Headache

Question 1

what aspects of headache should be covered in a history

Answer 1

SOCRATES 
unilateral/bilateral 
timing - morning 
duration 
associated with autonomic symptoms, N+V, photophobia
worsens with valsalva manoeuvres 
PMH of cancer

Question 2

what are red flags to look out for in someone with a headache

Answer 2

>55 yo
immunosuppressed 
previous/current known malignancy 
worse in the morning 
associated with N+V, worsens with valsalva

Question 3

what can headaches be categorised as

Answer 3

primary and secondary headache complexes

Question 4

list the primary headache complexes

Answer 4

migraine
tension type headache
autonomic cephalgias: cluster headache, paroxysmal hemicrania, SUNCT

Question 5

list the secondary headache complexes

Answer 5

idiopathic intracranial hypertension

trigeminal neuralgia

Question 6

sore head upon standing is intracranial hypo/hyper tension

Answer 6

HYPO tension

Question 7

sore head upon lying down is intracranial hypo/hyper tension

Answer 7

HYPER tension

Question 8

migraine with/without aura is more common

Answer 8

without aura is more common

Question 9

IHS criteria is for defining migraine with/without aura

Answer 9

without aura

Question 10

what is the criteria for defining migraine without aura

Answer 10

at least 5 attacks
each lasting 4-72 hours
2 of: mod/severe, unilateral, throbbing pain, worse with movement
1 of: autonomic features, photo/phonophobia

Question 11

who gets migraines

Answer 11

females
teens / 40-50s menopausal
menstrually related

Question 12

what is the pathophysiology of migraines

Answer 12

neurovascular problem in susceptible individuals
serotonin release causes vasoconstriction and dilatation
substance P irritates nerves and vessels causing pain

Question 13

describe aura associated with migraines

Answer 13

fully reversible symptoms - visual, sensory, motor or language
lasts 20-60 minutes

Question 14

triggers of migraine

Answer 14

stress 
sleep 
diet - dark chocolate, cheese, alcohol
hormonal 
physical exertion

Question 15

what can be used to help identify triggers of migraine

Answer 15

headache diary

Question 16

what are the main groups of management in migraine

Answer 16

pharmacological and non-pharmacological

Question 17

list non-pharmacological Mx of migraine

Answer 17

avoid triggers 
stress avoidance 
headache diary 
hydration - 2L water daily 
reduce caffiene 
regular exercise

Question 18

what is acute management of migraine

Answer 18

NSAIDs +- anti emetic

Triptans

Question 19

why would you give an anti-emetic with NSAID in acute migraine

Answer 19

if there is gastroparesis

Question 20

what are triptans and how do they work

Answer 20

serotonin (5HT) agonists

cause vasoconstriction of dilated vessels

Question 21

how can triptans be administered

Answer 21

PO
SC
sublingual

Question 22

when would you give someone migraine prophylaxis

Answer 22

if they have had more than 3 attacks per month

or very severe migraines

Question 23

what prophylaxis can be given for migraines

Answer 23

amitriptyline (tricyclic antidepressant)
propranolol (B blocker)
topiramate (anti-convulsant/carbonic anhydrase inhibitor)

Question 24

side effects of amitriptyline

Answer 24

postural hypotension
dizziness
sleepiness
dry mouth

Question 25

side effects of propranolol

Answer 25

``` bronchoconstriction cold peripheries bradycardia sleep disturbance GI upset tiredness ```

Question 26

when is propranolol contraindicated

Answer 26

asthma/COPD heart failure peripheral vascular disease

Question 27

topiramate is teratogenic, true or false

Answer 27

TRUE

Question 28

side effects of topiramate

Answer 28

weight loss parasthesia poor cognition enzyme inducer

Question 29

other treatments of migraine

Answer 29

``` gabapentin pizotifen sodium valproate (teratogenic) botox scalp injection anti CGRP Ab ```

Question 30

list some "fancy" types of migraine

Answer 30

``` acephalgic basilar retinal ophthalmic hemiplegic (familial) abdominal (children) ```

Question 31

describe symptoms of tension type headache

Answer 31

bilateral pressing/tingling pain absence of autonomic features

Question 32

management of tension type headache

Answer 32

relaxation physiotherapy anti-depressants: dothiepin, amitriptyline reassurance

Question 33

what are trigeminal autonomic cephalgias (TACs)

Answer 33

group of primary headache complexes with unilateral trigeminal distribution pain along with ipsilateral cranial autonomic features

Question 34

list cranial autonomic features

Answer 34

``` nasal stuffiness eye tearing ptosis miosis N+V eyelid oedema ```

Question 35

what are the 4 main types of autonomic cephalgias

Answer 35

cluster headache paroxysmal hemicrania hemicrania continuum SUNCT

Question 36

who gets cluster headaches

Answer 36

men | 30-40s

Question 37

symptoms of cluster headahces

Answer 37

severe unilateral pain 45-90 min cluster bout moving makes it better

Question 38

management of cluster headaches

Answer 38

high flow oxygen 100% for 2 min SC sumitriptan steroids reduced over 2 weeks

Question 39

prophylaxis for cluster headaches

Answer 39

verapamil

Question 40

who gets paroxysmal hemicrania

Answer 40

females | 50-60s

Question 41

symptoms of paroxysmal hemicrania

Answer 41

severe unilateral headache 10-30 min more frequent episodes

Question 42

management of paroxysmal hemicrania

Answer 42

very sensitive to indomethicin

Question 43

what is SUNCT

Answer 43

``` Short lived 15-120 sec Unilateral Neuralgiaform headache Conjuctival injections Tearing ```

Question 44

management of SUNCT

Answer 44

lamotrigine, gabapentin

Question 45

what investigations do those with new onset unilateral cranial autonomic features get

Answer 45

MRI brain | MR angiogram

Question 46

what is idiopathic intracranial hypertension IIH and who gets it

Answer 46

^ICP females obese BMI>30

Question 47

symptoms of IIH

Answer 47

headaches worse in the morning N+V visual loss (papilloedema needs to be checked for)

Question 48

LP is indicated in all cases of IIH, true or false

Answer 48

FALSE LP is only done if scan is normal contraindicated in ^ICP

Question 49

management of IIH

Answer 49

MRI, CSF, visual fields Weight loss!!! acetazolamide (carbonic anhydrase inhibitor) ventricular-peritoneal shunt

Question 50

who gets trigeminal neuralgia

Answer 50

females | >60 yo

Question 51

triggers of trigeminal neuralgia

Answer 51

``` touch chewing swallowing talking eating ```

Question 52

symptoms of trigeminal neuralgia

Answer 52

sharp stabbing unilateral pain lasting 1-90 seconds

Question 53

management of trigeminal neuralgia

Answer 53

MRI - rules out compression carbamazepine, gabapentin, phenytoin, baclofen surgery - ablation, decompression