BMB 2 - Headaches; Brain Herniations

Question 1

What is the mnemonic used for headache work-up to screen for a more serious, insidious etiology?

Answer 1

‘SNOOP 4 Problems’

Question 2

List the relevant work-up described by ‘SNOOP 4 Problems’ as a method of determining if a patient’s headaches are due to a serious, insidious etiology.

Answer 2

Systemic symptoms

Neurologic deficits

Older age at onset ( 50)

Onset (thunderclap or not)

Papilledema (indicative of hydrocephalus and/or elevated ICP)

Position

Precipitation (by Valsalva or exertion)

Progression

Question 3

Migraines are the _________ leading cause of neurologic disability in individuals under 50 and the _________ leading cause of worldwide disability.

Answer 3

Migraines are the first leading cause of neurologic disability in individuals under 50 and the second leading cause of worldwide disability.

Question 4

Describe the typical presentation of subarachnoid hemorrhages in terms of S/Sy, age, etc.

Answer 4

Thunderclap (sudden onset)

Systemic symptoms (e.g. vomiting)

Individuals > 50 years of age

Xanthochromic tap

Question 5

Describe the typical onset of subdural hematomas.

Answer 5

Chronic;

slow and insidious over weeks or months prior to diagnosis

Question 6

How do subdural hematomas typically present?

Answer 6

Mental status changes, changes in personality, or focal neurologic deficits

Question 7

A patient brings his 63-year-old father to see you. He reports that his father is ‘acting differently,’ as well as recurrently complaining of headaches over the past few weeks.

His father was involved in a car accident three weeks ago.

What do you do next?

Answer 7

Order head imaging

(possible subdural hematoma)

Question 8

A unilateral headache couple with an elevated ESR in an older individual is indicative of what concerning pathology?

Answer 8

Giant cell arteritis

Question 9

Subarachnoid hemorrhage may take on an insidious prodrome as a “__________ hemorrhage.”

Answer 9

Subarachnoid hemorrhage may take on an insidious prodrome as a “sentinel hemorrhage.”

Question 10

What is the classic presentation of a patient with an epidural hematoma?

Answer 10

Head trauma followed by lucid period then deteriorating mental status

Question 11

Arterial dissections of the head and neck often affect which arteries?

Answer 11

The internal carotid arteries

The vertebral arteries

Question 12

What is the most common presenting symptom of arterial dissections of the head and neck?

Answer 12

Headache

Question 13

What are the characteristic S/Sy of an arterial dissection of the head and neck?

Answer 13

Headache

+

Focal neck pain

+

Horner’s syndrome

Question 14

Make the diagnosis:

A patient presents with a headache, papilledema, and a ‘rushing water’ noise in her ears.

Answer 14

Idiopathic intracranial hypertension

(can also present with tinnitus)

Question 15

Idiopathic intracranial hypertension is defined by a CSF pressure over > ____ mmHg.

Answer 15

Idiopathic intracranial hypertension is defined by a CSF pressure over > 250 mmHg.

Question 16

Idiopathic intracranial hypertension is most common in what patient population?

Answer 16

Obese females of childbearing age

Question 17

Name some of the risk factors for idiopathic intracranial hypertension.

Answer 17

Oral contraceptive use,

hypervitaminosis A,

hypoparathyroidism,

obesity,

tetracyclines

Question 18

For every patient over 50 who presents with a headache, you must do what?

Answer 18

Order an ESR and CRP

(rule out temporal arteritis)

Question 19

How is temporal arteritis treated?

Answer 19

Corticosteroids

Question 20

A patient with likely temporal arteritis presents with negative biopsy.

What do you do?

Answer 20

Treat them for temporal arteritis

(The inflammation is notoriously patchy, and so a negative biopsy is still inconclusive.)

Question 21

How is trigeminal neuralgia treated?

Answer 21

Carbamezapine or oxcarbazepine

Question 22

Describe the typical location of the pain in a patient with trigeminal neuralgia.

Answer 22

Unilateral, lower face

(can be idiopathic or caused by MS, compressive vascular loop, malignancy, inflammatory disease, dental pathology, etc.)

Question 23

Describe the stereotypical presentation of a migraine.

Answer 23

Throbbing, unilateral headache;

photo/phonophobia, nausea, vomiting;

worsens with normal activities

Question 24

How long do migraines typically last?

How bad is the pain?

