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Mind, Brain, and Behavior > Headache > Flashcards

Headache Flashcards

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1
Q

The goal of history and physical exam for a headache

A

To figure out whether a headache is secondary to a more sinister underlying cause or is one of the primary headache syndromes.

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2
Q

Broad classification of secondary headaches

A
  • Those related to intracranial structures: meninges, brain, and/or cerebral blood vessels
  • Those related to head and neck structures: eyes, ears, nose, sinuses, jaw/teeth, neck
  • Those related to systemic causes: hypertension, systemic infection, medications
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3
Q

In some patients in whom a cause for headache cannot be found, headache may be a symptom of . . .

A

In some patients in whom a cause for headache cannot be found, headache may be a symptom of an underlying psychiatric disorder (e.g., somatization disorder).

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4
Q

Headache characteristics

A
  • Onset: concerning if acute and maximal in intensity at or shortly after onset (thunderclap headache)
  • Evolution: concerning if increasing in frequency and/or severity
  • Timing: concerning if worse at night
  • Relation to prior headaches: concerning if different in quality, severity, and/or timing
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5
Q

Provoking factors of headaches

A

Concerning if worsens with coughing, straining, sneezing, supine position

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6
Q

Accompanying signs and symptoms for headaches

A

Concerning if fever, seizure, focal neurologic signs, and/or papilledema present

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7
Q

Patient history of headaches

A

Concerning if:

  • New headache in an older adult with no prior history of headache
  • History of cancer
  • History of immunosuppression (e.g., medications or HIV)
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8
Q

Patient >60 y.o. presents with a new headache with scalp tenderness, jaw claudication, myalgias, and/or visual loss. What is the most concerning etiology?

A

Giant cell arteritis

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9
Q

Migraine

A
  • Form of primary headache syndrome
  • Classic migraine headache is unilateral, pulsating/throbbing, sufficiently severe to impede daily activities, lasts hours to a few days, is accompanied by photophobia, phonophobia, nausea, and/or vomiting, and causes the patient to seek a dark, quiet, relaxing space.
  • An aura accompanies migraine headache in only about 20%–25% of patients, most commonly visual or somatosensory.
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10
Q

Patient presents with new headache that is worse with standing and improves in the supine position. What is the likely etioloy?

A

Intracranial hypotension

This syndrome describes an orthostatic headache. This is classically caused by caused by cerebrospinal fluid (CSF) leak due to prior trauma or prior lumbar puncture, or may be spontaneous

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11
Q

Headaches with visual changes and/or pulsatile tinnitus in a patient with obesity, endocrine disease, or in a child taking tetracycline should raise concern for . . .

A

Pseudotumor cerebri (idiopathic intracranial hypertension)

Early intervention with weight loss and/or acetazolamide can prevent visual loss

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12
Q

Migraine auras

A
  • Auras typically emerge over minutes and precede the headache. However, the aura and headache may occur concurrently. Some patients experience migraine aura without headache (acephalgic migraine)
  • Visual aura is often described as bright spots or wavy lines that move through the visual field (scintillating scotoma)
  • Somatosensory aura that may accompany migraine is generally unilateral tingling that slowly spreads over minutes across one side of the body
  • There are several less common auras affecting speech, sense of balance, sight, etc.
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13
Q

Differentiating migraine somatosensory auras from somatosensory seizures

A

Although somatosensory seizures can produce similar spreading tingling symptoms, the spread of symptoms in migraine is generally slower as compared to the rapid spread of symptoms with somatosensory seizures.

Migraines and seizures both generally cause positive symptoms (e.g., tingling, scintillating scotoma) as compared to transient ischemic attack (TIA) and ischemic stroke, which typically cause negative symptoms (e.g., numbness or visual field deficit), though there can be exceptions.

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14
Q

Acephalgic migraine

A

When migraine aura occurs without the migraine headache

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15
Q

A clinical diagnosis of migraine does not necessarily exclude ___.

A

A clinical diagnosis of migraine does not necessarily exclude another etiology for the headache.

Therefore, neuroimaging is warranted when migraines occur for the first time in older adults, although a first migraine can occur at any age including in older adults.

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16
Q

In patients with migraine with no underlying cause who undergo neuroimaging, ____ may be observed on imaging.

