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154 Cards in this Set

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  • Back
Headaches are the ___ most common presentation to GPs.
Headaches are the 9th most common presentation to GPs.

It adds up to about 1.9 million GP consults per year.
On an physical examination, what should you examine with a presenting complaint of a headache?
- BP.
- Head.
- Temporal arteries.
- Cervical spine.
- Sinuses.
- Teeth.
- Temporomandibular joint.
- Meningism.
- Visual acuity, fields, pupil responses, eye movements.
- Neurological examination: cranial nerves, power, sensation in face and limbs.
What are the 3 main IHS categories for headache?
1. Primary.
2. Secondary.
3. Neuralgia, facial pain.
What are the types of headaches that comprise a 'Primary' classification (according to the IHS)?
The big three:
- Migraine.
- Tension headache.
- Cluster headache.

Other primary headaches:
- Exertional.
- Hypnic.
- Sexual.
- Thunderclap.
...and others.
'Secondary' headaches (IHS) comprise of what causes? (List it)
- Head/neck trauma.
- Cranial/cervical vascular disorder.
- Non-vascular intracranial disorder (e.g. tumour, hydrocephalus, sarcoidosis).
- Substance use or withdrawal.
- Infection.
- Disorder of homeostasis (e.g. hypoxia, altitude sickness, sleep apnoea).
- Facial or cranial disorder (e.g. sinusitis, TMJ dysfunction, glaucoma).
- Psychiatric disorder.
What are the main causes of cranial neuralgias and central causes of facial pain?
- Trigeminal neuralgia.
- 'Ice cream' headache.
- Nerve root compression.
- Herpes zoster.
- Multiple sclerosis.
What are the main causes to look for in an acute single headache?
- Febrile illness, sinusitis.
- 1st attach of migraine.
- Head injury.
- SAH, meningitis.
What are the main causes to look for in recurrent headaches?
- Migraine.
- Cluster headache.
- Episodic tension headache.
- Trigeminal/post-herpetic neuralgia.
- Paroxysmal hemicrania.
What are the main triggers to think about in triggered headaaches?
- Cough, strain, exertion.
- Coitus.
- Food and drink.
What are the main causes to look for in dull headache of increasing severity?
- Usually benign.
- Overuse of medication (e.g. codeine).
- Neck disease.
- Temporal arteritis.
- Benign intracranial hypertension.
- Cerebral tumour.
What are the main causes to look for in a dull headache that's been unchanged for months?
- Chronic tension headache.
- Depression, atypical facial pain.
What are the indications for referral/imaging for a headache (i.e. the RED FLAGS)?
- 1st or worst headache, especially of sudden onset.
- Short history of headache, especially in the elderly.
- Concern (often voiced) over tumour, MS, stroke.
- Increased vomiting and headache on waking.
- Headache triggered by coughing, straining, or postural changes.
- Persistent physical symptoms or signs after attacks, neuro or endocrine.
- Meningism, confusion, impairment of consciousness, seizure.
What is the probability diagnosis of a headache?
- Acute: Respiratory.
- Chronic: Tension, combination.
- Migraine.
What serious disorders should not be missed with a headache?
- Vascular: SAH, intracerebral haemorrhage, temporal arteritis.
- Neoplastic: cerebral or pituitary tumour.
- Severe infections: meningitis.
- Haematoma: extradural/subdural.
- Glaucoma.
- Benign intracranial hypertension.
What are the pitfalls that are often missed with a presenting complaint of a headache?
Common pitfalls:
- Cervical spondylosis/dysfunction.
- Dental disorders.
- Refractive errors of the eye (uncommon).
- Sinusitis.
- Ophthalmic herpes zoster.
- Exertional headache.
- Hypoglycaemia.
- Post-traumatic headache.
- Post-spinal procedure: e.g. epidural.

