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What is the first-line treatment of migraine?

Can reduce or stop headache symptoms with early use of NSAIDs. Paracetamol can help some sufferers.


How does anti-emetics help with migraines?

Gastric stasis (delayed emptying) often causes nausea and emesis during migraines.
e.g. domeperidone, prochlorperazine, metoclopramide
Restore gut motility and enhance medication absorption.


What receptors are involved with nausea and vomiting?

Histamine, muscarinic, dopaminergic, sertongergic and opioid receptors. Anatagonising these will help with nausea and vomiting.


What are triptans?

e.g. sumatriptain, zolmitriptan
Strong antagonist at serotonin (5-HT) receptor. Triptans have been shown to induce vasoconstriction, mediated by action on 5-HT1B receptions in arterial smooth muscle.


What are contraindications of triptans?

- History of TIA and CVA
- History of IHD, including MI. Also, in patients with severe or poorly controlled hypertension.


What is the second-line treatment for migraines?

NSAID + triptan (e.g. naproxen, sumatriptan) or repeat dose of a triptan following the first.
- Second dose of triptan only indicated for relapse after inital response and further doses should not be taken for at least 2 hours after 1st dose.


What is the criteria for consideration of prevention treatment of migraines?

- Quality of life/business, school attendance is severely affected
- 2 or more attacks per month
- Migraine attacks do not respond to acute drug treatment
- Frequent, very long or uncomfortable auras occur


What is used for the first-line prophylaxis of migraines?

Beta blockers, tricyclics or low dose amitriptyline are considered as first line choices.


What is used for prophylaxis of migraines caused by menstruation?

Transdermal oestrogen patches, starting 3 days before menstruation.


What is the second-line medication for the prophylaxis of migraines?

- Several antiepileptic drugs e.g. sodium valproate or topirimate.
- Antihypertensive agents - ACEi, ARBs, calcium channel blockers sometimes (verapamil and amlodipine)


What should be administered if there is a clinical suspicion of bacterial meningitis?

Empirical antibiotic therapy with an IV 3rd generation cephalosporin such as ceftriaxone.


What is the first-line treatment for meningitis in a GP setting?

IM benzylpenicillin
If listeria is suspected ampicillin should be added.


What should be administered if there is concern regarding encephalitis?

IV antivirals


What will be offered to household members as prophylaxis?

Antimicrobials (rifampicin)


What is the management of gliomas?

- Surgery
- Steroids
- Radiotherapy
- Chemotherapy
- Treatment of any associated problems


What is the treatment for meningioma?

Surgical excision
- Can recur when incompletely removed or is atypical/higher grade/malignant
- Radiotherapy. stereo-radiotherapy and hormonal therapies are also used


What are general routine measures to control ICP?

- Head up tilt 30-45 degrees. Promotes venous outflow and CSF movement.
- Keep neck straight and avoid tight ETT tapes: obstruction to jugular venous outflow
- Avoid hypertension: to maintain cerebral blood flow (use vasopressors as required)
- Maintain adequate sedation: reduces metabolic demands, ventilator asynchrony and sympathetic responses
- Maintain euvolaemia and normo-hyper osmolar state: reduces cerebral oedema
- Maintain normal pCO2: raised causes cerebral vasodilation and increases cerebral blood flow


What is the management of sustained acute rise in ICP?

- Heavy sedation +/- paralysis
- CSF drainage
- Osmotic therapy (mannitol)
- Hyperventilation
- Barbituate therapy e.g. phenobarbitone, thiopentane
- Decompressive craniectomy


What is the treatment for a cluster headache?

- Sumatriptan injection - contraindicated for IHD and stroke
- Hi-flow oxygen through a non-rebreathe bag and mask
- Prednisolone for 1 week


What is the treatment of giant cell arteritis?

- Start prednisolone 60mg/day immediately
- IV methylprednisolone if evolving visual loss or history of amaurosis fugax