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PR3153 > CA Headache and Migraine Clinicals > Flashcards

CA Headache and Migraine Clinicals Flashcards

1
Q

For antiepileptic drugs, test drug levels only when:
1.
2.
3.

A
  1. Assessment of compliance to therapy for pts w refractory epilepsy
  2. Assessment of symptoms due to possible antiepileptic drug toxicity
  3. Titration of phenytoin dose
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2
Q

What is the pathophysiology of headaches and migraines?

A

Vasodilation of in intracranial extracerebral blood vessels → activation of perivascular trigeminal nerves that release vasoactive neuropeptides to promote neurogenic inflammation → headache/ migraine

Central pain transmission may activate other brainstem nuclei → associated symptoms (N/V, photophobia, phonophobia)

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3
Q

What are the possible causes of hyper-responsiveness of a patient’s brain during a migraine headache

A

Inherited abnormality in overactive Ca and/or Na channels and Na/K pumps → regulate release of serotonin (5-HT) and other neurotransmitters → regulate cortical excitability

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4
Q

Explain why is serotonin an important mediator of migraine headache?

A

Serotonin is an agonist of vascular and neuronal 5-HT1 receptor → vasoconstriction of meningeal blood vessels and inhibition of vasoactive neuropeptide release and pain signal transmission → reduce vasodilation, reliever pain → reverse pathophysiology process of migraines

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5
Q

List 3 triggers of tension-type headaches.

A
  • Physical/ emotional stress
  • Activities that cause the head to be held in one position for a long time
  • Alcohol, caffeine
  • Cold/flu or sinus infections
  • Dehydration
  • Hunger
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6
Q

List 5 red flags for secondary headaches.

Germ: not in learning outcomes, so maybe not tested for CA?? (cross fingers)

A

SNNOOP10 GUIDE:
* Systemic symptoms including fever
* Neoplasm in hx
* Neurologic deficit/ dysfunction
* Onset of headahce is sudden/ abrupt
* Older age, >50yo
* Pattern change/ recent onset of headache
* Positional headache
* Precipitated by sneezing, coughing, or exercise
* Papilledema
* Progressive headache with atypical presentation
* Pregnancy/ post-partum
* Painful eye with autonomic features
* Post-traumatic onset of headache
* Pathology of immune system such as HIV/ immunocompromised
* Painkiller overuse/ new drug at onset of headache

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7
Q

What are the durations of:
1. Tension-type headache
2. Migraine
3. Cluster headache

A
  1. 30mins to 7 days
  2. 4 to 72 hours
  3. 15 to 180 minutes
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8
Q

True or false?

Tension-type headaches are bilateral, while both migraine and cluster headache are unilateral

A

False
Migraine can be bilateral too

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9
Q

True or false

The pain of a tension-type headache can be described as pressing/ tightening, while that of migraine is pulsating/ throbbing.

A

True

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10
Q

What are some pharmacological, acute and prophylactic, treatments for tension-type headaches?

A

Acute:
* Paracetamol (alone/ w caffeine), aspirin
* NSAIDs: ibuprofen, naproxen, diclofenac, ketoprofen

Prophylactic:
* Amitriptyline (1st line)
* Mirtazapine, venlafaxine

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11
Q

Which are some non-pharmacological methods used to treat tension-type headaches and migraines? There is more than one answer.

A. Cognitive behavioural therapy
B. Alcohol
C. More Sleep
D. Meditation
E. Crying

A

A, C, D
Cognitive behavioural therapy, biofeedback, relaxation (meditation)
Physical and/or occupational therapy
Lifestyle modification (include sleep hygiene)

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12
Q

Match the duration to the correct phase of a migraine attack. I.e. prodrome, aura, headache, and postdrome

A. 5-60mins
B. 4-72 hours
C. A few hours to days
D. <12-24 hours

A

Prodrome: C
Aura: A
Headache: B
Postdrome: D

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13
Q

What is the pathophysiology of the prodrome phase of a migraine attack?
Activation of ________ and ____________

A

Hypothalamus and neuropeptides

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14
Q

What are the symptoms experienced during the prodrome phase of a migraine attack?

