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Neurology Clerkship > Headache > Flashcards

Headache Flashcards

1
Q

Differential diagnosis of “thunderclap headache”:

A 
1!!!! Subarchnoid hemorrhage (SAH)
2. sentinel headache
3. cerebral venous sinus thrombosis
4. cervical artery dissection
5. sponatneous intracranial hypotension
5. reversible cerebral vasoconstriction syndrome
6. pituitary apoplexy
7. retroclival hematoma
8. acute ischemic or hemorrhagic stroke
9. acute hypertensive crisis
...
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2
Q

Presentation of malignancy headache:

A

Recurrent over a period of months.
Worse with coughing and straining and in the morning.
Focal deficits in sensory and motor: numbness, mild clumsiness.
Focal brisk reflexes.

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3
Q

Red Flags that necessitate imaging:

A
  • Recent head or neck trauma
  • HA begins after age 50
  • Sudden-onset HA
  • Accelerating pattern of HA
  • New-onset HA in a patient with cancer or HIV
  • HA with systemic illness (fever, rash, stiff neck)
  • Focal neurological symptoms of signs (other than typical aura)
  • Papilledema
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4
Q

Tension-Type headache diagnosis criteria:

A
  1. At least 10 prior HAs
  2. Lasts 30min-7days
  3. At least 2 of the following:
    • Pressing/tightening (non-pulsating) quality
    • Mild or moderate intensity
    • Bilateral location
    • Not aggravated by physical activity
  4. No nausea/vomiting
  5. No photo AND phonophobia (can have 1 of them)
  6. No other cause
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5
Q

Abortive treatment for tension-type HA:

A
  • NSAIDs or Tylenol high dose

- analgesic +caffeine

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6
Q

Prophylaxis for tension-type HA:

A
  • TCA antidepressants
  • muscle relaxants
  • migraine prophylaxis regimen
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7
Q

Migraine without aura = common migraine, diagnostic criteria:

A
  1. at least 5 attacks
  2. last 4-72hrs
  3. at least 2 of the following:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe intensity
    • Aggravated by physical activity
  4. at least 1 of the following:
    • Nausea and/or vomiting,
    • Photo and phonophobia (osmophobia…)
  5. No other cause
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8
Q

Migraine with aura = classic migraine, diagnostic criteria:

A
  1. at least 2 attacks
  2. at least 3 of the following:
    • One or more fully reversible aura symptoms
    • At least 1 aura Sx develops gradually over ≥5 min or 2 or more Sx occur in succession
    • Each aura Sx last 5-60 minutes
    • Headache follows aura with a free interval of less than 60 min (it may also begin before or simultaneously with the aura)
  3. No other cause
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9
Q

Abortive treatment for migraine:

A
  • NSAIDS: Ibuprofen, Naproxen, Diclofenac, Ketorolac
  • Combination analgesics:
    1. Triptans: Suma-, Nara-, Riza-, Zolmi-, Almo-, Frova-, Eletriptan
    2. Ergots: Dihydroergotamine (DHE)
    3. Antiemetics: : Prochlorperazine, Metoclopramide
    4. Opiates: Butorphanol or Acetaminophen with codeine
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10
Q

Preventative migraine treatment:

A
  1. Antidepressants: TCAs, SSRIs, MAOIs
  2. Beta-Blockers: -lol
  3. AED: Valproic acid, topiramate, gabapentin
  4. Ca2+ blockers: Verapamil
  5. other: butterbur, riboflavin, Mg
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11
Q

Most common HA seen in tertiary care center HA clinic:

Looks like:

A

Rebound HA = medication overuse HA.

Longstanding band-like pressure HA, constant for months, takes multiple NSAIDs or Tylenol a week.

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12
Q

Treatment of rebound HA:

A

Difficult!

