Headache 1

Question 1

Primary headaches are headaches that are not due to tumors, we don’t know why we get them, and include

Answer 1

1. migraine headaches
2. tension headaches
3. trigeminal autonomic cephalgias
4. chronic daily headache

Question 2

Because the eye receives a rich innervation from CN ____, many headache syndromes are associated with pain concentrated around the eye

Answer 2

5

Question 3

Important features in taking a history for headaches include:

Answer 3

1. frequency
2. location
3. laterality
4. mode of onset
5. duration
6. nature: throbbing, aching, pressure, dull, sharp, thunderclap

Question 4

Associated symptoms of headaches may include:

Answer 4

1. visual aura
2. photophobia
3. phonophobia
4. GI symptoms
5. motor weakness
6. sensory deficit

Question 5

Secondary headache disorders include an ____ cause for the headache present

Answer 5

organic; tumor, aneurysm

Question 6

The trigeminal nerve innervates:

Answer 6

1. skin and blood vessels of scalp.
2. dura
3. venous sinuses
4. cerebral arteries
5. cervical and cranial muscles and blood vessels
6. CN II and III

Question 7

Headache pain may result from tension, _____, dilation, inflammation ,and/or pressure applied to any one of the pain sensitive structures

Answer 7

distention

Question 8

______% of women exp migraine headaches, and the highest prevalence is in 30-50 year olds. 90% have disability of some sort and many patients self treat with OTC analgesics.

Answer 8

18

Question 9

explain the mechanism of a migraine.

Answer 9

1. vasoconstriction of cerebral vessels, which cuts off oxygen, and results in neurologic deficits.(visual aura’s on opposite side)
2. vasodilation causes pain due to irritation of trigeminal nerve.

Question 10

what are some migraine triggers?

Answer 10

1. stress
2. menstrual cycle
3. insomnia
4. hunger
5. exercise
6. scents
7. weather
8. foods: nitrate in preserved meats, chocolates, caffeine, cheese

Question 11

Two major types of migraines are with aura and without aura. With aura is a _____type of migraine. It includes transient focal neurological symptoms that precede/sometimes accompany the headache. Without aura is a recurrent headache disorder without preceding neurologic symptoms

Answer 11

classic

Question 12

Migraine without aura often has a ______relationship. It includes a positive family history, and peak onset is in 2nd-3rd decade.

Answer 12

menstrual

Question 13

What is the IHS diagnostic criteria for migraine without aura

Answer 13

A. 5 attacks fulfilling criteria B-D.
B. Headache lasting 4-72 hours (with/without treatment)
C. Headache has atleast 2 of the following characteristics:
-unilateral location
-pulsating quality
-moderate to severe intensity
-aggravated by routine physical activity
D. During headache, at least one of the following occurs:
-nausea/vomiting
-photophobia/phonophobia
E. not attributed to another disorder.

Question 14

Migraine with aura happens because of _______phase happening first. You get a scintillating scotoma (zig zag flashing light), parastheisias in parietal lobe (opposite side), aphasias (temporal lobe -cant verbalize), and ______which affects your motor pathways. Headache comes after or occurs in tandem with aura, and is always confined to one hemisphere. (opposite of where their visual aura has been.)

Answer 14

vasoconstrictive; hemiparesis

Question 15

What is the diagnostic criteria of migraine with aura.

Answer 15

A. At least two attacks fulfilling criteria B-D.
B. Fully reversible aura consisting of at least ONE of the following, but NO motor weakness:
-visual symptoms include positive features: flickering lights or spots or negative features (vision loss)
-sensory symptoms including positive features (pins and needles) and/or negative features (numbness).
-Speech or language disturbance.
C. At least TWO of the following are present:
-Homonymous visual symptoms/unilateral sensory symptoms.
-At least ONE aura dev’s gradually over > 5 mins and or diff aura symptoms occur in succession over > 5 mins.
-Each symptom lasts > 5 mins and

Question 16

The difference bet migraine and TIA is that migraine contains _____visual symptoms, gradual onset/evolution, repetitive attacks of identical nature, flurry of attacks in midlife, lasts

Answer 16

positive

Question 17

Basilar artery migraine is a subtype of migraines and is very rare. It involves the distribution of basilar artery which supplies the ______. Symptoms include diplopia (brainstem nuclei), ataxia and poor coordination (cerebellum), and speech problems.

Answer 17

brainstem

Question 18

Complicated migraine is a permanent neurologic deficit, visual, motor, or sensory. Usually located in _____-parietal regions. there is no effective therapy for evolving complicated migraine. Sublingual calcium channel blockers may help reduce vasospasm.

Answer 18

occipito

Question 19

Retinal migraine is another migraine subtype. It is usually ______, with negative visual phenomena (graying or blacking out of vision). It is a diagnosis of exclusion. May see constriction of retinal arterioles and venues during _____episodes but rarely leaves permanent deficits. Must evaluate carotid doppler and possible blood workup: hyper coagulate state in a young ind, or antiphospholipid antibodies.

