Primary and Secondary Headaches

Question 1

what are the red flags of a headache?

Answer 1

new onset headache >55

known / previous malignancy

immunosuppressed

early morning headache

exacerbated by valsalva (coughing, sneezing - raises ICP)

Question 2

what should you be aware of in terms of past medical history when someone has headache?

Answer 2

cancer - predisposition to thrombosis

Question 3

what is family history particularly important in?

Answer 3

migraine

Question 4

what gender is migraine more common in?

Answer 4

women

Question 5

on average, most migraine sufferers have how many attacks per month?

Answer 5

1

Question 6

what % of migraines are those with aura (specific warning signs)?

Answer 6

20

80% are without aura

Question 7

how do you diagnose migraine without aura by IHS criteria?

Answer 7

at least 5 attacks (duration 4-72 hours)

2 of: moderate / severe, unilateral, throbbing pain, worst movement

1 of: autonomic features, photophobia / phonophobia

Question 8

what is the pathophysiology of a migraine?

Answer 8

both vascular and neural influences cause migraines in susceptible individuals

stress - serotonin released

blood vessels constrict and dilate

chemicals inc substance P irritate nerves and vessels causing pain

Question 9

what areas in brain are known as migraine centre?

Answer 9

dorsal raphe nucleus

locus coeruleus

Question 10

what is “aura”?

Answer 10

fully reversible visual, sensory, motor or language symptoms

Question 11

what is the duration of aura and when does this occur in relation to headache?

Answer 11

aura duration 20-60 mins

headache follows <1 hour later but aura can occur simultaneously

Question 12

what is most common aura symptom?

Answer 12

visual (positive symptoms usually monochromatic)

eg central scotomata, central fortification, hemianopic loss

Question 13

what tends to trigger a migraine?

Answer 13

sleep 
diet 
stress
hormonal 
physical exertion

Question 14

what may help patient to identify triggers?

Answer 14

headache diary

Question 15

what are types of non-pharmacological management of migraine?

Answer 15

realistic goals 
avoid trigger 
balanced diet and hydration 
avoid caffeine 
relaxation / stress management
regular exercise

Question 16

what are two types of pharmacological management of migraine?

Answer 16

acute

prophylaxis

Question 17

what 2 types of medications can be given as abortive treatment of migraine?

Answer 17

NSAIDs

Triptans (5HT agonist)

Question 18

what types of NSAIDs can be given as migraine abortive treatment?

Answer 18

aspirin 900mg
naproxen 250mg
ibuprofen 400mg

Question 19

when should NSAIDs be taken for a migraine?

Answer 19

as early as possible

Question 20

when should anti emetic be considered when giving NSAIDs?

Answer 20

if gastroparesis

Question 21

how can triptans be administered?

Answer 21

oral, sublingual and subcutaneous

consider method of administration in those with N&V

Question 22

when should triptans be given for migraine?

Answer 22

at start of headache

Question 23

what is name of triptans given for migraine?

Answer 23

rizatriptan, eletriptan, sumatriptan

frovatriptan for sustained relief

Question 24

when should you consider prophylaxis for migraine?

Answer 24

more than 3 attacks per month or very severe

Question 25

how long must you trial each prophylaxis drug for?

Answer 25

minimum of 3 months aim is to titrate drug as tolerated to achieve efficacy at lowest dose possible

Question 26

what non-pharmacological methods of prophylaxis should you consider?

Answer 26

acupuncture | relaxation exercises

Question 27

what are the main medications that can be given for migraine prophylaxis?

Answer 27

amitriptyline propranolol topiramate

Question 28

how much amitriptyline should be given for migraine prophylaxis?

Answer 28

10-25mg (max 75mg)

Question 29

what are the adverse effects of amitriptyline?

Answer 29

dry mouth postural hypotension sedation

Question 30

how much propranolol should be given for migraine prophylaxis?

Answer 30

80-240mg daily

Question 31

when should propranolol be avoided?

Answer 31

asthma peripheral vascular disease heart failure

Question 32

what class of drug is topiramate?

Answer 32

carbonic anhydrase inhibitor

Question 33

how much topiramate should be given for migraine prophylaxis?

Answer 33

25mg - 100mg daily start slowly due to poor side effect profile

Question 34

what are the adverse effects of topiramate?

