Chapter 10: Headache and Facial Pain

Question 1

Most common reason for referral to a neurologist?

Answer 1

Headache

Question 2

What things are pain-sensitive in the brain?

Answer 2

Meninges (pia mater), cranial nerves, arteries of the circle of Willis and its proximal branches, meningeal vessels, the external carotid artery, the scalp, pericranial muscles, the mucosa of the paranasal sinuses, the teeth, and cervical nerve roots.

Question 3

Headache history should focus on…

Answer 3

Location, quality, tempo, duration, and periodicity of the headache; the presence of absence of associated symptoms; and the factors that alleviate and aggravate the headache.

Question 4

Neurologic exam in patients with primary HA disorders typically have significant findings…true or false.

Answer 4

False, they are usually normal

Question 5

Important things to look for in patients with HA….

Answer 5

Neck stiffness, papilledema, limitation of eye movements, visual field defects, and other focal neurologic deficits

Question 6

Describe migraines

Answer 6

Typically unilateral with a throbbing or pulsating quality; often associated with N/V, exacerbated by movement, light, and sounds; typically last from several to 72 hrs.

Question 7

Visual finding migraines

Answer 7

Scintillating scotoma

Question 8

What is cortical spreading depression

Answer 8

A wave of hyperpolarization followed by a wave of depolarization

Question 9

Treatment for migraines

Answer 9

Triptans to abort them

Question 10

When to use prophylactic therapy in migraines…

Answer 10

When HA occur more frequently than once per month

Question 11

What do migraine patients do behaviorally?

Answer 11

They retreat to a quiet dark place

Question 12

Tension-Type Headache description

Answer 12

Bilateral or holocranial of a pressing, squeezing, or tightening sensation.

Question 13

How long to tension types last

Answer 13

30 minutes to several days

Question 14

Nausea in tension types

Answer 14

Nope

Question 15

What affects tension types and are there any neurologic findings?

Answer 15

No neurologic symptoms and not exacerbated by physical activity

Question 16

Tx for tension types

Answer 16

Simple forms of analgesia. Over-use of caffeine and barbiturates can cause withdrawal or rebound headaches.

Question 17

Cluster headaches are in what group of primary headaches

Answer 17

Trigeminal autonomic cephalgias (TAC)

Question 18

Where does the name Cluster come from

Answer 18

The temporal pattern, headaches cluster for discrete time periods followed by headache-free periods that many last many months to years.

Question 19

Describe cluster HAs

Answer 19

Strictly unilateral, orbital or temporal region, cranial autonomic symptoms like lacrimation, conjunctival injection, facial or forehead swelling, eyelid edema, nasal congestion, rhinorrhea, and signs of Horner syndrome (miosis,ptosis).

Question 20

Cluster HA behavior

Answer 20

Patients are restless

Question 21

Cluster tx

Answer 21

Triptans are most effective, steroids may shorten the duration of a cluster and frequency of headache during a cluster

Question 22

Alcohol and cluster HA

Answer 22

Avoid it

Question 23

Cluster prophylaxis

Answer 23

Verapamil and lithium

Question 24

Paroxysmal hemicrania description

Answer 24

Also a TAC, strictly unilateral with autonomic symptoms. Last only 10-30 minutes, with great frequency up to 40 attacks per day.

Question 25

Paroxysmal hemicrania tx

Answer 25

Indomethacin works well

Question 26

How to diagnose Subarachnoid hemorrhage

Answer 26

Head CT followed by lumbar puncture for zanthochromic CSF

Question 27

How to treat low pressure headaches

Answer 27

Recumbency, aggressive fluid replacement, caffeine, and possibly an epidural blood patch

Question 28

Pseudotumor cerebri symptoms

Answer 28

Increasing severity when recumbent with relief upon standing. Worse in morning, pulsatile tinnitus, transient visual obscurations from activities like valsalva.

Question 29

Pseudotumor exam findings

Answer 29

Papilledema, unilateral or bilateral sixth nerve palsies, elevated opening pressure

Question 30

Who gets pseudotumor

Answer 30

Young overweight women

Question 31

Pseudotumor tx

Answer 31

Reduce CSF volume: repeated lumbar puncture and diuretics, optic nerve fenestration, and lumboperitoneal shutning

Question 32

Most important complication of pseudotumor

Answer 32

Visual loss from compressive optic neuropathy from persistently elevated CSF pressures

Question 33

Temporal arteritis (giant cell arteritis (GCA)) description

Answer 33

Systemic granulomatous arteritis that affects medium and large caliber arteries, typically patients over age 50

Question 34

Symptoms of GCA

Answer 34

Tenderness of scalp, thickening, nodulation, and tenderness of the temporal arteries to palpation.

Claudication of jaw with chewing.

Systemic symptoms: Fever, weight loss, fatigue.

Question 35

Most feared complication of GCA

Answer 35

Visual loss from an anterior ischemic optic neuropathy

Question 36

Labs in GCA

Answer 36

ESR and CRP are elevated

Temporal artery biopsy shows vasculitis with mononuclear cell infiltration and granulomatous changes.

Question 37

GCA tx

Answer 37

Steroids

Question 38

Trigeminal neuralgia causes what kind of pain

Answer 38

Paroxysms of severe neuropathic pain in one of the CN V distributions.
Electrical-like pain of anything that touches that part of the face

Question 39

Trigeminal neuralgia tx

Answer 39

Tegretol, other anticonvulsants, or percutaneous radiofrequency ablation and microvascular decompression for refractory cases.

Question 40

Postherpetic neuralgia

Answer 40

Neuropathic pain after shingles: burning, itching, and hypersensitivity to light tough.

Question 41

Other causes of facial pain.

Answer 41

Dental and temperomandibular joint diseases: more common than neurologic disease

Question 42

Facial pain neurologic exam

Answer 42

Typically normal