Primary and Secondary Headache Syndromes Flashcards Preview

Neurology > Primary and Secondary Headache Syndromes > Flashcards

Flashcards in Primary and Secondary Headache Syndromes Deck (55):
1

What are important facts to elicit in the history of a headache?

Onset/ peak: acute vs subacute
Relieving features: posture, headache
Exacerbating features: posture, valsalva, diurnal variation
Assoc features; autonomic, photophobia, phonophobia, positive visual symptoms, ptosis, miosis, nasal stuffiness
Consider demographic

2

What are the red flags in terms of headaches?

New onset headache >55yrs
Known/ previous malignancy
Immunosuppressed; think about intracranial infection
Early morning headache
Exacerbation by valsalva

3

What is the demographics of a migraine?

Commoner in women
Most will have an attack once a month
Migraine without aura: 80%
Migraine with aura: 20%

4

What is the IHS criteria for a migraine without aura?

At least 5 attacks of duration 4-72 hours
2 of: moderate/severe pain, unilateral, throbbing, worse with movement
1 of: autonomic features, photophobia, phonophobia, N+V

5

What is the pathophysiology of migraines?

Vascular and neural influences
Stress will trigger changes in the brain resulting in the release of serotonin
Blood vessels constrict and dilate
Chemicals including substance P, neurokinin A and CGRP irritate nerves and blood vessels resulting in pain

6

In what stages of a migraine will the blood vessels constrict and dilate?

Constrict: aura phase
Dilate: headache phase

7

What are common triggers of migraines?

Lack of sleep
Dietary; dark chocolate, cheese, alcohol, hangovers
Stress
Hormonal; menstrual cycle
Physical exertion

8

What are the non-pharma treatments of migraines?

Set realistic goals
Education; avoid triggers
CHOCOLATE:
Chocolate
Hangovers
Orgasms
Cheese/ caffeine
OCP
Lie-ins
Alcohol
Travel
Exercise
Headache diary
Relaxation/ stress management

9

What are the pharmacological principles to treating migraines?

Acute treatment
Prophylactic treatment

10

What drugs are used in the acute management of a migraine?

NSAID; 900mg aspirin, 350mg naproxen, 400mg ibuprofen
+/- antiemetic
Triptans - selective 5-HT agonists

11

Do NSAIDs help with migraine pain?

60% significant reduction in headache at 2 hours
Only 25% to complete pain relief

12

What are triptans?

5-HT agonist

13

When should triptans be give?

At the start of the headache; similar efficacy to NSAIDs

14

What are examples of triptans?

Rizatriptan
Eletriptan
Sumatriptan
Fovatriptan

15

How can triptans be given?

Oral
Sub-lingual
Subcut

16

When should you consider prophylaxis for migraines?

More than 3 attacks a month or very severe

17

What is the aim with prophylaxis?

Titrate drug as tolerated to achieve efficacy at the lowest dose possible
Must trial each for a minimum of 3 months
GO SLOW AND KEEP LOW

18

What are examples of migraine prophylaxis?

Amitriptyline
Propranolol
Topiramate
Gabapentin
Pizotifen
Sodium valproate
Botulinum toxin
Anti calcitonin gene related peptide (CGRP) Ab

19

What dose of amitriptyline is given in migraine prophylaxis and what are the adverse effects?

10-25 mg - max 75mg
Adverse: dry mouth, postural hypotension, sedation: Anticholinergic effects

20

What dose is given on propranolol in migraine prophylaxis and what are the contraindications?

80-240 mg daily
Avoid in asthma, PVD

21

What mechanism of action of topiramate?

Carbonic anhydrase inhibitor

22

What dosage of topiramate is given in migraine prophylaxis and what are the adverse effects?

25-100mg
Adverse: weight loss, paraesthesia, impaired concentration, enzyme inducer, teratogenic

23

Should you give sodium valproate in young women?

No - highly teratogenic
Give in menopausal women

24

What lifestyle factors can be used as prophylaxis of migraines?

