ic5 - headaches and migraines

Question 1

what do you use to classify headaches and how would you classify them

Answer 1

classify into primary, secondary and neuropathies, facial pain and others

[primary] migraine, tension type headaches, trigeminal autonomic cephalagias, other primary HA disorders

[secondary] trauma/ injury to head and/or neck, cranial or cervical vascular disorder, non vascular intracranial disorder, infection, homeostasis disorder, HA or facial pain attributed to disorder of any facial feature, psychiatric disorder

[neuropathies, facial pain and others] painful lesions of the cranial nerves and other facial pain, other HA disorders

Question 2

what do the red flags s/sx point towards to

Answer 2

they point towards secondary headache

Question 3

what are the red flags of headaches

Answer 3

use SNNOOP10 guide

systemic sx like fever
neoplasm (hx of)
neurologic deficit or dysfunction
onset of HA sudden or abrupt
older age (>50yo)
pattern change or recent onset of HA
positional headache
precipitated by sneezing, coughing or exercise
papilledema
progressive HA with atypical presentation
pregnancy or puerperium
painful eye with autonomic features
post traumatic onset of headache
pathology of immune system (HIV/ immunocompromised)
painkiller overuse or new drug at onset of HA

Question 4

what are the types of tension headaches

Answer 4

episodic (frequent or infrequent) and chronic

[episodic infrequent] >10 HA <1d/m on average, <12 HA a year

[episodic frequent] >10 HA occurring on 1-14d/m on avg for >3m

[chronic] HA on more than 15d/m for >3m and assoc with vit deficiencies

Question 5

what are the risk factors of tension headache

Answer 5

females (3:2), depression and anxiety disorders, insomnia, temporomandibular joint disorder, vitamin deficiencies (B12, D)

Question 6

what are the clinical features of tension headaches

Answer 6

gradual or constant onset
mild to moderate intensity
characteristics: non pulsating, tightening/ pressing, band/ visor like, fullness
location: bilateral, frontal, nuchal occipital
better in the morning, worse in the evening
may not worsen with activity but improve with rest
others: difficulty concentrating, muscle stiffness and tightness, decr in appetite, some sensitivity to light and sound
no prodrome, N/V or aura sx

Question 7

what is the diagnostic criteria of tension headache

Answer 7

more than two of the following: bilateral, non pulsating, pressing/ tightening pain, mild to moderate, not worse with exertion

no N/V, not both photo and phonophobia

at least 10 of such headache episodes that occur for at least 30mins within 7 days

exclude other possible causes through imaging or redflags s/sx

Question 8

what are the triggers for tension headaches

Answer 8

dehydration hunger, sleep deprivation, anxiety or stress, poor posture (excessive neck flexion), alcohol, caffeine, cold or flu or sinus infection, noise exposure

Question 9

why might episodic tension headaches become chronic in nature

Answer 9

it can become chronic if there is central sensitisation (incr responsiveness of nociceptors in CNS)

Question 10

what is the goals of tx for tension headaches

Answer 10

pain relief and prevent progression to chronic TTH

Question 11

what is the tx for tension headaches

Answer 11

identify and avoid triggers (usage of headache diary) and pt education

self limiting, rest

pharmacological acute tx: [for episodic] paracetamol (alone or w caffeine), aspirin, NSAIDs [for chronic] tricyclic antidepressants and cognitive behavioral therapy

pharmacological for prophylactic tx: amitriptyline (first line), mirtazapine, venlafaxine

non pharm tx: CBT, biofeedback, relaxation, physical and/or occupational therapy, lifestyle modification incl sleep hygiene

Question 12

what drugs is assoc with tension headaches resulting from medication overuse

Answer 12

paracetamol, NSAIDs, opioids, triptans, barbiturates

Question 13

how might tension headaches arise from medication overuse

Answer 13

typically headache -> medication -> pain relief

but in this case, headache -> medication -> short term pain relief -> rebound headache -> higher medication doses -> short term pain relief (viscious cycle)

Question 14

how would you classify migraines

Answer 14

episodic (migraine without aura migraine with aura) and chronic migraines

[episodic migraine] at least 5 migraine attacks lasting 4-72h during lifetime
-> then look at w/wo aura

[episodic migraine wo aura] at least 5 attacks fulfilling (i) to (iii)
(i) headache attacks lasting 4-72h
(ii) headache has at least 2 of the following: unilateral, pulsating, moderate to severe, aggravation or causing avoidance of routine physical activity
(iii) phono/photophobia, N/V during headache experience

[episodic migraine w aura] at least 2 attacks fulfilling (i) and (ii)
(i) at least 1 of the following fully reversible aura sx: visual, sensory, speech and/or language, motor, brainstem, retinal
(ii) at least 3 of the following: at least 1 aura sx spread gradually over 5mins or longer, aura sx occur in succession, each individual aura sx last 5-60min, at least one aura sx is unilateral, at least one aura sx is positive, aura is accompanied or followed within 60mins by headache

