Primary Headache

Question 1

Difference between primary and secondary headache? Which is more common?

Answer 1

• Primary headache has no underlying medical cause, secondary has an identifiable structural or biochemical cause
• Primary is more common (9:1 in GP, 3:2 in A&E)

Question 2

Is a tension type headache primary or secondary? How severe is it?

Answer 2

TTH is a primary headache, the most common kind

It is not disabling and rarely presents to doctors

Question 3

Describe a tension type headache in terms of location and character

Answer 3

• Mild, bilateral headache. Usually pressing or tightening in character
• No significant associated features and not aggravated by physical activity

Question 4

Options for abortive and preventative treatment of tension type headaches?

Answer 4

Abortive:
- NSAIDs
- Aspirin or paracetamol
(limit to 10 days/month to avoid medication overuse headache)

Preventative: (rarely requires)
- Tricyclic antidepressants (amitriptyline, dothiepin)

Question 5

What is the most frequent disabling primary headache?

Answer 5

Migrane

WHO rank it in top 20 most disabling conditions

Question 6

Describe the pattern of recurrence of migraines? What is the basic pathophysiology?

Answer 6

• Migraine is a chronic disorder with episodic manifestation
• Pathophysiology largely unknown, slides say primary brain dysfunction leads to activation and sensitization of trigeminal system

Question 7

What symptoms tend to characterize migraines?

Answer 7

• Unilateral location (book says may become diffuse after 1-2hrs)
• Pulsating/throbbing character
• Aggravation by routine physical activity
• Nausea & vomiting
• Photophobia
• Phonophobia
• Some have preceding aura

Question 8

What is Aura? Does it affect everyone with migraine?

Answer 8

• Aura is a period (usually 15-60mins) of neurological deficit that may be experienced prior to migraine attack. Can affect sensory/motor/speech areas of the brain and is often mistaken for TIA symptoms
• Affects ~33% if migraine patients

Question 9

What are the stages of a migraine episode? Brief description for each

Answer 9

1. Premonitory: mood change, fatigue, muscle pain, food craving
2. Aura: fully reversible neurological deficits
3. Early Headache: dull pain, nasal congestion
4. Advanced Headache: unilateral pulsation, nausea, photophobia, phonophobia
5. Postdrome: fatigue, cognitive changes, muscle pain

Question 10

What are the classification guidelines for chronic migraine?

Answer 10

• Headache for at least 15 days per month, of which at least 8 must be migraines, for more than 3 months

Question 11

What tends to happen to a patients migraine symptoms as transforms to chronic migraine?

Answer 11

• Frequency of headaches increases
• Migrainous symptoms become less frequent and less severe
• Many patients have episodes of severe migraine on a background of less severe, frequent/daily headache

Question 12

What is medication overuse headache?

Answer 12

Headache present for at least 15 days/month which has developed or worsened whilst taking regular symptomatic medication

• Can occur in any primary headache, migraine patients more susceptible

Question 13

Which drugs cause medication overuse headache over what sort of period of time?

Answer 13

• Triptans, ergots, opiods and combination analgesics for more than 10 days a month
• Simple analgesics for more than 15 days a month
• Caffeine overuse (coffee/tea/sodas)

Question 14

Prophylactic treatment of migraines?

Answer 14

• Anti-epileptics (topiramate, valproate)
• B-Blockers (propranolol)
• Tricyclic antidepressants (amitriptyline)
• SSRI’s (venlafaxine)

Question 15

Abortive/acute treatment of migraines? How frequently should these be taken?

Answer 15

• Analgesics (aspirin, NSAIDs, paracetamol)
• Triptans
• Anti-emetics

Limit to 10 days/month

Question 16

How can migraine symptoms change during pregnancy?

Answer 16

• Migraine without aura usually gets better during pregnancy
• Migraine with aura usually no change
• First migraine may occur during pregnancy (particularly migraine with aura)

Question 17

What drug considerations should be taken in women of child bearing age who are experiencing migraines?

Answer 17

• OCP (oral contrac) contraindicated in active migraine with aura (ok if no attacks for >5 yrs, stop if aura recurs)
• Avoid anti-epileptics in women of child bearing age (if necessary counsel about teratogenicity)

Question 18

Treatment of migraines during pregnancy?

