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Neuro Round 2 wk 1 > Headache Disorders > Flashcards

Headache Disorders Flashcards

1
Q

What is our acronym for work up of secondary HA?

A
  • S - systemic symptoms, secondary risk factors
  • N - neurologic ssx, abnl signs
  • O - onset
  • O - older age onset (new and progressive, giant cell arteritis or CA)
  • P - pattern change
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2
Q

HA + wide based gait + dementia + incontinence

A

normal pressure hydrocephalus

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3
Q

sudden severe HA + nuchal rigidity

A

subarachnoid hemorrhage

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4
Q

sudden HA + localized findings + HTN

A

Intracerebral hemorrhage

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5
Q

HA + pt over 50 + tender temporal arteries

A

temporal arteritis

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6
Q

Pt 50 yo + presents with jaw claudication or occipital pain. Has a thickened non-pulsatile temporal artery.

Dx? How?

Tx?

If not treated, what could be sequelae?

What other disease is this often seen with?

A
  • Giant Cell Arteritis/Temporal Arteritis
    • granulomatous (giant cell) inflammation on biopsy
  • high dose corticosteroids - prednisone
  • irreversible blindness
  • Polymyalgia rheumatica
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7
Q

What is at the top of my ddx for a ‘thunderclap’ HA? When is the best time to find this on an LP and how do you know it is there?

A

subarachnoid hemorrhage

within 6 hours of onset - get an LP and the blood is not diluting over 4 tube draws of CSF

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8
Q

Pt is having recurrent thunderclap HA over 1-2 weeks. No aneurysmal SAH (but cortical SAH can be seen?), near normal CSF.

Dx?

What is happening?

A

Reversible Cerebral Vasoconstrictive Syndrome (RCVS)

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

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9
Q

Who normally gets RCVS? What are the HA triggered by and what are Risk Factors?

A
  • females in 40s and 50s
  • triggered by urinating, bathing, valsalva, sex
  • RF: postpartum, THC, antidepressants, stimulants including cold meds and migraines
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10
Q

How does RCVS compare to Primary CNS Angiitis?

A
  • RCVS
    • CSF normal
    • tx with CCBs
  • PACNS
    • CSF abnormal
    • tx with steroids/immunosuppressants
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11
Q

If my pt is sufferring from intracranial hypotension, what would my CSF opening pressure be on LP?

When are their symptoms better or worse?

How do I tx this?

A
  • opening pressure is <6 cm H2O
  • pain is better when laying down and worse when standing d/t CSF shifts
  • caffeine, rest, blood patch to stop CSF leak
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12
Q

What is the diagnostic criteria for Pseudotumor Cerebri?

A
  • any HA filling criterion C
  • idiopathic intracranial HTN (IIH) has been diagnosed with CSF pressure >250 mm H2O
  • evidence of causation by at least two of the following
    • HA developed in temporal relation to IIH or led to its discovery
    • HA is relieved by reducing intracranial HTN
    • HA is aggravated in temporal relation to increase in intracranial pressure
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13
Q

What neuroimaging would be consistent with Pseudotumor Cerebri/ IIH?

A
  • empty sella
  • orbital flattening
  • tortuous optic nerves
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14
Q

What happens during the prodrome phase of migraine? What causes this?

A
  • pt has fatigue, mood changes, food cravings, yawning, photophobia, muscle tenderness
  • HT dysfunction with increased parasympathetic tone activating meningeal nociceptors
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15
Q

When does the aura phase of a migraine occur and what happens?

A
  • 30-60 minutes prior to migraine
  • consists of focal neuro ssx that persist up to one hour
    • visual, sensory, language, ssx localizing brainstem
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16
Q

What is idiopathic recurrent moderate to severe midline abdominal pain with nausea and vomiting, lasting 2-72 hours with interval complete resolution called?

HA does not occur during these episodes

A

abdominal migraine

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17
Q

What do we call an episodic head tilt in an infant or young child a/w features such as pallor, irritability, malaise, vomiting, or ataxia?

A

benign paroxysmal torticollis

18
Q

Migraine is a disorder of what… People with migraine lack the ability to …

A

brain/brainstem hyperexcitability

habituate electrically to repetitive stimuli

19
Q

How is an aura prior of a migraine best described?