Rare pitfalls:
- Paget's disease.
- Post-sexual intercourse.
- Cushing's syndrome.
- Conn's syndrome.
- Addison's disease.
- Dysautonomic cephalgia.
Which of the 7 masquerades can cause headache?
ALL of them, although depression and drugs moreso than the others.
What are the most important and common causes of headache in children?
- Intercurrent infections.
- Psychogenic.
- Migraine.
- Meningitis.
- Post-traumatic.
What are the most important and common causes of headache in adults including middle age?
- Migraine.
- Cluster headache.
- Tension.
- Cervical dysfunction.
- SAH.
- Combination.
What are the most important and common causes of headache in the elderly?
- Cervical dysfunction.
- Cerebral tumour.
- Temporal arteritis.
- Neuralgia.
- Paget's disease.
- Glaucoma.
- Cervical spondylosis.
- Subdural haemorrhage.
List red flag signs to look out for in a headache.
- Confusion.
- Drowsiness.
- Vomiting.
- Neurological signs persisting between headaches.
- Fever.
- New headache > 50 years of age.
- Sudden onset.
- Headache that wakes.
- Head injury.
- Severe, debilitating pain.
Describe the typical severity of a migraine.
Moderate to severe.
Describe the typical quality of a migraine.
Pulsating, throbbing.
What is the typical location of a migraine?
Classical, unilateral hemicranium (but not always).
What are some of the associated features of a migraine?
- Prodrome.
- Nausea.
- Visual aura.
- Light and sound sensitivity.
- Worse with activity.
What is the best kind of environment a person having a migraine should be placed in?
Dark, quiet room.
What pharmacological treatments are available to treat an acute attack of a migraine?
- Analgesia: paracetamol, aspirin, NSAIDs, codeine, tramadol, (DANGER! morphine, pethidine).
- Anti-emetic: metoclopromide (Maxolon), prochlorperazine (Stemetil), domperidone.
- Triptans: sumatriptan, naratriptan, zolmitriptan (oral or nasal administration).
- Ergotamine
What is the mechanism of action of the triptans?
They are serotonin receptor agonists.
What are the contraindications for use of the triptans?
- Patients with vascular disease, IHD or poorly controlled hypertension.
- Ergotamine or dihydroergotamine given within 24 hours.
- History of CVA/TIA.
- Use of MAO-I.
- Severe liver impairment.
- Focal migraine.
Possible adverse reactions to triptan medication include...
- Angina-like symptoms.
- Transient hypertension.
- Pain.
- Hypotension.
- Arrhythmias.
- Serious coronary events (rare).
Can triptans be taken with propanolol, pizotifen or alcohol?
What is the mechanism of action of the triptans?
They are serotonin receptor agonists.
What are the contraindications for use of the triptans?
- Patients with vascular disease, IHD or poorly controlled hypertension.
- Ergotamine or dihydroergotamine given within 24 hours.
- History of CVA/TIA.
- Use of MAO-I.
- Severe liver impairment.
- Focal migraine.
Possible adverse reactions to triptan medication include...
- Angina-like symptoms.
- Transient hypertension.
- Pain.
- Hypotension.
- Arrhythmias.
- Serious coronary events (rare).
Can triptans be taken with propanolol, pizotifen or alcohol?
Typically, how long does it take for triptans to completely stop a migraine?
After 2 hours.
When does triptans work best?
When given as soon as possible after the beginning of a headache.
In what percentage of patients does a headache return within 24 hours after triptan administration?
Around 30%. The patient may try a second dose.
What are the possible routes of administration of triptans?
- Oral.
- Nasal spray.
- Subcutaneous injection.
If the patient still has the headache after a dose of triptan, what should he/she not do?
Repeat the dose.
Under the PBS, which patients may be prescribed a triptan with PBS funding?
Migraine attacks in patients who are receiving or who failed a reasonable trial of prophylactic medication and where attacks in the past have usually failed to respond to oral therapy with ergotamine and other appropriate agents, or in whom these agents are contraindicated.
How does ergotamine work on a migraine?
Vasoconstrictive action on the dilated extracranial arteries.
What are the possible routes of administration of ergotamine?
- Oral: Ergotamine 1-2mg PO as initial dose at first sign of headache (max of 6mg/day; 10mg/week).
- IM/SC injection of dihydroergotamine.
- Suppository ergotamine/caffeine.
How long do you have to wait after taking a triptain before you can take ergotamine?
6 hours.
List the contraindications of ergotamine.
- Coronary, obliterative and peripheral vascular disease.
- Severe and/or inadequately controlled hypertension.
- Hepatic and renal insufficiency.
- Certain medications including macrolides, concomitant vasoconstrictors including ergot alkaloids, sumatriptans, and other 5HT1 agonists.
- Temporal arteritis, hemiplegic or basilar migraine.
- Pregnancy, lactation.
List the possible adverse reactions of ergotamine.
- Peripheral vascular disturbance (discontinue immediately).
- GI upset.
- Hypertension.
- Dizziness.
- Pleural, retorperitoneal, pericardial, cardiac valvular fibrosis.
- Paraesthesia.
What are the possible indicators that a patient may require prevention therapy for migraines?
- Frequent migraines (>2/month) with significant disability.
- Extremely frequent migraines (>2/week).
- Acute therapies unacceptable.
- Medication overuse.
- Hemiplegia, risk of permanent damage.
- Progression of disease.
- Patient preference.
What are the possible preventative drugs that could be used for migraine?
- Beta-blockers: propanolol, atenolol.
- Anti-epileptics: Valproate, topiramate. DANGER! women of childbearing age.
- Anti-depressants: amitriptyline.
- Serotonin antagonists: pizotifen, methysergide.
- Nutriceuticals: riboflavin, coenzyme Q10, magnesium.

