Headache Disorders Flashcards
SSNOOP for secondary headache?
-
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)
What is the most likely diagnosis for a patient that presents with:
headache + fever
meningitis
What is the most likely diagnosis for a patient that presents with:
headache + fever + stupor
encephalitis
What is the most likely diagnosis for a patient that presents with:
headache + wide-based gait + dementia + incontinence
Normal Pressure Hydrocephalus
What is the most likely diagnosis for a patient that presents with:
sudden severe headache + nuchal rigidity
subarachnoid hemorrhage
What is the most likely diagnosis for a patient that presents with:
sudden headache + localized neurologic finding + hypertension
interacerebral hemorrhage
What is the most likely diagnosis for a patient that presents with:
chronic progressive worsening headache + focal neurologic finding
neoplasm
What is the most likely diagnosis for a patient that presents with:
headache + patient >50 + tender temporal arteries
temporal arteritis
What is the presentation of a patient with Temporal arteritis?
What is the major concern with this diagnosis?
Treatment?
-
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)
What is the differential for a “thunderclap headache”
- subarachnoid hemorrhage
- reversible cerebral vasoconstriction syndrome
- carotid ? vertebral artery dissection
- cerebral venous sinus thrombosis
- spontaneous intracranial hypotension
What is the term for a very severe, abrupt onset headache that reaches maximum intensity in less than 1 minute?
thunderclap headache
If you suspect a SAH in a patient, what are your next steps?
- CT
- highest sensitivity w/in 6 hr
- Lumbar puncture
- xanthrochromia (not present until 2 hrs - can last 2 weeks)
What are the characteristics of Reversible Cerebral Vasoconstriction Syndrome?
Cause?
recurrent thunderclap headaches over 1 to 2 weeks
multivessel, multifocal segmental vasoconstriction of cerebral blood vessels that reverses within 12 weeks of onset
What demographics most commonly experience reversible cerebral vasoconstriction syndrome?
triggers?
- female 40-50
- risk factor
- postpartum, THC, antidepressants, stimulants (cold medicines & migraines)
- Triggers
- urinating, bathing, valsalva, sexual activity
What lab values would you expect to see in a patient with RCVS?
CSF?
no aneurysmal SAH
near normal CSF (protein <100mg/dL, WBC <15)
Fill out the provided table comparing RCVS to Primary CNS Angiitis
Headaches due to intracranial hypotension are usually due to what causes?
CSF opening pressure <6 cm H20
lumbar puncture
head trauma (CSF fistula)
spontaneous idiopathic
What is the clinical picture of a patient with headaches due to intracranial hypotension?
Treatment?
- 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
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?
- Fluid test
- beta-2-transferrin
- MRI
- diffuse meningeal enhancement
- Radioisotope cisternography
- abnormal
What do you need to be conscious of about the bevel when doing a lumbar puncture? Why?
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
What is Chiari Type I malformation headache & what are the symptoms?
cerebella tonsillar ectopia ~5mm
- Symptoms:
- occiptial/suboccipital headache
- pain triggered by valsalva
- associated with syrngomyelia
You get an MRI like this, what are the two things you are thinking?
CSF leak
or
Chiari Type I Malformation
What happens with pseudotumor cerebri?
(idiopathic intracranial hypertension)
high intracranial pressure; CSF > 25 cm H2O
lose peripheral visual field - v slow;
Treatment for pseudotumor cerebri?
idiopathic intracranial hypertension
treatment: acetazolamide, topiramate, lasix
What are the classic MRI findings in situation so increased cranial pressure?
- orbital flattening
- tortuous optic nerves
- empty sella
If a patient complains of episodic headaches, there is a >90% chance it is what?
migraine or probable migraine
What are the 5 phases of migraine with aura?
- prodrome
- aura
-
pain phases
- mid pain
- cutaneous allodynia
- moderate/severe pain
- mid pain
- resolution
- postdrome
Migraines are at least how long by definition? Greater than what length of time makes it migranosis?
4 hrs
>72 hrs
Migraine is what type of disorder?
neuronal hyperexcitability
lack the ability to habituate electrically to repetitive stimuli
What happens in the premonitory phase?
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
What happens in the aura phase?
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
What are the types of auras?
- 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
Migranous auras occur in what fraction of all migraines? What is the typical time length of an aura?
⅓ of migraine attacks
onset >5 minutes, does not last more than one hour, and is followed within one hour by migraine headache
Symptoms of migranous aura?
- fully reversible visual symptoms
- fully reversible sensory symptoms
- fully reversible dysphasic speech
NO weakness
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?