  • Detox - stop all meds, stop caffeine.
  • Naproxen bid for 1 month.
  • if necessary admit and treat IV DHE or chlopromazine or solumedrol
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13
Q

Cluster HA:

A 
1. Autonomic features - all ipsilateral!
–	Conjunctival injection
–	Lacrimation
–	Nasal congestion and/or rhinorrhea
–	Forehead and facial sweating
–	Myosis, mild ptosis (Horner’s)
–	Eyelid edema
2. Severe, unilateral orbital, supraorbital or temporal pain
3. 15-180min
4. episodic or chronic
5. M>F
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14
Q

Abortive treatment for cluster HA:

A

O2
Sumatriptan
DHE

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15
Q

Short term prevention of cluster HA:

A

Prednisone burst and taper

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16
Q

Long term prevention of cluster HA:

A

Verapamil
Lithium
VPA, Topiramate
Occipital n. block or stimulation

17
Q

Idiopathic intracranial hypertension = pseudotumor cerebri, diagnostic criteria:
Typical presentation:

A
  1. CSF pressure >25cm H2O with patient on lateral decubitus
  2. otherwise normal CSF
  3. normal neurologic exam except papilledema and possible CNVI palsy
  4. Normal MRI.
    Typical presentation:
    90% is obese female.
    mean age 30yo.
    visual changes: dimming, blurry precipitated by bending over,
    Papilledema
18
Q

Treatment of idiopathic intracranial hypertension:

A
  1. Weight loss and low salt diet
  2. abortives similar to migraine
  3. preventives: acetazolamide, topiramate, furosemide
  4. surgery: optic nerve sheath fenestration, VP shunt
19
Q

Intracranial Hypotension HA:

A
  • Occurs or worsens within 15 min after getting up
  • Improves within 30 min after recumbency
  • May be throbbing, associated with nausea/vomiting, dizziness, tinnitus
  • CSF opening pressure 0-6.5 cm H2O
  • CSF elevated protein, pleocytosis and few RBC possible
  • Rare VI CN palsy
20
Q

Causes of intracranial hypotension HA:

A 
LP
trauma with CSF leak 
postsurgical 
spontaneous
valsalva 
exercise
...
21
Q

complication of intracranial hypotension

A

subdural, CN III,IV,VI,VIII palsies

22
Q

Treatment of intracranial hypotension:

A 
•	Bed rest and po/iv fluids
•	Medications:
–	Caffeine, theophyline – po or iv
–	Steroids
•	Interventions
–	Blood patch
–	Surgical exploration and repair
23
Q

Trigeminal neuralgia diagnostic criteria:

A
  1. Paroxysmal attacks of facial or frontal pain lasting a few seconds to
24
Q

Treatment of trigeminal neuralgia:

A
  1. carbamazepine: 100 mg qd-bid, 400-800 mg/day
  2. Baclofen, Phenytoin, Oxcarbazepine, Lamotrigine, Gabapentin, Valproic acid, Topiramate
  3. Ablative procedures
  4. microvascular decompression: occipital craniotomy, gamma knife
25
Q

Giant Cell Arteritis!!!! (temporal arteritis) cannot miss –> permanent blindness.
Typical presentation:

A

Fluctuating generalized HA for a few wks. Generalized weakness, pain in large joints, weight loss and fever. Pain when combing hair. Jaw pain when chewing. Vision loss (curtain like) for a few seconds. Normal exam. May be prominent temporal arteries.

26
Q

Labs/workup for Giant Cell Arteritis.

A

SED 89
Normocytic normochromic anemia.
Temporal artery biopsy:
intimal proliferation, fragmented internal elastic lamina, lymphocytic infiltrate in the media, multinucleated giant cells

27
Q

Treatment of Giant Cell Arteritis:

A

Immediate!
Solumedrol 1gx3days
then Prednisone 80mg qd.
Pain resolves within 48hrs, weakness resolves withing 2wks. Taper prednisone by 5mg q month.

Neurology Clerkship (21 decks)

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