A

In patients with migraine with no underlying cause who undergo neuroimaging, nonspecific T2/FLAIR hyperintensities in the subcortical white matter may be observed on imaging.

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17
Q

Chronic migraine

A

When episodic migraine involves daily or near-daily headaches.

This is more common in patients with psychiatric comorbidities, poorly controlled migraines, and/or overuse of caffeine and/or analgesics (medication overuse headaches)

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18
Q

Triggers of migraine

A

May be triggered by: particular foods or beverages, alcohol, caffeine, irregular eating schedule, irregular sleeping pattern, stress, or the menstrual cycle.

It is helpful to ask patients to keep a headache diary documenting headache occurrence in relation to such factors

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19
Q

____ is a very common trigger for migraines.

A

Excessive or irregular caffeine use is a very common trigger for migraines.

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20
Q

Counseling a patient with caffeine-induced migraines

A

Patients should be counseled to slowly wean off of caffeine.

It must be explained to patients that their headaches may worsen during the period of caffeine withdrawal, but that they will ultimately feel better with respect to headache frequency and severity after this period.

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21
Q

Treatment approach for migraines

A

Treatment of migraine requires a plan for both acute headaches (abortive treatment) and, if headaches are sufficiently frequent (≥4 days/month) or incapacitating, consideration of a prophylactic agent.​

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22
Q

Acute treatment of migraines

A
  • Migraine-specific therapies: triptans, ergotamine
  • Anti-inflammatory medications: nonsteroidal anti-inflammatory drugs (NSAIDs), oral steroids
  • Antiemetics: metoclopramide, prochlorperazine, ondansetron
  • Supportive treatment: hydration
  • In patients whose acute migraine does not respond to the above medications, a single dose of intravenous steroids and/or valproate can be considered
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23
Q

Is it safe to combine acute migraine treatments?

A

For the most part it is not only safe, but suggested.

However, ergots and triptans are not safe to take in combination due to the risk of coronary vasoconstriction. Also for this reason, ergots and tripans are contraindicated in patients with coronary artery disease.

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24
Q

Ergots and tripans are contraindicated in patients with ____.

A

Ergots and tripans are contraindicated in patients with coronary artery disease, and are also generally avoided in hemiplegic and basilar migraines due to concern for increased risk of stroke

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25
Q

What should a patient who is about to start taking acute anti-migraine medications know before they begin?

A

It is imperative to explain to patients that acute treatment agents must be used only for the most severe headaches and generally no more than twice per week.

If acute abortive agents or analgesics are used more than 10–15 days per month they can induce medication overuse headache

26
Q

Preventative treatment of migraines

A
  • Consideration for those who experience four or more migraines per month or disabling migraines of any frequency that interfere with the patient’s lifestyle
  • Unlike acute migraine medications, these must be taken daily
  • Any individual agent should be slowly uptitrated over several months before deciding whether or not it is effective.
    • Antihypertensives: beta blockers, calcium channel blockers
    • Antidepressants: tricyclic antidepressants, SSRIs
    • Antiepileptics: valproate and topiramate
    • Alternative agents: riboflavin, magnesium, feverfew, butterbur
27
Q

Contraindications for valproate and topiramate

A

These medications are teratogenic, so they are contraindicated for pregnancy. However, to be safe, they are officially contraindicated for all women of child-bearing age.

28
Q

____ may be ideal migraine treatments in a patient with depression and/or insomnia

A

Tricyclic antidepressants may be ideal migraine treatments in a patient with depression and/or insomnia

29
Q

____ may be the ideal migraine treatment in a patient with a history of childhood seizures and obesity.

A

Topiramate may be the ideal migraine treatment in a patient with a history of childhood seizures and obesity.

30
Q

Tension headaches

A
  • Typically holocephalic, “squeezing” in quality, mild to moderate in intensity (i.e., not impeding daily activities as migraine does)
  • Generally have no associated features aside from possible phonophobia or photophobia (but not both)
  • Stress is a common provoking factor
  • Stress reduction and NSAIDs for acute treatment
  • Tricyclic antidepressant in patients who need preventative treatment
31
Q

Cluster headache

A
  • One of the Trigeminal Autonomic Cephalalgias
  • Occurs in clusters over a particular period of the year (usually weeks), and can last from 15 minutes to 3 hours.
  • More common in men
  • Brain imaging with vascular imaging is usually obtained to evaluate for an underlying cause
  • Commonly associated with agitation
32
Q

