Headache MCQs

BIH is typically associated with papilloedema, reduced venous pulsation and normal appearances of the magnetic resonance imaging (MRI). A VIth nerve palsy is a recognised association. Reflexes are preserved and plantars are flexor. Extensor plantars suggest an alternative diagnosis. Reference: Harrison's Principles of Internal Medicine, 21 st Ed, Ch: 16Pg: 116

The patient in the question suffers from cluster head ache. The bouts or episodes occur for a very short period of 1 weeks. The preventive therapy of cluster head ache depends up on the duration of bouts. For shorter bouts the drugs that are approved are: Prednisolone CGRP monoclonal antibody Galcanezumab Great Occipital nerve injection with lignocaine or steroids Verapamil For bouts that are longer, the drugs that are approved are Verapamil 160-960mg/day Lithium 400-800mg/day Non invasive vagal stimulation Deep brain stimulation Melatonin, Topiramate and Gabapentin are of unproven benefits So among the options, the CGRP monoclonal antibody is useful not for chronic cluster head ache or longer bouts, but for shorter bouts of head ache. Reference : Harrison's Principles of Internal Medicine, 21 st ed, Ch: 430, Pg: 3367

CADASIL is a diffuse disease of small arteries, predominantly in the brain. It starts during mid adulthood and is characterised by: Recurrent ischaemic events (transient or permanent) Attacks of migraine with aura Severe mood disorders Sub-cortical dementia and A wide spread leukoencephalopathy on magnetic resonance imaging (MRI). CT brain is not diagnostic. Characteristic MRI changes include T2 weighted hyperintensity of the periventricular white matter. A family history is almost always present, as it is an autosomal dominant condition, located to chromosome 19. Infarcts are subcortical, and the thalami and basal ganglia are usually involved. Reference: Harrison's Principles of Internal Medicine, 21 st ed, Ch: 427, Pg: 3343

CADASIL is a diffuse disease of small arteries, predominantly in the brain. It starts during mid adulthood and is characterised by: Recurrent ischaemic events (transient or permanent) Attacks of migraine with aura Severe mood disorders Sub-cortical dementia and A wide spread leukoencephalopathy on magnetic resonance imaging (MRI). CT brain is not diagnostic. Characteristic MRI changes include T2 weighted hyperintensity of the periventricular white matter. A family history is almost always present, as it is an autosomal dominant condition, located to chromosome 19. Infarcts are subcortical, and the thalami and basal ganglia are usually involved. Reference: Harrison's Principles of Internal Medicine, Ch:427, Pg: 3343-3344

The history suggests temporal arteritis. In view of the vision threatening nature of disease, the patient should be commenced on steroids, pending the confirmatory tests. Typically 60 mg of prednisolone per day is recommended. Reference: Harrison’s Principles of Internal Medicine 21 st edition Ch:363 Pg:2811-2812

Triptans are a group of anti migraine drugs that cause vasoconstriction. So they have the propensity to precipitate angina.

In acute migraine attack, the first line treatments are simple analgesics such as aspirin, ibuprofen or paracetamol. Second line treatment in acute migraine are the triptans (e.g. sumatriptan) which work by selectively stimulating 5-hydroxytriptamine 1 (5HT1) receptors. Reference: Harrison's Principles of Internal Medicine 21 st edition Ch: 430, Pg: 3361

This patient requires prophylaxis as the symptoms are not getting controlled on triptans. Reference: Harrison's Principles of Internal Medicine, 21 st ed, Ch: 430, Pg: 3361-3364