Migraines

Question 1

Primary headaches = no known cause
Secondary headaches = have a known cause

Which of these is more common?

Answer 1

• primary

Question 2

What is the most common type of primary headache?

1 - migraines
2 - thunderclap
3 - tension type
4 - cluster

Answer 2

3 - tension type
- migraine is the 2nd most common form of primary headache

• incidence of 0.5-5%
• difficult to identify exact incidence

Question 3

What is the most common debilitating headache?

1 - tension headache
2 - thunderclap headache
3 - Migraine
4 - Cluster headaches

Answer 3

3 - Migraine
- also 2nd most common type of primary headaches

• 7th highest cause disability globally
• 2.9% of years of life lost to disability
• twice as likely in women

Question 4

Can migraines be pulsatile in nature?

Answer 4

• yes

Pulsatile may suggest increases BP or increased intracranial pressure

Question 5

What is the incidence of migraines?

1 - 50/100,000
2 - 500/100,000
3 - 5000/100,000
4 - 50,000/100,000

Answer 5

3 - 5000/100,000

Question 6

At what time do migraines generally start and begin to decline?

1 - starts at puberty and declines around 20y/o
2 - starts at puberty and declines around 40y/o
3 - starts at puberty and declines around 60y/o
4 - starts at puberty and declines around 80y/o

Answer 6

2 - starts at puberty and declines around 40y/o

• 2% have chronic migraines, causing medication overuse

Question 7

Are migraines more common in men or women?

Answer 7

• women
• 3x more likely

Question 8

Menstrual migraines can occur in women. When would these generally occur?

1 - days 1-2
2 - days 2-3
3 - days 5-7

Answer 8

2 - days 2-3
- before the period of during the period

Question 9

Are patients with comorbid psychiatric disorders such as anxiety & depression more or less likely to experience medication overuse headaches?

Answer 9

• more likely

Question 10

The trigeminal nerve (CN5) is derived from the 1st pharyngeal arch and is the largest of all the cranial nerves. What functions does this cranial nerve have?

1 - sensory only of the face
2 - motor only of mastication muscles
3 - both of the above
4 - none of the above

Answer 10

3 - both of the above

Question 11

What is the trigeminocervico complex?

1 - CN V (5) meets cervical vertebrae 1
2 - CN V (5) synapses in same nucleus as cervical vertebrae 1
3 - CN V (5) synapses in same nucleus as cervical vertebrae 1 and 2
4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3

Answer 11

4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3

• sensory only from CV V (5)
• this essentially means any sensory information from cervical vertebrae 1-3 can revert pain to the head causing a headache
• region of the brain receives nociceptive stimulus

Question 12

The trigeminocervico complex is a nucleus where CN V (5) synapses in same nucleus as cervical vertebrae 1-3 for sensory receptors only. Where is this located?

1 - cerebellum
2 - brain stem
3 - pons
4 - medulla oblongata and upper cervical spine

Answer 12

4 - medulla oblongata and upper cervical spine

Question 13

Which of the following is not part of the trigeminal nerve?

1 - ophthalmic
2 - maxillary
3 - accessory
4 - mandibular

Answer 13

3 - accessory

Question 14

The spinal trigeminal nucleus is a nucleus in the medulla that receives information about deep/crude touch, pain, and temperature from the ipsilateral (same side) face. Which of the following is important for pain and temperature sensations?

1 - Pars oralis
2 - Pars interpolaris
3 - Pars caudalis

Answer 14

3 - Pars caudalis

Question 15

Which of the following are typical triggers for developing a migraine?

1 - tiredness, stress, dehydration
2 - alcohol
3 - combined oral contraceptive pill
4 - cheese, chocolate, red wines, citrus fruits
5 - menstruation
6 - bright lights
7 - all of the above

Answer 15

7 - all of the above
Remember the mnemonic CHOCOLATE:

C = chocolate
H = hangovers
O = orgasms
C = cheese/caffeine
O = oral contraceptive
L = lie-ins
A = alcohol
T = travel
E = exercise

Question 16

Migraines are a form of primary headaches, which essentially means the cause is unknown. Do migraines typically present unilaterally or bilaterally?

Answer 16

• unilaterally

Question 17

Which of the following locations would the main symptom of a migraine be felt?

1 - on one side of the face
2 - around the eye on one side of the face
3 - across the top of the forehead
4 - all of the above

Answer 17

1 - on one side of the face

Question 18

Migraines are a form of primary headaches, which essentially means the cause is unknown. Which of the following do migraines NOT typically present with?

