Headache

Question 1

Aneurysm and dissection or stroke presentation will NOT have

Answer 1

pain with eye movement but will have headache and visual changes

Question 2

multiple short attacks (15-180 min) of severe unilateral orbital and supraorbital or temporal pain and headache

Answer 2

cluster headache presentation

Question 3

ipsilateral autonomic symptoms of ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea/nasal congestion with short multiple headache attacks over the temporal area

Answer 3

cluster headache presentation with autonomic symptoms

Question 4

what is characteristic of cluster headache presentation?

Answer 4

see agitation and restlessness and attacks occurring in clusters 6 to 12 weeks with separated periods of remission

Question 5

acute treatment of cluster headache

Answer 5

100% oxygen at 6 to 12 L/min for 15 minutes sumatriptan (subcutaneous) zolmitriptan nasal spray

Question 6

preventative treatment cluster headache

Answer 6

verapamil (plus maybe a short course of steroids) lithium topiramate

Question 7

when to consider a cluster headache?

Answer 7

when pts has 5 or more severe headache attacks with 1 or more ipsilateral autonomic symptoms (ptosis, miosis, lacrimination, conjunctival injection, rhinorrhea and nasal congestion. MRI may also be done of the brain to exclude other diagnoses

Question 8

When should you start preventative therapy for cluster headache?

Answer 8

right away after first presentation of cluster headache.

Question 9

medication induced headache happens after

Answer 9

someone uses medications >15 days per month Usually if they’ve been on opioids or other analgesic medications.

Question 10

unilateral throbbing headache with nausea and vomiting and photophobia?

Answer 10

migraine headache

Question 11

bilateral non throbbing headache with gradual onset, mild to moderate without pericranial muscle tenderness

gets worse at the end of the day

has band like around neck

Answer 11

tension type

Question 12

headache that develops or worsens with daily medication use episodic migraine or tension like

Answer 12

medication overuse headache

Question 13

unilateral with trigeminal distribution and see ipsilateral autonomic symptoms duration of headache is 2-30 minutes with >5 attacks a day. See complete resolution with indomethacin

Answer 13

chronic paroxsymal hemicrania.

sometimes called indomethacin responsive headaches.

Question 14

unilateral in trigeminal distribution, ipsilateral autonomic sympotms which lasts for 15 min to 3 hrs and has a circadian “alarm clock headache” that can be invoked by nicotine or ETOH. seen in men?

Answer 14

cluster headache

Question 15

trigeminal auto cephalalgias are

Answer 15

unilateral trigeminal pain with associated ipsilateral autonomic findings.

Question 16

difference between cluster headache and paroxysmal hemicranias?

Answer 16

high frequency and shorter duration of attacks and response to indomethacin headaches

Question 17

paroxysmal hemicrania can turn into

Answer 17

daily chronic headache or chronic paroysmal hemicrania (daily headache with pain free periods) or hemicrania continua (daily headache without pain free periods).

need to treat with indomethacin!

Question 18

progressive diffuse, severe headache, bitemporal visual field deficits, and paresis of the oculomotor nerve 3. See hypotension

Answer 18

pituitary apoplexy - hemorrhage into pituitary gland or adenoma

can have acute secondary adrenal insufficiency

needs immediate IV steroids to prevent refractory hypotension.

Question 19

differential for meningeal signs (neck stiffness)

Answer 19

meningitis subarachnoid head bleed pituitary apoplexy get CT head, MRI and LP

Question 20

Definition of chronic migraine headache:

Answer 20

unilateral headache (with or without aura) that is worsened with physical activity seen with photophobia and phonophobia and osmophobia, nausea, or vomiting

OCCURS >15 days/month for 3 consecutive months in absence of secondary causes

Question 21

Medication overuse headache (MOH) is

Answer 21

can occur in the primary headache (migraine) when a pt takes daily analgesics (NSAIDS, butabital + aspirin + caffeine, tylenol, triptan, opioids) >15 days a month

Question 22

most common causes of medication overuse headache (MOH)

Answer 22

highest incidence: opioids, butalbital containing compounds tylenol/caffeine combinations intermediate to high incidence: triptans, aspirin, ergotamine lowest incidence: NSAIDS other than aspirin

Question 23

how to treat medication overuse headache (MOH)

Answer 23

very difficult but needs immediate discontinuation of offending analgesic agent (including tylenol)

pts will have significant worsening of headache shortly after discontinuing their analgesic agent will need a bridging agent (1-2 week course of oral steroids) to help control headache

In addition, if the pt has an underlying chronic migraine headache they need to be started on a migraine preventative agent _ topiramate

Question 24

potential MRI findings in someone with idiopathic intracranial HTN (pseudotumor cerebri)

Answer 24

flattening of posterior scleral, empty sella see elevated CSF pressure

Question 25

when to order a MRV

Answer 25

exclude cerebral sinus venous thrombosis

Question 26

signs suggestive of cerebral sinus thrombosis?

