פרק 9 Chapter 9 Headache and Other Craniofacial Pains Flashcards
מבוגר בן 80 מתעורר מכאבי ראש בלילה, דו”צ, ללא דמעת או אודם בעיניים. מה יש לו?
א. hypnic headace
ב. tension headache
ג. cluster headache
hypnic headache
בן 70 עם אמאורוזיס פוגקס, כאבי ראש ושקיעה מוחשת.
מהו הצעד הראשון בטיפול?
מתן סטרואידים!
the earliest suspicion of Temporal
arteritis should lead to the administration of corticosteroids
and then to biopsy of the appropriate scalp
artery. Microscopic examination discloses an intense
granulomatous or “giant cell” arteritis.
,תשובה ב
Temporal Arteritis (Giant Cell Arteritis, Cranial Arteritis)
In this disease, which is common among older persons, arteries of the external carotid system, particularly the temporal branches, are the sites of a subacute granulomatous inflammatory exudate consisting of lymphocytes and other mononuclear cells, neutrophilic leukocytes, and giant cells. The most severely affected parts of the artery usually become thrombosed. The sedimentation rate is characteristically elevated above 80 mm/h and sometimes exceeds 120 mm/h, but a small number of cases occur with values below 50 mm/h. may result in stroke on the basis of ischemic occlusion or secondary embolus. However, significant inflammatory involvement of intracranial arteries from temporal arteritis is uncommon, perhaps because of a relative lack of elastic tissue.
Regional or bilateral headache or head pain is the chief complaint, and there may be severe pain, aching, and Stiffness in the proximal muscles of the limbs associated With the markedly elevated sedimentation rate Thus the clinical picture overlaps that of polymyalgia rheumatica Occlusion of branches of the ophthalmic artery (mainly those to the posterior ciliary artery and the choroidal circulation that supply the anterior optic nerve) results in blindness in one or both eyes, is the most feared complication, often unpredictably.
In a few cases, blindness is preceded by transient visual loss, thereby simulating a TIA (transient monocular blindness). Other symptoms include jaw claudication due to ischemia of the masseter muscles. Occasionally the arteries of the oculomotor nerves are also
involved, causing various ophthalmoplegias. The administration of prednisone, 50 to 75 mg/ d, provides striking relief of the headache and polymyalgic symptoms within days and sometimes within hours, and also prevents blindness. The medication must be given
for at least several months or longer, guided by the symptoms and the sedimentation rate. The latter begins to drop within days but seldom falls below 25 mm/h.
בת 36, סובלת מכאב ראש חד צדדי משמאל, פוטופוביה ובחילות, ומלווה בכפל ראיה, מגבלה בתנועות העיניים משמאל לכיוון מעלה מטה ומדיאלית, ומלווה בנפיחות של העפעף. מה האבחנה הסבירה?
1. המיפלג׳יק מיגריין משפחתי
2. המיפלג׳יק מיגריין
3. אופתלמופלגי’ק מייגריין
- opthalmoplegic migraine
Ophthalmoplegic Migraine
Ophthalmoplegic migraine in the current terminology of “recurrent painful ophthalmoplegic neuropathy” rather than migraine but it is most conveniently described here. It consists of a recurrent unilateral headaches associated with weakness of extraocular muscles. A transient third-nerve palsy with ptosis, with or without involvement of the pupil, is the usual picture; rarely, the sixth nerve is affected. This disorder almost exclusively occurs in children. As a general rule, the diagnosis should not be made in adults unless there had been recurrent bouts in childhood. The ocular paresis often outlasts the headache by days or weeks; after many attacks, a slight mydriasis and some degree of ophthalmoparesis may remain permanently. We and others have encountered instances of gadolinium enhancement of the proximal, cisternal portion of the third nerve during and after an attack. However, in adults the syndrome of headache, unilateral ophthalmoparesis, and loss of vision may have more serious causes, including temporal (cranial) arteritis.