[chronic migraine] at least 15 MHDs and at least 8 MMDs for >3m

Question 15

what does MHD and MMD refer to

Answer 15

MHD is monthly headache day which refers to a day with migraine type or tension type headache

MMD is monthly migraine day which refers to at least 2 migraine characteristics

Question 16

what are the phases of a migraine attack

Answer 16

phase 1: premonitory - lasts few hrs to days (fatigue, cognitive difficulties, mood changes, food cravings, yawning, neck pain)

phase 2: aura - 5-60mins (visual, retinal, motor, brainstem, speech and/or language, sensory)

phase 3: HA - 4-72h (N/V, photo/phonophobia)

phase 4: postdrome - <12-24h (feeling tired or weary, difficulty concentrating, neck stiffness)

Question 17

what is the tx for migraines (acute and adjuntive)

Answer 17

[acute tx] NSAIDs, triptans, ergotamine, MAb that blocks CGRP receptor or CGRP

[adjunctive tx] antiemetics

Question 18

what is the moa of NSAIDs

Answer 18

anti inflamm, analgesic and antipyretic properties mediated by blockade of COX enzymes and subsequent inhibition of PG synthesis

Question 19

what is the moa of triptans (vs sumatriptan)

Answer 19

triptans are 5HT1B and D receptor agonists that results in a decrease in trigeminal neuronal activity and causes vasoconstriction of cerebral blood vessels, inhibition of vasoactive peptide release by trigeminal neurons and inhibition of nociception

sumatriptan is a selective 5HT1D receptor agonist and thus causes vasoconstriction in carotid artery circulation but does not alter cerebral blood flow

Question 20

what are the indications for triptans

Answer 20

for acute tx of migraine if analgesics do not adequately relieve pain

largely replaced ergot alkaloids as triptans have better s/e profile bc ergotamine has greater vasoconstrictive effects

Question 21

what are the c/i for triptans

Answer 21

HTN, coronary heart disease, raynaud’s disease, pregnancy and lactation, hx of ischemic stroke

due to its vasconstrictive effects

Question 22

what is the significance of CGRP (structure, function, role in migraine attack)

Answer 22

calcitonin gene related peptide (CGRP) is present in trigeminal nerve fiber and vessels which triggers the whole cascade of pain to spread

CGRP is a 37AA peptide found throughout body that functions as a vasodilator

levels of CGRP found to increase during a migraine attacks

Question 23

list the drugs that are CGRP receptor blocker and CGRP blocker

Answer 23

CGRP receptor blockers are erenumab and -gepants (atogepant, rimegepant, ubrogepant)’

CGRP blockers are -zumab (eptinezumab, fremanezumab, galcanezumab)

Question 24

what is the moa of -gepants

Answer 24

CGRP receptor antagonists which binds to CGRP receptors and prevent signalling

Question 25

compare the difference between antiCGRP Ab and antiCGRP receptor Ab

Answer 25

anti-CGRP Ab binds to CGRP

anti-CGRP receptor Ab binds to CGRP receptor

Question 26

what is the potential indication for anti-CGRP Ab

Answer 26

for use of prevention of migraines (certain -gepants)

Question 27

what are the limitations of anti-CGRP therapies

Answer 27

CGRP hypothesised to act as a ‘vasodilator safeguard’ during ischemia thus mild and transient ischemic events might be worsened if receive long term CGRP blockade tx

and long term safety data required

Question 28

list an example of antiemetics and why might it be used

Answer 28

metoclopramide to address N sx

Question 29

how to assess efficacy of tx

Answer 29

headache diary, disability assessment (eg. MIDAS score), s/e from medications

Question 30

what is the criteria for migraine prophylaxis

Answer 30

there are two criterias for migraine prophylaxis: AHS and EHF

AHS is based on number of HA days per month and degree of disability caused by attacks

EHF states to offer if not well controlled with acute tx alone

[AHS] prevention offered if (i) at least 6 MHDs with no disability (ii) at least 4 MHDs with some disability (iii) at least 3 MHDs with severe disability; prevention considered if (i) 4-5 MHDs with no disability (ii) 3 MHDs with some disability (iii) 2 MHDs with moderate disability

[EHF] migraine prophylaxis indicated if (i) migraine impairs QoL AND (ii) (a) attacks cause disability on 2 or more days per month and optimised acute tx does not prevent above OR (b) risk of overfrequent use of acute tx and pt willing to take daily meds

Question 31

what are the drugs used for migraine prophylaxis

Answer 31

BB, antiepileptics

Question 32

what are some migraine triggers

Answer 32

nutritional deficiencies
dairy products
processed food
sugar
alcohol
not eating
chocolate
weather
lights
neck pain
exercise
sleep disturbances
sleeping late
heat
muscle ache
excessive sexual activity
perfume or odor
allergies
hormone disruption
sinuses
smoke
stress
environmental stress
caffeine
MSG
artificial sweeteners
gluten