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Neuro II > Headache Disorders > Flashcards

Headache Disorders Flashcards

1
Q

SSNOOP for secondary headache?

A
  • S: ystemic symptoms
    • fever/weight loss
  • S: econdary risk facrors
    • underlying disease, history of head injury, family history brain aneurysm
  • N: eurologic symptoms / abnormal signs
    • confusion, trouble speaking or walking, impaired alertness or consciousness, focal examination
  • O: nset -
    • sudden, abrupt or split second; first is worst, onset with exertion
  • O: lder age onset
    • new onset & progressive headache, especially >50yr
  • P: attern change
    • first headache or different or change from previous headache (frequency, severity or clinical features)
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2
Q

What is the most likely diagnosis for a patient that presents with:

headache + fever

A

meningitis

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3
Q

What is the most likely diagnosis for a patient that presents with:

headache + fever + stupor

A

encephalitis

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4
Q

What is the most likely diagnosis for a patient that presents with:

headache + wide-based gait + dementia + incontinence

A

Normal Pressure Hydrocephalus

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5
Q

What is the most likely diagnosis for a patient that presents with:

sudden severe headache + nuchal rigidity

A

subarachnoid hemorrhage

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6
Q

What is the most likely diagnosis for a patient that presents with:

sudden headache + localized neurologic finding + hypertension

A

interacerebral hemorrhage

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7
Q

What is the most likely diagnosis for a patient that presents with:

chronic progressive worsening headache + focal neurologic finding

A

neoplasm

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8
Q

What is the most likely diagnosis for a patient that presents with:

headache + patient >50 + tender temporal arteries

A

temporal arteritis

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9
Q

What is the presentation of a patient with Temporal arteritis?

What is the major concern with this diagnosis?

Treatment?

A
  • presentation
    • >50 yr
    • thickened tender non-pulsatile temporal artery
    • jaw claudication/occipital pain
    • elevation ESR (>50)
    • granulomatous (giant cell) inflammation on biopsy
  • major concern
    • irreversible blindness if not diagnosed & treated urgently
  • treatment
    • high-dose corticosteroids
    • tocilizumab (anti IL-6)
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10
Q

What is the differential for a “thunderclap headache”

A
  • subarachnoid hemorrhage
  • reversible cerebral vasoconstriction syndrome
  • carotid ? vertebral artery dissection
  • cerebral venous sinus thrombosis
  • spontaneous intracranial hypotension
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11
Q

What is the term for a very severe, abrupt onset headache that reaches maximum intensity in less than 1 minute?

A

thunderclap headache

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12
Q

If you suspect a SAH in a patient, what are your next steps?

A
  • CT
    • highest sensitivity w/in 6 hr
  • Lumbar puncture
    • xanthrochromia (not present until 2 hrs - can last 2 weeks)
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13
Q

What are the characteristics of Reversible Cerebral Vasoconstriction Syndrome?

Cause?

A

recurrent thunderclap headaches over 1 to 2 weeks

multivessel, multifocal segmental vasoconstriction of cerebral blood vessels that reverses within 12 weeks of onset

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14
Q

What demographics most commonly experience reversible cerebral vasoconstriction syndrome?

triggers?

A
  • female 40-50
  • risk factor
    • postpartum, THC, antidepressants, stimulants (cold medicines & migraines)
  • Triggers
    • urinating, bathing, valsalva, sexual activity
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15
Q

What lab values would you expect to see in a patient with RCVS?

CSF?

A

no aneurysmal SAH

near normal CSF (protein <100mg/dL, WBC <15)

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16
Q

Fill out the provided table comparing RCVS to Primary CNS Angiitis

A
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17
Q

Headaches due to intracranial hypotension are usually due to what causes?

A

CSF opening pressure <6 cm H20

lumbar puncture

head trauma (CSF fistula)

spontaneous idiopathic

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18
Q

What is the clinical picture of a patient with headaches due to intracranial hypotension?

Treatment?

A
  • headache that is holocephalic
    • associated with neck pain, tinnitus, changer in hearing, photophobia and/or nausea
    • rhinorrhea
  • pain is better when lying down & worse when standing
  • Treatment:
    • strict bed rest & hydration
    • blood patch to stop CSF leak
    • surgery may be needed
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19
Q

What test do you perform on a patient with a headache due to intracranial hypotension to discern if rhinorrhea is CSF?

What would you see on MRI?
Radioisotope cisternogrophay?

A
  • Fluid test
    • beta-2-transferrin
  • MRI
    • diffuse meningeal enhancement
  • Radioisotope cisternography
    • abnormal
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20
Q

What do you need to be conscious of about the bevel when doing a lumbar puncture? Why?

