Chapter 10: Headache and Facial Pain Flashcards
Most common reason for referral to a neurologist?
Headache
What things are pain-sensitive in the brain?
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.
Headache history should focus on…
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.
Neurologic exam in patients with primary HA disorders typically have significant findings…true or false.
False, they are usually normal
Important things to look for in patients with HA….
Neck stiffness, papilledema, limitation of eye movements, visual field defects, and other focal neurologic deficits
Describe migraines
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.
Visual finding migraines
Scintillating scotoma
What is cortical spreading depression
A wave of hyperpolarization followed by a wave of depolarization
Treatment for migraines
Triptans to abort them
When to use prophylactic therapy in migraines…
When HA occur more frequently than once per month
What do migraine patients do behaviorally?
They retreat to a quiet dark place
Tension-Type Headache description
Bilateral or holocranial of a pressing, squeezing, or tightening sensation.
How long to tension types last
30 minutes to several days
Nausea in tension types
Nope
What affects tension types and are there any neurologic findings?
No neurologic symptoms and not exacerbated by physical activity
Tx for tension types
Simple forms of analgesia. Over-use of caffeine and barbiturates can cause withdrawal or rebound headaches.
Cluster headaches are in what group of primary headaches
Trigeminal autonomic cephalgias (TAC)
Where does the name Cluster come from
The temporal pattern, headaches cluster for discrete time periods followed by headache-free periods that many last many months to years.
Describe cluster HAs
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).
Cluster HA behavior
Patients are restless
Cluster tx
Triptans are most effective, steroids may shorten the duration of a cluster and frequency of headache during a cluster
Alcohol and cluster HA
Avoid it
Cluster prophylaxis
Verapamil and lithium
Paroxysmal hemicrania description
Also a TAC, strictly unilateral with autonomic symptoms. Last only 10-30 minutes, with great frequency up to 40 attacks per day.
Paroxysmal hemicrania tx
Indomethacin works well
How to diagnose Subarachnoid hemorrhage
Head CT followed by lumbar puncture for zanthochromic CSF
How to treat low pressure headaches
Recumbency, aggressive fluid replacement, caffeine, and possibly an epidural blood patch
Pseudotumor cerebri symptoms
Increasing severity when recumbent with relief upon standing. Worse in morning, pulsatile tinnitus, transient visual obscurations from activities like valsalva.
Pseudotumor exam findings
Papilledema, unilateral or bilateral sixth nerve palsies, elevated opening pressure
Who gets pseudotumor
Young overweight women
Pseudotumor tx
Reduce CSF volume: repeated lumbar puncture and diuretics, optic nerve fenestration, and lumboperitoneal shutning
Most important complication of pseudotumor
Visual loss from compressive optic neuropathy from persistently elevated CSF pressures
Temporal arteritis (giant cell arteritis (GCA)) description
Systemic granulomatous arteritis that affects medium and large caliber arteries, typically patients over age 50
Symptoms of GCA
Tenderness of scalp, thickening, nodulation, and tenderness of the temporal arteries to palpation.
Claudication of jaw with chewing.
Systemic symptoms: Fever, weight loss, fatigue.
Most feared complication of GCA
Visual loss from an anterior ischemic optic neuropathy
Labs in GCA
ESR and CRP are elevated
Temporal artery biopsy shows vasculitis with mononuclear cell infiltration and granulomatous changes.
GCA tx
Steroids
Trigeminal neuralgia causes what kind of pain
Paroxysms of severe neuropathic pain in one of the CN V distributions.
Electrical-like pain of anything that touches that part of the face
Trigeminal neuralgia tx
Tegretol, other anticonvulsants, or percutaneous radiofrequency ablation and microvascular decompression for refractory cases.
Postherpetic neuralgia
Neuropathic pain after shingles: burning, itching, and hypersensitivity to light tough.
Other causes of facial pain.
Dental and temperomandibular joint diseases: more common than neurologic disease
Facial pain neurologic exam
Typically normal
