IC 5 - Headaches

Question 1

What are the three types of primary headache?

Answer 1

1. Tension
2. Migraine
3. Cluster

Question 2

Tension type headaches are _____ in nature.

Answer 2

bilateral

Question 3

Migraine can be ________ or ________.

Answer 3

unilateral, bilateral

Question 4

Which of the primary headaches is affected by routine activities of daily living?

Answer 4

Migraine

Question 5

Mr Lee has a headache where the pain is bilateral. He explains that he feels a band liked tightness around the head and it does not worsen with activity. What kind of headache does Mr Lee has?

Answer 5

Tension type headache

Question 6

What are the symptoms of migraine?

Answer 6

N/V
Sensitivity to light or sight
Aura (e.g. visual, sensory, speech disturbance)

Question 7

Cluster headache confers pain which is _______ in nature.

Answer 7

unilateral (around eyes or face)

Question 8

What are some symptoms accompanying cluster headaches?

Answer 8

Red, watery or swollen eye, nasal congestion/ runny nose, sweating

Question 9

Differentiate between infrequent, frequent episodic and chronic TTH in terms of frequency.

Answer 9

Infrequent episodic: <1 ep/month
Frequent episodic: 1 to 14 days/month
Chronic: 15 or more days/month

Question 10

What can trigger TTH?

Answer 10

Physical/ emotional stress
Poor posture (especially neck flexion)
Alcohol, caffeine
Cold/flu or sinus infections
Dehydration
Hunger

Question 11

What are the typical clinical presentation of TTH?

Answer 11

No aura, premonitory symptoms
Bilateral
Non-pulsatile
Tightness or pressure
Mild/Mod intensity
Pericranial or cervical muscles tenderness

Question 12

What are some non-pharmacological methods that can relieve TTH?

Answer 12

CBT, biofeedback, relaxation
Physical and/or occupational therapy
Lifestyle modification (include sleep hygiene)

Question 13

What are the three medications that can be given as prophylaxes for TTH?

Answer 13

Amitriptyline (1st line)
Mirtazapine
Venlafaxine

Question 14

What are the three medications for acute TTH?

Answer 14

Paracetamol (alone or with caffeine)
Aspirin
NSIADs: Ibuprofen, Naproxen, Diclofenac, Ketoprofen

Question 15

What are the 4 phases of migraine?

Answer 15

Prodrome, aura, headache, postdrome

Question 16

________is involved in the prodrome phase.

Answer 16

Hypothalamus

Question 17

________ is involved in the aura phase.

Answer 17

Cortex

Question 18

Briefly explains the pathophysiology of migraine.

Answer 18

1. Bodily changes in prodrome stage due to effects of hypothalamus
2. Leads to involvement of cortex, leading to “aura” (sensory and motor changes)
3. CGRP and PACAP is then released, leading to symptoms of headaches
4. After episode, there will be a post period of “energy being drained”, leading to tiredness

Question 19

Differentiate between chronic and episodic migraine.

Answer 19

Episodic: ≥ 5 migraine attacks lasting 4 to 72 hours
Chronic: ≥ 15 monthly headache and ≥ 8 monthly migraine day, > 3 months

Question 20

List 3 non-pharmacological method to manage migrane.

Answer 20

Identify triggers
Headache diary
Healthy lifestyle

Question 21

What are the medications that have established efficacy for migraine?

Answer 21

Triptans
Ergotamine derivatives
Gepants
Lasmiditan
NSAIDs (aspirin, celecoxib oral solution, diclofenac, ibuprofen, naproxen)
Combination Analgesic (Acetaminophen, aspirin, caffeine)

Question 22

How does NSAIDs help with migraine?

Answer 22

Inhibit prostaglandin synthesis

Question 23

Which population should NSAIDs be avoided in for migraine?

Answer 23

Hypersensitivity, previous ulcer, renal disease and severe CVS

Question 24

What are the adverse effect of NSAIDS?

Answer 24

Hypersensitivity, GI (N/V etc), CNS (dizzy etc)

Question 25

What is the indication of NSAIDs in migraine?

Answer 25

Mild to moderate

Question 26

How does triptans help with migrane?

Answer 26

Selective agonists at 5HT-1B and 1D 1. Vasoconstrict intracranial extracerebral blood vessels 2. Inhibit vasoactive peptide release by trigeminal neurons 3. Inhibit nociception neurotransmission within trigeminocervical complex

Question 27

When is triptan used for migraine?

Answer 27

Mild pain

Question 28

Which group of patients with pre-existing conditions should not be given triptans and Ergotamine and dihydroergotamines?

Answer 28

1. Stroke/ TIA 2. Ischemic coronary artery 3. Coronary artery vasospasm 4. Uncontrolled HTN 5. Peripheral vascular disease 6. Gastrointestinal ischemia 7. History of hemiplegic or basilar migraine

Question 29

Triptans should not be given to people who are on __________ as medication.

Answer 29

1. Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation 2. Concomitant use of ergotamine-containing or ergot- type medication within 24hours

Question 30

Ergotamine derivatives should not be used in patients on ______ medication.

Answer 30

1. Triptans (within 24 hours) 2. Potent CYP3A4 inhibitors e.g. macrolides and proteases inhibitors (increase vasospasm risk)

Question 31

How does the 2 components in cafergot works for migraine?

Answer 31

Ergotamine: Induce vasoconstriction and inhibit norepinephrine uptake and alpha adrenoreceptors Caffeine: Adenosine A1, A2A, A2B receptor antagonist, vasoconstrict cerebral vasculature and increase ergotamine GI absorption

Question 32

Describe medication overuse headaches.

Answer 32

Use of too much medications and results in headaches ≥ 15 days/mths in PT with preexisting headaches

Question 33

What causes medication overuse headaches?

Answer 33

1. Panadol or ≥1 NSAID on ≥15 days/months for 3 months 2. Triptan or ≥1 opioid on ≥10days/months for 3 months

Question 34

What is the criteria for assessment for migraine preventive measures?

Answer 34

No of days + disability degree

Question 35

What are the oral drugs that can be used for migraine preventive measures?

Answer 35

Candesartan Valporate Frovatriptans Metoprolol/ Propranolol/ Timolol Topriamte Divalproex sodium

Question 36

What are the parental drugs that can be used for migraine preventive measures?

Answer 36

1. Eptinezumab 2. Fremanezumab 3. Galcanezumab 4. Erenumab

Question 37

A minimum of _____ weeks should be given to patients to determine if the drug is effective or a switch is needed.

Answer 37

8

Question 38

What should be done to monitor patients with migraine?

Answer 38

Headache diary Disability Assessment Adverse effects from medication