Answer 26

increased cranial pressure (papilledema, transient visual obscurations, worsening of headaches with cough, valsalva maneuver or lying flat)

Question 27

post dural puncture headache or post lumbar headache is

Answer 27

head from persistent CSF leakage where needle penetrated the subarachnoid space. Results from intracranial hypotension after LP - 10-30% and described as mild headache but can be severe and typically worse with standing and better with lying flat. see sniffness, blurred vision and tinnitus and vertigo post LP. Resolves within days but can last weeks to months.

Question 28

most common complication of lumbar puncture

Answer 28

post dural puncture headache or post LP headache

Question 29

headache worsens with standing and improves with lying flat see sniffness, blurred vision and tinnitus and vertigo post LP. Resolves within days but can last weeks to months.

Answer 29

presentation of post dural puncture headache or post LP headache. “headache worsens with standing and improves with lying flat” is characteristic

Question 30

post dural puncture headache or post LP headache treatment

Answer 30

conservative therapy with bed rest, oral or IV caffeine can be done for first 24-48 hrs pain relief agents opioids can be used if >24 hrs of pain then can do epidural blood patch if needed - inject 15 ML of whole blood into epidural space where initial LP was done.

Question 31

rare complication of lumbar puncture

Answer 31

cerebral venous thrombosis

Question 32

presentation of cerebral venous thrombosis

Answer 32

headache is unilateral and gradual. Sometimes can be severe worsens with lying flat and can see associated encephalopathy, hemiparesis and seizures if severe need MR V to diagnosis. CT scan of head is normal.

Question 33

what is a primary stabbing headache

Answer 33

transient localized stabs of head pain that occur spontaneously in absence of organic disease and lasts several seconds. seen commonly in migraine heaches

Question 34

characteristics of stabbing headache:

Answer 34

ice pick headache transient localized stabs of head pain that occur spontaneously in absence of organic dx and lasts seconds some lingers for 1-3 minutes and soreness may last minutes can occur anhwerhe on head including the eye but face is generally spared no cranial autonomic signs - differentiates between cluster headache.

Question 35

treatment of primary stabbing headache?

Answer 35

indomethacin may be helpful but often necessary.

Question 36

Red flag symptoms of headache?

Answer 36

first or worse headache abrupt onset or thunderclap attack progression or fundamental change in headache pattern abnormal physical exam findings neurological symptoms that last >1 hr new headache in persons younger than 5 years or older than 50 yrs new headache in pt with cancer, coagulopathy, immunosuppression or pregnant association with alteration in or loss of consciousness headache triggered by exertion, sexual activity or valsalva maneuver

Question 37

headache associated with medication withdrawal

Answer 37

nitrates (adverse event) ETOH caffeine withdrawal medication overuse

Question 38

what to be done for a thunderclap headache?

Answer 38

needs evaluation and this is a medical emergency needs CT head non contrast needs LP with opening pressure checked need to rule out SAH

Question 39

Cavernous sinus thrombosis presentation:

Answer 39

-headache is most common symptom and maybe only symptom abrupt onset and unremitting. - can see headache worsens with valsalva movement and see pulsatile tinnitus -can see ICP and papilledema, decreased mentation, seizures and can see a cranial nerve 6 (abducens) palsy

Question 40

cavernous sinus thrombosis is often associated with a

Answer 40

bacterial sinus infection that is a n acute onset headache, proptosis and periorbital edema and opthalmoplegia - needs to get immediate antibiotics and surgical drainage.

Question 41

what is reversible cerebral vasoconstriction syndrome?

Answer 41

recurrent thunderclap headache and multifocal constriction of intracranial vessels normalizing within 3 months of onset

Question 42

intracranial hypotension presentation:

Answer 42

postural change headache headache is weeks to months see either thunderclap or subacute headache see falsely localizing cranial nerve 6 palsy

Question 43

treatment of intracranial hypotension is

Answer 43

epidural blood patch. if don’t respond get a CT myelography for potential detection of site of CSF leak.

Question 44

causes of intracranial hypotension

Answer 44

seen in females and middle age and connective tissue disorders results from CSF leakage from LP, surgery, trauma or spontaneously.

Question 45

MRI findings of intracranial hypotension

Answer 45

see diffuse non nodular pachyemingeal enhancement and cerebellar tonsillar abnormalities and subdural fluid collections

Question 46

in diagnosing a secondary headache what is the best initial imaging study?

Answer 46

MRI brain not the CT head. that is mean for acutely emerging changes like acute severe headache or history of trauma.

Question 47

when do we use verapamil for headache?

Answer 47

can use with migraine with basilar aura

meant for prophylaxis for cluster headache not really used in migraine prophylaxis except in women of childbearing or pregnant due to safety in pregnancy.

Question 48

if pt has eyes that look funny and a headache for past 3 days. Exam shows both eyes are slightly inward when she tries to look straight.

what to order?

If this exam is negative, what to order next?

what is causing this eye problem?

Answer 48

order a CT head to rule out bleeding or structural abnormality.

If negative order a MRV. Could have a DVT

The increased intracranial pressure from blockage of veins causes CN6 compression.

Question 49

FIRST neuroimaging study for headache should be

BUT if headache, stroke, hemorrhage or head trauma is suspected, neuroimaging that should be done FIRST

Answer 49

MRI, not CT head

CT head non contrast, if neg then get MRI.

don’t pick EEG ever