Headaches and Migraines

Question 1

How can primary headaches by categorised?

Answer 1

1. Tension-type headache
2. Migraine
3. Trigeminal autonomic cephalgias
4. Other primary headache disorders

Question 2

What are characteristics of tension-type headaches?

Answer 2

TTH characteristics are that they are bilateral, pressing or tightening in quality, mild-to-moderate in intensity and with no nausea.

They are not aggravated by physical activity although there may be pericranial tenderness and sensitivity to light or noise

Question 3

What are characteristics of migraines?

Answer 3

Migraine headaches tend to be unilateral, throbbing and disproportionately disabling. Nausea is common.

Visual symptoms are the most common manifestation of an aura and consist of flickering lights, spots or zig-zag lines, fortification spectra or blind spots.

Question 4

What are characteristics of trigeminal autonomic cephalgias?

Answer 4

This encompasses cluster headaches, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks and hemicrania continua.

The TACs are characterised by hemicranial headache, usually with ipsilateral autonomic features.

They are thought to arise from a trigeminal-parasympathetic reflex.

Question 5

What is the first line medication for tention-type headaches?

Answer 5

Ibuprofen

Question 6

Name a couple secondary headaches?

Answer 6

Secondary to a substance, or its withdrawal

Vascular intracranial disorders (haemorrhage)

Raised intracranial pressure

Intracranial infection (meningitis)

Question 7

What is the most frequent cause of morning headaches?

Answer 7

Migraine

Question 8

What are the different types of migraines?

Answer 8

Migraine without aura.
Migraine with aura.
Hemiplegic migraine.
Chronic migraine.

Question 9

How does migraine without aura present?

Answer 9

This is a recurring disorder, and the diagnosis is not made until the patient has a history of at least five attacks

Typically the headaches last between 4 and 72 hours and have at least two of the following features:

1. Unilateral.
2. Pulsating.
3. Moderate or severe intensity of pain.
4. Aggravated by, or resulting in the avoidance of, routine physical activity.

In addition, there is at least one of:

1. Nausea and vomiting during migraine attacks
2. Photophobia and phonophobia, which are also very common

Question 10

How does migraine with aura present?

Answer 10

Common features are depression, tiredness, difficulty concentrating, irritability, stiff neck and food cravings

Typically, aura symptoms are progressive, of gradual onset over minutes, last five minutes to an hour and occur before the headache:

1. Visual disturbance starts in one eye and may spread
2. Sensory symptoms that are unilateral and fully reversible (numbness)
3. The headache either begins before the end of the aura or within an hour of the end
4. One patient may at different times have migraine attacks with and without aura.

Question 11

Of those who have migraines, how many experience migraine with aura?

Answer 11

This affects about a third of those who experience migraine, and is usually easier to diagnose

Question 12

What causes menstrual migraines?

Answer 12

Falling oestrogen levels

Question 13

How would you manage migraines?

Answer 13

NSAID
Triptans
Antiemetic

Preventive treatment (use when around 7 migraines per month):

• amitryptiline
• Magnesium
• Valproate
• Topiramate§

Question 14

How would you manage cluster headaches?

Answer 14

1. High flow O2
2. Triptans

ALWAYS use preventative treatment

Question 15

What preventative treatment would you usually use for people with cluster headaches?

Answer 15

Verapamil

Topiramate, lithium