CA Headache and Migraine Clinicals Flashcards by Germaine Aw

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

Assessment of compliance to therapy for pts w refractory epilepsy
Assessment of symptoms due to possible antiepileptic drug toxicity
Titration of phenytoin dose

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What is the pathophysiology of headaches and migraines?

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

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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Explain why is serotonin an important mediator of migraine headache?

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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List 3 triggers of tension-type headaches.

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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List 5 red flags for secondary headaches.

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

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

30mins to 7 days
4 to 72 hours
15 to 180 minutes

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True or false?

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

False
Migraine can be bilateral too

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True or false

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

True

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

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

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

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

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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

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

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

Hypothalamus and neuropeptides

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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, B, H, I, J

Non-pain / n/v

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

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

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

F, G + visual aura

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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

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

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

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C, D, E

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

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A, B, C, J

List 5 triggers of migraines

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

What are the diagnostic criteria for episodic migraine without aura?

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≥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

What are the diagnostic criteria for episodic migraine with aura?

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≥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

What are the diagnostic criteria for chronic migraine?

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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

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?

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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

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

stratified, pain severity

What are some drugs used in acute treatment of migraine?

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

# 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.

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

# 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

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

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

**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

List 3 treatment successes for prophylactic treatment of migraine.

* 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 ## Footnote HRQoL: health-related QoL

# True or false? Prophylactic treatment of migraine should be **offered** if patient has 5 headache days per month and some degree of disability

True

# True or false? Prophylactic treatment of migraine should be **considered** if patient has 3-4 headache days per month and severe degree of disability

**False** Treatment should be **offered**

# True or false? Prophylactic treatment of migraine should be **offered** if patient has 6 headaches per month and moderate degree of disability

True

# True or false? Prophylactic treatment of migraine should be **considered** if patient has 2 headaches per month and no degree of disability

**False** Should not be considered at all

# True or false? Prophylactic treatment of migraine should be **considered** if patient has 4 headaches per month and mild degree of disability

True

Based on EHF guidelines, when is migraine prophylaxis inidicated?

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

What is medication overuse headache?

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

Limit acute treatments to ____ headache days/ week

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

Kenneth

main trigger for cluster headaches

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

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.**

CA Headache and Migraine Clinicals Flashcards

(40 cards)