines tx if they have migraine with aura?

Answer 9

With the onset of the headache NOT the onset of the aura.
If it hasn’t worked within 2h of the headache its unlikely to work

Question 10

Risks to a woman of childbearing age with topiramate

Answer 10

To fetus: Fetal malformations and neurodevelopmental impairment.

Topiramate can reduce blood levels of ethinyl estradiol (used in contraceptive pills - may therefore reduce efficacy of hormonal contraceptives - consider barrier + hormonal pills or IUS/D. Implant doesn’t count

Question 11

How long might it take migraine prevention to work?

Answer 11

Up to 6 weeks

Question 12

first line options for migraine prevention

When do you review

Answer 12

Review after 3-6m then if no good consider changing.

Topiramate 50-100mg- C/I if wanting a family. Need good contraception

Propranolol (80–160 mg daily, in divided doses)- careful if e.g. depressed (propranolol high risk in OD). Also caution but not CI in pregnancy.

Amitriptyline 25-75mg ON

NICE also lists Candesartan 16 mg daily. C/I in pregnancy and mentions valproate however I think now this is specialist initiation. Only in people over 55
- Sodium valproate (400–1,500 mg daily - only in people over 55.

Question 13

What non pharmacological interventions can be used in migraine

Answer 13

Relaxation/CBT

Acupuncture (up to 10 sessions over 5–8 weeks) if both topiramate and propranolol are unsuitable or ineffective

Riboflavin 400 mg once a day

Question 14

When would you consider stopping migraine prophylaxis and when

Answer 14

once sx have beenfter 6-12m successful therapy
Gradually withdraw

Question 15

If first line migraine management doesn’t work what further tx options are available and when

Answer 15

If 3 first line haven’t worked/ aren’t tolerated/ C/I

• Sublingual rimegepant for episodic migraines (at least 4 but fewer than 15 migraines a month)
• Episodic or chronic - Atogepant or various MABs that have various routes e.g. IV/ SC
• Chronic migraine: Botox

Question 16

What should you consider with a headache in the context of a current or recent pregnancy

Answer 16

pre-eclampsia
Central venous sinus thrombosis.

Question 17

Paroxysmal hemicrania

Answer 17

Similar to cluster headaches. These respond to indomethacin whereas cluster headaches respond to o2.
These are more common in women. Cluster more common in men.

Question 18

Who cant have triptans

Answer 18

hx of or significant risk factors for IHD or stroke

Question 19

What can be given for menstrual related migraines

Answer 19

If standard acute treatment fails can try
Frovatriptan (2.5 mg twice daily) from 2d before to 3d after period starts (5d max) or on the days migraine is expected.

or

Zolmitriptan 2.5 mg BD/TDS - smae rules as above

Question 20

If a patient has migraines but wants to become pregnant then what

Answer 20

Migraine without aura usually gets better so stop prophylaxis

Migraine with aura can get worse so specialist advice

If youre starting women on prophylaxis need to tell them if they plan to get pregnant to come back for meds review

Question 21

What acute management can be given for migraine in pregnancy

Answer 21

Paracetamol
Ibuprofen till 28 weeks but NOT AFTER
Triptans are ok

Question 22

Triptans in pregnancy - is this ok?

Answer 22

BNF says avoid unless potential
benefit outweighs risks.

Sumatriptan preferred

Risks should be discussed:
* Not associated with increased risk of premature delivery or major congenital malformation (best evidence for sumatriptan).
* Spontaneous abortion: risk increased in one meta-analysis, not in a larger cohort study.
* Possible increased risk of externalising behaviour problems in the child (e.g. hitting) (cohort
study, low-quality evidence).

Question 23

What can you use as tension headache prophylaxis

Answer 23

Acupuncture/ amitriptyline