1 - severe, bilateral, throbbing headache
2 - nausea, photophobia (sensitive to light) and phonophobia (fear of sound)
3 - can last up to 72h
4 - patients typically stay in dark and quiet rooms
5 - auras maybe present
6 - stiff neck
7 - vary 1-2/month or 1/year

Answer 18

1 - chronic, bilateral, throbbing headache

• typically migraines are unilateral

Question 19

A migraine aura is something that you experience when having a migraine. which of the following is true?

1 - can be visual only
2 - can be auditory only
3 - can be motor or sensory
4 - all of the above

Answer 19

4 - all of the above

• most common is visual, and it is completely reversible
• builds up over time and can last up to 60 minutes
• more common in older patients, but no headaches

Question 20

An aura is when there are visual changes that are associated with migraines. What visual symptoms can be experienced in an aura?

1 - Sparks in vision
2 - Blurring vision
3 - Lines across vision
4 - Loss of different visual fields
5 - all of the above

Answer 20

5 - all of the above

Question 21

Auras typically occur prior to a migraine and can include visual (most common), auditory, motor and sensory aspects. Typically how long can the auras last for?

1 - <10 minutes
2 - <40 minutes
3 - <60 minutes
4 - <2 hours

Answer 21

3 - <60 minutes

Question 22

How long do migraines typically last?

1 - 4-72 hours
2 - 15-180 minutes
3 - 30 minutes to 1 week
4 - >1week

Answer 22

1 - 4-72 hours

Question 23

When migraines are present are they continuous or episodic?

Answer 23

• episodic
• typically throbbing unilaterally, but can be bilateral
• feels like someone is drilling on the side of your head

Question 24

Is the pain experienced during a migraine typically severe or moderate?

Answer 24

• Can range from moderate to severe

Question 25

Overuse of medication can present in a similar way to migraines. Which of the following are present in migraines that helps distinguish migraines from medication overuse in headaches? 1 - occurrence of headache 2 - duration of the migraine 3 - nausea and vomiting 4 - gender

Answer 25

3 - nausea and vomiting - both are present in migraines

Question 26

When performing a history on a patient with a headache, if there is an increase in headache symptoms when performing a Valsalva manoeuvre bad?

Answer 26

- Yes Indicates a space occupying lesion in cranial cavity Causes an increased intracranial pressure

Question 27

When performing a history on a patient with a headache, which of the following is NOT typically a red flag? 1 - patient wakes up with headache 2 - change in character 3 - age of onset 4 - sudden onset (thunderclap) 5 - focal neurological deficits 6 - constitutional symptoms (fever, meningism, rash, weight loss)

Answer 27

1 - patient wakes up with headache A RED FLAG here would be if the headache wakes the patient whilst they are asleep

Question 28

When examining a patient, all of the following are RED FLAGS except which one? 1 - patient appears sick-appearing, skin changes 2 - evidence of trauma 3 - altered cognitive state 4 - ocular: hyphema, pupil non-reactivity, optic disc swelling, proptosis, restricted eye movements 5 - meningism 6 - weight gain 7 - focal neurological findings (eg limb weakness)

Answer 28

6 - weight gain Weight loss is a red flag as it could be caused by malignancy

Question 29

Of the following, which is most likely to trigger a migraine? 1 - dehydration and stress 2 - food and weather 3 - cigarettes and alcohol 4 - medications

Answer 29

2 - food and weather

Question 30

When diagnosing a migraine if the patient has no aura, how many migraines lasting 4-72h should a patient have had? 1 - >3 2 - >5 3 - >8 4 - >12

Answer 30

2 - >5

Question 31

When diagnosing a migraine if the patient has no aura, patients should have >5 migraines lasting 4-72h with nausea or vomiting. They should also have how many of the following? - unilateral pain - pulsing pain - impairs ADL - photophobia/phonophobia 1 - >2 2 - >3 3 - all 4

Answer 31

1 - >2

Question 32

In addition to aura, which of the following occurring would suggest that the patient is having a migraine over tension headaches and cluster headaches? 1 - ipsilateral (same side) autonomic features 2 - no features at all (including aura) 3 - aura, vomiting and nausea 4 - none of the above

Answer 32

3 - aura, vomiting and nausea

Question 33

Following a migraine, which of the following symptoms are unlikely to occur? 1 - fatigue 2 - tired 3 - lacrimation and ptosis 4 - difficulty concentrating 5 - stiff neck

Answer 33

3 - lacrimation and ptosis - this commonly occurs in cluster headaches

Question 34

What is typically the 1st line treatment patients with migraines are given as part of abortive approach? 1 - paracetamol 2 - lifestyle advice 3 - NSAIDs 4 - Triptan (serotonin agonist)