- Menstrual: NSAIDs, continuous OCP, triptans, transdermal oestrogen.
- Exercise induced: Beta-blockers, indomethacin.

AVOID clonidine and cyproheptadine (no evidence of any effect).
What is the typical severity of a tension headache?
Mild to moderate, rarely severe.
What is the typical quality of a tension headache?
What is the typical location of a tension headache?
Band around the headache, but not always.
What are the associated features of a tension headache?
- Musculoskeletal signs.
- Emotional stress.
- Sedentary workers.
- The most common headache
What is the treatment for a tension headache (acute and prevention)?
- Reassurance.
- Analgesia: paracetamol, aspirin, NSAIDs, codeine.

- Physiotherapy for musculoskeletal causes.
- Psychotherapy, meditation, relaxation exercises, biofeedback.

- Anti-depressants: amitriptyline (withdraw upon remission).
- Anti-epileptics: valproate (withdraw upon remission).
- Refer to pain management clinic.
What is the typical severity of a cluster headache?
Very severe +++.
What is the typical quality of a cluster headache?
Intense, lacinating, boring.
What is the typical location of a cluster headache?
Unilateral, usually around the eye.
What are the associated features of a cluster headache?
- Cluster timeline.
- Agitation, restlessness.
- Red, watery eye and runny nose.
- Ptosis.
- Men 1:1000, Women 1:6000.
- Smokers.
- Alcohol triggers.
What is the standard treatment for a cluster headache?
- Urgent referral to the specialist.
- Standard analgesia: inappropriate except as an adjunct.
- Sumatriptan 6mg subcutaneous.
- 100% oxygen at 7 L/min via mask and regulator (in some people).
- Ergotamine.
- Intranasal lignocaine.

- Verapamil +/- lithium.
- Ergotamine, methysergide.
- Corticosteroids.
Suspect medication overuse headache if:
- Any acute migraine drugs are used 10 or more days per month (e.g. triptans, ergotamine, compound analgesics, opioids) OR
ii) If simple analgesics are used 15 or more days per month.
How do you treat medication overuse headache?
Withdraw the overused agent. This may take weeks or even months.
What are the typical features of sinusitis?
- Frontal/retro-orbital.
- Unilateral > bilateral.
- Dull and throbbing.
- Onset usually in morning and often settles late afternoon.
- Associated URTI, +/- fever, and malaise.
- Aggravated by bending forward.
- Tenderness of sinuses.
Describe the treatment plan for sinusitis.
- Steam inhalations.

- Analgesics e.g. codeine/paracetamol.

- Decongestants may help.

- Consider antibiotic therapy in severe cases displaying at least 3 of the following features:
-- Persistent mucopurulent nasal discharge.
-- Facial pain.
-- Poor response to decongestants.
-- Tenderness over the sinuses, especially unilateral maxillary tenderness.
--- Tenderness on percussion of maxillary molar and premolar teeth that cannot be attributed to a single tooth.

Drug of first choice = amoxycillin as usually bacterial in nature (Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis).
A Combination Headache may be due to a combination of causes including...
- Tension.
- Cervical dysfunction.
- Vasospasm (migraine).
- Drugs e.g. medication overuse, alcohol, caffeine, etc.
What are the 'red flag' causes of headache?
- Temporal arteritis.
- Raised intracranial pressure.
- Subarachnoid haemorrhage.
- Benign intracranial hypertension.
What are the typical clinical features of temporal arteritis?
- Age > 50.
- Forehead and temporal region; may radiate to the side of the head.
- Unilateral.
- Severe burning pain, constant ache.
- Onset usually non-specific; worse in the morning.
- Aggravated by stress and anxiety.
- +/- tender, thickened, palpable temporal arteries.