What is spreading cortical depression?
the cortical impairment progressed at a rate of 2 to
3 mm/min over the surface of the brain. Similarly; during
the aura, there is a regional reduction in blood flow, as
noted above. It begins in one occipital lobe and extends
forward slowly (2.2 mm/min) as a wave of “spreading
oligemia” that does not respect arterial boundaries
(Lauritzen and Olesen). Both of these events are intriguingly
similar to the above-mentioned phenomenon of
“spreading cortical depression,” first observed by Leao
in experimental animals. He demonstrated that a noxious
stimulus applied to the rat cortex was followed by vasoconstriction
and slowly spreading waves of inhibition of
the electrical activity of cortical neurons, moving at a rate
of approximately 3 mm/min.
how and when to treat acute migraine attack
status migranousus
diagnosis and treatment:
The pain is initially unilateral, later more generalized, more or less throbbing, but with a constant superimposed ache and is disabling;
vomiting or nausea is common at the outset but abates. Almost without exception, there is a preceding history compatible with migraine; in fact, the absence of prior headaches should raise concern about a more serious cause.
Status migrainosus sometimes follows a head injury or a viral infection, but most cases have no explanation.
Relief is sought by increasing the intake of ergot or serotonin agonist preparations or even opiates, often to an alarming degree, but with only temporary relief, serving at times to perpetuate the condition through a rebound mechanism.
In the diagnosis of such cases, the possibility should be considered that migraine has been combined with tension headache (migraine-tension or mixed-pattern headache) or transformed to so-called analgesia-rebound headache, or ergotamine, or serotonin agonist-dependency headache. Narcotic addiction is another consideration. Although not generally popular, it is our practice to admit such patients to the hospital,discontinue all narcotic medications, and administer intravenous hydration, corticosteroids, one of the serotonin agonist medications, or dihydroergotamine intravenous infusion in selected patients
Triptan contraindications:
בת 26 , סובלת כבר 16 שנים מכאב ראש בעל אופי פועם, נמשך לעתים עד 4 שעות, תמיד באזור
הרקה ומאחורי עין שמאל. לפעמים לפני הופעת הכאבים רואה הבזקי אור ולאחר מכן כתם שחור בצד
ימין. הכאב מגיב לרוב לטיפול ב
NSAID .
איזה ממצא דימות באזור אוקסיפיטלי שמאלי עשוי להסביר את התמונה הקלינית?
א. Cortical dysplasia
ב. Meningioma
ג. Developmental Venous Angioma
ד. Arteriovenous Malformation
ד. AVM
Recurrent painful ophthalmoplegic cranial neuropathy (formerly ophthalmoplegic migraine, mentioned earlier) may suggest a carotid-cavernous or supraclinoid aneurysm.
antiphospholipid syndrome, which has some ill-defined relationship to migraine, does cause episodic unilateral visual loss explanation for transient monocular blindness with or without headache.
invariant occurrence of migraine-like headache on the same side of the head increases the likelihood of an underlying arteriovenous malformation (AVM) or other structural lesion. ,more than 1,200 patients with AVM found that the headaches, which occurred in more than 30 percent of these individuals, In most, the AVM was in the occipital region and on the side of the headache. Approximately half of the patients with AVM and migraine had a family history of migraine.
familial hemiplegic migraine
איזו תעלה פגועה?
Familial Hemi plegic Migraine
In a related disorder, known as hemiplegic migraine, a condition mostly of infants and children (rarely adults), there are episodes of unilateral paralysis that may long outlast the headache. Several families have been described in which this condition is the result of a mutation in an ion channel (familial hemiplegic migraine; alternating hemiplegia of childhood). Of the known loci, which together account for approximately 50 percent of cases, the most common one is in the gene coding for the P /Q-type calcium channel a. subunit (CACNAlA). A second locus is in the gene for the Na+/K+-adenosine triphosphatase (ATPase) channel and a rarer subtype is caused by mutations in a sodium channel a.-subunit gene, SCNA1. These do not account for all cases, indicating that there are other mutations that will inevitably be discovered. It is reasonable to surmise that many of the nonfamilial cases of hemiplegic migraine are also caused by these mutations. By their nature, these channelopathies would be expected to have clinical and genetic overlap with other neurologic diseases. Indeed, there are shared traits between some of the genetic forms of familial hemiplegic migraine and both episodic and degenerative cerebellar diseases.