A

the bevel needs to be parallel to the long axis of the patient (if patient is laying down, it needs to be horizontal) → spread the fibers rather than chopping them & decrease risk of post-dural headache

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21
Q

What is Chiari Type I malformation headache & what are the symptoms?

A

cerebella tonsillar ectopia ~5mm

  • Symptoms:
    • occiptial/suboccipital headache
    • pain triggered by valsalva
    • associated with syrngomyelia
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22
Q

You get an MRI like this, what are the two things you are thinking?

A

CSF leak

or

Chiari Type I Malformation

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23
Q

What happens with pseudotumor cerebri?

A

(idiopathic intracranial hypertension)

high intracranial pressure; CSF > 25 cm H2O

lose peripheral visual field - v slow;

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24
Q

Treatment for pseudotumor cerebri?

A

idiopathic intracranial hypertension

treatment: acetazolamide, topiramate, lasix

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25
Q

What are the classic MRI findings in situation so increased cranial pressure?

A
  • orbital flattening
  • tortuous optic nerves
  • empty sella
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26
Q

If a patient complains of episodic headaches, there is a >90% chance it is what?

A

migraine or probable migraine

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27
Q

What are the 5 phases of migraine with aura?

A
  1. prodrome
  2. aura
  3. pain phases
    1. mid pain
      1. cutaneous allodynia
    2. moderate/severe pain
  4. resolution
  5. postdrome
28
Q

Migraines are at least how long by definition? Greater than what length of time makes it migranosis?

A

4 hrs

>72 hrs

29
Q

Migraine is what type of disorder?

A

neuronal hyperexcitability

lack the ability to habituate electrically to repetitive stimuli

30
Q

What happens in the premonitory phase?

A

activation of meningeal nociceptors → via increased parasympathetic tone

  • thalamic activation of superior salivary nucleus
  • spenopalatine ganglion activation
  • meningeal vasodilation, release of inflammatory molecules
  • trigeminal ganglion/trigeminal cervical complex activation
31
Q

What happens in the aura phase?

A

spreading cortical depression

  • repeated slow depolarization of neuronal/glial membranes
    • K+ efflux → ionic gradient disruption → Ca+, Na+, glutamate release
    • inhibition of cortical activation up to 30 minutes
  • wave of spreading depression is associated with hyperemia/cortical oligemia
32
Q

What are the types of auras?

A
  • fortification spectra
    • enhancements like zigzag fort structure
  • positive scotoma
    • local perception of additional structures
  • negative scotoma
    • loss of awareness of local structures (mostly one sided)
  • combined
33
Q

Migranous auras occur in what fraction of all migraines? What is the typical time length of an aura?

A

⅓ of migraine attacks

onset >5 minutes, does not last more than one hour, and is followed within one hour by migraine headache

34
Q

Symptoms of migranous aura?

A
  • fully reversible visual symptoms
  • fully reversible sensory symptoms
  • fully reversible dysphasic speech

NO weakness

35
Q

if an aura occurs for the first time after 40 yr, is fast onset, brief, purely negative in nature & associated with weakness→ what do you suspect?

A

TIA

36
Q

Migraine with aura is associated with a 2x risk of what kind of stroke?

A

ischemic

37
Q

Migraine with visual aura is associated with what other conditions?

A

incident atrial fibrillation

stroke/TIA

38
Q

Women with migraine have an additional increased risk of stroke based on what other predisposing factors?

A

high dose estrogens (synthetic estrogens are contraindicated - <20 micrograms/day)

smoking

39
Q

What happens in the headache portion of a migraine?

A
  • dilation of meningial vessels
  • sterile neurogenic inflammation
    • stimulates trigeminal ganglion
    • trigeminal cervical complex
    • ascending irritation of various pain centers (SSN, PB, PAG)
    • thalamus (central sensitization - from “my head hurts” to “everything hurts”)
40
Q

What are the criterion for migraine without aura?

A
  • headache lasting 4-72 hrs
  • unilateral
  • pulsating
  • nausa and/or vomiting
  • photophobial & phonophobia
41
Q

What are the criterion for tension-type headache?

A
  • lasting 30min - 7 days
  • bilatearl
  • pressing/tightening (non-pulsating)
  • no nausea or vomiting
  • can have photophobia OR phonophobia, but not both
42
Q

What is the pharmacological treatment for migraines?

A
  • Preventative
    • propranolol, topiramate, amitryptyline, valproic acid
  • Abortives (rescue)
    • NSAIDS, tylenol
    • triptans: 5-HT1B/1D agonists
    • dihydroergotamine (DHE): 5-HT1B/D/F agonist
43
Q

Triptans are contraindicated in what patients?

A

patients with cardiac risk b/c cause vasoconstriction

patients with migraine with atypical aura

44
Q

What are the non-pharmacological treatments for migraines?