Associated features:
- Malaise.
- Intermittent blurred vision (50%).
- Vague aches and pains in muscles.
- Weight loss.
- Scalp sensitivity.
- Jaw claudication on eating.
- Polymyalgia rheumatica.
What are the investigations for temporal arteritis?
- ESR usually markedly elevated.
- Temporal artery biopsy.
What is the treatment of temporal arteritis?
- Oral corticosteroids immediately (starting dose 60-100mg daily prednisolone).
- Delayed treatment may result in blindness.
- May take 1-2 years to resolve.
What are the clinical features of raised intracranial pressure?
- Headache generalised, often occipital.
- May radiate retro-orbitally.
- Dull ache.
- Occurs daily, can last hours.
- Worse in mornings, usually intermittent, can waken from sleep.
- Aggravated by coughing, straining, sneezing.
- Some relief with analgesics.
- Associated vomiting, vertigo/dizziness, drowsiness, confusion, neurological signs.
- Examination may demonstrate focal CNS signs, papilloedema.
- Consider tumour, subdural haematoma.
- Investigate with CT scan.
What are the typical features of SAH?
- Life-threatening.
- Sudden onset headache of moderate to severe intensity.
- Occipital.
- Localised at first, then generalised.
- Neck pain and stiffness follow headache.
- Vomiting and loss of consciousness can occur.
- Kernig's sign positive.
- Neurological deficits may include hemiplegia/3rd nerve palsy (dilated pupils, ptosis).
- Urgent referral for CT scan. LP is CT is negative.
What are the typical features of benign intracranial hypertension?
- Usually young obese women.
- Key clinical features = headache, visual blurring, nausea, papilloedema.
- Main concern = visual deficits.
- Sometimes linked to drugs including tetracyclines, OCP, nitrofurantoin, Vitamin A preparation.
What investigations can be done for benign intracranial hypertension?
- CT and MRI = normal.
- LP = increased CSF pressure and normal CSF analysis.
What treatment is available for benign intracranial hypertension?
- Weight reduction.
- Corticosteroids.
- Diuretics.
- Sometimes repeated LP relieves pressure.
- Rarely - surgery to decompress optic nerves.
List some CAM approaches to headache.
- Avoid tyramine, phenyl ethylamine, aspartame, MSG, many others.
- Supplement riboflavin, magnesium.

- Volatile organic compounds.

Sleep hygiene.

- Relaxation + biofeedback, especially in children.
- Feverfew.
- Acupuncture.
Explain the 3 main etiololgies underlying the mechanism of stroke.
Focal ischaemia or infarction:
- Usually caused by thrombosis of cerebral arteries, or emboli.
- TIAs fall into this class.

Global hypoxia-ischaemia
- Reduction in blood pressure/cardiac output, if sustained, results in infarction of the border zones between the major cerebral artery distributions. This results in global cerebral effects including cognitive effects.

Cerebral haemorrhage
- Produces neurological symptoms by producing a mass effect on neural structures or from the toxic effects of blood itself.
What are the risk factors for stroke?
- Hypertension.
- Atrial fibrillation.
- Diabetes.
- Smoking.
- Hyperlipidaemia.
- Asymptomatic and symptomatic carotid stenosis.
What are the recommendations made to patients at risk of stroke?
To immediately call emergency medical services if they experience:
- Loss of sensory and/or motor function on one side of the body (nearly 85% of ischaemic stroke patients have hemiparesis).
- Change in vision, gait, or ability to speak or understand.
- A sudden, severe headache.
What are the strategies of acute care for stroke management?
- Rapid evaluation: thrombolysis is most effective < 3 hours.
- Urgent CT of the head if stroke considered (as 15% are haemorrhagic).
- Stabilise patient.
- For ischaemic stroke: tissue plasminogen activator (tPA) IV within 3 hours of stroke may be beneficial in restoring cerebral perfusion.
- Reduce complications - e.g. pneumonia, DVT with subcutaneous heparin/compression stockings, reduce fever, reduce hyperglycaemia.
What are the strategies for long term care in stroke management?
- Secondary prevention - antiplatelet agents (aspirin) within 48 hours of stroke onset reduces both stroke recurrence risk and mortality.
- Management in comprehensive stroke units followed by rehabilitation services improves neurological outcomes and reduces mortality.
- Identify and manage the underlying cause. E.g. AF, MI, Prosthetic valves, rheumatic heart disease, and ischaemic cardiomyopathy, carotid atherosclerosis.
What underlying problems can predispose a patient to AF?
- AF.
- MI.
- Prosthetic valves.
- Rheumatic heart disease.
- Ischaemic cardiomyopathy.
- Carotid atherosclerosis.
In a patient with AF, what is his/her average annual risk of a stroke?
What is likely to be beneficial in an asymptomatic patient with severe carotid artery stenosis?
Carotid endarterectomy may reduce the risk of stroke.
What secondary prevention steps can help prevent stroke in a high risk patient?
- BP reduction.
- Cholesterol reduction.
- Antiplatelet treatment (usually aspirin).
- Carotid endoarterectomy in people with moderately severe (50-69%) or severe (>70%) symptomatic carotid artery stenosis.