Trigeminal Autonomic Cephalalgias

A
  • Group of headaches which share characteristics
  • Includes: Cluster Headache, Hemicrania Continua, Paroxysmal Hemicrania, SUNCT, and SUNA
  • Characterized by unilaterality, sharp stabbing severe facial/periorbital pain, and associated autonomic features: lacrimation, rhinorrhea, conjunctival injection, facial sweating, pupillary abnormalities, ptosis, and/or eyelid edema
  • These headache syndromes can lead to agitation during headaches (especially cluster headache and hemicrania continua), in contrast to the desire for a calm environment that patients describe during migraine.
33
Q

Chronic Daily Headache

A
  • Occur in patients with a prior history of episodic migraines or tension headaches
  • When a new daily headache arises suddenly in a patient with no prior history of episodic headaches, this generally necessitates brain imaging to evaluate for an underlying cause. If none is found, the designation new daily persistent headache may be applied.
  • Arise suddenly and have characteristics similar to migraine or tension headache
  • Prophylactic agent should be chosen based on resemblance to other types of headache
34
Q

Treatment of cluster headaches

A

Cluster headache is treated acutely with 100% oxygen or a triptan;

verapamil or lithium can be used for prophylaxis.

35
Q

When working a patient up for chronic daily headache, you should always. . .

A

. . . obtain a detailed medication history to evaluate for whether there is analgesic overuse, which itself can lead to headache

36
Q

Types of conjunctival injection

A
37
Q

Treating medication overuse headache

A
  • Analgesic overuse can result in daily headaches if analgesics are taken more than 10–15 days per month
  • These will only improve if patients wean off the analgesic, which may be done slowly or rapidly for all drugs except optiates or butalbital​ which must be gradual
  • Patients may feel worse in the interim, but headaches should subside after
  • Clear plan for an abortive option that does not simply entail going back to analgesics is necessary
  • Patients should also be given prophylaxis during this period
38
Q

Occipital neuralgia

A
  • Presents with episodic shock-like pain radiating from the occiput over the crown of the head (distribution of the C2 nerve root)
  • On exam, pain may be reduced with percussion over the occipital condyle. This sign is highly specific, but not very sensitive.
  • MRI of the brain is often performed to evaluate cranial nerve root compression, but nothing is found
39
Q

Treating occipital neuralgia

A
  • Occipital nerve block may be performed with injection of lidocaine and is highly effective.
  • If this is ineffective or does not last, anti-epileptics may be effective.
40
Q

Headache and Neurologic Deficits with Cerebrospinal Fluid Lymphocytosis (HaNDL)

A
  • Syndrome in which there is a headache (typically migraine in character) accompanied by transient focal neurologic deficits, as well as lymphocytic pleocytosis in the CSF (generally in the hundreds/μL)
  • The diagnosis is one of exclusion after meningitis, encephalitis, and CNS vasculitis are ruled out by neuroimaging and CSF bacterial and viral studies
  • The headache, focal deficit, and pleocytosis often recur within a few weeks after the original attack, but typically do not recur after that. Thus, the disease is self limited and resolves spontaneously.
  • Since these cases raise concern for more serious conditions, patients are often treated empirically with antibiotics and/or antivirals anyway
41
Q

How is CSF obtained for analysis?

A

Lumbar puncture

42
Q

What parameters of CSF may be measured by lumbar puncture?

A
  • CSF pressure
  • CSF chemistry: glucose and protein
  • Counts/types of blood cells, cytology, FACS
  • CSF microbiology: cultures, PCR, antibodies
  • Paraneoplastic antibody markers
  • Biomarkers of degenerative disease
  • Oligoclonal bands
43
Q

Normal CSF pressure

A
  • below 20 cm H2O
  • CSF pressure can be elevated due to any process raising intracranial pressure (intracranial hypertension), and can be decreased in any condition decreasing intracranial pressure (intracranial hypotension)
44
Q

CSF glucose

A
  • Should be ~60% serum glucose
  • Can be decreased in bacterial, fungal, and tubercular CNS infections and leptomeningeal metastases
    • This lowering may be due to consumption, or may be due to factors impairing glucose transport to starve the organisms
  • Hypoglycorrhachia means decreased CSF glucose
  • A rare cause of decreased CSF glucose is GLUT1 deficiency
  • Increased CSF glucose can be seen when there is serum hyperglycemia.
45
Q

