TACs

Question 1

Trigeminal Autonomic Cephalgias (TACs)

Answer 1

• Unilateral
• Autonomic Features

Question 2

TACs: Autonomic Features

Answer 2

• Conjunctival Injection or Lacrimation
• Nasal Congestion or rhinorrhea
• Eyelid Edema
• Forehead and Facial
  Sweating
  Flusing
• Full sensation in ear
• Miosis or ptosis

Question 3

What are the different types of TACs?

Answer 3

• Cluster Headache
• Paroxysmal Hemicrania
• Short-lasting unilateral neuralgiform headache attacks (SUNCT/SUNA)
• Hemicrania Continua

Question 4

Rank the different types of TACs based on frequency and duration? (GRAPH)

Answer 4

Question 5

Cluster Headache: General

Answer 5

• Most painful Primary HA
• Piercing, Boring, Stabbing
• Peak: 3-5 mins
• Restless & motor agitation (NOT IN MIGRAINES)
• Circadian & circannual periodicity
  Nocturnal > Daytime attacks
  onset=90 mins after falling alseep (REM Sleep)

Question 6

Cluster Headache: ICHD-3 criteria

Answer 6

1. 5 or more attacks
2. Severe/very severe unilateral orbital, supraorbital, or temporal pain; Lasts; 15-180 mins (untreated)
3. Either or both:
   1 ipsilateral autonomic symptom/sign
   restlessness or agitation
4. Frequency b/w 1 every other day and 8 per day for more than 1/2 the time when active

Question 7

Define: Cluster Headache

Answer 7

• Aka Cluster Attack
• Individual Attack

Question 8

Define: Cluster Period

Answer 8

• Period when attacks recur
• 6-12 wks

Question 9

Define: Remission

Answer 9

• No attacks
• Avg=12 months

Question 10

Cluster Headache: Triggers

Answer 10

• Vasodilators
  Nitroglycerin
  Histamine
• Alcohol
  abstain during cluster periods
  rarely causes attack during remission

Question 11

Cluster Headache: Management

Answer 11

• Abortive:
  Triptans
  Oxygen
• Maintenace Prohpylaxis:
  Verapamil (1st line)
  Topiramate
  Lithium
• Transitional Prophylaxis:
  Corticosteroids
  Ergotamine, DHE
• CGRP
• Greater Occipital Nerve Stimulation

Question 12

Paroxysmal Hemicrania

Answer 12

• Rare
• Several Attacks per day
  Mean=11
  ICHD-3: > 5/day more than half the time
• Median Length: 19 mins
• No Nocturnal Predilection (unlike cluster HA)
• Indomethacin-Therapeutic doses Prevent

Question 13

SUNCT/SUNA

Answer 13

• rare
• unilateral neuralgiform HA attacks w:
  Conjunctival Injectioon & Tearing= SUNCT
  Cranial Autonomic Symptoms=SUNA
• Frequent Attacks: 3-200/day
• Short lasting: 1-600 secs
• Cutaneous Triggers
• Tough to Tx: Lamotrigene

Question 14

Compare Cluster HA, Paroxysmal Hemicranis, SUNCT/SUNA:
-Sex
-Location
-Attacks per day
-Length (min)
-Episodic vs Chronic (%)
-Circadian/circannual periodicity (y or n)
-Tx of choice

Answer 14

Question 15

Hemicrania Continua

Answer 15

• Continuous unilateral HA
• Intensity waxes and wanes
• At least one of:
  Autonomic Symptom
  Restlessness/Aggitation
  Aggravation by movement
• Indomethacin- Absolute response