Answer 34

weight loss paraesthesia impaired concentration enzyme inducer

Question 35

what types of "fancy" migraine can you get?

Answer 35

``` acephalgic basilar retinal ophthalmic hemiplegic (familial / sporadic) abdominal ```

Question 36

what is difference in symptoms of tension type headache and migraine?

Answer 36

tension type is bilateral absence of N&V, photophobia and phonophobia

Question 37

what type of pain is tension type headache?

Answer 37

pressing tingling quality

Question 38

how sore is a tension type headache?

Answer 38

mild to moderate

Question 39

how can tension type headache be treated?

Answer 39

relaxation physiotherapy reassure antidepressant - 3 months of dothiepin or amitryptyline

Question 40

what is trigeminal autonomic cephalgias (TACs)?

Answer 40

group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features

Question 41

give examples of ipsilateral cranial autonomic features seen in TACs?

Answer 41

``` ptosis miosis nasal stuffiness nausea / vomiting tearing eye lid oedema ```

Question 42

what are the 4 main types of trigeminal autonomic cephalgias (TACs)?

Answer 42

cluster paroxysmal hemicrania hemicrania continua SUNCT

Question 43

who gets a cluster headache?

Answer 43

young (30-40s) | men > women

Question 44

when do cluster headaches often occur?

Answer 44

striking circadian (around sleep) and seasonal variation

Question 45

what are the features of a cluster headache?

Answer 45

severe unilateral headache duration: 45-90 mins frequency: 1 to 8 per day cluster bout may last from few weeks to months

Question 46

what is the treatment for a cluster headache?

Answer 46

high flow oxygen 100% for 20 mins sub cut sumatriptan 6mg steroids - reducing course over 2 weeks verapamil for prophylaxis

Question 47

who gets paroxysmal hemicrania?

Answer 47

elderly (50s-60s) | women > men

Question 48

what are the features of paroxysmal hemicrania?

Answer 48

severe unilateral headache, unilateral autonomic features duration: 10-30 mins frequency: 1 to 40 per day ie shorter duration and more frequent than cluster

Question 49

what is treatment of paroxysmal hemicrania?

Answer 49

indomethicin

Question 50

what are features of SUNCT headache?

Answer 50

``` short lived (15-120 secs) unilateral neuralgiaform headache conjunctival injections tearing ```

Question 51

what is treatment of SUNCT headache?

Answer 51

lamotrigine, gabapentin

Question 52

what patients that present with headache require imaging?

Answer 52

those with new onset unilateral cranial autonomic features

Question 53

what imaging is carried out for these patients?

Answer 53

MRI brain and MR angiogram

Question 54

who is more likely to be affected by idiopathic intracranial hypertension?

Answer 54

F > M | obese

Question 55

what are symptoms of IIH?

Answer 55

headache - diurnal variation morning N & V visual loss

Question 56

what investigations should take place in IIH?

Answer 56

MRI brain with MRV sequence - normal CSF - elevated pressure, normal constituents visual field

Question 57

how should IIH be treated?

Answer 57

weight loss acetazolamide ventricular atrial / lumbar peritoneal shunt monitor visual fields & CSF pressure

Question 58

who gets trigeminal neuralgia?

Answer 58

elderly (>60) | women > men

Question 59

when does trigeminal neuralgia occur?

Answer 59

triggered by touch, usually V2/3

Question 60

what are features of trigeminal neuralgia?

Answer 60

severe stabbing unilateral pain duration: 1 sec to 90 secs frequency: 10 per day to 100 per day bouts pain may last from a few weeks to months before remission

Question 61

what investigation should take place in trigeminal neuralgia?

Answer 61

MRI brain

Question 62

what is medical and surgical treatment options for trigeminal neuralgia?

Answer 62

medical - carbamazepine, gabapentin, phenytoin, baclofen surgical: ablation or decompression

Question 63

when someone presents with facial pain, you must consider non-neurological structures such as what?

Answer 63

``` eyes ears sinuses teeth TMJ etc ```

Question 64

how is diagnosis of primary headache syndromes (inc TCA) established?

Answer 64

clinically based on demographics, duration, frequency and triggers

Question 65

what is 1st line for uncomplicated migraine?

Answer 65

symptomatic OTC medication