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Brain Power: Adam and Victor's Neurology > Headache > Flashcards

Headache Flashcards

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1
Q

What proportion of migraine patients have a unilateral character?

A

2/3

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2
Q

Identify which primary headache

  1. Onset in the wee hours of the morning or in the daytime
  2. Lasts for 4-24 hours
  3. Appears after falling asleep as severe unilateral orbitotemporal pain
A
  1. Onset in the wee hours of the morning or in the daytime: MIgraine
  2. Lasts for 4-24 hours: Migraine
  3. Appears after falling asleep as severe unilateral orbitotemporal pain lasting 30-45 minutes: Cluster
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3
Q

Enumerate ALL the pain sensitive structures of the head:

A
  1. Skin, subcutaneous tissue, muscles, extracranial arteries, external periosteum
  2. Eye, ear, nasal cavity, paranasal sinuses
  3. Intracranial venous sinuses and tributaries
  4. Dura at the base of the brain, arteries in the dura– proximal ACA, MCA and intracranial ICA
  5. MIddle meningeal and superficial temporal arteries
  6. Cervical nerves 1, 2, 3 and cranial nerves as they pass the dura
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4
Q

T or F: Pia arachnoid, parenchyma, and ependyma and choroid plexus LACK SENSITIVITY

A

T

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5
Q

Identify where pain is referred in the following instances:

  1. Pain from middle meningeal artery distention
  2. Pain from intracranial ICA and proximal MCA and ACA
  3. Supratentorial structures
  4. Ingratentorial structures
A
  1. Pain from middle meningeal artery distention: back of they eye and temporal area
  2. Pain from intracranial ICA and proximal MCA and ACA: eye and orbitotempora regions
  3. Supratentorial structures: V1 and 2 area
  4. Infratentorial structures: referred to the vertex and back of the head and neck by the second cervical roots
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6
Q

What nerves innervate?

  1. Nasoorbital region
  2. Inferior temtorium and posterior fossa
  3. Forehead, orbit, anterior and middle fossae and upper part of the tentorium
A
  1. Nasoorbital region: Spenopalatine branches of the CN7
  2. Inferior temtorium and posterior fossa: CN9 and 10
  3. Forehead, orbit, anterior and middle fossae and upper part of the tentorium: CN V1 and V2
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7
Q

T or F: The tentorium roughly demarcates the trigeminal from the cervical-vagal-glossopharyngeal zones

A

T

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8
Q

What are the only 2 structures that extracranial but have referred pain to the head?

A

Cervical portion ICA: pain in supraorbital region/ eyebrow

Upper cervical spine: pain at occiput

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9
Q

Where are these vascular pain felt?

  1. Vertebral artery dissection:
  2. Basilar artery thrombosis
  3. Carotid artery or MCA:
A
  1. Vertebral artery dissection: Upper neck of post-auricular area
  2. Basilar artery thrombosis causes pain to be projected to the occiput
  3. Carotid artery or MCA: Forehead and ipsilateral brow
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10
Q

Why are patients post LP encouraged to lay flat on their back?

What is the treatment for post LP headache?

A

They may develop post LP headache. There can be a persistent leakage of CSF into the lumbar tissues through the needle track.

Blood patch

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11
Q

What types of headache are worse on recumbency?

A

Subdural
Tumor of the posterior fossa
Idiopathic intracranial hypertension

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12
Q

What are the 2 types of migraine? Which is classic and which is common?

A

Migraine with aura and migraine without aura

Classic and common

1:5 incidence

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13
Q

Which type of migraine has a strong familial tendency of about 60-80% inheritance?

A

Classic

Migraine with aura

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14
Q

How to differentiate focal neurologic symptoms migraine from that of TIA or a seizure?

A

TIA: All body parts involved suddenly
Migraine: Slow spread from one body part to another over minutes
Seizure: Spread to body parts is over seconds

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15
Q

What is the most common genetic pathology for familial hemiplegic migraine?

A
  1. P/Q-type calcium channe alpha subunit CACNA1A
  2. Less common second locus in the gene for Na/K ATPase channel
  3. Rare: SCNA1 alpha subunit gene
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16
Q

During in an aura what can be seen on PET scan?

A

Decreased blood flow to the occipital lobes– then there is a 2.2mm/min forward spreading cortical depression (oligemia)

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17
Q

What theory is proposed by Moskowitz to explain migarine PP?

How about the Harold Wolff hypothesis?

How about the Woods and Lashley hypothesis?

A

Moskowitz: Activation of the unmyelinated fibers trigeminal nerve fibers innervating the extracranial and intracranial vessels (trigeminovascular complex) that results in the release of substance P, calcitonin related peptide on the vessel wall– sensitizing these vessels to the pulsatility of cranial vessels and to increase their permiability thereby promoting an inflammatory response

Wolff: Headache is caused by the distention and excessive pulsation of the branches of the external carotid artery

W and L: Spreading cortical depression from reduced blood flow

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18
Q

What is the MOA of

  1. Triptans
  2. Ergotamines
A
  1. Triptans: Serotonin agonists

2. Ergotamines: Alpha adrenergic agonist with strong serotonin receptor affinity and vasoconstricting action

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19
Q

For preventive migraine therapy:

  1. How is propranolol given?
  2. What medications can be given for perimenstrual migraine?
A
  1. Start 10mg to 20mg per tab 3x per day until 240mg per day

2. Isometheptene, indomethacin, cyproheptadine

20
Q

What are the serious complications with the use of Methysergide, an ergot derivative?

