HEADACHES Flashcards
PAIN SENSITIVE CRANIAL STRUCTURES
1) skin, subcutaneous tissue, muscles, ___________ of the skull;
(2) the
delicate structures of the eye, ear, nasal cavities, and paranasal
sinuses;
(3) ___________ because they are intradural
extracranial
arteries, and external periosteum
intracranial venous sinuses and their
large tributaries
(4) parts of
the dura at the ______________
the dura, particularly the ________________ and the intracranial segment
of the internal carotid artery; (5) the middle meningeal
and __________; and (6) the first three
cervical nerves and cranial nerves as they pass through
the dura.
base of the brain and the arteries within
proximal parts of the anterior
and middle cerebral arteries
superficial temporal arteries
Much of the __________________ and choroid plexuses lack sensitivity.
pia-arachnoid, the parenchyma of the brain,
and the ependyma
Pain that arises from distention of the
middle meningeal artery is projected to the __________
back of the
eye and temporal area.
Pain from the intracranial segment
of the internal carotid artery and proximal parts
of the middle and anterior cerebral arteries is felt in the
_______
eye and orbitotemporal regions.
The sphenopalatine branches of the facial
nerve convey impulses from the _______
nasoorbital region
The
ninth and tenth cranial nerves and the first three cervical
nerves transmit impulses from the ___________
inferior surface of
the tentorium and all of the posterior fossa.
To summarize, pain from supratentorial structures
is referred to the anterior two-thirds of the head, i.e., to
the territory of sensory supply of the_______________;
pain from infratentorial
structures is referred to the vertex and back of the head
and neck predominantly by the__________
first and second
divisions of the trigeminal nerve
second cervical roots.
The _____________
cranial nerves refer pain to the nasoorbital region, ear,
and throat
seventh, ninth, and tenth
Dental or temporomandibular
joint pain impulses are carried by the _____________
second and third
divisions of the trigeminal nerve
most patients with high intracranial pressure complain
of _____________ headaches that fluctuate in
severity, probably because of traction on vessels or dura.
bioccipital and bifrontal
The headaches that
follow seizures and ingestion of alcohol are probably all
caused by _________
cerebral vasodilatation.
increased _____________activates pain-sensitive structures
within their walls or around the base of the brain
pulsation
of meningeal vessels
A similar mechanism may be operative in the severe,
bilateral, throbbing headaches associated with ________________in blood pressure, as occurs with pheochromocytoma,
malignant hypertension, sexual activity, and
in patients being treated with monoamine oxidase inhibitors.
extremely
rapid rises
Activation of the
_______________ (the trigeminal nerves and the
blood vessels they supply), leading to an inflammatory
response that is generated by local neural mechanisms,
_______________” has also been assigned a role
in migraine headache.
trigeminovascular system
“neurogenic inflammation,
With regard to cerebrovascular diseases causing
head pain, the ______ AND ____________
when involved in giant cell arteritis (cranial or “temporal”
arteritis), give rise to severe, persistent headache,
at first localized on the scalp and then more diffuse
extracranial temporal and occipital arteries,
basilar artery thrombosis causes pain
to be projected to the _______
occiput and sometimes to the forehead;
Expanding or ruptured
intracranial aneurysms of the _________________ very often cause pain
projected to the eye.
posterior communicating
or distal internal carotid arteries
Infection or blockage of paranasal sinuses is accompanied by pain over the affected_____________
Usually it is associated with tenderness of the skin and
cranium in the same distribution
maxillary or frontal sinuses.
With _________, the pain tends
to be worse on awakening and gradually subsides when the patient is upright;
the opposite pertains with __________sinusitis
pain is ascribed
to __________ and its relief to their emptying,
induced by the dependent position of the ostia.
frontal and ethmoidal sinusitis
maxillary and sphenoidal
filling of the sinuses
When
_________ causes headache, the sclera
is invariably red.
Dilating the pupil risks precipitating
IT, a situation that can be reversed
by the administration of __________
acute angle closure glaucoma
pilocarpine 1 percent drops
Headaches that accompany disease of ligaments, m uscles,
and apophysial joints in the upper part of the cervical spine
are referred to the ______________on the
same side and sometimes to the__________
occiput and nape of the neck
temple and forehead.
The pain
of _____________ a controversial entity, is characterized
by tender areas near the cranial insertion of cervical and
other muscles.
fibromyalgia,
The______________(usually due to
infection or hemorrhage) is typically acute in onset, usually
severe, generalized, deep seated, constant, and associated
with stiffness of the neck, particularly on forward
bending.
headache of meningeal irritation
dilatation and inflammation of meningeal
vessels and the chemical irritation of pain receptors
in the large vessels and meninges by endogenous chemical
agents, particularly _________________, are
probably more important factors in the production of
pain and spasm of the neck extensors
serotonin and plasma kinins
__________________characterized by a
steady occipitonuchal and frontal pain coming on within
a few minutes after arising from a recumbent position
(orthostatic headache) and is relieved within a minute
or two by lying down.
Its cause is a persistent leakage
of CSF into the lumbar tissues through the needle track
installation of
an _____________relieves the headache.
