Headache

Question 1

What are the features of a complicated migraine?

Answer 1

Dramatic, frightening symptoms that precede, accompany, or follow a headache and mimic an acute stroke syndrome; in rare instances, ischemic infarction does occur with some of these migraine variants

Symptoms may be hemiplegia or ophthalmoplegia

Basilar migraine consists of a variety of brainstem symptoms or blindness from occipital lobe involvement

Question 2

Features of cluster headache?

Answer 2

M>F
Severe headaches of shorter duration (2-3 hours) occurring in clusters of days or weeks, followed by long periods of remission

Unilateral, periorbital pain of boring or stabbing nature

Painful eye appears red, watery, and tearing, occasionally with a transient Horner’s syndrome

Question 3

What are the mechanisms of a migraine?

Answer 3

• Spread wave of cortical depolarization (early component) - spontaneous or triggered, causes scintillating scotoma if affecting the occipital cortex, activates trigeminovascular system if it reaches trigeminal afferent nerves -> impulses to brainstem and hypothalamus, causing N/V, photophobia, activation of thalamus or cortex -> pain, other neuro symptoms
• Trigeminal ganglia may depolarize their afferents in reverse -> release substance P -> neurogenic inflammation

Question 4

Rx migraines?

Answer 4

• Abortive treatment: NSAIDs or analgesics (mild), antiemetic if N/V present, triptans, dihydroergotamine (appropriate if migraines are as infrequent as 1-2x monthly)
• Prophylactic treatment: beta-blockers (propranolol), CCBs (verapamil), TCAs (amitriptyline), anticonvulsants (VPA, gabapentin, topiramate)

All have effects at serotonin receptors

Question 5

Features of traction headache?

Answer 5

Positional -> relieved when lying flat and recurring when sitting or standing

Question 6

Frequent cause of traction headache? Rx if not resolving spontaneously?

Answer 6

Persistent CSF leak from LP

Epidural blood patch to seal off the dural leak

Question 7

Features of pseudotumor cerebri?

Answer 7

Throbbing headaches, may be accompanied by N/V

Patients often obese and have bilateral papilledema on exam; due to increased ICP from impaired CSF reabsorption, can lead to permanent blindness

Normal brain scan
LP with normal CSF at very high pressure
Headache temporarily relieved by removing large volumes of CSF

Question 8

Manage pseudotumor cerebri?

Answer 8

Weight loss
Acetazolamide to inhibit CSF production
Surgical shunt procedure

Question 9

Presentation of temporal arteritis?

Answer 9

Elderly patients
Temporal arteries tender to palpation
Jaw muscles may be sore during chewing
Polymyalgia
Low grade fever in the absence of infection
Very elevated ESR

Question 10

Dx and Rx temporal arteritis?

Answer 10

Biopsy; prompt corticosteroid treatment to prevent blindness

Question 11

Red flag features of headaches?

Answer 11

Suddenly severe or unrelenting
Accompanied by seizure, syncope, coma, or abnormal neurologic signs
Severe neck stiffness or meningeal signs in the presence of a fever (meningitis) or in the absence of a fever (SAH)
N/V, dimming of vision -> increased ICP
Focal neurologic signs or papilledema (mass lesion)
Mass lesions (brain hemorrhage, tumor, abscess)