JC26 (Medicine) - Headache and Neuralgia Flashcards

Question

Causes of subacute headache (7)

Answer 1

1. Infection: e.g. chronic meningitis, TB, brain abscess 2. Intracranial tumor 3. Chronic subdural haematoma 4. Hydrocephalus 5. Idiopathic intracranial hypertension 6. Temporal arteritis 7. Intracranial hypotension

Answer 2

1. Tension-type headache 2. Transformed migraine 3. Medication overuse headache 4. Ocular eye strain/ Refractive error 5. Drugs/ toxins (e.g. vasodilators) 6. Cervical spondylosis

Answer 3

Definition: migraine patient defined as □ ≥2 attacks with aura □ ≥5 attacks without aura Types: □ Migraine with aura (20%): with a warning of visual, sensory or motor type followed by headache □ Migraine without aura (80%): without aura symptoms □ Mixed: Up to 33%

Answer 4

Pathophysiology: still unclear □ **Cortical spreading depression (CSD)**: dysfunctional ion channels → spreading front of cortical depolarization followed by hyperpolarization → ‘aura’ symptoms □ **Neurogenic inflammation**: CSD → stimulation of **trigeminal nerve endings at cranial vessels** → **nociceptive neurones on dural** blood vessels release plasma proteins and pain neurotransmitters → ‘neurogenic inflammation’ with vasodilatation □ Pain due to **activation of nociceptors and central pain sensitization** (∵dysfunction of BS pathways that normally modulate sensory input, eg. dorsal raphe nucleus, locus ceruleus…)

Answer 5

Typical course of migraine: □ **Prodrome** (77%): preceding **mental and mood fluctuations, fatigue or autonomic symptoms** for 24-48h □ **Aura**: gradual development of transient focal neurological symptoms; develop over 4-60min **before/ during headache** □ **Headache**: moderate-severe unilateral or bilateral pulsating headache for 4-72h □ **Postdrome: hangover-like state w/ listlessness** + sudden head mov’t trigger headache for up to 24h

Answer 6

**Visual** (99%): * **Scotoma** (-ve): gradually spreading visual defect, often bordered by fortification spectra * **Fortification spectra** (+ve): shimmering, silvery zig-zag lines that march across visual fields **Sensory**: (31%): **tingling (+ve) followed by numbness** (-ve) spreading from one part of the body to another **Aphasic** (18%): **transient speech disturbance** due to dominant hemisphere involvement **Motor (6%): hemiplegic aura**

Answer 7

1. **Chronic migraine** if ≥15d/mo for \>3mo w/o medication overuse 2. **Status migrainosus**: debilitating **migraine attack lasting for \>72h** 3. **Persistent aura w/o infarction**: if aura lasts for \>1w 4. **Migrainous infarctio**n: aura symptoms lasting for \>1h + ischaemic infarct on CT/MRI 5. **Migraine-triggered seizure**: epileptic seizure occur during or ≤1h of aura

Answer 8

**Familial hemiplegic migraine (FHM):** □ Cause: mutations in VGCC α1 subunits (FHM1) or Na+/K+/ATPase α2 subunit (FHM2) □ Pathophysiology: changes in ion transport → hyper neuronal excitability → susceptibility to cortical spreading depression

Answer 9

→ Dietary: alcohol, chocolate, tyramine-containing (eg. dairy products), starvation, caffeine → Hormonal: often premenstrual or related to OCP (fluctuation in oestrogen) → Emotional: stress, anger, excitement → Others: change in sleep, irregular meals, certain drugs, smoking, fluorescent lights, weather

Answer 10

simple analgesics for mild attacks, migraine-specific agents for severe attacks Simple analgesics: aspirin, paracetamol, NSAIDs, combination D2-blocker anti-emetic (↓nausea/vomiting + ↓headache): metoclopramide, domperidone Triptans for severe headache: sumatriptan (oral, subcutaneous, nasal), naratriptan (PO), zolmitriptan (PO) Ergotamine (also 5HT1 agonist like Triptan)

Answer 11

* Indication: Severe migraine headache * MoA: 5HT1 agonist → vasoconstriction, peripheral neuronal inhibition, ↓trigeminal neurotransmission * S/E: dizziness, somnolence, asthenia, nausea * C/I: IHD, stroke, CAD, uncontrolled HTN

Answer 12

* Indication: Severe migraine headache * MoA: 5HT1 agonist → vasoconstriction, ↓trigeminal neurotransmission * S/E: vascular events (sustained generalized vasoconstriction), high risk of overuse syndrome and rebound headache * C/I: IHD, thyrotoxic heart disease, PVD, uncontrolled HTN

Answer 13

* Indication - Attacks weekly or \>2 times a month - Attacks less often but very prolonged and debilitating * Drug types - **Prophylactic NSAID**s in menstrual or orgasmic migraine - **Antihypertensives**: β-blockers, CCB - **Antidepressants**: amitriptyline, venlafaxine - **Anticonvulsants**: topiramate, valproate - **CGRP antagonists**, eg. erenumab, fremanezumab, galceanezumab - Others: pizotifen (5HT2 blocker), botox injections around H&N q12w (if refractory)

