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What is the pathophysiology of migraine?
- Activation of a hypersensitive "central generator"
- Disrupted ion homeostasis, release of neurochemicals and cortical spreading depression
- Meningeal blood vessel dilation and activation of trigeminovascular system
- Release of vasoactive neuropepetides (cGRP, neurokinins, substance P) from activated trigeminal sensory nerves
- Worsening dilation
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Contraindications of Triptans?
Coronary artery disease.
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MoA of Triptans?
- Agonists at 5HT1B and D
- Agonist action at 1B causes vasoconstriction
- Agonist action at 1D causes decrease release of nociceptive mediators from the TNC
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Differentials for a long-lasting abrupt onset headache that patients can remember the date of onset of?
- CVST
- SIH
- New daily persistent headache - not allowed to have a postural component, must have normal MR and MRV and not allowed to have more than 1 migrainous feature.
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What are the indomethacin responsive headaches?
- Hemicrania continua
- Paroxysmal hemicrania
- Cough headaches
- Primary stabbing headaches
- Primary headaches associated with sexual activity
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Definition of a thunderclap headache?
Headache that reaches maximal intensity in 1 minute and lasts for 5mins or more
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First line prophylactic agent for Suna/Sunct
Lamotrigine
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What is the definition of Chronic Migraine?
A headache occurring on 15 or more days/ month for more than three months, which, on at least eight days/month, has the features of migraine headache
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How do you qualify for Botox for headaches?
Have clearly defined chronic migraine and have failed 3 preventatives
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What does glossopharyngeal neuralgia present with?
- Severe intermittent pain in ear, base of tongue, tonsillar fossa or below the angle of the jaw.
- Attacks last several seconds to minutes.
- Swallowing, chewing, yawning and talking can all trigger these attacks.
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What are the more concerning symptoms of glossopharyngeal neuralgia?
Bradycardia, hypotension, asystole and palatal myoclonus.
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What is Epicrania Fugax?
- ‘Electric’ or ‘stabbing’ pain across the surface of one hemicranium.
- Starts posteriorly and quickly moves anteriorly in either a straight or zig-zag line to reach the ipsilateral forehead, eye or nose.
- Duration 1 to 10 seconds
- One third of patients have autonomic signs.
- Lamotrigine and gabapentin can provide partial or complete relief.
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What is a Hypnic headache?
- Occurs in over 50s
- ‘Alarm Clock’ headache that wakes them from sleep
- Attacks last 15 mins to 6hrs
- Caffeine, lithium and melatonin can all help
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Lancinating deep ear pain triggered by stimulation of EAC?
Nervus intermedius neuralgia
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Whats the difference between CRPS 1 and 2?
2 has identifiable nerve injury on NCS.
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What do you do for nummular headaches?
Indomethacin or Gabapentin
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Bilateral ear redness sparing the Lobes?
Relapsing polychondritis.Can cause migraines, meningitis, confusion and psychosis as it can cause a vasculitis.Also causes CSF pleocytosisTreat with steroids and then sparing agent.
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Unilateral red and painful ear thats episodic?
- Red ear syndrome
- Can be idiopathic or secondary
- Attacks are usually less than 1 hour
- Usually happens in younger people with history of migraine
- Secondary cases are due to upper cervical spine pathology and temporo-mandibular joint dysfunction
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Lowest platelet count allowed for LP?
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Whats the difference between Factitious disorder and Malingering?
- Factitious is to become a patient
- Malingering is for secondary gain
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How are the personality disorders divided?
- Cluster A (Odd/eccentric)
- Cluster B (dramatic/erratic)
- Cluster C (anxious/fearful)
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Cluster A (Odd/eccentric)
- Paranoid
- Schizoid (apathetic and detached)
- Schizotypal (magical thinking)
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Cluster B (dramatic/erratic)
- Antisocial
- Borderline
- Histrionic
- Narcissistic
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Cluster C (anxious/fearful)
- Avoidant
- Dependent
- Obsessive compulsive
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Which SSRI has the shortest half life and is therefore most likely to cause withdrawal?
- Paroxetine
- (Fluoxetine has the longest)
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Which gene mutations cause familial hemiplegic migraine?
- FHM1 - CaCNA1A
- FHM2 - ATP1A2
- FHM3 - SCN1A
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Rizatriptan and Propranalol?
Propranalol increases the concentration of i=Rizatriptan so half the dose of Riza
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