Headache and Facial Pain Flashcards
What are the important historical questions to ask a patient during evaluation of a headache?
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?
The examination is usually normal in HA patients, but what are some important things to look for to rule out secondary causes of headache?
papilledema temporal artery tenderness nuchal rigidity visual field defects eye movement abnormalities
Describe the classic presentation of a migraine.
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
What is the proposed pathophysiologic mechanism for migraine?
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
What drugs are mainstays for abortive treatment of migraine?
the triptans
but also ergotamine derivatives, caffeine-containing compounds, metoclopramide and prochlorperazine
What are the drugs typically used for prophylactic prevention of migraine?
beta blockers, TCAs and anticonvulsants
What is the most common type of headache?
tension
Describe the classic presentation of a tension headache.
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
Describe the classic presentation of cluster headaches.
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
What are some of the management options for cluster headaches?
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
Describe the classic presentation of paroxysmal hemicrania?
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)
What medication do paroxysmal hemicrania headaches respond to?
indoemthacin
What is the typical headache that occurs with a subarachnoid hemorrhage?
a HA that begins suddenLy and peaks in intensity within seconds of its onset - a thunderclap headache
What is the characteristic feature of a low-pressure headache?
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
Describe the management of a low-pressure headache.
recumbency, aggressive fluid replacement, caffeine and occasionally an epidural blood patch
Describe the HA that occurs with idiopathic intracranial hypertension.
headaches that are worse when laying down, and in the mornings
often associated with pulsatile tinnitus and transient visual obscurations
What might exam reveal in the workup for intracranial hypertension headaches?
papilledema
sixth nerve palsies
What are some possible etiologies of idiopathic intracranial hypertension?
impaired resorption of the CSF throguh damaged arachnoid granulations
clot formation within the dural venous sinuses
What are some treatment options for IIH?
repeated LPs
diuretics
optic nerve fenestration
lumboperitoneal shunting
What is the most worrisome complication of IIH?
visual loss due to a compressive optic neuropathy
A new headache in a patient over 50 yo should raise concern for what?
temporal arteritis
What will a temporal artery biopsy reveal in temporal arteritis?
a vasculitis with mononuclear cell infiltration and granulomatous changes, segmental
What is the likely etiology of trigeminal neuralgia?
compression of the trigeminal nerve root at the cerebelopontine angle, most often by an aberrant vascular loop
What is the treatment of choice for trigeminal neuralgia?
carbamazepine
What is the typical treatment for postherpetic neuralgia?
TCAs or gabapentin
