Headache

Question 1

What are the different types of onset of a headache?

Answer 1

Acute
Sub-acute
Gradual

Question 2

What are some relieving features of a headache?

Answer 2

Posture

Headache behaviour

Question 3

What are some exacerbating features of a headache?

Answer 3

Posture
Valsalva (sneezing, coughing, straining etc)
Diurnal variation

Question 4

What are some associated features of a headache?

Answer 4

Autonomic features (N+V)
Photophobia
Phonophobia
Positive visual symptoms
Ptosis
Miosis
Nasal stuffiness

Question 5

What are red flags for headaches?

Answer 5

New onset headache >55
Known/previous malignancy
Immuno-suppressed
Early morning headache
Exacerbation by valsalva

Question 6

What is important in the PMHx for headache?

Answer 6

Beware previous CA, predisposition to thrombosis

Question 7

What is important in the FHx for headache?

Answer 7

Migraines in family members

Question 8

What is important in DHx for headache?

Answer 8

Headache diary- need to account for OTC medication

Question 9

Are migraines more common in men?

Answer 9

No women!

Question 10

What percentage of migraines are with aura?

Answer 10

20%

Question 11

What is the IHS criteria for migraine without aura?

Answer 11

At least 5 attacks
Duration 4-72 hours
2 of: moderate/severe, unilateral, throbbing pain. worst movement
1 of: autonomic features, photophobia/phonophobia

Question 12

What is the pathophysiology of migraines?

Answer 12

Vascular and neural influences in susceptible individuals
Stress triggers- cause serotonin to be released
Blood vessels constrict and dilate
Substance P irritates nerves and blood vessels causing pain

Question 13

What is the duration of a migraine with aura?

Answer 13

20-60 minutes

Question 14

What is the onset of headache after a migraine with aura?

Answer 14

<1 hour later

Question 15

What are the symptoms of a migraine with aura?

Answer 15

Mostly visual- positive symptoms usually monochromatic)

Question 16

What are the 3 types of visual aura?

Answer 16

Central scotomata
Central fortification
Hemianopic loss

Question 17

What are some triggers of migraine?

Answer 17

Sleep
Dietary
Stress
Hormonal
Physical exertion

Question 18

What are the non-pharmacological treatments for migraine?

Answer 18

Set realistic goals
Education- avoid triggers
Headache diary
Relaxation/stress management

Question 19

What are the pharmacological treatments for migraine?

Answer 19

NSAIDS +/- anti-emetic

Triptans- 5HT agonist

Question 20

Which triptans can be used in treatment of migraine?

Answer 20

Rizatriptan = electrician > sumatriptan

Frocatriptan for sustained relief

Question 21

When is prophylaxis for migraines indicated?

Answer 21

More than 3 attacks per month or very severe

Question 22

How is prophylaxis used for migraines?

Answer 22

Titrate drug as tolerated to achieve efficacy at lowest dose
Go slow and keep low
Trial each for minimum 4 months

Question 23

What drugs can be used for prophylaxis?

Answer 23

Propranolol
Topiramate (Carbonic anhydrase inhibitor)
Others: Amitriptyline, gabapentin, pizotifen, Na valproate, Botox, Anti-calcitonin gene related peptide Ab

Question 24

When should propranolol be avoided?

Answer 24

Asthma
Peripheral vascular disease
Heart failure

Question 25

What are the side effects of topiramate?

Answer 25

Weight loss Paraesthesia Impaired concentration Enzyme inducer

Question 26

What are the side effects of amitriptyline?

Answer 26

Dry mouth Postural hypotension Sedation

Question 27

How can lifestyle be modified for treatment of migraines?

Answer 27

Diet- regular intake, avoid triggers Hydration- 2L/day minimum. decrease caffeine Decrease stress Regular exercise

Question 28

Give examples of more complex migraines

Answer 28

``` Acephalgic Basilar Retinal Ophthalmic Hemiplegic Abdominal ```

Question 29

What are the characteristics of a tension type headache?

Answer 29

``` Pressing tingling quality Mild to moderate Bilateral Absence of N+V Absence of photophobia or phonophobia ```

Question 30

What are treatments for tension type headache?

