T3-HA

Question 1

Tension and migraine headaches are more common in ____ than ____

Answer 1

Females than males

Question 2

Headaches are now thought to be more of a ______ dysfunction than a _____ dysfunction

Answer 2

Sensory processing
Vascular

Question 3

5 phases of a migrane.

Answer 3

Prodromal - hours or days before aura
Aura
HA
Post drone
Interictal

Question 4

Describe the prodromal stage of migraines? What is it mediated through?

Answer 4

Yawning, polyuria, neck pain, food cravings, mood changes, mental fogginess, light sensitivity
Mediated through the hypothalamus and connections to other structures such as locus coeruleus and TCC (trigeminocervical complex where TG and cranial structures converge with cervical afferent s from upper cervical spine) which impact sleep and neck pain respectively.

Question 5

Describe the aura and what it is pathophysiologically

Answer 5

Aura is before or during the HA - visual or sensory motor language or brainstem dysfunction.

Related to Cortical spreading Depression (CSD) - spreading depolarization across cortex followed by a relative depression of electro graphic activity

Question 6

What is Cortical Spreading Depression?

Answer 6

spreading depolarization across cortex followed by a relative depression of electro graphic activity. Responsible for the aura and associated migraine

Question 7

what is the Trigeminal Cervical Complex (TCC)

Answer 7

Where Trigeminal afferent s from the trigeminal ganglion (TG) and cranial structures converge with cervical afferent s from upper cervical spine.

Question 8

What part of the brain may be activated during the postdrome of migraine?

Answer 8

Locus coeruleus.

Question 9

SNOOP4 acronym helps to identify warnings sings of _______ headaches.

Answer 9

Secondary

Question 10

SNOOP4 acronym

Answer 10

S - systemic symptoms/secondary diseases
N - Neurological symptoms/signs
O - onset (thunderclap)
O - Older (age >50yrs)
P1 - positional
P2 - prior history
P3 - pregnancy/post partum
P4 - precipitated by Valsalva.

Question 11

What are some concerning features of secondary headache that align with the S in SNOOP4 and what could be some DDX?

Answer 11

Systemic symptoms = Fever, night sweats, chills, weight loss, jaw claudication
Secondary disease = Cancer, immunosuppression, chronic infx (HIV, TB)

Metastasis, Giant Cell Arteritis, infection (CNS, systemic)

Question 12

What are some concerning features of secondary headache that align with the N in SNOOP4 and what could be some DDX?

Answer 12

Neurological symptoms/signs = confusion, focal neuro symptoms, diplopia, transient visual obscurations, pulsitile tinnitus.

Mass lesion, structural lesion, stroke, hydrocephalus

Question 13

What are some concerning features of secondary headache that align with the 1st O in SNOOP4 and what could be some DDX?

Answer 13

Onset - Thunderclap

Reversible cerebral vasoconstriction syndrome (RCVS), stroke, subarachnoid hemorrhage, cerebral venous sinus thrombosis, arterial dissection, pituitary apoplexy, idiopathic intracranial hypertension

Question 14

What are some concerning features of secondary headache that align with the 2nd O in SNOOP4 and what could be some DDX?

Answer 14

Older (>50) - new onset, persistent/progressive HA

Mass lesion, giant cell arteritis

Question 15

What are some concerning features of secondary headache that align with the 4Ps in SNOOP4 and what could be some DDX?

Answer 15

Positional - orthostatic, recumbent or worsens with change in position
Low ICP (CSF leak), mass lesion, cerebral venous sinus thrombosis, sinus pathology

Prior history - new onset or change to persistent/daily HA
Mass lesion, infection (CNS or systemic)

Pregnancy/Post partum - new onset during pregnancy
Cerebral venous sinus thrombosis, preeclampsia, RCVS, pituitary lesion, stroke

Precipitated by valsalva - cough, sneeze, bending, straining
Intracranial/posterior fossa mass, Chiari malformation

Question 16

International Classification of HA disorders (ICHD -3) has 3 categories of HA:

Answer 16

Primary
Secondary
Cranial neuralgias/facial pain

Question 17

Migraine, tension type and trigeminal autonomic cephalgias (cluster) are types of _______ headaches.

Answer 17

Primary.