Answer 19

unilateral; active

Question 20

Acephalgic migraine, includes transient neuroligic events WITHOUT headache. If present in patients > 40 years, you have an inc. risk for TIA. You need to do an MRI to rule out structural lesions. Consider ______in any age group. Distinct features include buildup of ______, episodes last longer than TIA, and usually a remote history of migraine headaches. Treatment includes aspirin or _____ channel blockers

Answer 20

seizures; scintillations; calcium

Question 21

migraine diagnostic testing includes:

Answer 21

1. threshold visual fields: exclude permanent deficits
2. ESR: elderly patients (65+)
3. MRI: only if red flags are present
4. LP: if arachnoid hemorrhage, meningitis, or IIH suspected.

Question 22

what does treatment for migraines include

Answer 22

1. abortive therapy: for pain, no treatment for visual aura
   - OTC: acetominophen and NSAIDs
   - Triptan: migraine specific
   - Antiemetics
2. preventive therapy:
   - beta blockers
   - ca channel blockers
   - antidepressants
   - anticonvulsants: topiramate, gabapentin, valproic acid

Question 23

Tension headaches are ____and episodic. Described as “tightness,” usually in a band like distribution. Triggers contraction of the _____ muscle and cervical musculature in the neck, so headache is due to muscle spasm or stiffness. There is no photophobia, photophobia, or disruption in activity. May occur in tandem with migraine.

Answer 23

bilateral

Question 24

Common locations of headache are:

Answer 24

1. over the eyes
2. top of the head
3. over the temples
4. over the occipital region.
   - most are episodic with pain free intervals
   - usually relieved by OTC pain meds

Question 25

chronic daily headache occur ____days per month, and rep evolution from migraine or tension headache. It may be due to ____ rebound. Associated with narcotic use _____ days per month or OTS analgesic use _____ times per month. Treatment is to taper the overused meds and may require hospitalization for IV therapy depending on severity and duration of overuse.

Answer 25

15+; analgesic; 10+; 15+

Question 26

______headaches include at least 5 attacks of severe, unilateral, periocular pain. It lasts 15-180 mins. Pt's are extremely restless. Pain typically awakens patients from sleep. Two types are _____ and chronic.

Answer 26

cluster Episodic: occurs in clusters that last between 2-12 weeks, with remission periods lasting at least one month to several years in duration. Chronic: occurs over one year without remission period, or remission periods lasting less than one month.

Question 27

Onset of cluster headaches are usually ____to 30 years of age. MEN have it more. Pain is localized to the eye, temple, forehead, or cheek region. Associated with ipsilateral autonomic symptoms. ____is a common trigger. Treatment includes oxygen or _____

Answer 27

20; alchohol; sumatriptan

Question 28

Differntial diagnosis of cluster headache include:

Answer 28

1. ocular inflammation 2. meningeal inflammation 3. trigeminal neuralgia - age of onset: greater than 50 years - no accompanying symptoms - triggered by light facial touch

Question 29

What is the IHS diagnostic criteria for a cluster headache

Answer 29

A. At least 5 attacks fulfilling criteria B-D. B. Severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 mins untreated. C. Headache associated with at least ONE of the following signs which have to be present on the painful side: -conj injection/lacrimation -nasal congestion/rhinorrhea -eyelid edema -forehead and facial swelling -forehead and facial swelling -miosis/ptosis (horners) D. frequency of attacks: from one to eight per day E. Not attributable to another disorder.

Question 30

treatment of cluster headaches include:

Answer 30

``` 6 mg of subcutaneous sumatriptan, or nasal spray; zolmitriptan nasal spray or portable oxyen tank. preventive therapy: -verapamil -lithium -gabapentin -topiramate ```

Question 31

Paraoxysmal Hemicrania include at least ____ attacks of brief hemicranial head pain lasting 2-45 mins. Multiple attacks per day (more than 5). Includes icepick pain. Variant of cluster headache. More common in females. Extremely responsive to _____

Answer 31

indomethacin

Question 32

Short acting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and last between 1 s and 10 mins. Strictly _____, occurs at least once per day. Usually associated with prominent lacrimation and redness of ipsilateral eye.

Answer 32

unilateral

Question 33

What are some headache "red flags"

Answer 33

1. abrupt onset and/or unusual intensity 2. associated with fever, myalgia, weight loss 3. change with postion/exertion 4. focal neurologic symptoms/signs 5. change in mental status 6. onset after 4th decade 7. wakes patient from sleep 8. ocular signs/symptoms: papilledema, transient visual obscuration 9. progressive worsening or resistance to usual headache therapy 10. unusual age of onset for a specific primary headache diagnosis 11. underlying systemic disorder

Question 34

What should you "worry" about when patients say they have a headache

Answer 34

"SNOOP 1. Systemic symptoms or secondary risk factors 2. neurologic symptoms -confusion, impaired alertness 3. onset: sudden, never present before 4. older: new onset and progressive headache in 40+ year olds. 5. Previous headache history; first headache, or change in reg headache pattern. (frequency, severity, features)