Headache

Question 1

What is the difference between a primary headache and a secondary headache?

Answer 1

Primary headaches are benign and are not related to an underlying disease process. Secondary headaches are a manifestation of an underlying disease process

Question 2

What diagnoses are associated with headaches described as “split second, unexpected, worst/not previously encountered, LOC, vertigo, vomiting”?

Answer 2

Aneurysmal subarachnoid hemorrhage

Cerebellar hematoma

Question 3

What diagnoses are associated with headaches accompanied by fever and skin rash?

Answer 3

Meningitis

Question 4

What diagnoses are associated with headaches in immune-suppressed patients?

Answer 4

Crypto meningitis

Toxoplasmosis

Question 5

What diagnoses are associated with headaches in addition to coagulopathy or anticoagulation therapy?

Answer 5

Subdural or intradural hematoma

Question 6

What are the 3 key clinical questions used to diagnose migraine?

Answer 6

Nausea/sick to stomach?
Light sensitivity
Pain limiting daily activities

Severity is not necessarily a feature

Question 7

Typical clinical presentation of a migraine

Answer 7

Periodic unilateral pulsating headache beginning in late childhood/early adulthood. More common in women than men. Associated with specific triggers.

Question 8

What are some common triggers of migraines?

Answer 8

Stress, lack of sleep, hunger, hormonal fluctuations, certain foods/lack of food, alcohol/nitrates, weather changes, smoking, scents, fumes

Question 9

What are the phases of a migraine headache?

Answer 9

Prodrome (6-48hr before)
Aura (visual disturbances)
Pain
Postdrome

Question 10

Describe the visual aura of a migraine

Answer 10

A blind spot near the center of vision that prevents reading. Peripheral flashing/pulsating bands of light spread out across the visual field

Question 11

What is spreading cortical depression (SCD)?

Answer 11

Susceptible patients may have a gain in NMDA-receptor function that leads to bursts of focal cerebral activity (causes positive symptoms). Following this burst, neuronal activity is suppressed.

Associated with a slow (3mm/min) spreading wave through the brain

Question 12

What is the treatment for migraines?

Answer 12

Treat early with high doses of NSAIDs or triptans (if NSAIDs) do not work.

Question 13

How do triptans work?

Answer 13

Agonists of 5HT1B/D receptors leading to vasoconstriction, which decreases the inflammatory process responsible for migraine headaches

Question 14

What is the major contraindication for triptan prescription?

Answer 14

Avoid triptan use if patient has or has high risk of ischemic heart disease, pregnancy

Question 15

What is serotonin syndrome?

Answer 15

Excessive activation of 5HT1a and 5HT2 receptors causes leg rigidity, dysautonomia and encephalopathy. Happens within 24 hours of medication exposure/change

Question 16

How does BoTox help with migraine headaches?

Answer 16

Very strong muscle relaxant, used in cases where multiple other medications do not work

Question 17

What is a cluster headache?

Answer 17

One of the most severe headache types, more common in men than women. Associated with smoking and drinking. Unilateral, rapid onset with 1-4attacks per day for 20m-3hr

Question 18

What medications are used for cluster headache?

Answer 18

Inhaled oxygen
Supatriptan injections
Intranasal: triptans, lidocaide, DHE
Prednisone

Question 19

What is the most common type of headache?

Answer 19

Tension headache (35-75% of adults)

Question 20

What are the clinical features of a tension headache?

Answer 20

Bilateral pain for 30min-6hours with a pressure/tightening quality. Not associated with nausea/vomitting.

Often resolves with improved sleep, diet, exercise habits

Question 21

What is the difference between trigeminal neuralgia and cluster headaches?

Answer 21

Trigeminal neuralgia is more rapid and electricity-like pain along the jaw line. Cluster headaches last longer and are typically felt behind the eye.

Question 22

What is pseudotumor cerebri?

Answer 22

A medical emergency in which increased intracranial pressure causes headaches. Risk for blindness if not treated.

Question 23

What is a primary exertional headache?

Answer 23

A pulsating headache that occurs during or after physical activity for 5min-48h. Typically in young males.