CSF protein

A
  • Normally less than 50 mg/dL
  • Elevated in any inflammatory or infectious state
  • May also be elevated when there is obstructed circulation of CSF due to spinal lesions (spinal block)
    • when extreme, this may cause the CSF to coagulate in the test tube (Froin’s syndrome)
46
Q

White Blood Cells in the CSF

A
  • Normal range is 0–5 WBCs/μL
  • Increases in CSF WBC count can occur due to CNS infection, inflammation, and CNS hematologic malignancy
    • PMNs predominate in bacterial meningitis, but may also be seen in viral meningitis/encephalitis
    • Lymphocytes are commonly seen in viral, fungal, and tubercular CNS infections, CNS inflammation, and lymphoma
  • FACS and cytology may be used to evaluate for malignancy
47
Q

Red cells in the CSF

A
  • Normal range is 0–5 RBCs/μL
  • Elevated RBC can be seen in subarachnoid hemorrhage or if lumbar puncture is traumatic
    • If blood is present from subarachnoid hemorrhage, it will have been present in the CSF for some time and RBCs will have begun to break down. In contrast, a traumatic lumbar puncture will yield fresh RBCs that have not yet had the time to break down
    • Xanthochromia is an indication of RBC breakdown
48
Q

Xanthochromia

A

A yellow tinge to the CSF (more sensitively detected by spectrophotometry) is an indication of broken-down red blood cells in the CSF, suggesting subarachnoid hemorrhage.

49
Q

Albuminocytologic Dissociation

A
  • Pattern of Elevated Protein With No or Few Cells on CSF analysis
  • Nonspecific, but suggestive of an inflammatory process
50
Q

Pattern of Elevated WBCs and Protein With Normal Glucose on CSF analysis

A

Suggestive of viral infection

51
Q

Pattern of Elevated WBCs and Protein With Low Glucose on CSF analysis

A
  • Generally indicates a nonviral CNS infection (bacterial, fungal, or tubercular).
  • The most extreme values for low glucose, elevated WBCs, and elevated protein are seen with CNS bacterial infections.
  • In CNS bacterial infections, the WBCs are predominantly neutrophils, whereas they are predominantly lymphocytes in other types of CNS infections
52
Q

Traumatic lumbar puncture pattern on CSF analysis

A
  • Elevations of protein and WBCs can occur in a traumatic lumbar puncture since there is contamination of the CSF with peripheral blood.
  • Protein elevation and WBC elevation are both approximately 1 per 1000 RBCs (1 mg/dL of protein per 1000 RBCs/mm3, and 1 WBC/mm3 per 700–1000 RBCs/mm3)
53
Q

Neurologic infections are classified on the basis of. . .

A

. . . clinical syndrome/localization (ie, meningitis, encephalitis) and infectious etiology (ie, tuberculosis, bacterial, fungal, viral, parasitic)

54
Q

A ruptured aneurysm causes a headache that is characterized by. . .

A

. . . sudden onset and intense severity (“thunderclap” headache)

55
Q

The headaches that are ___ at night are more concerning.

A

The headaches that are worse at night are more concerning.

This suggests that lying in a supine position worsens the headache, and that it is thus related to intracranial pressure.

56
Q

Why are we concerned when a patient tells us that their headache gets worse with sneezing, coughing, valsalva, lying a certain way, etc?

A

Because this indicates that the headache gets worse with increased intracranial pressure, suggesting that there is an anatomical problem

57
Q

Papilledema on fundoscopy exam suggests. . .

A

. . . increased intracranial pressure

58
Q

Migraine presentation summary

A
59
Q

Tension headache presentation summary

A
60
Q

TAC presentation summary (cluster headache)

A
61
Q

Quality of headache

A

is ONLY useful for primary headache disorders.

A secondary headache disorder can feel kind of like anything (meningitis, stroke, etc).

62
Q

Indications for CT prior to LP

A

Anything that suggests risk for intracranial hypertension

  • Age >50
  • Focal deficits on exam
  • Bilateral papilledema on fundoscopy
    • Unilateral less concerning, but maybe a red flag
  • Anything that takes up space in the CSF compartment!
    • Inflammation
    • Blood
    • Cancer

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