There is some evidence that carotid endoarterectomy will also be beneficial for asymptomatic carotid artery stenosis.
In terms of Frequency, how would you divide primary headaches into categories?
- Episodic: Low to moderate frequency (<15 headache days per month).
- Chronic Daily: High frequency (>15 headache days per month).
What are the primary episodic headache disorders?
- Migraine.
- Episodic tension type headache.
- Cluster headache and trigeminal autonomic cephalalgias.
What are the primary frequent (chronic daily) headache disorders?
- Transformed migraine.
- Chronic tension type headache.
- New daily persistent headache.
- Hemicrania continua.
You have a patient with low to moderate frequency headache with longer duration of attacks (>4 hours per day).

What are your main suspicions?
- Migraine.
- Episodic tension type headache.
You have a patient with low to moderate frequency headache with short duration of attacks (<4 hours per day).

What are your main suspicions?
- Cluster headache.
- Trigeminal autonomic cephalgias.
What is a migraine usually aggravated with?
- Positional change.
- Jolting.
- Exercise.
What location is migraine most commonly associated with?
Unilateral frontal.
This headache is excruciating, unilateral, located behind one eye, boring in character and not affected adversely by exercise or position. It may rarely shift from one attack to another to the other side, but tends to be ‘side locked’ for an individual.

What type of headache is it?
Cluster headache.
What causes of secondary headache is associated with the skull?
- Paget's disease.
- Mastoiditis.
- Secondary malignancy.
What causes of secondary headache is associated with the ears?
Otitis media and externa.
What causes of secondary headache is associated with the eyes?
- Glaucoma.
- Strabismus.
- Ocular strain.
- Iritis.
What causes of secondary headache is associated with the nose and nasal sinuses?
Acute and chronic sinusitis.
What causes of secondary headache is associated with the teeth?
Tooth abscess and malocclusion.
What causes of secondary headache is associated with the cervical spine?
Cervical spondylosis.
What causes of secondary headache is associated with the cranial nerves?
- Herpes zoster.
- Occipital neuralgia.
List the intracranial vascular disorders associated with causing secondary headaches.
- Venous sinus thrombosis.
- Ruptured aneurysm.
- Cerebral haemorrhage.
What causes of secondary headache are there involving extracranial vascular disorders?
- Carotid artery dissection.
- Cranial arteritis.
- Carotidynia.
What causes of secondary headache are there involving disorders of intracranial pressure?
- Raised intracranial pressure.
- Low CSF pressure. e.g. post-lumbar puncture leak.
What causes of secondary headache are there involving intracranial infection?
- Encephalitis.
- Meningitis.
Do patients with cluster headache get nausea and vomiting?
Generally not.
What sort of aura symptoms may a migraine sufferer have?
- Predominantly visual.

- Numbness and paraesthesia circumorally.
- Difficulty in finding words.
- Clumsiness.
- Weakness of limb (usually upper limb).
How long do migraine aura usually last?
They come on gradually and last for about half to one hour.
In cluster headaches, what accessory symptoms may occur?
- Lacrimation.
- Nasal blockage.
- Nasal discharge.

All on the side ipsilateral to the headache.
The patient lies down, chooses silence, tries to sleep (often finding that sleep relieves the headache), and does not want to be disturbed.

What is the differential diagnosis of headaches it could be?
- Migraine (most likely).
- Subarachnoid haemorrhage.
- Meningitis.
- Encephalitis.
The patient cannot lie quietly, gets up and walks in an agitated fashion, and sometimes will beat their head or take up unusual positions of the body. Some sufferers run to ease the pain.

