Headache and Migraine

Question 1

What are the 3 main primary headaches? How likely are they?

Answer 1

Tension (80%)
Migraine (20%)
Cluster (0.2-0.3%)

Question 2

Which primary headaches are more common in females?

Answer 2

Tension and migraines

Cluster headaches are more common in males

Question 3

What are the characteristics of a tension type headache?

Answer 3

Band like
Bilateral
Tightness/pressure
Radiates to neck/shoulders Mild to moderate

Question 4

How do you treat tension type headaches?

Answer 4

Simple analgesics

Will disappear soon after noxious stimulus has ceased

Question 5

What are the characteristics of cluster-type headaches?

Answer 5

Affects one side of head
Triggered at sleep
Can get up to 8 attacks
Eye very affected - red, watery
Get rhinitis

Question 6

How do you treat cluster type headaches?

Answer 6

High flow oxygen 100% 7-15L per minute (oxygen acts as a vasoconstrictor)
Other vasoconstrictors - triptan (in red bull)

Question 7

How do you diagnose a migraine?

Answer 7

Does light bother you more?
Does it affect your ability to work/study/do a task?
Do you feel nauseated/sick?

If yes to 2/3 - 93% migraine diagnosis

Question 8

How are migraines associated with genetics?

Answer 8

• inherit ‘over responsive’ brain

- heightened sense to smell/lights/sounds/touch

Question 9

What is the migraine threshold?

Answer 9

• number of triggers build up (e.g. lack of food, dehydration, lack of sleep) and add on, if go over the threshold of triggers you will get a migraine

Question 10

What are the types of migraine and how common are they?

Answer 10

Migraine without aura - 70-80% of attacks

Migraine with aura - 20-30% of attacks, 1& without headache

Question 11

What are the 5 stages of a migraine?

Answer 11

1 - premonitory
2 - aura
3 - headache
4 - resolution
5 - recovery

Question 12

What is the mechanism of the premonitory stage of a migraine?

Answer 12

• mood deterioration/neck stiffness 48 hours before migraine
• serotonin release
• symptoms come from hypothalamus

Question 13

How do you treat the premonitory stage of a migraine?

Answer 13

Focus on replenishing serotonin stores - triptan acts on 5HT1D/B agonists

Question 14

What are the characteristics of aura?

Answer 14

Visual (99%) and/or sensory and/or speech/language symptoms

True aura remains even when eyes are closed

Question 15

What are the causes of aura?

Answer 15

Cortical spreading depression:
transient and local suppression/depression of spontaneous electrical activity in the cortex which moves slowly across the brain

Question 16

What is stage 3 of a migraine associated with?

Answer 16

Trigeminovascular pathways

Question 17

What is stage 4 of a migraine?

Answer 17

Resolution - deep sleep, medication to promote sleep, vomiting

Question 18

What are the trigeminovascular pathways?

Answer 18

• start in the meningeal blood vessels releasing serotonin causing dilation
• neuropeptide release (CGRP)
• neuropeptides activate nerve pathways to the trigeminal ganglion (peripheral sensitisation mediating throbbing pain)
• trigeminal nerve transmits pain impulses to spinal trigeminal nucleus caudalis in brainstem (central sensitisation mediating allodynia)
• pain message relayed to thalamus
• perceived by patient as headache

Question 19

What is CGRP?

Answer 19

Neuropeptide
Potent vasodilator
Rises during migraine

Question 20

What are CGRP receptor antagonists?

Answer 20

Gepants

Question 21

What is allodynia?

Answer 21

Over sensitvity

Question 22

What is the difference between peripheral sensitivity and central sensitivity?

Answer 22

Peripheral - mediates throbbing pain

Central - mediates allodynia

Question 23

What are the 2 sites of action for migraine treatment? Which drugs do which?

Answer 23

• preventative: central (CGRP monoclonal antibodies)

- acute: peripheral (triptans)

Question 24

What are some examples of triptans?

Answer 24

Sumatriptan
Naratriptan
Zolmitriptan

Question 25

What are some examples of CGRP monoclonal antibodies?

Answer 25

Erenumab
Fremanezumab
Eptinezumab

Question 26

How do you diagnose secondary headaches?

Answer 26

Diagnosis made on history of presence of physical signs