בת 30 , בריאה בד”כ. מזה כשנה סובלת מהתקפים של כאב ברקה ובארובת העין השמאלית. ההתקפים
נמשכים כ 20 דקות כל-אחד וחוזרים 4-5 פעמים ביום. באותה עת יש גודש בלחמית משמאל ונזלת
מנחיר שמאל.
מה טיפול המניעה המומלץ?
א. Topiramate
ב. Verapamil
ג. Propranolol
ד. Indomethacin
ד.- מדובר בפרוקסיזמל המיקרניאה והטיפול הוא אינדומד
מהם דומה ומה שונה בין
cluster headache
paroxysmal hemicrania
SUNCT
table 9-3 indomethacin responsive headaches
Valsalva related headache (3)
Trigeminal autonomic cephalgias (3)
Stabbing headaches (2)
CLUSTER HEADACHE
מאפיינים:
Cluster Headache
This headache pattern occurs predominantly in adult men (age range: 20 to 50 years; male to-female ratio approximately 5:1) and is characterized by a severe consistent unilateral orbital localization. The pain is felt deep in and around the eye, is very intense and nonthrobbing as a rule, and often radiates into the forehead, temple, and cheek. -less often to the ear, occiput, and neck. Its denominative feature is the nightly recurrence, between 1 and 2 h after the onset of sleep, or several times during the night for several or more consecutive Days; thus cluster. Less often, it occurs during the day or early evening, unattended by aura or vomiting.
The headache has been called the “alarm clock headache” because it may recur with remarkable regularity each night for periods extending as long as many weeks, followed
thereafter by complete freedom for many months or even years. However, in approximately 10 percent of patients, the headache becomes chronic, persisting over days, months, or even years.
There are several associated vasomotor phenomena: a blocked nostril, rhinorrhea, injected conjunctivum, lacrimation, miosis, and a flush and edema of the cheek, all lasting on average for 45 min (range: 15 to 180 min). ptosis may become permanent after repeated attacks. The homolateral temporal artery may become prominent and tender during an attack, and the skin over the scalp and face may be hyperalgesic.
בזמן התקף- אלכוהול הוא טריגר. לא בזמן התקף- אלכוהול אינו מעורר
התקפים.
הבדלים בין cluster headache
למיגרנה
הבדלים עיקריים בין מיגרנה ל cluster type:
אודם של הלחי בקלאסטר וחיוורון במיגרנה
לחץ תוך עיני מוגבר בקלאסטר, רגיל במיגרנה
עור חם ע”פ מצח, לחי ורקה בקלאסטר, קר במיגרנה
קלאסטר גברים, מיגרנה נשים
גיל הופעה – קלאסטר יכול יותר מאוחר (עד 50)
אופי הכאב
בעיקר – תגובה לטיפול.
בנוסף במיגרנה כאב לרוב פועם ואילו בקלאסטר בהגדרה אינו פועם
Table 9-1COMMON TYPES OF HEADACHE
VERAPAMIL
בן 36 , מתאמן כמה פעמים בשבוע במכון כושר. פונה לבדיקה עקב כאבי ראש עזים שהופיעו בכל פעם
לאחר שהרים משקולות. הכאב בעל אופי לוחץ, מגיע לשיא תוך כמה דקות. בדיקה נוירולוגית ודימות
תקינים.
מה הטיפול התרופתי המומלץ למניעת התופעה?
א. Valproate
ב. Verapamil
ג. Indomethacin
ד. Amitriptyline
INDOMETHACIN
Exertional headache
Table 9-2 TRIPTANS FOR ORAL USE
Table 9-4
CAUSES OF THUNDERCLAP HEADACHE (8)
Figure 9-1. Drawings by K.S. Lashley of his own expanding scotoma with fortification spectra at the edges. “X” indicates point of fixation. The visual aberration expands over minutes (indicated by numbers) and slowly moves peripherally. (Reproduced with permission from Lashley KS: Archives of Neurology 46:331, 1941.)