Answer 14

- Limit to 2-3d/week → Limit medication overuse headache - Keep headache diary → monitor for escalation in drug use - Avoid opioids: mask pain without suppressing pathophysiological mechanism → cognitive impairment or addiction

Answer 15

Character: → Gradual ↑headache frequency and drug consumption → Change in headache characteristics → Ultimately take analgesics and large amounts of caffeine Causes daily analgesic use (\>10-15d/month) or compound analgesics (esp opiates) and triptans Mx Abrupt withdrawal from painkillers or antimigraine drugs

Answer 16

syndromes with **combination of facial pain and autonomic dysfunction** □ **Cluster headache**: severe unilateral periorbital pain of 10min-3h + unilateral autonomic activation □ **Paroxysmal hemicrania**: similar to cluster headaches but shorter (2-45min) □ **SUNCT**: brief, severe, sharp periorbital pain (15s-3min) a/w conjunctival injection and tearing, ↑by touch or neck movement

Answer 17

Pathophysiology: unknown, a/w Abnormal hypothalamic or thalamic activity Paroxysmal discharges of central trigeminal and PN pathways Types: Episodic: clusters (7-365d) with pain-free remissions (\>1mo) Chronic: recurrent attacks (\>1y) without or with pain-free remissions \<1mo S/S: Headache: extreme unilateral periorbital piercing/throbbing pain Autonomic features: unilateral lacrimation, nasal congestion, conjunctival injection, sweating ± transient Horner’s syndrome Agitation Periodic pain daily with clustering period of pain over days, followed by pain-free periods

Answer 18

Acute attacks: → SC sumatriptan OR 100% O2 (15L/min) as 1st line → Intranasal lidocaine (administered ipsilaterally) → PO ergotamine or IV dihydroergotamine (5HT1 agonist) Prophylaxis: should be started during cluster periods → Verapamil → Short course oral corticosteroids → Other drugs: topiramate, methysergide, gabapentin, Lithium

Answer 19

intracranial large artery aneurysms, AVMs, cavernous haemangiomas, meningiomas…

Answer 20

Pathology: subacute granulomatous inflammation of large/medium sized arteries with lymphocyte, plasma cell, neutrophil and giant cell infiltration □ Results: → Thrombosis due to vessel wall thickening: - Ophthalmic artery → amaurosis fugax - Basilar artery → posterior circulation infarct → Stimulation of nociceptive neurones → pain □ Site: often involves superficial temporal artery → tender, thickened, non-pulsatile on examination

Answer 21

□ **Headache**: new onset, bitemporal, intense throbbing headache □ **Neurological** S/S: Stroke, hearing loss, myelopathy, neuropathy Blindness due to acute ischaemic optic neuropathy (AION) □ ***_Jaw claudication_***: pain when chewing or talking due to ischaemia of masseter □ **Visual S/S: amaurosis fugax** (transient), can progress into permanent blindness (sight-threatening) Due to arteritic acute ischaemic optic neuropathy (AAION) □ **Systemic** S/S: Fever, anorexia, malaise Polymyalgia rheumatica (50%): pain and stiffness over shoulder and pelvic girdle muscles

Answer 22

Diagnostic criteria: ≥3 criteria (1) Onset ≥50y (2) New headache (3) Abnormalities of temporal artery at PE: tender, thickened, non-pulsatile superficial temporal artery (4) ↑ESR (\>50mm/h) (5) Abnormal findings on biopsy of temporal artery

Answer 23

**Tx: urgent prednisolone 60mg qd** □ Urgent Tx prevents blindness and brainstem stroke and ↓headache □ Parenteral high dose if complications already occurred □ Gradual ↓dosage to maintenance level according to ESR level

Answer 24

□ Sudden intense sharp, aching, lancinating, burning, stabbing pain in distribution of nerve □ Lasts **seconds to \<2min**, occurring repeatedly within short periods □ Often triggered by **sensory/mechanical stimulus**

Answer 25

Trigeminal Neuralgia S/S: paroxysmal attacks of unilateral severe, short, sharp, stabbing pain Site: typically unilaterally following V2 or V3 distribution Triggers: spontaneous or touching a specific spot or doing certain activities (eg. touching/washing face, shaving, brushing teeth, chewing) Course: → Paroxysmal attacks for many times per day, lasting several days or weeks → Then stop abruptly followed by pain-free periods for months or years → Tend to become more frequent over years with ↓duration of remission periods

Answer 26

□ Classical TN: → **Vascular loop compression**: most common, 80-90% → Idiopathic □ Other causes (secondary TN): → **Multiple sclerosis**, esp young and when bilateral → **CPA masses**: vestibular neuroma, meningioma, epidermoid cyst, AVM, angiomas… → **Herpes zoster and post-herpetic neuralgia**

Answer 27

Medical Tx: for classic TN **Carbamazepine** (first-line, most effective, 75% responsive) Surgical Tx: for refractory classic TN * **Peripheral neurectomy**, eg. alcohol ablation (temporary relief) * **Microvascular decompression** (separate vessels from trigeminal nerve root) * **Percutaneous radiofrequency thermocoagulation rhizotomy** (artificial lesion for trigger spot on Trigeminal nerve) Treatment of underlying condition (eg. surgical decompression) for secondary TN

JC26 (Medicine) - Headache and Neuralgia Flashcards

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