Headaches and Migraines

Question 1

List the red flags that could indicate something more severe.

Answer 1

New onset headaches >35
History or present malignancy
Immunosuppression
Early morning headache
Worsened by valsalva manoeuvre

Question 2

Describe the frequency of migraines without an aura.

Answer 2

At least 5 attacks with a duration of 4-72 hours

Question 3

Describe migraine without an aura?

Answer 3

Moderate to severe unilateral throbbing which is worse on movement.
Can be accompanied by photophobia or phonophobia

Question 4

What is the pathophysiology of migraines?

Answer 4

Both vascular and nueronal causes
Stress causes seretonin release
Blood vessels constrict or dilate
Substance P is released which irritates vessels and nerves causing pain

Question 5

What is an aura?

Answer 5

A fully reversible sensory motor or language symptom

Question 6

How long do auras related to a migraine last?

Answer 6

20-60 mins

Question 7

Do auras usually precede or follow a migraine?

Answer 7

Usually occur one hour prior to migraine onset.

Question 8

Describe some common visual auras?

Answer 8

Central scotoma - central fuzziness

Hemianopia loss

Question 9

What regions of the brain are linked to migraines?

Answer 9

Dorsal raphe nucleus

Locus Coeruleus

Question 10

What chemicals have been linked to triggering a migraine?

Answer 10

Substance P
Neurokinin A
CGRP

Question 11

What system when activated is thought to trigger a migraine with aura?

Answer 11

Trigeminal Vascular system

Question 12

List some causes of migraines with aura?

Answer 12

Sleep deprivation
Diet
Stress
Hormones
Physical exertion

Question 13

What are some non pharmacological treatments for migraines?

Answer 13

Prevention

Education on triggers e.g. diet sleep relaxation etc

Question 14

What are some pharmacological treatments for migraines once they have started?

Answer 14

NSAIDs Aspirin Naproxene Ibuprofen

Triptans- Fovatriptan

Question 15

What are Triptans?

Answer 15

5HT seretonin agonists

Question 16

How are triptans administered and when?

Answer 16

Orally, Sublingually or subcutaneously

Start of the headache for sustained relief

Question 17

In order to be put on migraine prophylaxis what must the patient present with?

Answer 17

More than three attacks per month

Very severe migraines

Question 18

What is the rule in terms of pharmacological treatment of migraines?

Answer 18

Start low go slow

Question 19

What tricyclic can be used for migraine prophylaxis?

Answer 19

Amitriptyline 10-25mg

Question 20

What are some common side effects of amitriptyline?

Answer 20

Dry mouth

Postural hypertension

Question 21

What is first line in migraine prophylaxis?

Answer 21

Propanolol 80mg

Question 22

What are some common side effects of propanolol?

Answer 22

Avoid in asthma

Peripheral vascular disease

Question 23

If beta blockers are unsuitable what can be given for migraine prophylaxis ?

Answer 23

Topiramate 25-100mg

Question 24

What is Topiramate?

Answer 24

Carbonic anhydrase inhibitor

Question 25

What are some of the side effects with Topiramate?

Answer 25

AVOID if looking to conceive Weight loss Paraesthesia Impaired concentration

Question 26

List some other drugs which can be used for migraine prophylaxis?

Answer 26

Gabapentin Sodium Valproate Botulinum Toxin

Question 27

How long should prophylaxis be used for before determining whether or not it is effective?

Answer 27

3 months at maximum dosage

Question 28

What lifestyles factors should be altered in someone complaining of chronic migraines?