TIA
Migraine with aura is associated with a 2x risk of what kind of stroke?
ischemic
Migraine with visual aura is associated with what other conditions?
incident atrial fibrillation
stroke/TIA
Women with migraine have an additional increased risk of stroke based on what other predisposing factors?
high dose estrogens (synthetic estrogens are contraindicated - <20 micrograms/day)
smoking
What happens in the headache portion of a migraine?
- 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”)
What are the criterion for migraine without aura?
- headache lasting 4-72 hrs
- unilateral
- pulsating
- nausa and/or vomiting
- photophobial & phonophobia
What are the criterion for tension-type headache?
- lasting 30min - 7 days
- bilatearl
- pressing/tightening (non-pulsating)
- no nausea or vomiting
- can have photophobia OR phonophobia, but not both
What is the pharmacological treatment for migraines?
- Preventative
- propranolol, topiramate, amitryptyline, valproic acid
- Abortives (rescue)
- NSAIDS, tylenol
- triptans: 5-HT1B/1D agonists
- dihydroergotamine (DHE): 5-HT1B/D/F agonist
Triptans are contraindicated in what patients?
patients with cardiac risk b/c cause vasoconstriction
patients with migraine with atypical aura
What are the non-pharmacological treatments for migraines?
- CoQ10
- Vitamin B2
- Magnesium Oxide
- Lifestyle modifications
- exercise/manipulation/physical therapy
- avoid triggers (keep headache diary)
- regular sleep & meal times
What are the migraines with atypical auras?
- hemiplegic migraine
- includes contralateral paralysis/paresis
- Migraine with Brainstem Aura
- aka “basilar migraine”
- symptoms originate from brainstem
- dysarthria, vertigo, tinnitus, ataxia, diplopia
In a patient with migraine with atypical aura, what needs to be excluded as part of the diagnosis?
TIA/Stroke
What are childhood periodic syndromes that may be precursors to or associated with migraine?
- cyclical vomiting of childhood
- benign paroxysmal vertigo of childhood
- abdominal migraine of childhood
What are the complications of migraine?
- migraine aura triggered seizure (migralepsy); rare
- migranous infarction
What are trigeminal autonomic cephalgias? What are the 4 types?
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)
- cluster
- paroxysmal hemicrania
- hemicrania continua
- SUNA/SUNCT
What is the typical clinical presentation of a cluster headache?
- 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)
What is a common trigger for cluster headache?
EtOH
What is the treatment for cluster headache?
- acute
- sumatriptan SC
- oxygen (10L/min - 15L/min 15-20min)
- prophylactic
- verapamil
What is the typical clinical presentation of a patient with paroxysmal hemicrania?
- F
- similar to cluster - but shorter attacks
- 2-30min & occur higher daily frequency than cluster
- chronic (>1yr)
- ipsilateral autonomic features
What is a common trigger for paroxysmal hemicrania?
prominent nuchal/mechanical trigger
What is the treatment for paroxysmal hemicrania?
indomethacin
always completely responsive
What is hemicrania continua
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
Hemicrania continua can easily be misdiagnosed as what?
chronic migraine
What is the typical clinical picture of a patient with SUNA/SUNCT?
- F:M 1:1.5
- short lasting unilateral neuralgiform headache attacks (1-600s) & occur 1- 00 times/day
Treatment for SUNA/SUNCT?
Iamotrigine
Taking excessive amount of over the counter medicine can lead to what condition?
medication-overuse headache
What medications commonly cause medication overuse headache?
- butalbital
- >5 dayes/month
- opioids
- >8 days/month
- triptans, NSAIDS, analgesics
- >10days/month
Identify the type of headache indicated by the shown distribution
What is the pain quality & distribution of Trigeminal Neuralgia?
Triggers?
Causes?
- shock-like / stabbing pain
- V2/V3
- trigger: cold, wind, brushing teeth, tactile stimulation
- vascular loop compression / MS / Tumor
What is the pain quality & distribution of Glossopharyngeal Neuralgia?
Triggers?
Causes?
- shock-like, stabbing pain
- ear, base of tongue, throat
- may also cause bradycardia / asystole
- Trigger: swallowing, coughing, yawning, talking
- cause: neoplasm
How would you differentiate between trigeminal neuralgia & cluster headache?
trigeminal neuralgia: V2/v3
cluster: has V1 involvement
Treatment for tirgeminal neuralgia?
Process of diagnosis?
Treatment: carbamazepine
need MRI/MRA brain to exclude pathology (superior cerebellar artery in contact with CN V)
What are the possible secondary causes for glossopharyngeal neuralgia?
- pontocerebellar angle tumor
- peritonsillar abscess
- carotid aneurysm
- calcified stylohyoid ligament
