Headache And Lymphatics

Question 1

Headache prevalence

Answer 1

30% general population

Question 2

Primary headache

Answer 2

. W/o underlying pathology
. 90% headaches
. Categories: tension, migraine, cluster, chronic daily headache

Question 3

Sinus headache

Answer 3

. Pain behind browbone and/or cheek bone

Question 4

Cluster headache

Answer 4

. Pain in and around eye
. <1%, more common in men
. Sharp, continuous pain, severe intensity
. Abrupt onset, peaks in minutes
. 15 min-3 hrs
. Episodic, clustered in time w/ several times a day for 4-8 weeks, relief for several months
. Lacrimation, rhinorrhea, miosis, eyelid edema, conjunctival infection

Question 5

Tension headache

Answer 5

. Pain like band squeezing head
. Bilateral upper neck, frontotemporal region
. Steady non-throbbing, mild to moderate intensity
. 30 min-7 days
. Episodic but can be chronic
. Sometimes photophobia, phonophobia, no nausea
. Triggers: sustained muscle tension, stress, sleep issues
. Relieving factors: massage, relaxation

Question 6

Migraines

Answer 6

. Classic (has aura) vs common (no aura)
. 10% headaches
. Unilateral in 70%, bilateral/global 30%
. Throbbing, aching, severe in intensity
. Rapid onset, peak 1-2 hrs
. Durations 4-72 hours
. Recurrent course

Question 7

Migraine symptoms, triggers, and relieving factors

Answer 7

. Nausea, vomiting, photophobia, phonophobia, visual or sometimes motor auras
. Triggers: alcohol, certain food, stress, period, high altitude
. Better w/ quiet, dark room, sleep, pressure on involved a.

Question 8

Secondary headache

Answer 8

. From underlying cause 
. People over 50 y/o
. Either type worst or. First headache 
. Fever, night sweats 
. Vomiting preceding headache 
. Local tenderness 
. Recent head trauma 
. Papilledema, stiff neck, abnormal neuro findings on exam

Question 9

Differentials for thunderclap headache

Answer 9

.subarachoid hemorrhage 
. Cerebral venous sinus thrombosis
. Pituitary apoplexy 
. Cervicocephalic dissection 
. Sentinel bleed 
. Spontaneous intracranial hypotension
. Acute hypertensive crisis

Question 10

Meningitis

Answer 10

. Viral/bacterial infection of meninges
. Steady or throbbing, very severe
. Onset rapid (less than 24 hrs)
. Viral lasts less than a week, bacterial persists until treatment
. Symptoms: fever, stiff neck, photophobia, change in mental status
. Star empiric antibiotics until diagnosis of viral v. Bacterial is confirmed

Question 11

Brain tumor

Answer 11

. Lesion causing displacement or traction on pain-sensitive aa., vv., or nn.
. Aching, steady, dull pain worse on awakening, better after hours
. Intermittent but can progress in intensity over days
. Assoc. w/ seizures, hemiparesis, personality changes, nausea, vision change, gait changes

Question 12

Giant cell arteritis (temporal arteritis)

Answer 12

. Transmural lymphocytic vasculitis w/ multinucleated giant cells that disrupt internal internal elastic lamina of large aa.
. Localized near involved artery (temporal most often)
. Can have fever, fatigue, weight loss, new headache, visual loss, jaw claudication
. Assoc. w/ polymyalgia rheumatica
. Give steroids

Question 13

Cranial neuralgia

Answer 13

. Pain that follows nerve distribution
. Paroxysmal
. Max at onset, electrical shock, lancinating quality
. Can be single sharp pain or repetitive pains
. Last second to several seconds

Question 14

Trigeminal neuralgias

Answer 14

. Common cause of facial pain
. Occur in paroxysms
. Max at or near onset
. Electric shock, stabbing

Question 15

Occipital neuralgias

Answer 15

. Paroxysmal jabbing pain in greater, lesser, and/or 3rd occipital n.
. Accompanied by diminished sensation in affected area
. Tenderness overlying n. Present

Question 16

Lymph function

Answer 16

. Removal of interstitial fluid from tissues
. Absorption and transport of FA and fat
. Formation of defense for body
. Thymus, bone marrow, lymph nodes, tonsils, and spleen

Question 17

Lymphadenopathy

Answer 17

. Lymph node enlargement
. 1cm or less normal (2cm inguinal normal)
. Need over 2cm in abdomen
. Need over 1cm in chest

Question 18

Right supraclavicular node is a classic sign of ___

Answer 18

Intrathoracic process

Question 19

Lymphadenopathy causes

Answer 19

. Infections 
. Cellulitis, abscess, pharyngitis 
. Zoonosis: plague, tularemia
. TB
. Fungal 
. Viral (mono, CMV, HIV)
. Parasitic

Question 20

Tests to order for lymphadenopathy

Answer 20

. Labs: CBC, ESR, blood culture, EBV/CMV, HIV, quantGold
. Imaging: CT, US, MRI, PET
. Procedural: FNA, core needle biopsy, excisional biopsy

Question 21

Advantages and disadvantages of FNA

Answer 21

. Advantages: easy, painless, office-based very small needle
. Disadvantages: requires expert, unable to evaluate histology

Question 22

Advantages and disadvantages of core needle biopsy

Answer 22

. A: easy, painless, office-based, standard histopathology, able to obtain receptor status and assess tissue architecture
. D: slightly larger needle

Question 23

Excisional biopsy advantages and disadvantages

Answer 23

A: standard histopathology, able to assess tissue architecture and obtain receptor status
D: requires operating room, larger incision, more painful

Question 24

Characteristics of lymphangitis

Answer 24

. Inflammation of lymph channels
. Causes infection at site distal to channel
. Shows as red streaks on skin
. Prognosis good when treated w/ right antibiotics

Question 25

Characteristics of lymphadenitis

Answer 25

. Localized infiltration of inflammatory cells in response to infection of lymph nodes
. Generalized response from lymphocytes and macrophages to viral/bacterial infections

Question 26

Characteristics of lymphedema

Answer 26

. Primary or secondary blockage of lymphatics
. Secondary: from malignancy, global, primarily filariasis
. Different from venous insufficiency

Question 27

Acute lymphedema

Answer 27

. Reversible
. Pitting
. Mild

Question 28

Chronic lymphedema

Answer 28

. Irreversible 
. Non-pitting
. Severe
. Scarring, hardening, ulceration 
. Elephantiasis