Headache and Facial Pain

Question 1

What are the important historical questions to ask a patient during evaluation of a headache?

Answer 1

Headache tempo and evolution (onset and progression)
Location
Quality
What is their behavioral response to the HA?
How often does it recur?
Associated with n/v, photophobia, phonophobia?
What visual symptoms do you have? Paresthesias, difficulty walking? weakness, difficulty concentrating or speaking?

Question 2

The examination is usually normal in HA patients, but what are some important things to look for to rule out secondary causes of headache?

Answer 2

papilledema
temporal artery tenderness
nuchal rigidity
visual field defects
eye movement abnormalities

Question 3

Describe the classic presentation of a migraine.

Answer 3

unilateral and throbbing, often accompanied by nausea, photophobia, phonophobia

can be with or without an aura, which is usually visual (scintillating scotoma)

typically lasts from several to 72 hours

Question 4

What is the proposed pathophysiologic mechanism for migraine?

Answer 4

cortical spreading depression - a wave of hyperpolarizationi followed by a wave of depolarization that spreads across a region of the cortex at a rate of 2-3 mm/minute

probably leads to release of chemical substances that activate the trigeminal nerve afferents

Question 5

What drugs are mainstays for abortive treatment of migraine?

Answer 5

the triptans

but also ergotamine derivatives, caffeine-containing compounds, metoclopramide and prochlorperazine

Question 6

What are the drugs typically used for prophylactic prevention of migraine?

Answer 6

beta blockers, TCAs and anticonvulsants

Question 7

What is the most common type of headache?

Answer 7

tension

Question 8

Describe the classic presentation of a tension headache.

Answer 8

recurrent attacks of bilateral or holocranial headaches of a pressing, squeezing or tightening sensation, duration of which may be from 30 minutes to several days

not accompanied by nausea or neurologic symptoms and not exacerbated by physical activity

Question 9

Describe the classic presentation of cluster headaches.

Answer 9

unilateral headache usually over the orbital or temporal region accompanied by autonomic signs like lacrimation, conjunctival injection, facial swelling, eyelid edema, rhinorrhea, and horner’s syndrome

Question 10

What are some of the management options for cluster headaches?

Answer 10

triptans and oxygen for abortive therapy

steroids to shorten the duration of and HA frequency in a cluster

Verapamil and lithium for long-term prophylaxis

Question 11

Describe the classic presentation of paroxysmal hemicrania?

Answer 11

strictly unilateral HA with accompanying autonomic signs, differing from cluster headaches in that the headaches are typically of much shorter duration (typically 10-30 minutes) and occur with greater frequency (several to 40 attacks a day)

Question 12

What medication do paroxysmal hemicrania headaches respond to?

Answer 12

indoemthacin

Question 13

What is the typical headache that occurs with a subarachnoid hemorrhage?

Answer 13

a HA that begins suddenLy and peaks in intensity within seconds of its onset - a thunderclap headache

Question 14

What is the characteristic feature of a low-pressure headache?

Answer 14

it gets worse in the upright position and alleviated by recumbency (so opposite of an increased intracranial pressure headache)

this happens because the brain descends due to low CSF volume when you’re in an upright position and pulls/pushes on the dura, causing pain

Question 15

Describe the management of a low-pressure headache.

Answer 15

recumbency, aggressive fluid replacement, caffeine and occasionally an epidural blood patch

Question 16

Describe the HA that occurs with idiopathic intracranial hypertension.

Answer 16

headaches that are worse when laying down, and in the mornings

often associated with pulsatile tinnitus and transient visual obscurations

Question 17

What might exam reveal in the workup for intracranial hypertension headaches?

Answer 17

papilledema

sixth nerve palsies

Question 18

What are some possible etiologies of idiopathic intracranial hypertension?

Answer 18

impaired resorption of the CSF throguh damaged arachnoid granulations

clot formation within the dural venous sinuses

Question 19

What are some treatment options for IIH?

Answer 19

repeated LPs
diuretics
optic nerve fenestration
lumboperitoneal shunting

Question 20

What is the most worrisome complication of IIH?

Answer 20

visual loss due to a compressive optic neuropathy

Question 21

A new headache in a patient over 50 yo should raise concern for what?

Answer 21

temporal arteritis

Question 22

What will a temporal artery biopsy reveal in temporal arteritis?

Answer 22

a vasculitis with mononuclear cell infiltration and granulomatous changes, segmental

Question 23

What is the likely etiology of trigeminal neuralgia?

Answer 23

compression of the trigeminal nerve root at the cerebelopontine angle, most often by an aberrant vascular loop

Question 24

What is the treatment of choice for trigeminal neuralgia?

Answer 24

carbamazepine

Question 25

What is the typical treatment for postherpetic neuralgia?

Answer 25

TCAs or gabapentin