Question 18

_____ % of migraines are withOUT aura.

Answer 18

75

Question 19

1st line Tx for migraines

Answer 19

Triptans - 5HT-1B and 1D receptor targets (serotonin)

Question 20

What type of pharmacotherapy for migraines is newer and actually have a preventative action on migraines?

Answer 20

CGRP receptor agonists - Gepants.

Question 21

How are Ditans different from Triptans if they both treat migraines and target serotonin receptors?

Answer 21

Ditans do not vasoconstrict however they may have AEs including dizziness, sedation and and 8hr driving restriction after use. Lasmiditan is a schedule V

Question 22

What is the MOST important aspect to address in patient’s with chronic migraines?

Answer 22

Stress reduction. If you can’t get stress under control, then treatments are less likely to be effective.

Question 23

What are some characteristics of a brain tumor headache?

Answer 23

30% of patients with brain tumors report HA.

Worse with position change, awakens them from sleep, non-descript (dull, achy). Associated with other neurological abnormalities.

Question 24

What are some nutrition/herbal supplements to help support migraine health?

Answer 24

None approved by FDA, but
Mg, vit B2, feverfew have level B evidence in prevention
Coenzyme Q10 has level C evidence.
Melatonin.

Question 25

Lifestyle factors to prevent migraines?

Answer 25

Quality sleep, good hydration, healthy diet meals, caffeine and alcohol in moderation, regular exercise and STRESS management.

Question 26

When does Temporal Arteritis typically show up, what are symptoms and what is a serious complication if not treated?

Answer 26

Average age onset of 70 Dull aching HA in temporal location. Blindness if not treated promptly with steroids.

Question 27

How are Tolosa-Hunt syndrome and cluster type headaches similar and different

Answer 27

Similar: severe, unilateral periorbital headache Different: THS - long term and ophthalmoplegia. Inflammation of cavernous sinus with relapsing remitting course and attacks every few months to years. Cluster type: shorter (1-4hours) with no ophthalmoplegia. Non-inflammatory.

Question 28

Your patient has nausea, vomiting, severe, throbbing headache, photophobia, neck stiffness and fever. What are you suspecting as diagnosis? Why?

Answer 28

Meningitis. Fever. Migraine also has all of the above s/s but no fever.

Question 29

IIH - Idiopathic Intracranial HTN - criteria for Dx?

Answer 29

S/s of increased ICP (HA, transient visual obscurations, pulse synchronous tinnitus, papilledema, visual loss) No other neurological abnormalities or impaired LOC Elevated ICP with normal CSF composition Neuroimigaing study shows no etiology for ICH No other cause of intracranial HTN apparent.

Question 30

Other than HA, what other s/s accompany Cerebral venous sinus thrombosis?

Answer 30

Focal neurological deficits, AMS, seizure and papilledema.

Question 31

RCVS is a result of ______

Answer 31

Reversible Cerebral Vasoconstriction Syndrome Diffuse segmental vasoconstriction oof intracranial arteries. Severe and recurrent.

Question 32

Glossopharangeal neuralgia, occipital neuralgia, trigeminal neuralgia are all examples of ______ neuralgias

Answer 32

Cranial

Question 33

first line tx for trigeminal neuralgia?

Answer 33

Carbamazepine or oxcarbazepine.

Question 34

What is the pathophysiology related to Trigeminal neuralgia

Answer 34

Demyelination of the primary sensory trigeminal afferent s in the root entry zone.

Question 35

What are some examples of painful trigeminal neuropathies?

Answer 35

Herpes zoster, infection, post-herpetic neuralgia, post traumatic, MS plaque and neoplasm.

Question 36

Trigeminal Autonomic Cephalgias 3 kinds:

Answer 36

Cluster HA Paroxysmal Hemicrania SUNHA - short lasting Unilateral Neuralgiform headache attack.

Question 37

3 main systems prominent in pathophysiology of Trigeminal Autonomic Cephalgias

Answer 37

Pain - starts in V1 branch then projects to the trigeminocervical complex Cranial Autonomic system - responsible for lacrimation, conjunctival injection and other autonomic features - sphenopalatine ganglion, VIP, target system for oxygen Hypothalamus - includes circadian system and aggression areas which may explain regularity and restlessness (molecules melatonin, target for verapamil and lithium) .