Headache

Question 1

What is the basis of abortive treatment for migraine?

Answer 1

Aiming for complete relief of headache in two hours. Triple therapy of anti-inflammatory (cox 1 and cox 2) metoclopramide and triptan.

Question 2

What is the mechanism of migraine?

Answer 2

Related to trigeminal pain pathways and their upregulation following a sensory input

Question 3

What receptors do triptans act on?

Answer 3

serotonin antagonists 5ht1D and 5ht1B

Question 4

most effective triptan?

Answer 4

sc sumitriptan, fast acting and most side effects.

Question 5

What is the role of dihydoergotamine (DHE)?

Answer 5

No longer available in NZ. For prolonged, refractory attacks of migraine. Can be given IM, IV or IN. Specifically good for late in migraine (when there is allodynia) when triptans not effective as has central penetration.

Question 6

GIPANs (remegipan and …) Are what?

Answer 6

CGRP receptor antagonists. (calcitonij gene related peptide) present during migraine attacks in CNS.

Question 7

oral sumitriptan vs remegipan (c
CGRP receptor inhibitor) w regards to efficacy?

Answer 7

clinical efficacy comparable to triptans but take a bit longer to work. Very well tolerated.

Question 8

Side effects of triptans?

Answer 8

Chest pressure, wooziness or..
Vasoconstrictive effects that have worried people in the past re cv disease and stroke.

Question 9

5HT1F “ditan” lesmiditan.

Answer 9

serotonin antagonists that has good pain efficacy at 2 hours and doesn’t have side effects of other triptans. But due to central action patients are not supposed to drive for 8 hours afterwards which can limit use.

Question 10

what are the features of trigeminal autonomic cephalagias in general?

Answer 10

side locked, severe to very severe, conjunctival tearing, red eye, runny nose, poses or eye lid oedema.

Question 11

How can you use frequency and duration to differentiate between the different TACs?

Answer 11

Cluster - last hours, less than 8 per day (in a cluster)
paroxysmal hemicrania - minutes, dozens per day
SUNCT and SUNA - last seconds, hundreds per day.

Question 12

Which TACs are indomethacin responsive?

Answer 12

paroxysmal hemicrania
hemicrania continua

Question 13

How should a trial of indomethacin be given?

Answer 13

25mg TDS for 3 days, 50mg TDS for 3 days then 75mg TDS for 3 days, stopping if efficacy is achieved before max dose. (plus omeprazole)

Question 14

indomethacin side effects?

Answer 14

gastric ulceration, give with omeprazole

Question 15

What does SUNCT stand for and how is it different to SUNA?

Answer 15

SUNCT = short lasting unilateral neuralgiform headaches with conjunctival injection and tearing. SUNA = shortlasting unilateral neuralgiform headaches with autonomic features (other than conjunctival tearing).

Question 16

What is the first line treatment for SUNA and SUNCT?

Answer 16

lamotrigine, can also try topiramate. Not indomethacin responsive.

Question 17

How can the distribution of facial pain help with determining the cause?

Answer 17

V1 and V2 = more likely to be a trigeminal autonomic cephalalgia
V3 = more likely to be trigeminal neuralgia

Question 18

trigeminal neuralgia can be primary or secondary. What are some important secondary causes?

Answer 18

Multiple sclerosis, especially in a young woman - get brainstem imaging.

Microvascular compression at trigeminal nerve roots. - get MRI proving focal demyelination or compression, touching only not usually enough to cause trigeminal neuralgia.

Question 19

trigeminal neuralgia treatment

Answer 19

1st - carbamazepine or oxcarbazapine
2nd - lamotrogine
3rd - surgical

Question 20

side locked headache in a male, occurring at change of season occurring less than 10 times per day at the same time each day, worse with alcohol. pacing around, conjunctival tearing and runny nose.

Answer 20

cluster headache