What is the most likely headache this patient is suffering from?
Cluster headache.
The onset of the headache is typically abrupt, with an upswing of about 5 minutes to the peak of discomfort, a plateau of about half an hour, and then a gradual decrement of about 20 minutes.

What kind of headache is it most likely?
Cluster headache.
How long do untreated or unsuccessfully treated migraines last?
4-72 hours.
How long do cluster headaches usually last?
15-180 minutes.
Episodic tension type headaches have a duration of....
30 minutes to 7 days.
A patient has a headache that is mainly occipital, but sometimes radiates to the temple, exacerbated by examination of neck mobility.

What kind of headache is it most likely to be?
Cervicogenic headache or cervical spondylosis.
What are the blue flag headaches?
- Headache that is mainly occipital, but sometimes radiates to the temple, exacerbated by examination of neck mobility (cervicogenic headache or cervical spondylosis).
- Headache temporally linked to whiplash injury of the neck.
- Headache related to reading (eye strain).
- Headache clearly temporally linked to the ingestion of medications (eg. vasodilators).
- Headaches associated with systemic viral illness (eg. influenza).
RED FLAG - A headache that is progressive may suggest...
A mass lesion.
RED FLAG - A headache of sudden onset may indicate...
A bleed either into the subarachnoid space or the cerebral parenchyma.
RED FLAG - A headache with rash may indicate...
Meningococcal meningitis or Lyme disease.
What is the differential diagnosis of a headache with a raised ESR?
- Temporal arteritis.
- Collagen disease.
- Systemic illness.
A headache with papilloedema may indicate...
Raised intracranial pressure due to a mass lesion or benign intracranial hypertension.
A nonmigraine headache in pregnancy or postpartum might indicate...
Cerebral vein thrombosis.
A headache triggered by coughing or straining might indicate...
Either a mass lesion or a subarachnoid bleed.
A headache clearly triggered by a change in posture may indicate...
Low cerebrospinal fluid [CSF] pressure, for instance due to spontaneous CSF leak.
This headache is characterised by recurrent stabs of sharp, jabbing pain in the distribution of the first division of the trigeminal nerve. These recurrent attacks are alarming for the patient and very often stops them ‘in their tracks’. There are no autonomic features.

What kind of headache is it?
Primary stabbing headache.
Hypnic headache occurs primarily in the elderly, is relatively short lived (~30 minutes) and wakes patients from sleep, often in the early morning hours. It is usually bilateral, and lacks the severity of cluster headache. There are no autonomic features.

What kind of headache is it?
Hypnic headache.
Migraine is considered a complex interplay of different pathophysiological processes. What are they?
- Alteration of pain and sensory input.
- Increased sensitivity of the cortex leading to aura phenomena.
- Central pain facilitation.
- Neurogenic inflammation.
- Brainstem nociceptor sensitisation.
How do the triptans exert their effect?
The triptans exert their effect in part by producing selective carotid vasoconstriction via 5-HT1B receptors and by pre-synaptic inhibition of the trigeminovascular (sterile) inflammatory response via 5-HT1D/5-ht1F receptors.
Migraines must have 2 of the following headache characteristics:
– The headache should be unilateral.
– The quality of the pain should be throbbing.
– The headache should be aggravated by movement.
What percentage of migraine sufferers would get a prodrome?
What would the prodrom of a migraine consist of?
Craving for food, thirst, and altered emotional state.
Describe the visual aura that may occur with a migraine sufferer.
Visual auras may take the form of central loss of vision (central scotoma) or a hemianopia. Often there are scintillations that may occur separately or as part of the shimmering edge of the scotoma. Some migraineurs experience zig-zag formations (fortification spectra) with double or triple outlines, and in some, the visual phenomena will move slowly across the visual field; this is almost pathognomonic of migraine.
When does migraine usually start in females?
Childhood or adolescence, especially with beginning of the menstrual cycle.