A

Retroperitoneal and pulmonary fibrosis

21
Q

Give examples of indomethacin responsive headaches.

A

Valsalva related headaches
Trigeminal autonomic cephalgias
Short lasting unilateral neuralgiform attacks with conjunctival injection and tearing (SUNCT)
Stabbing headaches

22
Q

What is aka as: paroxysmal nocturnal cephalgia, migranous neuralgia, histamine cephalgia (Horton’s headache)?

A

Cluster headache

23
Q

What vasomotor phenomena are associated with cluster headaches?

A 
Blocked nostril
Rhinorrhea
Injected conjunctivum
Lacrimation
Miosis
Flush and edema of the cheek
Ptosis

Lasting 45mins

24
Q

Describe the sxs:

  1. Tolosa Hunt
  2. Paratrigeminal syndrome of Raeder
A
  1. Tolosa Hunt: eye pain and ocular motor paralysis caused by dural granuloma at the orbital apex
  2. Paratrigeminal syndrome of Raeder: Paroxysms of pain somewhat like that of tic douloureux in the distribuition of the ophthalmic and maxillary (V1 and V2) divisions of the fifth nerve in association with unilateral Horner syndrome (Ptosis and miosis)– may be associated with ICA dissection

Compare with trigemnial neuralgia that affects V2 and V3 more commonly

25
Q

What is Gardner’s theory regarding the PP of cluster headache?

A

Paroxysmal parasympathetic discharge mediated through the greater superficial petrosal nerve and sphenopalatine ganglion

26
Q

What are the “shorter” versions of cluster headache?

A
  1. Chronic paroxysmal hemicrania

2. SUNCT (Short lasting unilateral neuralgiform attacks with conjunctival injection and tearing)

27
Q

What is the treatment for cluster headache?

A
  1. 100% O2 via face mask for 10 to 15 mins
  2. Verapamil
  3. Sumatriptan and ergots can also be used to abort attacks
  4. Preventive therapy is anticipatory dose of ergotamine at bedtime
28
Q

What is the most common variety of headache?

A

Tension headache

29
Q

What is the PP of tension headache?

A

Hardened pericranial and trapezius muscles

30
Q

What drugs can be given on top of NSAIDs for tension type headaches?

A

Amitryptyline. Given as a single dose at night.

31
Q

Where is pain felt for tumors:

  1. Supratentorial
  2. Infratentorial
A

S: Anterior to the interauricular circumference of the skull
P: Posterior to this line

32
Q

What is the most serious complication of giant cell temporal arteritis?

A

Blindness from thrombosis of the ophthalmic or posterior ciliary arteries

33
Q

The earliest suspicion of cranial arteritis should lead to administration of?

A

Corticosteroids and then biopsy of the scalp artery

34
Q

What can be given 3 days before the onset of catamenial migraine?

A
  1. NSAIDS

2. Sumatriptan 25mg QID

35
Q

What is recommended for exertional headaches and repeated coital headache?

A

Indomethacin

36
Q

What are the causes of thunderclap headache besides SAH or accelerate hypertension (DBP>120)?

A 
Diffuse cerebral vasospasm (aka Call Fleming syndrome/ REVERSIBLE cerebral vasconstrictino syndrome)
Pituitary apoplexy
Perimesencephalic non-aneurysmal SAH
CVT
Migraine
37
Q

What is the common location for trigeminal neuralgia?

A

V2 and V3

38
Q

T or F: Sensory and motor deficits are not seen in trigeminal neuralgia

A

T– only in a minority of cases are they invovled

Pain is only a few seconds or up to a minute so that the patient winces hence “tic” douloureux

39
Q

What percentage of TN patients benefit with CBZ alone? At what does?

A

70-80%

600-1200mg per day

40
Q

What areas hurt in glossopharyngeal neuralgia?

AKA as vagoglossopharynteal neuralgia

A

Throat and ear (by auricular branch of the vagus nerve)

May be accompanied by bradycardia and syncope by triggering the cardioinhibitory reflexes by afferent vagal pain impulses

41
Q

What is the etiology of the Ramsay Hunt Syndrome?

A

Herpes zoster auricularis
Varicella

Herpes shingles rash of the external auditory meatus, pinna with or without deafness, tinnitus and vertigo– COMBINED WITH FACIAL PARALYSIS

42
Q

Where is the most common location of herpes zoster of the gasserian ganglion?

A

Ophthalmic division (V1)

Pain 4-5 days before onset of rash

Compare with paratrigeminal syndrome of Raeder that affects V1 and V2 primarily and trigeminal neuralgia that affects V2 and V3.

43
Q

What can be given with acyclovir for herpes zoster?

A

Amitriptyline and fluoxetine

44
Q

What should symptom should be suspected with focal neck pain, localized headache over an eye and corresponding neuro signs: Horner’s, ischemia?

A

Arterial dissection

45
Q

What is Costen syndrome?

A

Temporomandibular joint pain

46
Q

What are the symptoms of Tolosa Hunt Syndrome?

A

Pain behind the eye with invovlement of the CN 3,4,6,V1

caused by dural granuloma at the orbital apex

Brain Power: Adam and Victor's Neurology (19 decks)

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