Migraines

Question 1

What is the most common type of primary headache?

1 - migraines
2 - thunderclap
3 - tension type
4 - cluster

Answer 1

3 - tension type
- migraine is the 2nd most common form of primary headache

• incidence of 0.5-5%
• difficult to identify exact incidence

Question 2

What is the most common debilitating headache?

1 - tension headache
2 - thunderclap headache
3 - Migraine
4 - Cluster headaches

Answer 2

3 - Migraine
- also 2nd most common type of primary headaches

• 7th highest cause disability globally
• 2.9% of years of life lost to disability
• twice as likely in women

Question 3

What is a primary headache?

1 - no known underlying cause
2 - trauma related headache
3 - infectious related headache
4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Answer 3

1 - no known underlying cause

Question 4

What is a secondary headache?

1 - no known underlying cause
2 - trauma related headache
3 - infectious related headache
4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Answer 4

4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Question 5

Are primary or secondary headaches more common?

Answer 5

• primary

Question 6

What is the incidence of migraines?

1 - 50/100,000
2 - 500/100,000
3 - 5000/100,000
4 - 50,000/100,000

Answer 6

3 - 5000/100,000

Question 7

At what time do migraines generally start and begin to decline?

1 - starts at puberty and declines around 20y/o
2 - starts at puberty and declines around 40y/o
3 - starts at puberty and declines around 60y/o
4 - starts at puberty and declines around 80y/o

Answer 7

2 - starts at puberty and declines around 40y/o

• 2% have chronic migraines, causing medication overuse

Question 8

Are migraines more common in men or women?

Answer 8

• women
• 3x more likely

Question 9

Menstrual migraines can occur in women. When would these generally occur?

1 - days 1-2
2 - days 2-3
3 - days 5-7

Answer 9

2 - days 2-3

Question 10

Are patients with comorbid psychiatric disorders such as anxiety & depression more or less likely to experience medication overuse headaches?

Answer 10

• more likely

Question 11

Which cranial nerve is the trigeminal nerve?

1 - 2
2 - 4
3 - 5
4 - 7

Answer 11

3 - 5

Question 12

The trigeminal nerve is cranial nerve V (5) is derived from the 1st pharyngeal arch and is the largest of all the cranial nerves. What functions does this cranial nerve have?

1 - sensory only of the face
2 - motor only of mastication muscles
3 - both of the above
4 - none of the above

Answer 12

3 - both of the above

Question 13

What is the trigeminocervico complex?

1 - CN V (5) meets cervical vertebrae 1
2 - CN V (5) synapses in same nucleus as cervical vertebrae 1
3 - CN V (5) synapses in same nucleus as cervical vertebrae 1 and 2
4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3

Answer 13

4 - CN V (5) synapses in same nucleus as cervical vertebrae 1-3

• sensory only from CV V (5)
• this essentially means any sensory information from cervical vertebrae 1-3 can revert pain to the head causing a headache
• region of the brain receives nociceptive stimulus

Question 14

The trigeminocervico complex is a nucleus where CN V (5) synapses in same nucleus as cervical vertebrae 1-3 for sensory receptors only. Where is this located?

1 - cerebellum
2 - brain stem
3 - pons
4 - medulla oblongata and upper cervical spine

Answer 14

4 - medulla oblongata and upper cervical spine

Question 15

Which of the following is not part of the trigeminal nerve?

1 - ophthalmic
2 - maxillary
3 - accessory
4 - mandibular

Answer 15

3 - accessory

Question 16

The spinal trigeminal nucleus is a nucleus in the medulla that receives information about deep/crude touch, pain, and temperature from the ipsilateral (same side) face. Which of the following is important for pain and temperature sensations?

1 - Pars oralis
2 - Pars interpolaris
3 - Pars caudalis

Answer 16

3 - Pars caudalis

Question 17

Which of the following are typical triggers for developing a migraine?

