3 Headache, pt 2

Question 1

The most common non-life-threatening headache in the ED

Answer 1

Migraine

Question 2

Features of Migraine

Answer 2

Pulsatile, throbbing
Photosensitivity, phonosensitivity
Lasts hOurs (4-72 hours)
Unilateral
Nausea, vomiting
Debilitating, worse with exertion
4/5 has positive likelihood ratio of 24 for migraine

Question 3

Chronic migraine is defined as

Answer 3

5 or more migraine headache days per month over the past 3 months

Question 4

First-line abortive therapy for migraine at home

Answer 4

Triptans

Question 5

ED treatment of migraine

Answer 5

Dopamine receptor antagonist (metoclopramide, droperidol)
+ NSAIDs
Steroids may be useful to reduce the risk for headache recurrence after ED discharge

Question 6

Opiates in migraine

Answer 6

Opiates and barbiturate-containing compounds should not be used routinely for abortive migraine thearpy unless other standard treatments fail

Question 7

Remarks on cluster headache

Answer 7

severe (excruciating)
unilateral
lasts 15-180 mins (brief and self-limited)
Circardian / circannual

Can mimic dental pain
More common in men

Question 8

distinguishing feature of cluster headache

Answer 8

the need for the patient to “pace”

Question 9

Treatment of cluster headache

Answer 9

100% oxygen administered at 12L/min for 15 mins through NRM
Sumatriptan, 6 mg SC

Question 10

Presentation of PRES

Answer 10

Posterior Reversible Encephalopathy Syndrome
severe headache,
visual changes,
seizures,
encephalopathy
marked hypertension

Question 11

PRES is most common in

Answer 11

Patients undergoing active treatment with immune-suppresing or -modulating medications
or chemotheraptuic agents,
and in end-stage renal disease

Question 12

Imaging findings in PRES

Answer 12

MRI: symmetrical vasogenic edema in the occipital area of the brain

Question 13

Treatment of PRES

Answer 13

BP control and supportive care

Question 14

This condition can mimic subarachnoid hemorrhage

Answer 14

RCVS
Reversible cerebral vasoconstriction syndrome
characterized by the occurrence of 1 or more “thunderclap” headache
should be considered only when the evaluation for SAH has proven negative

also mimic SAH: CVT, carotid artery dissection

Question 15

Diagnosis of RCVS

Answer 15

1. The clinical presentation of thunderclap headache without evidence of SAH should be the main prompt to making this diagnosis or consulting with a neurologist
2. Head CT is most commonly normal
3. the key diagnostic feature (multiople areas of cerebral vasoconstriction on MRA) is most commonly found on follow-up angiography between 2 and 3 weeks after symptom onset

Question 16

Remarks on occipital neuralgia

Answer 16

paroxysms of pain at the back of the head
described as stabbing or electric shock-like

Question 17

Treatment in occipital neuralgia

Answer 17

occipital nerve block typically results in marked improvement of symptoms
- results can persist for weeks after injection
- both diagnostic and therapeutic
- can be performed with easy in any setting and requires minimal expertise

Question 18

remarks on idiopathic intracranial hypertension

Answer 18

1. aka pseudotumor cerebri
2. most common in obese women
3. if untreated, can lead to permanent vsual impairment

Question 19

diagnostic criteria of idiopathic intracranial hypertension

Answer 19

papilledema
otherwise normal neurologic exam
elevated opening pressure on LP (>25 cm H2O in adults, >28 cm H2O in children)
normal CSF composition
normal imaging

Question 20

treatment of idiopathic intracranial hypertension

Answer 20

Focused on preservation of vision
LP may provide temporary relief of symptoms (target pressure of 15-20 cm H2O)
In general, removal of 1 mL of CSF will lower the CSF pressure by about 1 cm H2O

Question 21

Detecting increased ICP

Answer 21

US of the optic nerve sheath diameteter
<5 mm is normal
>6 mm is abnormal
5-6 mm is controversion

Question 22

Clinical feature of intracranial hypotension

Answer 22

AKA low-pressure headache
Headache that increases in severity with upright posture but improves or resolves in the supine position
LP, if performed, should have an opening pressure <6 cm H2O

Question 23

Most effective therapy for low-pressure headache

Answer 23

epidural blood patch, typically performed by anesthesiologists

Question 24

Hypertensive headache

Answer 24

There is no compelling evidence linking mild to moderate hypertension with headache.

Question 25

Pituitary tumor apoplexy requires immediate treatment with

Answer 25

corticosteroids
and urgen neurosurgical consultation

Question 26

Most common tumor of the third ventricle

Answer 26

Third ventricle collloid cysts
- rare cause of acute neurologic deterioration and sudden death
- usually congenital
- hx of severe paroxysmal and episodic attacks of (typicall frontal) headache with N/V
- the presumptive cause is the intermittent obstruction of CSF flow through the foramina of Monro

Question 27

Acute angle-closure glaucoma diagnosis includes ocular pressure greater than

Answer 27

21 mm Hg
although this is usually greater than 30 mm Hg

Question 28

Remarks on preeclampsia

Answer 28

May present with headache
after 20 weeks AOG up to 6 weeks postpartum
Proteinuria is NOT required for diagnosis

Question 29

Remarks on CVT

Answer 29

Cerebral Venous Thrombosis
Mean age of 39 years
More common in women
May present with a “thunderclap” headache
Diagnosed definitively with magnetic resonance venography
LP can safely be performed in patients with CVT