Answer 30

Relaxation physiotherapy Antidepressants- dothiepin or amitriptyline Reassure

Question 31

What are trigeminal autonomic cephalgias (TACs)?

Answer 31

Group of primary headache disorders characterised by unilateral trigeminal distribution pain Associated with ipsilateral cranial autonomic features

Question 32

What are ipsilateral autonomic features?

Answer 32

``` Ptosis Miosis Nasal stuffiness Nausea/vomiting Tearing Eye lide oedema ```

Question 33

What are the 4 main types of TAC?

Answer 33

Cluster Paroxsymal hemicrania Hemicrania continua SUNCT

Question 34

Who gets cluster headaches?

Answer 34

Young (30-40s) | Men > women

Question 35

When do cluster headaches occur?

Answer 35

``` Striking circadian (around sleep) Seasonal variation ```

Question 36

What are the features of a cluster headache?

Answer 36

Severe, unilateral headache Occurs 1-8 per day Cluster bout may last from a few weeks to months

Question 37

What is the duration of cluster headaches?

Answer 37

45-90mins | 20mins-3hrs

Question 38

What is the treatment for cluster headaches?

Answer 38

High flow O2 100% for 20mins Sub-cutaneous sumatriptan Steroids- reducing over 2 weeks Verapamil for prophylaxis

Question 39

Who gets paroxysmal hemicrania?

Answer 39

Elderly (50-60s) | Women> men

Question 40

What are the features of a paroxysmal hemicranial?

Answer 40

Severe unilateral headache with unilateral autonomic features

Question 41

What is the duration of paroxysmal hemicrania?

Answer 41

10-30 minutes (2mins-45mins) 1 to 40 times a day N.B. shorter duration and more frequent than cluster

Question 42

What is the treatment for paroxysmal hemicrania?

Answer 42

Absolute response to indomethicin

Question 43

What does SUNCT stand for?

Answer 43

``` S= short lived (15-120 secs) U= unilateral N= neuralgiaform headache C= conjunctival injections T= tearing ```

Question 44

What is the treatment for SUNCT headaches?

Answer 44

Lamotrigine | Gabapentin

Question 45

What investigations are done for new onset unilateral cranial autonomic features?

Answer 45

MRI brain | MR angiogram

Question 46

Who gets idiopathic intracranial hypertension?

Answer 46

Females> males | Obese

Question 47

What are some symptoms of idiopathic intracranial hypertension?

Answer 47

Headache- diurnal variation Morning N+V Visual loss

Question 48

What investigations can be done for IIH and what would be found?

Answer 48

MRI brain w/ MRV sequence- normal CSF- elevated pressure, normal constituents Visual fields- impaired

Question 49

What are treatments for IIH?

Answer 49

Wgt loss Acetazolamide Ventricular atrial/lumbar peritoneal shunt Monitor visual fields & CSF pressure

Question 50

Who gets trigeminal neuralgia?

Answer 50

Elderly (>60) | Women > men

Question 51

When does trigeminal neuralgia occur?

Answer 51

Triggered by touch | Usually V2/3

Question 52

What are the features of trigeminal neuralgia?

Answer 52

Severe stabbing unilateral pain

Question 53

What is the duration of trigeminal neuralgia?

Answer 53

1 -90secs 10-100 times per day Bouts pain may last from few weeks to months before remission

Question 54

What is the treatment for trigeminal neuralgia?

Answer 54

``` Carbamazepine Gabapentin Phenytoin Baclofen Surgical: ablation/decompression ```

Question 55

What investigations can be done for trigeminal neuralgia?

Answer 55

MRI brain

Question 56

What structures should be considered with facial pain?

Answer 56

``` Eyes Ears Sinuses Teeth TMJ ```