Headaches

Question 1

What parts of the symptoms graph are important to include in the history?

Answer 1

1. onset
2. peak
3. relieving factors
4. exacerbating factors
5. associated features

Question 2

What are the headache red flags?

Answer 2

• new onset headache in >55 years old
• known/previous malignancy
• immunosuppressed
• early morning headache
• exacerbation by valsalva - coughing, sneezing

Question 3

How often do migraines usually occur?

Answer 3

One attack a month

Question 4

What is the criteria for headache diagnosis without an aura?

Answer 4

At least 5 attacks lasting 4-72 hours
2 of moderate severity, unilateral throbbing, worse on movement
1 with associated autonomic features - phonophobia/photophobia

Question 5

Describe the pathophysiology of a migraine

Answer 5

Vascular and neural influences as a result of stress triggers leads to serotonin release - blood vessels constrict and dilate - chemicals including substance P irritate nerves and blood vessels causing pain

Question 6

What is the migraine generating centre?

Answer 6

Dorsal raphe nucleus and locus coeruleus

Question 7

What causes a migraine with an aura?

Answer 7

Triggers will cause activation of the trigeminal vascular system causing dilatation of cranial blood vessels, cortical spreading of depolarisation and ultimately release of substance P, neurokinin A and CGRP

Question 8

How long do visual auras last?

Answer 8

20-60 minutes with a headache less than an hour after - can be simultaneous

Question 9

What is the most common visual symptom?

Answer 9

Monochromatic

Question 10

Name the triggers of migraines

Answer 10

• sleep deprivation
• dietary
• stress
• hormonal
• physical exertion

Question 11

What is the acute treatment for a migraine?

Answer 11

Analgesia - aspirin, naproxen, ibuprofen
+/- antiemetic if gastroporesis
Triptans

Question 12

What are triptans?

Answer 12

5HT agonists that should be taken at the start of a headache

Question 13

Name two triptans used?

Answer 13

Rizatriptan

Frovatriptan - for sustained relief

Question 14

When should prophylaxis be given in migraines?

Answer 14

More than 3 attacks a month or very severe attacks - trial for 10-12 weeks aim to titrate drug as tolerated to achieve efficacy at lower dose

Question 15

Name three drugs that can be used as prophylaxis for migraines

Answer 15

• Amitriptyline
• Propranolol
• Topiramate

Question 16

State the five types of ‘fancy’ migraine

Answer 16

Acephalgic - aura without a headache 
Basilar - vertigo 
Retinal/ophthalmic 
Hemiplegic - encephalopathic, weakness
Abdominal - usually in kids +/- headache

Question 17

Describe a tension type headache

Answer 17

Episodice, chronic pressing tingling, tends to be mild to moderate bilateral with no associated features

Question 18

How is a tension headache treated?

Answer 18

Identify cause/triggers and relaxation physiotherapy

Amytriptyline/dothiepin can be used for three months

Question 19

What is a trigeminal autonomic Cephalgia? Name the three types

Answer 19

Primary headache complexes affecting the trigeminal nerve

• cluster headache
• paroxysmal hemicrania/continua
• SUNCT

Question 20

What are the signs of trigeminal autonomic cephalgia?

Answer 20

Ptosis, miosis, nasal stuffiness, nausea/vomiting, tearing, eye lid oedema

Question 21

What is a cluster headache?

Answer 21

Often in young men, circadian rhythm with seasonal variation - severe unilateral headache lasting 20mins -3hours and 1-8 per day. Clusters can last weeks to months

Question 22

How are cluster headaches treated?

Answer 22

High flow oxygen at home
Sub-cutaneous sumatriptan (reduces severity)
Steroids for 2 weeks
Verampamil prophylaxis

Question 23

Describe paroxysmal hemicrania/continua

Answer 23

More common in elderly females - severe unilateral headache with unilateral autonomic features - lasts 2 mins to 45 hours and can have up to 40 attacks a day

Question 24

What does paroxysmal hemicrania respond to?

Answer 24

Inclomethicin

Question 25

What does SUNCT stand for?

Answer 25

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

Question 26

How can SUNCT be treated?

Answer 26

Lamotrigine or gabapentin

Question 27

What investigation is given in all trigeminal cephalgias?

Answer 27

MRI including angiogram to check for aneurysm

Question 28

How does idiopathic intracranial hypertension present?

Answer 28

Bilateral papilloedema, diurnal variable headache with nausea and vomiting in the morning. Visual loss when standing up often in overweight females.

Question 29

What will an MRI of idiopathic intracranial hypertension show?

Answer 29

Empty sella and flattened optic disc

Question 30

What will CSF in idiopathic intracranial hypertension show?

Answer 30

Elevated pressure but normal constituents

Question 31

How is idiopathic intracranial hypertension treated?

Answer 31

Weight loss, acetazolamide | If persistent visual loss ventricular atrial/lumbar peritoneal shunt may be done

Question 32

Describe trigeminal neuralgia

Answer 32

Elderly women, severe sharp stabbing many times a day often aggregated by touch. 10-100 a day lasting 1-90 seconds can last weeks/months before remission

Question 33

What is the most common cause of trigeminal neuraliga?

Answer 33

Aberrant blood vessel irritating the nerve

Question 34

How is trigeminal neuralgia treated?

Answer 34

Anticonvulsant - carbamazepine, gabapentin, phenytoin, baclofen Ablation or compression if very severe