A
  • CoQ10
  • Vitamin B2
  • Magnesium Oxide
  • Lifestyle modifications
    • exercise/manipulation/physical therapy
    • avoid triggers (keep headache diary)
    • regular sleep & meal times
45
Q

What are the migraines with atypical auras?

A
  • hemiplegic migraine
    • includes contralateral paralysis/paresis
  • Migraine with Brainstem Aura
    • aka “basilar migraine”
    • symptoms originate from brainstem
      • dysarthria, vertigo, tinnitus, ataxia, diplopia
46
Q

In a patient with migraine with atypical aura, what needs to be excluded as part of the diagnosis?

A

TIA/Stroke

47
Q

What are childhood periodic syndromes that may be precursors to or associated with migraine?

A
  • cyclical vomiting of childhood
  • benign paroxysmal vertigo of childhood
  • abdominal migraine of childhood
48
Q

What are the complications of migraine?

A
  • migraine aura triggered seizure (migralepsy); rare
  • migranous infarction
49
Q

What are trigeminal autonomic cephalgias? What are the 4 types?

A

headaches that follow a trigeminal nerve pattern & are associated with cranial autonomic disturbance

(conjunctival injection / lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead & facial sweating / flushing, sensation ear fullness, miosis and/or ptosis)

  1. cluster
  2. paroxysmal hemicrania
  3. hemicrania continua
  4. SUNA/SUNCT
50
Q

What is the typical clinical presentation of a cluster headache?

A
  • M
  • orbital/temporal stabbing, boring pain (15-180 min) in clusters for weeks - months w/ pain free remission
    • circadian periodicity
  • autonomic features
    • photophobia/phonophobia
    • ipsilateral to headache (unlike migraine)
51
Q

What is a common trigger for cluster headache?

A

EtOH

52
Q

What is the treatment for cluster headache?

A
  • acute
    • sumatriptan SC
    • oxygen (10L/min - 15L/min 15-20min)
  • prophylactic
    • verapamil
53
Q

What is the typical clinical presentation of a patient with paroxysmal hemicrania?

A
  • F
  • similar to cluster - but shorter attacks
  • 2-30min & occur higher daily frequency than cluster
    • chronic (>1yr)
  • ipsilateral autonomic features
54
Q

What is a common trigger for paroxysmal hemicrania?

A

prominent nuchal/mechanical trigger

55
Q

What is the treatment for paroxysmal hemicrania?

A

indomethacin

always completely responsive

56
Q

What is hemicrania continua

A

long version of paroxysmal hemicrania

  • unilateral headache (mild to moderate) - unremitting w/ exacerbations latering 30-3 days
  • pain not as severe as cluster or paroxysmal hemicrania
  • complete response to indomethacin
57
Q

Hemicrania continua can easily be misdiagnosed as what?

A

chronic migraine

58
Q

What is the typical clinical picture of a patient with SUNA/SUNCT?

A
  • F:M 1:1.5
  • short lasting unilateral neuralgiform headache attacks (1-600s) & occur 1- 00 times/day
59
Q

Treatment for SUNA/SUNCT?

A

Iamotrigine

60
Q

Taking excessive amount of over the counter medicine can lead to what condition?

A

medication-overuse headache

61
Q

What medications commonly cause medication overuse headache?

A
  • butalbital
    • >5 dayes/month
  • opioids
    • >8 days/month
  • triptans, NSAIDS, analgesics
    • >10days/month
62
Q

Identify the type of headache indicated by the shown distribution

A
63
Q

What is the pain quality & distribution of Trigeminal Neuralgia?

Triggers?

Causes?

A
  • shock-like / stabbing pain
  • V2/V3
  • trigger: cold, wind, brushing teeth, tactile stimulation
  • vascular loop compression / MS / Tumor
64
Q

What is the pain quality & distribution of Glossopharyngeal Neuralgia?

Triggers?

Causes?

A
  • shock-like, stabbing pain
  • ear, base of tongue, throat
    • may also cause bradycardia / asystole
  • Trigger: swallowing, coughing, yawning, talking
  • cause: neoplasm
65
Q

How would you differentiate between trigeminal neuralgia & cluster headache?

A

trigeminal neuralgia: V2/v3

cluster: has V1 involvement

66
Q

Treatment for tirgeminal neuralgia?

Process of diagnosis?

A

Treatment: carbamazepine

need MRI/MRA brain to exclude pathology (superior cerebellar artery in contact with CN V)

67
Q

What are the possible secondary causes for glossopharyngeal neuralgia?

A
  • pontocerebellar angle tumor
  • peritonsillar abscess
  • carotid aneurysm
  • calcified stylohyoid ligament

Neuro II (30 decks)

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