Answer 34

2 - lifestyle advice - adequate sleep, hydration, exercise, cognitive behavioural therapy, biofeedback and avoiding triggers Patients may also be asked to complete a migraine diary

Question 35

If lifestyle advice fails in patients with migraines, which of the following can then be prescribed next as part of abortive approach? 1 - paracetamol 2 - aspirin 3 - NSAIDs 4 - Triptan (serotonin agonist)

Answer 35

1 - paracetamol - then it would be aspirin and NSAIDs - if these fail then we can use: + Triptan (eg sumatriptan, zolmitriptan) + Dopamine agonists (metoclopramide, prochlorperazine) + Monoclonal antibodies + Nerve block injections

Question 36

Which of the following can be prescribed as a one off dose for migraines? 1 - gabapentin 2 - tramadol 3 - sumatriptan 4 - prochlorperazine

Answer 36

3 - sumatriptan Dose of 50-100mg <6/day and prescribe no more than 6/month

Question 37

Sumatriptan is typically the 1st line management for patients with migraines. Is this used as a prophylaxis to stop migraines, or given at the onset of the migraine?

Answer 37

- given at the onset of the migraines

Question 38

Should opioids ever be prescribed for the acute management of patients with migraines?

Answer 38

- no

Question 39

What is typically the 1st line treatment patients with migraines are given as part of a preventative approach? 1 - Amitriptyline 2 - Lifestyle advice 3 - Propranolol 4 - Topiramate

Answer 39

2 - Lifestyle advice

Question 40

If lifestyle advice fails in patients with migraines, all of the following can be prescribed, EXCEPT which one? 1 - Amitriptyline 2 - Morphine sulphate 3 - Beta blockers 4 - Topiramate

Answer 40

2 - Morphine sulphate Never use opioids in migraines Topiramate = GABA agonist and AMPA antagonist Block neuronal excitability that is causing migraines

Question 41

Which of the following would be a suitable differential for a patient with suspected migraine? 1 - cluster/tension headache 2 - cervical spondylosis 3 - intracranial pathology 4 - increased BP 5 - TIAs 6 - sinusitis/otitis media 7 - all of the above

Answer 41

7 - all of the above

Question 42

Patients who are menstruating may experience a menstruating migraine. Typically this last 2-3 days of the menstrual cycle, and occurs in 2/3 of cycles. Which 2 of the following medications can be used to prevent menstruating migraines? 1 - fovatriptan (inhibit cranial vasodilation) 2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation) 3 - verapamil (induces vascular vasodilation) 4 - B-blockers (slows heart rate and reduces brain oxygen requirements)

Answer 42

1 - fovatriptan (inhibit cranial vasodilation) 2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation)

Question 43

Is it ok to prescribe the combined oral contraceptive (COC) pill in women who are experiencing migraines with aura?

Answer 43

- No This is a 4 on the Mec guidelines COC can increase the risk of stroke

Question 44

Medication-overuse headache are caused by taking painkillers too often for tension headaches . The body responds to this by increasing the number of pain receptors in the head. Which of the following is NOT typically linked to causing medication overuse headaches? 1 - codeine 2 - cyclizine 3 - triptans 4 - NSAIDs

Answer 44

2 - cyclizine All others are pain medications, except triptan which is specific for headaches

Question 45

Migraines = feature full headaches Tension like headaches = featureless headaches

Answer 45

This essentially means there are specific features associated with Migraines (aura, vomiting, photophobia etc..

Question 46

When thinking about red flags, which of the following is most likely to cause a new severe or unexpected headache? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - subdural bleed 4 - giant cell arteritis

Answer 46

2 - sub-arachnoid haemorrhage Also described as a thunderclap headache

Question 47

When thinking about red flags, which of the following is most likely to follow a head trauma? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - subdural bleed 4 - giant cell arteritis

Answer 47

3 - subdural bleed

Question 48

When thinking about red flags, which of the following is most likely to cause a headache in an immunocompromised patient? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - subdural bleed 4 - giant cell arteritis

Answer 48

1 - malignancy

Question 49

When thinking about red flags, which of the following is most likely to cause a persistent headache that then changes drastically? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - subdural bleed 4 - giant cell arteritis

Answer 49

1 - malignancy This is very common in >50s

Question 50

When thinking about red flags, which of the following is most likely to cause a headache in a current or recent pregnancy? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - pre-eclampsia 4 - giant cell arteritis

Answer 50

3 - pre-eclampsia

Question 51

When thinking about red flags, which of the following is most likely to cause a headache that is associated with pain, specifically in the temporal region? 1 - malignancy 2 - sub-arachnoid haemorrhage 3 - pre-eclampsia 4 - giant cell arteritis

Answer 51

4 - giant cell arteritis