Answer 18

• Abortive: paracetamol

- Prophylactic: B-blocker (propranolol) or amitriptyline

Question 19

What are Trigeminal Autonomic Cephalalgias? (TACs)

Answer 19

• Group of headache disorders characterized by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features

Question 20

Types of trigeminal autonomic cephalalgias?

Answer 20

• Cluster Headache
• Paroxysmal Hemicrania
• SUNCT (Short-lasting Unilateral Neuralgiform headache with Conjuctival injection and Tearing)
• SUNA (Short-lasting Unilateral Neuralgiform headache with Autonomic symptoms)

Question 21

Describe the character of the pain experienced during a cluster headache

Answer 21

• Unilateral
• Orbital and temporal localization
• Excruciatingly severe
• Rapid onset and rapid cessation
• Usually lasts 15mins to 3 hours

Question 22

How does a cluster headache usually present?

Answer 22

• Unilateral pain (orbital/temporal)
• Prominent ipsilateral autonomic symptoms
• Often have migrainous symptoms as well (vomiting/photophobia/phonophobia)

Question 23

Describe the pattern of recurrence and remission for cluster headaches

Answer 23

• Episodic in 80-90%: attacks cluster into bouts lasting 1-3 months, remission periods last at least 1 month. During bouts 1 attack every other day up to 8 attacks/day
• Chronic cluster in 10-20%: bouts last more than a year without remission OR remissions last less than a month
• Striking circadian rhythmicity: bouts occur same time each year, attacks at same time each day

Question 24

Describe the frequency, duration and pain quality of cluster headaches, paroxysmal hemicrania and SUNCT

Answer 24

• Cluster headache: 1-8 attacks per day, lasting 15-180mins, sharp, throbbing pain
• Paroxysmal Hemicrania: 1-40 attacks/day, lasting 2-30mins, sharp, throbbing pain
• SUNCT: 3-200 attacks/day, lasting 5-240secs, stabbing, burning pain.

Question 25

How can paroxysmal hemicrania be distinguished from a cluster headache?

Answer 25

- Similar symptoms, onset, location - Attack frequency in PH can be higher, with CH attacks lasting longer. PH attacks can be precipitated by rotating the head - 80% of PH patients have chronic PH, only 20% episodic. CH much more episodic - PH responds absolutely to indometacin

Question 26

How does SUNCT tend to present?

Answer 26

- Unilateral orbital, supraorbital or temporal pain. Stabbing/pulsating quality - 10-240 second attack duration, 3-200 attacks/day - Pain can have cutaneous triggers (cold/wind/touch) - Pain is accompanied by conjunctival injection and lacrimation

Question 27

What are some of the cranial autonomic symptoms that can occur during trigeminal autonomic cephalalgias?

Answer 27

- Conjunctival injection / lacrimation - Nasal congestion / rhinorrhoea - Eyelid oedema - Forehead and facial sweating - Miosis / ptosis (Horners syndrome)

Question 28

Treatment of cluster headaches?

Answer 28

- Abortive for headache: 100% oxygen via tight fitting, non-rebreathing mask. Or subcutaneous sumatriptan / nasal zolmatriptan - Abortive for bout: occipital depomedrone injection (ipsilateral). Or tapering course of oral prednisone - Preventative: verapamil, lithium, methysergide, topiramate

Question 29

Treatment of paroxysmal hemicrania?

Answer 29

- No abortive treatments - Prophylaxis with INDOMETACIN (alternatives: COX-II inhibitors, topiramate)

Question 30

Treatment of SUNCT/SUNA:

Answer 30

- No abortive treatment | - Prophylaxis: lamotrigine, topiramate, gabapentin, carbamazepine

Question 31

How does trigeminal neuralgia tend to present?

Answer 31

- Similar to SUNCT, stabbing pain, 3-200 attacks/day, can have cutaneous triggers - Attacks tend to last 5-10 seconds - Pain tends to be more localized to maxillary & mandibular divisions of trigeminal, less so for opthalmic - Autonomic features are uncommon

Question 32

Treatment of trigeminal neuralgia?

Answer 32

- No abortive treatment - Prophylaxis: carbamazepine / oxcarbazepine - Surgical intervention: glycerol ganglion injection, steriotactic radiosurgery, decompressive surgery