Diet; regular intake, avoid triggers, healthy balanced diet
Hydration; at least 2 L/ day, decrease caffeine
Stress - decrease
Regular exercise

25

What are the rare subtypes of migraines?

Basilar
Retinal/ ophthalmic
Hemiplegic
Abdominal

26

What is a tension type headache?

Episodic vs chronic
Pressing tingling quality
Mild to mod
Bilateral
Absence of N+V
Absence of photophobic or phonophobia

27

What is the treatment for tension type headaches?

Relaxation physiotherapy
Antidepressant; dothiepin or amitriptyline
Reassure

28

What are trigeminal autonomic cephalgias (TAC)

Primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in assoc with prominent ipsilateral cranial autonomic features

29

What are ipsilateral cranial autonomic features?

Ptosis
Miosis
Excess lacrimation
Injection of conjuntiva
Nasal stuffiness
N+V
Eye lid oedema

30

What are the 4 main types of TACs?

Cluster
Paroxysmal hemicrania
Hemicrania continua
SUNCT

31

What is the demographic of cluster headaches?

Young - 30s/40s
Men more than women

32

When will people get cluster headaches?

Striking circadian and seasonal variation

33

What are the features of cluster headaches?

Severe unilateral headache
Duration of 45-90 mins
Frequency of 1-8 a day
Cluster bout can last from a few weeks to months

34

What is the treatment of cluster headaches?

High flow oxygen 100% for 20mins
Subcut sumatriptan 6mg
Steroids; reducing course over 2 weeks
Verapamil for prophylaxis

35

What is the demographic of paroxysamal hemicrania headaches?

Elderly 50s/60s
Women more than men

36

What are the features of paroxysmal hemicrania headaches?

Severe unilateral headache, unilateral autonomic features
Duration of 10-30 mins
Frequency of 1-40 a day

37

What is the treatment for paroxysmal hemicrania headaches?

ABSOLUTE RESPONSE to indomethacin

38

What does SUNCT stand for?

Short lived
Unilateral
Neuralgioaform headache
Conjunctival injections
Tearing

39

What is the treatment for SUNCT?

Lamotrigine
Gabapentin

40

Describe the duration of all headaches

Migraine: hours
Cluster: 45-90 mins
Paroxysmal hemicrania: 10-30 mins
SUNCT: seconds

41

What are the indications for imaging in headaches?

ALL those with new onset unilateral cranial autonomic features requires imaging; MRI brain or MRA

42

Who is likely to get idiopathic intracranial hypertension?

Females
Obese

43

What are the symptoms of idiopathic intracranial hypertension?

Diurnal variation
Morning N+V
Visual loss`

44

Why will all those with idiopathic intracranial hypertension get a scan?

To ensure not tumour or obstructive hydrocephalus

45

What will be seen in fundoscopy of IIH?

Papilloedema

46

What will be seen on LP in IIH?

Increased pressure
Normal constituents; white cells, protein and glucose

47

What investigations should be done in IIH?

MRI brain with MRV sequence
LP
Visual fields

48

Do you do an LP in increased ICP?

NO: UNLESS CT SCAN IS NEGATIVE

49

What is the treatment for IIH?

Wt loss
Acetazolamide
Ventricular atrial/ lulmbar peritoneal shunt only if going blid

50

What is the demographic of trigeminal neuralgia?

Elderly (>60yrs)
Women more than men

51

What can trigger trigeminal neuralgia?

Touch in V2/3
Chewing
Eating
Swallowing

52

What are the features of trigeminal neuralgia?

Severe stabbing unilateral pain
Duration: 1 to 90 secs
Frequency: 10-100 day
Bouts pain may last from a few weeks to months before remission

53

What are the medical treatments of trigeminal neuralgia?

Carbamezapine
Gabapentin
Phenytoin
Baclofen

54

What are the surgical treatments of trigeminal neuralgia?

Ablation
Decompression

55

What investigations should be done in trigeminal neuralgia?

MRI brain