Change in pattern with pregnancy occurs as well.
Gastric stasis may occur with a headache in the onset of a migraine attack, hindering absorption of medication. What could be done to 'prime' the analgesic or NSAID for administration?
Use an anti-emetic 5 minutes earlier.
Sumatriptan is the only injectable 5-HT1B/D agonist. In what circumstances would that be useful?
- Where there is early vomiting.
- Where oral medications are not well tolerated.
- Where there is very rapid onset of migraine.
What may indicate the use of IV fluids (i.e. normal saline or dextrose water) for migraine headache?
Severe vomiting, causing lack of fluid intake, and the potential for dehydration.
What non-migraine specific analgesics are useful for acute migraine?
- Aspirin (900 mg).
- Paracetamol (1000 mg or as required).
- Naproxen (500–1000 mg or as required).
- Ibuprofen (400–800 mg).
What oral anti-emetics are useful for acute migraine?
- Metoclopramide (Maxolon) (10 mg).
- Prochlorperazine (Stemetil) (5–10 mg).
- Domperidone (Motilium) (10 mg).
What parenteral medications useful for severe attacks of migraine?
- Dihydroergotamine (DHE).
- Metoclopramide (Maxolon).
- Prochlorperazine (Stemetil).
- Chlorpromazine (Largactil): an anti-psychotic.
- Promethazine (Phenergan): an anti-histamine.
- Subcutaneous sumatriptan (6 mg).
- Intravenous valproate.
- Intramuscular droperidol.
What would be considered overuse of ergotamine?
Ergotamine intake on ≥10 days per month on a regular basis for >3 months.
What would be considered overuse of triptan?
Triptan intake (any formulation) on ≥10 days per month on a regular basis for >3 months
What would be considered overuse of simple analgesics?
Intake of simple analgesics on ≥15 days per month on a regular basis for >3 months
What would be considered overuse of combination analgesic medication?
Intake of combination analgesic medications on ≥10 days per month on a regular basis for >3 months.
What kind of foods might precipitate migraine?
Cheese, chocolate, monosodium glutamate, artificial sweeteners, hot dogs, citrus fruits and wine.

Low fat diets appear to reduce the intensity and duration of migraines.
What sort of medications may be preventative against migraines?
- Beta blockers (propanolol, metaprolol).
- Amitriptyline.
- Pizotifen.
- Methysergide.
- Valproate.
- Topiramate.
- Candesartan.
- Riboflavin.
- Magnesium.
How do sumatriptans work?
5HT1 agonist.
Intranasal administration of sumatriptan has a _______ onset of action but a ______ duration of action.
Intranasal administration of sumatriptan has a quicker onset of action but a shorter duration of action.
Ergot alkaloids (ergotamine, dihydroergotamine) and 5HT1 agon ists (naratriptan, sumatriptan, zolmitriptan) are contraindicated for use in what patients?
- Poorly controlled hypertension.
- History of myocardial infarction.
- Ischaemic heart disease.
- Cerebrovascular and peripheral vascular disease.

- Coronary vasospasm (for triptans).

- Raynaud's syndrome, hyperthyroidism, sepsis and porphyria (in ergot alkaloids).
Why is the use of monoamine oxidase inhibitors (MAOIs)
in combination with sumatriptan contraindicated?
Risk of serotonin syndrome.
What are common adverse effects associated with 5HT1 agonist (triptan) use?
- Sensations of tingling, heat, heaviness or tightness in any part of the body, including the chest and throat.
- Flushing.
- Dizziness.
- Feelings of weakness.
- Fatigue.
- Nausea.
- Vomiting.
- Dry mouth.
- Transient increase in blood pressure.
What are the rare but serious adverse effects of triptans?
Myocardial infarction, cardiac arrhythmias, stroke,
anaphylaxis and death.
If no response occurs to 5HT1 agonist (triptan) dose, should a second dose be tried?
No, a second dose should only be tried if there is already some sort of response.
Ergot alkaloids should not be used _______ after a triptan was taken.

A triptan should not be used ______ after an ergot alkaloid was taken.
Ergot alkaloids should not be used 6 hours after a triptan was taken.

A triptan should not be used 24 hours after an ergot alkaloid was taken.
What are the first line preventative medications for migraine?
Propanolol and metaprolol.
What adverse effects is pizotifen associated with?
Drowsiness and weight gain.
What kind of migraine would amitriptyline be best suited to prevent?
Those migraines also associated with tension headaches, sleep disturbances and depression.
What non-pharmacological management approaches could also be used for migraines?
- Stress management.
- Adequate sleep.
- Identify and avoid trigger factors.
- Relaxation techniques.
- Massage.
- Dietary modifications.
- Exercise.
- Headache diary.
Why can a migraine diary be useful?
- Identifies frequency, timing (e.g. nocturnal attacks, relationshipship to the menstrual cycle and use of acute-phase therapies).
- Identifies patients at risk of medication-overuse headache.