A

spreading cortical depression (SCD)

result of accumulation of extracellular K+ due to repeated depolarization and repolarization of hyperexcitable neurons

20
Q

If aura occurs for the first time after the age of 40, is fast in onset, brief, purely negative in nature, a/w weakness or not followed by a migraine HA…

A

think TIA and refer to neurology

21
Q

What is contraindicated in women with aura migraines?

A

synthetic estrogens

22
Q

Migraine with visual aura is a/w

A

incidental a fib, stroke/TIA

23
Q

What is the thought behind Trigeminovascular Activation?

A
  • CGRP and other vasoactive neuropeptides activate the trigeminal ganglion
  • afferents from here converge at the Trigeminal cervical complex (TCC) (extracranial structures also converge here)
  • TCC activates the Superior Salivatory Nuc. and other structures projecting to the cortices
24
Q

What features will a migraine without aura have?

A
  • unilateral
  • pulsating
  • at least one of
    • N/V
    • photophobia or phonophobia
25
Q

What are features of tension type HA?

A
  • bilateral
  • pressing or tightening (nonpulsating)
  • not aggravated by routine physical activity
  • BOTH
    • NO Nausea or Vomiting
    • NO more than 1 of photophobia or phonophobia
26
Q

What rx should I avoid in pts with a typical aura but without HA?

A

avoid triptans or vasoconstrictors

27
Q

Preventative rx tx should be for those pts who …

A

experience more than 1-2 HA/week or one severe prolonged episode monthly

28
Q

My pt has a migraine HA for longer than 72 hours.

Dx?

Tx?

A

Status Migrainous

  • IV fluids
  • valproic acid IV
  • Magnesium sulfate IV
  • Diphenhydramine IV
  • Metoclopromide IV
  • Solumedrol IV
  • DHE IV (Raskin Protocol)
29
Q

What is the Rasking Protocol?

A
  • Metoclopramide or prochlorperazine 10 mg IV over 60 seconds
  • wait 5 min
  • DHE 0.5 mg IV over 60 s
  • wait 3-5 min
  • may repeat 0.5 mg IV if no relief

follow with dexamethasone 4-12 mg IV

30
Q

Who is DHE contraindicated in?

A

pts at risk for MI

31
Q

What are examples of migraines with atypical auras?

What is contraindicated in these pts?

A
  • hemiplegic Migraine - CL motor paralysis
  • migraine with brainstem aura
  • TIAs must be excluded
32
Q

repeated attacks of monocular visual disturbance, including scintillations, scotoma or blindness, a/w migraine HA

dx?

What else must be ruled out?

A

retinal migraine

amaurosis fugax

33
Q

What are four types of trigeminal autonomic cephalgias?

A
  • cluster
  • paroxysmal hemicrania
  • hemicrania continua
  • SUNA/SUNCT
34
Q

What is usually a trigger of a cluster HA and what is the primary symptom?

A

etoh

orbital/temporal stabbing, boring pain; rapid, severe onset

35
Q

What is the acute tx for cluster HA?

What rx could prevent cluster HA?

A

sumatriptan SC with O2

verapamil

36
Q

How is Paroxysmal Hemicrania different from a cluster HA

A
  • more in females
  • shorter attack, but higher daily frequency
  • tends to be chronic (lasting about a year)
  • always unilateral
  • completely responsive to indomethacin
37
Q

What is unique to Hemicrania Continua?

A
  • unremitting pain lasting 30 minutes to 3 days
  • unilateral HA
  • pain not as bad as cluster or paroxysmal
  • complete response to indomethacin
38
Q

What is unique to SUNA/SUNCT? How do I tx it?

A
  • Short-lasting Unilateral Neuralgiform
  • attacks only 1-600 seconds, occur up to 100x /day
  • tx - Iamotrigine
39
Q

What should I be thinking clinically with trigeminal autonomic cephalgias?

A
  • r/o other with MRI and pituitary testing
  • cluster responds to short acting verapamil
  • avoid PO in acute cluster
  • if clusterlike without trigger in a female, think paroxysmal hemicrania
40
Q

What are three causes for medication overuse HA?

A
  • butalbital >5 d/mo
  • opioids >8 d/mo
  • triptans/NSAIDs/analgesics >10 d/mo
41
Q

How can you differentiate Trigeminal neuralgia from cluster HA?

A

Trigeminal neuralgia will likely include V2/3 while cluster is mostly V1

42
Q

Eagle’s syndrome is a calcified stylohyoid ligament that could cause …

A

glossopharyngeal neuralgia

Neuro Round 2 wk 1 (15 decks)

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