Answer 28

``` Healthy diet Increase water to >2L Reduce caffeine Regular exercise Reduce stress ```

Question 29

What class of drug should be taken alongside the acute migraine treatment?

Answer 29

Anti emetic - Metoclopramide Hydroxychloride

Question 30

What is a Acephalgic Migraine?

Answer 30

Aura without the headache/migraine

Question 31

What is a basilar migraine?

Answer 31

Vertigo and severe N+V

Question 32

What is a retinal migraine?

Answer 32

Visual aura

Question 33

What is a hemiplegic migraine?

Answer 33

Familial or sporadic | Self resolving weakness down one side for 1-2 weeks

Question 34

Give a list of acephalic migraines.

Answer 34

Basilar Hemiplegic Retinal

Question 35

What are tension type headaches ?

Answer 35

Normal everyday headache

Question 36

Describe a tension type headache.

Answer 36

Bilateral mild to moderate pain Photo/Phonophobia Absence of Nausea + Vomiting

Question 37

What are some non pharmacological treatments for a tension type headache?

Answer 37

Physiotherapy Relaxation Sleep Hydration

Question 38

What is the mainstay of pharmacological treatment for tension type headaches?

Answer 38

Amitriptyline | 3 months

Question 39

List some Trigeminal Autonomic Cephalgias

Answer 39

Cluster Paroxysmal Hemicrania Hemicrania continua SUNCT

Question 40

What are some autonomic features related to Trigeminal Autonomic Cephalgias?

Answer 40

``` Ptosis Miosis Nasal Stiffness N+V Eye lid oedema ```

Question 41

Who is affected by cluster headaches?

Answer 41

M>F | 30-40s

Question 42

Describe when someone is likely to be affected by a cluster headache?

Answer 42

``` Around sleep (Circadian rhythm) Seasonal variation ```

Question 43

Describe cluster headaches.

Answer 43

Sever unilateral headache 1-8 a day Clusters last weeks to months

Question 44

What is the acute treatment for a cluster headache?

Answer 44

High flow O2 Sub cutaneous Sumatriptan Reducing course of steroids

Question 45

What is the dosage of the 5HT serotonin agonist used in cluster headache treatment. Subcutaneous injection

Answer 45

Sumatriptan 6mg

Question 46

What is first line prophylaxis in cluster migraines?

Answer 46

Verapamil

Question 47

Who is affected in paroxysmal Hemicrania?

Answer 47

F>M | 50-60s

Question 48

Describe Paroxysmal Hemicrania.

Answer 48

Severe unilateral pain | Unilateral Autonomic features

Question 49

Describe the course of Paroxysmal Hemicrania.

Answer 49

Lasts 10-30 mins | 1 to 4x a day

Question 50

What is used in the treatment of Paroxysmal Hemicrania?

Answer 50

Absolute response to Idomethacin

Question 51

SUNCT

Answer 51

``` Short Lasting - 15/120s Unilateral Neuralgiaform Conjunctival injections Tearing ```

Question 52

What is the treatment for SUNCT?

Answer 52

Lamotragine | Gabapentine

Question 53

Epidemiology of Idiopathic Intracranial Hypertension

Answer 53

F>M Obese Female of chid bearing age

Question 54

How does someone with idiopathic intracranial hypertension present?

Answer 54

``` Diurnal variation headaches Morning D+V Visual Loss Bilateral Papilloedema Tinnitus ```

Question 55

What could be seen on the MRI of a patient with Idiopathic Intracranial Hypertension.

Answer 55

``` Flattened optic discs Empty Sella (Pituitary fossa) ```

Question 56

If a CSF sample was taken of someone with Idiopathic Intracranial Hypertension what would you expect to find?

Answer 56

Normal make up | Raised pressure

Question 57

What is an affective method of monitoring Idiopathic Intracranial Hypertension?

Answer 57

Visual Field | Take a base line and track progression

Question 58

What is the first line treatment for Idiopathic Intracranial Hypertension?

Answer 58

Weight Loss | Acetazolamide

Question 59

If Idiopathic Intracranial Hypertension continues to progress despite pharmacological treatment and lifestyle changes what is considered?

Answer 59

Lumbar peritoneal shunt

Question 60

Epidemiology of Trigeminal Neuralgia

Answer 60

F>M | >60 years

Question 61

How does someone with Trigeminal Neuralgia present?

Answer 61

Severe stabbing unilateral stabbing pain that lasts for up to 90s Bouts of pain may recur for 100 days before remission

Question 62

What nerves are involved in Trigeminal Neuralgia?

Answer 62

CN V2 / V3

Question 63

What investigations are undertaken in trigeminal Neuralgia?

Answer 63

MRI

Question 64

In a patient with Trigeminal Neuralgia what could be seen on MRI?

Answer 64

Usually a vessel touching and irritating a cranial nerve

Question 65

What is the treatment for Trigeminal Neuralgia?

Answer 65

Carbezamapine Gabapentine Surgical ablation