1 - tiredness, stress, dehydration
2 - alcohol
3 - combined oral contraceptive pill
4 - cheese, chocolate, red wines, citrus fruits
5 - menstruation
6 - bright lights
7 - all of the above

Answer 17

7 - all of the above
Remember the mnemonic CHOCOLATE:

C = chocolate
H = hangovers
O = orgasms
C = cheese/caffeine
O = oral contraceptive
L = lie-ins
A = alcohol
T = travel
E = exercise

Question 18

Migraines are a form of primary headaches, which essentially means the cause is unknown. Do migraines typically present unilaterally or bilaterally?

Answer 18

• unilaterally

Question 19

Which of the following locations would the main symptom of a migraine be felt?

1 - on one side of the face
2 - around the eye on one side of the face
3 - across the top of the forehead
4 - all of the above

Answer 19

1 - on one side of the face

Question 20

Migraines are a form of primary headaches, which essentially means the cause is unknown. Which of the following do migraines NOT typically present with?

1 - severe, bilateral, throbbing headache
2 - nausea, photophobia (sensitive t light) and phonophobia (fear of sound)
3 - can last up to 72h
4 - patients typically stay in dark and quiet rooms
5 - auras can be or not be present
6 - stiff neck
7 - vary 1-2/month or 1/year

Answer 20

1 - chronic, bilateral, throbbing headache

• typically migraines are unilateral

Question 21

A migraine aura is something that you experience when having a migraine. which of the following is true?

1 - can be visual only
2 - can be auditory only
3 - can be motor or sensory
4 - all of the above

Answer 21

4 - all of the above

• most common is visual, and it is completely reversible
• builds up over time and can last up to 60 minutes
• more common in older patients, but no headaches

Question 22

An aura is when there are visual changes that are associated with migraines. What visual symptoms can be experienced in an aura?

1 - Sparks in vision
2 - Blurring vision
3 - Lines across vision
4 - Loss of different visual fields
5 - all of the above

Answer 22

5 - all of the above

Question 23

Auras typically occur prior to a migraine and can include visual (most common), auditory, motor and sensory aspects. Typically how long can the auras last for?

1 - <10 minutes
2 - <40 minutes
3 - <60 minutes
4 - <2 hours

Answer 23

3 - <60 minutes

Question 24

How long do migraines typically last?

1 - 4-72 hours
2 - 15-180 minutes
3 - 30 minutes to 1 week
4 - >1week

Answer 24

1 - 4-72 hours

Question 25

When migraines are present are they continuous or episodic?

Answer 25

- episodic - typically throbbing unilaterally, but can be bilateral - feels like someone is drilling on the side of your head

Question 26

Overuse of medication can present in a similar way to migraines. Which of the following are present in migraines that helps distinguish migraines from medication overuse in headaches? 1 - occurrence of headache 2 - duration of the migraine 3 - nausea and vomiting 4 - gender

Answer 26

3 - nausea and vomiting - both are present in migraines

Question 27

When performing a history on a patient with a headache, is an increase in the headaches symptoms when performing the Valsalva bad?

Answer 27

- bad - indicates a mass or increased fluid overload in the cranial cavity - Valsalva is an increase in pressure with a closed glottis

Question 28

When performing a history on a patient with a headache, which of the following is NOT typically a red flag? 1 - patient wakes up with headache 2 - change in character 3 - age of onset 4 - sudden onset (thunderclap) 5 - focal neurological deficits 6 - constitutional symptoms (fever, meningism, rash, weight loss)

Answer 28

1 - patient wakes up with headache - RED FLAG if it wakes the patient whilst they are asleep

Question 29

When examining a patient, all of the following are RED FLAGS except which one? 1 - patient appears sick-appearing, skin changes 2 - evidence of trauma 3 - altered cognitive state 4 - ocular: hyphema, pupil non-reactivity, optic disc swelling, proptosis, restricted eye movements 5 - meningism 6 - weight loss 7 - focal neurological findings (eg limb weakness)

Answer 29

6 - weight loss

Question 30

Of the following, which is most likely to trigger a migraine? 1 - dehydration and stress 2 - food and weather 3 - cigarettes and alcohol 4 - medications

