Cluster headache. migraine and temporal arteritis

Question 1

Importance of excluding dental pain (4)

Answer 1

 56 ♀ Referred by GDP
to restorative dentistry
 No dental cause ? TN
 Atypical pain for TN –
 ‘ loath to start removing restorations’
 Restoration removed upper six – pain resolved

Question 2

Temporal arteritis (giant cell arteritis) is (1)

Answer 2

Unilateral or bilateral headache,
mainly continuous or throbbing,
usually in the elderly, with
temporal artery signs

Question 3

Cause of temporal arteritis (3)

Answer 3

 An intense inflammatory response centred around the arterial internal elastic lamina – primary antibody ?elastin
 Ischaemia and claudication
 Associated with polymyalgia rheumatica

Question 4

Symptoms of temporal arteritis (3)

Answer 4

A) A new persisting headache
B) At least one of the following
-Swollen tender scalp artery with elevated ESR or CRP
- Temporal artery biopsy
demonstrating arteritis
C) Major improvement within three days of steroid therapy

Question 5

Signs and epidemiology of termporal arteritis (9)

Answer 5

 Elderly
 New onset headache (70%)
 Pain on mastication (40%)
 Scalp tenderness
 Generally unwell

 Tenderness or decreased
pulsation of temporal vessels
 Elevated ESR >50mm/h
 Biopsy
 Doppler scanning

Question 6

Management of temporal arteritis (3)

Answer 6

NOTE: 50% have involvement of ophthalmic artery which may lead to blindness
Steroids (prednisolone)
 Visual symptoms – initially 80mg daily
 No visual symptoms - initially 60mg daily
Urgent referral to either GMP, rheumatology or
ophthalmology

Question 7

Cluster headache is part of (1) with (2)

Answer 7

Trigeminal autonomic cephalalgias (TAC)

• cluster headaches
• paroxysmal hemicrania
• SUNCT

Question 8

Definition of cluster headache

Answer 8

Unilateral pain principally in the ocular, frontal and temporal areas recurring in severe bouts with daily attacks for several months
and usually with rhinorrhoea and lacrimation -IASP

Question 9

Presentation of cluster headache (6)

Answer 9

Prevalence 1%
Males (5:1), aged 18-40 years
Unilateral
Throbbing, burning, severe pain. May wake patient from their sleep (alarm clock headache).
Severity comparable with trigeminal neuralgia
-but they will get restless whereas trigeminal neuralgia they stay still
-often at the same time every day
Associated factors;- lacrimation, rhinorrhoea, conjunctival injection, Horner’s syndrome.

Question 10

Cluster headache - management of acute attack (2)

Answer 10

Oxygen 100% 10-12 litres/minute
Sumatriptan (5HT1 agonist)
• Subcutaneous
• Intranasal

Question 11

Cluster headache - management - prevention (7)

Answer 11

 Avoid precipitating factors
• Alcohol
• Caffeine
 Verapamil
 Lithium
 Prednisolone
 Methylsergide
 Gabapentin
 GON

Question 12

Migraine presentation (5)

Answer 12

 Episodic headache usually accompanied by nausea, photophobia and photophobia
 Duration hours (4-72 hours)
 Pulsating
 Aura (15% patients)
 Triggers (hormonal/ relaxation/ perfume/ stress
oestrogen)

Question 13

Treatment of migraines (3)

Answer 13

Simple analgesia
• Ibuprofen
• Paracetaml
5HT1 agonist - ‘triptan’
Antiemetic (metoclopramide)

Question 14

Prevention of migraines (3)

Answer 14

 Patient education – triggers
 Psychological
 TENS/acupuncture intraoral splints etc.

Question 15

Medications for migraines (3)

Answer 15

• Amitriptyline
• β blocker
• Pizotifen etc