Headache syndromes flashcards
17 high-yield MRCP Part 1 cards from the Intellect Medicos Neurology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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What is the first-line acute treatment for migraine in adults?
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An oral triptan combined with an NSAID or paracetamol.
Why? Combination therapy works better than either drug alone. Take the triptan at the start of the headache, not during the aura.
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Name the first-line options for migraine prophylaxis.
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Propranolol, topiramate or amitriptyline.
Why? Since June 2025 NICE lists all three as equal "consider" options after discussing benefits and harms. Count it a success if attacks fall by 50% or more.
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Why is topiramate problematic for migraine prophylaxis in women of childbearing potential?
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It is teratogenic. The MHRA (2024) says it is contraindicated in pregnancy for migraine and needs a pregnancy prevention programme.
Why? Exposure in pregnancy is linked to malformations, low birth weight and neurodevelopmental problems. Propranolol or amitriptyline are often preferred.
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Can a woman with migraine WITH aura use the combined oral contraceptive?
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No. It is contraindicated because of the increased risk of ischaemic stroke.
Why? Aura plus oestrogen multiplies stroke risk (UKMEC category 4).
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What is the first-line acute treatment for a cluster headache attack?
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100% high-flow oxygen via a non-rebreather mask, and/or subcutaneous (or nasal) sumatriptan.
Why? Attacks are short (15-180 min), so the treatment must act quickly.
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What is the prophylactic drug of choice for cluster headache?
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Verapamil.
Why? Verapamil reduces attack frequency during a cluster bout.
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Unilateral orbital pain with ipsilateral tearing, attacks lasting 2-30 minutes and occurring more than 5 times a day: which drug gives a dramatic response?
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Indometacin (diagnosis: paroxysmal hemicrania).
Why? Complete response to indometacin is part of the definition of paroxysmal hemicrania and hemicrania continua.
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What is the first-line drug for trigeminal neuralgia?
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Carbamazepine.
Why? Sodium-channel blockade calms the hyperexcitable trigeminal nerve. Alternatives include oxcarbazepine, lamotrigine and baclofen.
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How is medication-overuse headache from simple analgesics or triptans managed?
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Stop all overused acute headache medicines abruptly (not gradually) for at least 1 month.
Why? Headache usually gets worse at first, then improves; give close follow-up and consider prophylaxis for the underlying headache disorder. MOH is headache on 15 or more days a month with regular overuse of acute drugs.
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What is the first-line drug for idiopathic intracranial hypertension (with weight loss)?
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Acetazolamide.
Why? Acetazolamide is a carbonic anhydrase inhibitor that reduces CSF production. Topiramate is an alternative.
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What are the key investigations in suspected idiopathic intracranial hypertension?
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MRI brain (with venography) to exclude a mass or venous sinus thrombosis, then LP showing raised opening pressure with normal CSF.
Why? IIH is a diagnosis of exclusion. Imaging must be normal before raised pressure is attributed to IIH.
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What is the most effective treatment for a post-lumbar-puncture headache that persists beyond 72 hours?
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Epidural blood patch.
Why? The headache comes from a CSF leak. Initial care is analgesia and rest. A blood patch seals the dural hole.
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What is the mechanism of action of triptans?
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Serotonin 5-HT1B/1D receptor agonists.
Why? They constrict cranial blood vessels and reduce release of pain neuropeptides (such as CGRP) from trigeminal nerve endings.
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Name two contraindications to triptans.
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Any two: ischaemic heart disease or coronary vasospasm, previous stroke or TIA, peripheral vascular disease, uncontrolled hypertension.
Why? Triptans are vasoconstrictors, so they can provoke ischaemia in diseased vessels.
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Which oral drug can treat acute migraine when triptans are ineffective or contraindicated, and what is its class?
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Rimegepant, a CGRP receptor antagonist ("gepant").
Why? It does not cause vasoconstriction, so it can be used when triptans are contraindicated.
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When are CGRP monoclonal antibodies (e.g. erenumab, fremanezumab) considered for migraine prevention?
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At least 4 migraine days a month after at least 3 preventive drugs have failed.
Why? They are specialist preventives. Oral gepants (atogepant; rimegepant for episodic migraine) have the same NICE threshold, and botulinum toxin A is an option for chronic migraine.
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How is predictable menstrual-related migraine prevented when standard acute treatment fails?
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Frovatriptan or zolmitriptan on the days migraine is expected (typically from 2 days before until 3 days after bleeding starts).
Why? Short-term triptan "mini-prophylaxis" covers the predictable high-risk days.