A. Fatigue
B. Cognitive difficulties/ difficulty concentrating
C. Nausea and/or vomitting
D. Photophobia
E. Phonophobia
F. Sensory and speech disturbance
G. Motor symptoms
H. Food cravings
I. Mood changes
J. Neck pain/ stiffness

A

A, B, H, I, J

Non-pain / n/v

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15
Q

What is the pathophysiology of the aura phase of a migraine attack?
Slow-spreading ________ in cortex → ________ activity → ________ activity and blood flow → activate ________ → aura symptoms

A

Slow-spreading neuronal depolarization in cortex → inhibit cortical activity → ↓ synaptic activity and blood flow → activate trigeminovascular system → aura symptoms

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16
Q

What are the symptoms experienced during the aura phase of a migraine attack?

A. Fatigue
B. Cognitive difficulties/ difficulty concentrating
C. Nausea and/or vomitting
D. Photophobia
E. Phonophobia
F. Sensory and speech disturbance
G. Motor symptoms
H. Food cravings
I. Mood changes
J. Neck pain/ stiffness

A

F, G + visual aura

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17
Q

What is the pathophysiology of the headache phase of a migraine attack?
Neuropeptides (e.g. CGRP) are implicated in ________ of primary ________, and central and peripheral ____________ → ↑________ and hypersensitivity to pain

A

Neuropeptides e.g. CGRP implicated in sensitization of primary nociceptors, and central and peripheral trigeminovascular system → ↑allodynia and hypersensitivity to pain

18
Q

What are the symptoms experienced during the headache phase of a migraine attack?

A. Fatigue
B. Cognitive difficulties/ difficulty concentrating
C. Nausea and/or vomitting
D. Photophobia
E. Phonophobia
F. Sensory and speech disturbance
G. Motor symptoms
H. Food cravings
I. Mood changes
J. Neck pain/ stiffness

A

C, D, E

19
Q

What are the symptoms experienced during the postdrome phase of a migraine attack?

A. Fatigue
B. Cognitive difficulties/ difficulty concentrating
C. Nausea and/or vomitting
D. Photophobia
E. Phonophobia
F. Sensory and speech disturbance
G. Motor symptoms
H. Food cravings
I. Mood changes
J. Neck pain/ stiffness

A

A, B, C, J

20
Q

List 5 triggers of migraines

A
  • Physical/ emotional stress
  • Environmental changes/ weather
  • Alcohol, caffeine
  • Lights
  • Sleep disturbances, sleeping late
  • Allergies, sinus
  • Hormone disruption
  • Diet (nutritional deficiencies, dairy, processed foods)
21
Q

What are the diagnostic criteria for episodic migraine without aura?

A

≥5 migraine attacks in a lifetime, lasting 4-72 hours
AND with at least 5 attacks fulfilling criteria A and B

A. Headache has at least 2 of the following: unilateral, pulsating quality, moderate/severe pain intensitiy, aggravation by/ causing avoidance of routine activities of daily living
B. During headache have at least 1 of the following: nausea +/- vomitting, photophobia + phonophobia

22
Q

What are the diagnostic criteria for episodic migraine with aura?

A

≥5 migraine attacks in a lifetime, lasting 4-72 hours
AND with at least 2 attacks fulfilling criteria A and B

A. At least 1 of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal
B. At least 3 of the following:
* At least 1 aura symptom spreads gradually over ≥5 mins
* ≥2 aura symptoms occur in succession
* Each individual aura symptoms lasts 5-60 minutes
* At least 1 aura symptoms is unilateral
* At least 1 aura symptom is positive
* Aura is accompanied/ followed within 60mins by headache

23
Q

What are the diagnostic criteria for chronic migraine?

A
  • Symotoms occuring for >3 months, with ≥15MHDs and ≥8 MMDs
  • During MMD, have ≥2 migraine characteristics: unilateral, pulsating, moderate/severe pain intensity, aggravation by/ causing avoidance of routine activities of daily living
  • If no aura, have ≥1 of the following: nausea +/- vomiting, photophobia + phonophobia

MHD: monthly headache day
MMD: monthly migraine day
Chronic migraine occurs to 7.7% of people with migraine

24
Q

Sarah:
* Presents with a history of recurrent, severe headaches localized to the right temple
* Associated with nausea, vomiting, and sensitivity to light and sound
* No visual changes noted during attack
* Describe pain as throbbing and debilitating, often lasting for several hours to days.
* Headaches started 2 months ago, has had 7 attacks since then

  • Notes that the headaches occur during stressful periods at work or after consuming certain foods like aged cheeses or red wine
  • Tried ibuprofen with little effect/ alleviation
  • QoL significantly impacted, cause her to miss work and social activities

What would you diagnose Sarah with?

