buzz Flashcards
imaging findings of CSF leak
pachymeningeal enhancement, “sagging brain” can look like Chiari I with crowded posterior fossa, big pituitary, small vents, engorged venous sinuses, can see subdural hematomas/hygromas too
most common location of spontaneous CSF leak
thoracic spine
causes of low pressure CSF headache
trauma, LP, neurosurgery, dural tear from spondylosis, meningeal diverticula
symptoms associated with CSF leak
low pressure headache (positional), neck pain, tinnitus/hearing changes, nausea, photophobia
SUNCT
short unilateral neuralgiform HA with conjuctival injection + tearing
20+ attacks, mod-severe pain, lasting 1-600 seconds, occuring 1x+ daily
MRI w/wo contrast is warranted to exclude secondary cause like pituitary or posterior fossa tumors/abnormalities
headache red flags
NEW HEADACHE > 50 years old
systemic sx, hx cancer/immunocomp, focal neuro sx, thunderclap HA
name the TACs (trigeminal autonomic cephalalgias)
cluster headache
hemicrania continua
paroxysmal hemicrania
SUNCT/SUNA
difference between paroxysmal hemicrania versus SUNCT/SUNA
paroxysmal hemicrania = 20 attacks lasting 2 - 30 MINUTES, >5 x per day
vs
SUNCT/SUNA = 20 attacks lasting 1-600 SECONDS, >1 x per day
how long does cluster headache last
15 minutes - 3 hours in duration
temporal arteritis management
check ESR, but don’t wait for biopsy to start prednisone, to prevent vision loss
hemicrania continua management
indomethacin 150 mg daily, up to 225 mg x 1 week (MUST RESPOND TO DIAGNOSE)
MRI/MRA w/wo to look at trigeminal nerve
hemicrania continua management
indomethacin 150 mg daily, up to 225 mg x 1 week (MUST RESPOND TO DIAGNOSE)
MRI/MRA w/wo to look at trigeminal nerve
MOA of triptans
agonists at 5HT1B (vasoconstricts) and 5HT1D (inhibits trigeminal inflammatory peptide release, treats N/V)
pathophy of autonomic sx in TACs
parasympathetic outflow from superior salivatory nucleus of facial nerve –> activates lacrimal and nasal mucosal glands.
noxious stim to trigeminal distribution –> trigeminal-autonomic reflex via brainstem connection between TNC and SSN
pathophys of migraine
- activation of super sensitive central generator
- cortical spreading depression
- blood vessel dilation + activation of trigeminovascular system
- release of vasoactive neuropepties (CGRP!!) –> inflammation
- worsening vasodilation, more neuropeptides, more pain
- pain signals to trigeminal nucleus caudalis –> thalamus –> cortex
- more pain signals –> N/V/photo/phono
- more TNC firing –> central sensitization and allodynia - triptans useless at this stage
absent venous pulsations
suggests increased ICP
options for cluster HA prevention
VERAPAMIL
+ valproic acid, lithium, high dose melatonin…
CADASIL gene and chromo
NOTCH3 gene
chromo 19
MRI findings for CADASIL
confluent deep white matter changes, extend to anterior temporal lobes
3 types of autosomal dominant familial hemiplegic migraine
FHM1 - CACNA1A gene on chromo 19 - P/Q calcium channel defect. cerebellar involvement, coma, prolonged hemiplegia
FHM2 - ATP1A2 gene on chromo 1 - defect in Na/K ATPase - can be seen with seizures/IDD
FHM3 - SCN1A gene on chromo 2, VG Na channels
idiopathic cranial pachymeningitis
dx of exclusion
healthy person with headache, other neuro sx, MRI shows leptomeningeal enhancement but infectious/inflamm studies negative. CSF may show lymphocytic pleocytosis, biopsy shows inflammation
the only FDA approved preventative for CHRONIC migraine (not just episodic) - or the first one at least
Botox
hypnic headache
headaches occurring only during sleep, waking patient up. >10 days for > 3 months. no restlessness or autonomic stuff.
more common in elderly
treatment: lithium, indomethacin, caffeine, melatonin
migraine with monocular visual aura
retinal migraine
migraine with aura and stroke risk
women younger than 45 years - increased stroke risk if aura
increases further with OCPs, smoking
in women with migraine with aura who smoke, OCPs with estrogen are contraindicated.
women who don’t spoke, ok to use OCPs if under 35 years but over that do not use
chronic migraine and medication overuse headache
it is thought that med overuse can convert episodic to chronic migraine (fioricet, opioids, triptans, NSAIDs)
