B7.001 Big Case: Headache

Question 1

3 components of neuro conditions

Answer 1

syndrome (symptoms and signs)
lesion (where in the nervous system?)
etiology

Question 2

characteristics of migraine without aura

Answer 2

attacks lasting 4-72 hours
2 of the 4:
1. unilateral
2. pulsating
3. moderate or severe
4. aggravation by or causing avoidance of routine physical activity
at least one of the following during the attack:
1. nausea / vomiting
2. photophobia and phonophobia
NO identifiable cause

Question 3

what constitutes severe pain

Answer 3

have to stop activity as a result

Question 4

4 common headache syndromes

Answer 4

migraine
chronic migraine
episodic tension-type
chronic tension type

Question 5

difference between tension type and migraine headaches

Answer 5

severity

tension type mild/mod where a person may carry on activity

Question 6

characteristics of migraine with aura

Answer 6

migraine headache features

preceded or accompanied by visual, sensory, or other focal neuro symptoms

Question 7

2 most common neuro symptoms associated with migraine with aura

Answer 7

visual hallucinations of bright shimmering lights (fortification spectra)
tingling / numbness

Question 8

status migrainosus

Answer 8

migraine lasting greater than 72 hours

Question 9

what are episodic tension type headaches

Answer 9

recurrent headaches not fulfilling criteria for migraine

Question 10

characteristics of episodic tension type headaches

Answer 10

last from 30 min to 7 days
2 of the 4:
1. bilateral
2. pressing or tightening
3. mild to moderate
4. not aggravated by routine physical activity such as walking or climbing stairs
both of the following:
1. no nausea / vomiting
2. no more than one photophobia or phonophobia

Question 11

most common headache type to present to physician

Answer 11

migraine

Question 12

most common headache type overall

Answer 12

episodic tension type

Question 13

what constitutes a chronic headache

Answer 13

daily or nearly daily

>15 days per month

Question 14

transformed migraine

Answer 14

recurrent migraines become more frequent until they become a constant tension type headache with superimposed migraines
classified as chronic migraine due to history of migraine

Question 15

reasons for chronic migraine

Answer 15

spontaneous
medication overuse (rebound headache)

Question 16

epidemiology of headaches

Answer 16

migraine prevalence 10%
tension : migraine = 5:1
women : men = 2: 1 for migraine with aura

Question 17

what is the etiology of most headaches

Answer 17

cryptogenic / unknown

Question 18

cranial pain sensitive structures

Answer 18

skin
periosteum
orbits
paranasal sinuses
teeth
dural sinuses
blood vessels

Question 19

common findings that usually DO NOT cause headaches

Answer 19

DJD of the neck
sinus disease
refractive eye problems
TMJ
psych problems

Question 20

does the brain itself feel pain?

Answer 20

no

Question 21

neurogenic migraine hypothesis

Answer 21

hypothesized when it was discovered that during migraine with aura, there was depressed cerebral activity during hallucinations
thought that part of the brain shuts down and then reactivation causes increased blood flow and headache

Question 22

vascular migraine hypothesis

Answer 22

blood vessel constriction > aura

blood vessel dilation > head pain

Question 23

trigeminal vascular migraine hypothesis

Answer 23

most current theory
synapse of neuron with blood vessel causes additional vasodilation and neurogenic inflammation
mediated by CGRP and serotonin which are now targets of drugs

Question 24

non specific headache abortive treatment

Answer 24

don't target hypothesized migraine pathophysiology
analgesics : NSAIDs, opioids
caffeine (vasoconstrictor)
sedatives: butalbital
antiemetics

Question 25

specific headache abortive treatments

Answer 25

ergotamine (5HT1 receptor affinity) - not used much due to side effects triptans: 5HT1 agonist - most effective, based on trigeminal vascular theory

Question 26

medication overuse induced chronic headache

Answer 26

most common cause of chronic migraine is overuse of symptomatic migraine drugs and/or analgesics diagnosis is important because patients rarely respond to preventative medications until withdrawn from the offending medication

Question 27

treatment for rebound headaches and transformed migraine

Answer 27

prophylactics

Question 28

types of headache prophylaxis

Answer 28

``` antiepileptics B-blockers antidepressants: amitriptyline, venlafaxine (low doses) NSAIDs herbal therapies / vits / minerals botulinum toxin injection CGRP inhibitors: erenumab ```

Question 29

when are NSAIDs used in headache prophylaxis

Answer 29

usually only for menstruation related headaches because they are predictable don't want people on NSAIDs long term

Question 30

what is a cluster headache

Answer 30

less common primary headache syndrome | trigeminal autonomic cephalgia

Question 31

characteristics of cluster headache

Answer 31

severe, unilateral, peri-orbital, 15-180 minutes untreated associated with 1 of the following on painful side: conjunctival injection, lacrimation, rhinorrhea, miosis, ptosis, eyelid edema frequency: qod to 8/day

Question 32

red flags in chronic headache

Answer 32

new onset > 35 yo neuro findings including altered mental status evidence of elevated intracranial pressure (optic nerve exam) inflammation, fever, neck stiffness

Question 33

steps in localization of headache lesion

Answer 33

1. determine subsystem involved 2. determine likely localization based on pattern and nature of deficits 3. confirm and refine localization with other subsystems

Question 34

components of CNS

Answer 34

cerebrum brain stem spinal cord

Question 35

components of PNS

Answer 35

``` cranial nerves (from brain stem) peripheral nerves (from spinal cord) ```

Question 36

upper motor neuron

Answer 36

motor neurons in the cerebrum that synapse in the brain stem / spinal cord with lower motor neurons to create an action in the face, arms, legs

Question 37

lower motor neurons

Answer 37

effector neurons that originate in the brain stem / spinal cord that act on the face, arms, legs

Question 38

what is the rule of thumb when looking at the position of UMN and LMN

Answer 38

UMN and LMN on contralateral sides of the brain/body

Question 39

what helps distinguish UMN from LMN lesions

Answer 39

reflexes 0-1 = low 2 = normal 3-4 = hyperreflexia

Question 40

what type of lesions presents with unilateral, asymmetric patterns of effects (hemiparesis)

Answer 40

focal | contralateral cerebral hemisphere to rostral brainstem

Question 41

focal lesions

Answer 41

pattern: unilateral, asymmetric etiology: structural pattern explained by: anatomy

Question 42

diffuse lesions

Answer 42

pattern: bilateral, symmetric etiology: toxic or metabolic pattern explained by: physiology

Question 43

modality to look at suspected focal lesion

Answer 43

MRI

Question 44

focal causes of acute headaches

Answer 44

vascular | trauma

Question 45

focal causes of chronic headaches

Answer 45

tumor | entrapment

Question 46

diffuse causes of acute headaches

Answer 46

toxins drugs electrolytes organ failure

Question 47

diffuse causes of chronic headaches

Answer 47

nutritional hereditary degenerative

Question 48

diagnostics / treatment of focal lesions

Answer 48

imaging | surgical

Question 49

diagnostics / treatment of diffuse lesions

Answer 49

blood work | pharmacological