A

Episodic migraine without aura
* Has had ≥5 migraine attacks in her lifetime
* has >7 attacks fulfilling symptoms in criteria (N/V, photophobia and phonophobia), unilateral (localised on right temple)
* meets triggers of a migraine attack

25
Q

During acute treatment of migraine, it is recommended to adopt a ________ approach (guide by ________) over step approach (start with simple analgesics)

A

stratified, pain severity

26
Q

What are some drugs used in acute treatment of migraine?

A

NSAIDs, triptans, ergotamine/ carfegot, opioids
FYI: gepants, ditans

27
Q

True or false?

A patient was initiated on sumatriptan for his migraine, but have not received any relief/ alleviation. It is then recommended for patient to switch to another drug class, as the triptans drug class may not be effective on him.

A

False
Lack of response to one triptan does not predict response to other triptans -> trial of another triptan

28
Q

True or false?

A patient was initiated on sumatriptan for his migraine. He had experienced initial relief, but 48 hours later had experienced another migraine attack. Patient should then take an additional dose of sumatriptan

A

True
20-50% of pts experience recurrence of migraine 48hrs after 1st dose → take additional dose of triptan

29
Q

What is the minimum duration of prophylactic treatment (CGRP) of migraine till you would consider switching preventive treatment?
1. Oral:
2. Injectable:

A

Oral: 8w, partial response may occur over 6-12m of continued use
Injectable: 3m for those administered monthly, 6m for those administered quarterly

CGRP no oral form bae -px

30
Q

List 3 treatment successes for prophylactic treatment of migraine.

A
  • 50%↓ in frequency of days w headache/migraine
  • Sig ↓of attack duration/ severity (defined by pt)
  • Improved response to acute tx
  • ↓migraine-related disability, and improvements in functioning in important areas of life
  • Improvements in HRQoL and ↓psychological distress due to migraine

HRQoL: health-related QoL

31
Q

True or false?

Prophylactic treatment of migraine should be offered if patient has 5 headache days per month and some degree of disability

A

True

32
Q

True or false?

Prophylactic treatment of migraine should be considered if patient has 3-4 headache days per month and severe degree of disability

A

False
Treatment should be offered

33
Q

True or false?

Prophylactic treatment of migraine should be offered if patient has 6 headaches per month and moderate degree of disability

A

True

34
Q

True or false?

Prophylactic treatment of migraine should be considered if patient has 2 headaches per month and no degree of disability

A

False
Should not be considered at all

35
Q

True or false?

Prophylactic treatment of migraine should be considered if patient has 4 headaches per month and mild degree of disability

A

True

36
Q

Based on EHF guidelines, when is migraine prophylaxis inidicated?

A

Migraine impairs QoL AND
* attacks cause disability on ≥2 days per month AND optimised acute therapy does not prevent the above
OR
* risk of over-frequent use of acute therapy AND patient is willing to take daily medication

37
Q

What is medication overuse headache?

A

Headache occurring on ≥15d/month in pt w a pre-existing primary headache, and developing as a consequence of regular overuse of acute/ symptomatic headache medication:
* Paracetamol or ≥1 NSAID on ≥15d/ month for >3m
* Triptan or ≥1 opioid on ≥10d/month for >3m

38
Q

Limit acute treatments to ____ headache days/ week

A

2 headache days/ week, preventive treatment considered for patients observed exceeding this limit

39
Q

Kenneth

A

main trigger for cluster headaches

40
Q

Oral opioids (codeine, tramadol) are indicated in migraine, and can be used to treat it frequently

A

Oral opioids (codeine, tramadol) are not a contraindication, BUT are not recommended for routine use in migraine, due to lack of evidence and superiority to standard drugs (NSAIDs and triptans), risk of dependence/ abuse, high potential for development of MOH, and possibility of withdrawal syndrome following discontinuation. May be used acutely/ once only.

PR3153 (10 decks)

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