Answer 30

2 - food and weather

Question 31

When diagnosing a migraine if the patient has no aura, how many migraines lasting 4-72h should a patient have had? 1 - >3 2 - >5 3 - >8 4 - >12

Answer 31

2 - >5

Question 32

When diagnosing a migraine if the patient has no aura, patients should have >5 migraines lasting 4-72h with nausea or vomiting. They should also have how many of the following? - unilateral painFred - pulsing pain - impairs ADL - photophobia/phonophobia 1 - >2 2 - >3 3 - all 4

Answer 32

1 - >2

Question 33

In addition to aura, which of the following occurring would suggest that the patient is having a migraine over tension headaches and cluster headaches? 1 - ipsilateral (same side) autonomic features) 2 - no features at all (including aura) 3 - aura, vomiting and nausea 4 - none of the above

Answer 33

3 - aura, vomiting and nausea

Question 34

Following a migraine, which of the following symptoms are unlikely to occur? 1 - fatigue 2 - tired 3 - lacrimation and ptosis 4 - difficulty concentrating 5 - stiff neck

Answer 34

3 - lacrimation and ptosis - this commonly occurs in cluster headaches

Question 35

What is typically the 1st line treatment patients with migraines are given as part of abortive approach? 1 - paracetamol 2 - lifestyle advice 3 - NSAIDs 4 - Triptan (serotonin agonist)

Answer 35

2 - lifestyle advice - adequate sleep, hydration, exercise, cognitive behavioural therapy, biofeedback

Question 36

If lifestyle advice fails in patients with migraines, which of the following can then be prescribed next as part of abortive approach? 1 - paracetamol 2 - aspirin 3 - NSAIDs 4 - Triptan (serotonin agonist)

Answer 36

1 - paracetamol - then it would be aspirin and NSAIDs - if these fail then we can use: + Triptan (eg sumatriptan, zolmitriptan) + Dopamine agonists (metoclopramide, prochlorperazine) + Monoclonal antibodies + Nerve block injections

Question 37

Should opioids ever be prescribed for the acute management of patients with migraines?

Answer 37

- no

Question 38

What is typically the 1st line treatment patients with migraines are given as part of a preventative approach? 1 - Amitriptyline 2 - Lifestyle advice 3 - Propranolol 4 - Topiramate

Answer 38

2 - Lifestyle advice

Question 39

If lifestyle advice fails in patients with migraines, which of the following can then be prescribed next as part of preventative approach? 1 - Amitriptyline 2 - Lifestyle advice 3 - Propranolol 4 - Topiramate

Answer 39

4 - Topiramate - GABA agonist - AMPA antagonist - combined they block neuronal excitability that is causing migraines

Question 40

Which of the following would be a suitable differential for a patient with suspected migraine? 1 - cluster/tension headache 2 - cervical spondylosis 3 - intracranial pathology 4 - increased BP 5 - TIAs 6 - sinusitis/otitis media 7 - all of the above

Answer 40

7 - all of the above

Question 41

Patients who are menstruating may experience a menstruating migraine. Typically how long can this last during the menstrual cycle? 1 - whole 28 days 2 - >15 days 3 - <15 days 4 - 2-3 days Prevention – fovatriptan 2.5mg bd for 2/7 before attack expected until 3/7 after bleeding stops Or zolmitriptan 2.5mg 2-3 x day as above Oestrogen supplementation – but may cause rebound

Answer 41

4 - 2-3 days - typically occurs in 2/3 menstrual cycles

Question 42

Patients who are menstruating may experience a menstruating migraine. Typically this last 2-3 days of the menstrual cycle, and occurs in 2/3 of cycles. Which 2 of the following medications can be used to prevent menstruating migraines? 1 - fovatriptan (inhibit cranial vasodilation) 2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation) 3 - verapamil (induces vascular vasodilation) 4 - B-blockers (slows heart rate and reduces brain oxygen requirements)

Answer 42

1 - fovatriptan (inhibit cranial vasodilation) 2 - zolmitriptan (serotonin receptor agonist and inhibit vasodilation)