In what age groups do they usually arise?

Answer 24

4 - 72 hours

Moderate-to-severe

18 - 55 years

Question 25

What is the aura associated with migraines?

Answer 25

Reversible neurologic symptoms that gradually develop and then recede as the headache starts

(typically visual or sensory disturbances)

Question 26

Name some of the drug categories used to treat migraines.

Answer 26

NSAIDS

Analgesics

Ergots

Triptans

Question 27

True/False.

Migraines and cluster headaches are basically opposites in presentation.

Answer 27

False.

Migraines and tension headaches are basically opposites in presentation.

Question 28

True/False.

Tension headaches may present with both mild photophobia and mild phonophobia.

Answer 28

False.

Tension headaches may present with either mild photophobia or also mild phonophobia (but not both simultaneously).

Question 29

Name the most prevalent headache in all age groups and populations.

Answer 29

Tension headaches

Question 30

What medications are used for tension headache management?

Answer 30

NSAIDs and other simple analgesics

Question 31

Which analgesic medications are specifically contraindicated for tension headache management?

Answer 31

Opioids, triptans, and muscle relaxants

Question 32

What non-pharmacological treatment options are useful in management of tension headaches?

Answer 32

Identify and eliminate triggers,

relaxation techniques,

EMG biofeedback,

CBT,

physical therapy

Question 33

True/False.

Cluster headaches are severely painful, occur 1 - 8 times per day, during the same time each year, often in the middle of the night, and follow a V1 pain distribution.

Answer 33

True.

Question 34

Name some of the features of cluster headaches outside of the pain.

Answer 34

Conjunctival injection/lacrimation,

nasal congestion/rhinorrhea,

eyelid edema,

forehead/facial sweating,

miosis/ptosis,

sense of restlessness or agitation

Question 35

What are some of the acute management options for cluster headaches?

Answer 35

Oxygen inhalation, subcutaneous/intranasal sumatriptan, intranasal lidocaine

(_Preventative options include _verapamil, glucocorticoids, lithium, and topiramate.)

Question 36

Identify the length of time the following headache types typically last:

Tension

Migraine

Cluster

Answer 36

0.5 hours - 168 hours

4 hours - 72 hours

0.25 hours - 3 hours

Question 37

Identify the pain distribution for the following headache types:

Tension

Migraine

Cluster

Answer 37

Bilateral

Unilateral

Unilateral (V1; largely orbital)

Question 38

Identify the pain severity for the following headache types:

Tension

Migraine

Cluster

Answer 38

Mild to moderate

Moderate to severe

Severe

Question 39

Name the headache here described:

Throbbing, unilateral pain;

photophobia and phonophobia;

nausea and sometimes vomiting;

worsens with activity;

lasts 4 - 72 hours;

sometimes preceded by aura

Answer 39

Migraine

Question 40

Name the headache here described:

Pulsating, bilateral, mild-to-moderate pain;

no aura, nausea, or vomiting;

not aggravated by activity;

lasts 30 min. to 7 days

Answer 40

Tension headache

Question 41

Name the headache here described:

Unilateral, severe orbital/retro-orbital/supra-orbital pain;

associated with lacrimation, eyelid edema, rhinorrhea, etc.;

lasts 15 min. to 3 hours

Answer 41

Cluster headaches

Question 42

From superior to inferior, name the four main types of brain herniation.

Answer 42

Subfalcine h.

Central h.

Uncal h.

Tonsillar h.

Question 43

Which form of CNS herniation is most common?

Answer 43

Subfalcine (cingulate) herniation

Question 44

What is a subfalcine brain herniation?

What major structure is at risk of being pinched off by the herniation?

Answer 44

The cingulate cortex herniates under the falx cerebri;

the anterior cerebral artery

Question 45

What is a central brain herniation?

What major structures are at risk of being damaged by the herniation?

Answer 45

The diencephalon and temporal cortex herniate through the tentorium cerebelli;

the basilar artery and brainstem

Question 46

What is an uncal brain herniation?

What major structure is at risk of being pinched off by the herniation?

Answer 46

The uncus of the temporal cortex herniates under the tentorium cerebelli;

CN III and the brainstem

Question 47

What is a tonsillar brain herniation?

What major structures are at risk of being damaged by the herniation?

Answer 47

The cerebellar tonsils herniate through the foramen magnum;

the brainstem