BMB 2 - Headaches; Brain Herniations Flashcards
What is the mnemonic used for headache work-up to screen for a more serious, insidious etiology?
‘SNOOP 4 Problems’
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.
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
Migraines are the _________ leading cause of neurologic disability in individuals under 50 and the _________ leading cause of worldwide disability.
Migraines are the first leading cause of neurologic disability in individuals under 50 and the second leading cause of worldwide disability.
Describe the typical presentation of subarachnoid hemorrhages in terms of S/Sy, age, etc.
Thunderclap (sudden onset)
Systemic symptoms (e.g. vomiting)
Individuals > 50 years of age
Xanthochromic tap
Describe the typical onset of subdural hematomas.
Chronic;
slow and insidious over weeks or months prior to diagnosis
How do subdural hematomas typically present?
Mental status changes, changes in personality, or focal neurologic deficits
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?
Order head imaging
(possible subdural hematoma)
A unilateral headache couple with an elevated ESR in an older individual is indicative of what concerning pathology?
Giant cell arteritis
Subarachnoid hemorrhage may take on an insidious prodrome as a “__________ hemorrhage.”
Subarachnoid hemorrhage may take on an insidious prodrome as a “sentinel hemorrhage.”
What is the classic presentation of a patient with an epidural hematoma?
Head trauma followed by lucid period then deteriorating mental status
Arterial dissections of the head and neck often affect which arteries?
The internal carotid arteries
The vertebral arteries
What is the most common presenting symptom of arterial dissections of the head and neck?
Headache
What are the characteristic S/Sy of an arterial dissection of the head and neck?
Headache
+
Focal neck pain
+
Horner’s syndrome
Make the diagnosis:
A patient presents with a headache, papilledema, and a ‘rushing water’ noise in her ears.
Idiopathic intracranial hypertension
(can also present with tinnitus)
Idiopathic intracranial hypertension is defined by a CSF pressure over > ____ mmHg.
Idiopathic intracranial hypertension is defined by a CSF pressure over > 250 mmHg.
Idiopathic intracranial hypertension is most common in what patient population?
Obese females of childbearing age
Name some of the risk factors for idiopathic intracranial hypertension.
Oral contraceptive use,
hypervitaminosis A,
hypoparathyroidism,
obesity,
tetracyclines
For every patient over 50 who presents with a headache, you must do what?
Order an ESR and CRP
(rule out temporal arteritis)
How is temporal arteritis treated?
Corticosteroids
A patient with likely temporal arteritis presents with negative biopsy.
What do you do?
Treat them for temporal arteritis
(The inflammation is notoriously patchy, and so a negative biopsy is still inconclusive.)
How is trigeminal neuralgia treated?
Carbamezapine or oxcarbazepine
Describe the typical location of the pain in a patient with trigeminal neuralgia.
Unilateral, lower face
(can be idiopathic or caused by MS, compressive vascular loop, malignancy, inflammatory disease, dental pathology, etc.)
Describe the stereotypical presentation of a migraine.
Throbbing, unilateral headache;
photo/phonophobia, nausea, vomiting;
worsens with normal activities
How long do migraines typically last?
How bad is the pain?
In what age groups do they usually arise?
4 - 72 hours
Moderate-to-severe
18 - 55 years
What is the aura associated with migraines?
Reversible neurologic symptoms that gradually develop and then recede as the headache starts
(typically visual or sensory disturbances)
Name some of the drug categories used to treat migraines.
NSAIDS
Analgesics
Ergots
Triptans
True/False.
Migraines and cluster headaches are basically opposites in presentation.
False.
Migraines and tension headaches are basically opposites in presentation.
True/False.
Tension headaches may present with both mild photophobia and mild phonophobia.
False.
Tension headaches may present with either mild photophobia or also mild phonophobia (but not both simultaneously).
Name the most prevalent headache in all age groups and populations.
Tension headaches
What medications are used for tension headache management?
NSAIDs and other simple analgesics
Which analgesic medications are specifically contraindicated for tension headache management?
Opioids, triptans, and muscle relaxants
What non-pharmacological treatment options are useful in management of tension headaches?
Identify and eliminate triggers,
relaxation techniques,
EMG biofeedback,
CBT,
physical therapy
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.
True.
Name some of the features of cluster headaches outside of the pain.
Conjunctival injection/lacrimation,
nasal congestion/rhinorrhea,
eyelid edema,
forehead/facial sweating,
miosis/ptosis,
sense of restlessness or agitation
What are some of the acute management options for cluster headaches?
Oxygen inhalation, subcutaneous/intranasal sumatriptan, intranasal lidocaine
(_Preventative options include _verapamil, glucocorticoids, lithium, and topiramate.)
Identify the length of time the following headache types typically last:
Tension
Migraine
Cluster
0.5 hours - 168 hours
4 hours - 72 hours
0.25 hours - 3 hours
Identify the pain distribution for the following headache types:
Tension
Migraine
Cluster
Bilateral
Unilateral
Unilateral (V1; largely orbital)
Identify the pain severity for the following headache types:
Tension
Migraine
Cluster
Mild to moderate
Moderate to severe
Severe
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
Migraine
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
Tension headache
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
Cluster headaches
From superior to inferior, name the four main types of brain herniation.
Subfalcine h.
Central h.
Uncal h.
Tonsillar h.
Which form of CNS herniation is most common?
Subfalcine (cingulate) herniation
What is a subfalcine brain herniation?
What major structure is at risk of being pinched off by the herniation?
The cingulate cortex herniates under the falx cerebri;
the anterior cerebral artery
What is a central brain herniation?
What major structures are at risk of being damaged by the herniation?
The diencephalon and temporal cortex herniate through the tentorium cerebelli;
the basilar artery and brainstem
What is an uncal brain herniation?
What major structure is at risk of being pinched off by the herniation?
The uncus of the temporal cortex herniates under the tentorium cerebelli;
CN III and the brainstem
What is a tonsillar brain herniation?
What major structures are at risk of being damaged by the herniation?
The cerebellar tonsils herniate through the foramen magnum;
the brainstem