Lumbar puncture (LP) or spontaneous low CSF pressure headache
epidural “blood patch”
___________
headache may follow a cough, sneeze, strain,
or athletic injury, sometimes as a result of rupture of the
arachnoid sleeve along a nerve root
“Spontaneous” lowpressure
The headache of ____________
when it occurs, is dull and unilateral, perceived over
most of the affected side of the head
subdural hematoma,
The ratio of classic to common
migraine is _____________.
1 :5
Migraine with
aura is ushered in by a disturbance of nervous function,
most often ________ followed in a few minutes to hours
by hemicrania! (or, in about one-third of cases, bilateral)
headache, nausea, and sometimes vomiting, all of which
last for hours or as long as a day or more
visual,
The __________
and the ___________aspects of migraine are
its most characteristic features in comparison to other
headache types.
hemicrania
throbbing (pulsating)
Migraine may have its onset in childhood but usually
begins in adolescence or young adulthood; in more than
80 percent of patients, the onset is before _________ years of
age,
30
Migraine tends to cease during
the second and third trimesters of pregnancy in
________ percent of women,
75 to 80
Although migraine commonly diminishes in severity
and frequency with age, it may actually ____________ in some postmenopausal women, and ______ therapy may
either increase or, paradoxically, diminish the incidence
of headaches
worsen
estrogen
Migraine with aura frequently has its onset soon
________, but it may occur at any time of day
after awakening
The visual or neurologic symptoms usually last for
less than ______
30 min, sometimes longer.
a migrainous personality
existed, characterized by _____________
tenseness, rigidity of
attitudes and thinking, meticulousness, and perfectionism
There may be associated vertigo,
staggering, incoordination of the limbs, dysarthria, and
tingling in both hands and feet, and sometimes around
both sides of the mouth. These symptoms last 10 to 30
min and are followed by headache, which is usually
occipital
Exceptionally; there is an
alarming period of coma or quadriplegia
basilar migraine
recurrent unilateral
headaches associated with weakness of extraocular
muscles. A transient third-nerve palsy with ptosis, with
or without involvement of the pupil, is the usual picture;
rarely, the sixth nerve is affected
The ocular paresis often outlasts the
headache by days or weeks; after many attacks, a slight
mydriasis and, rarely, ophthalmoparesis may remain
permanently.
O p ht h a l m o p l e g i c a n d Reti n a l M i g ra i n e
_______ of almost any degree may precipitate a
migraine headache in persons prone to the condition
Although a family
history of migraine is frequent in such cases, there has
been no history of hemiplegia in other family members.
Cranial trauma
Migraine symptoms in young children
Instead of complailling of headache, the child appears
limp and pale and complains of abdominal pain
a condition
mostly of infants and children (rarely adults), there
are episodes of unilateral paralysis that may long outlast the headache.
mutation for familial hemiplegic migraine
A second locus is in the
gene for the Na+/K+-adenosine triphosphatase (ATPase)
channel and a rarer subtype is caused by mutations in a
sodium channel a.-subunit gene, _________
hemiplegic migraine
the most common
one is in the gene coding for the P /Q-type calcium
channel a. subunit (CACNAlA).
SCNA1
Indeed, there are shared traits between some of the
genetic forms of familial hemiplegic migraine and both
_________________
episodic and degenerative cerebellar diseases
Rarely, migrainous neurologic symptoms, instead of
being transitory, leave a prolonged or even permanent
deficit (e.g., homonymous hemianopia), indicative of an
ischemic stroke. This has been called ________and a small number of these prove to be __________.
complicated migraine
migrainous infarctions
_______________________________________(on rather uncertain grounds) in the pathogenesis
of arterial occlusion and strokes that complicate migraine
Platelet aggregation, edema of the arterial wall,
increased coagulability, dehydration from vomiting, and
intense, prolonged spasms of vessels have all been implicated
In children and young adults with the _____________and in adults with the rare cerebral vasculopathy ___________________________ migraine may
be a prominent feature
mitochondrial disease MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes)
CADASIL
(cerebral autosomal dominant arteriopathy with subcortical
infarcts and leukoencephalopathy),
_____________ has been especially associated with
an open foramen
Migraine with aura
migraine that lapses into a condition of daily or virtually severe continuous
headache _________
(status migrainosus).
One-quarter of this group had a history of past migraine and a similar number had a viral-like illness within 3 weeks of the neurologic problem. The CSF contained from 10 to 760 lymphocytes per cubic millimeter, and the total protein was
elevated.
The transient neurologic deficits were mainly
sensorimotor and aphasic; only 6 patients had visual
symptoms. The patients were asymptomatic between
attacks and in none did the entire illness persist beyond
7 weeks
Headache with Neurological Deficits
and CSF Lymphocytosis
MIGRAINE PATHOPHYSIO
In reference to the extracranial vessels, Iversen and
associates, by means of ultrasonography, documented
a ___________ on the side of the migraine during the headache period.
there is frequently
a reduction in__________ during an
aura.
innervation of extracranial and intracranial vessels
by small unmyelinated fibers of the trigeminal nerve
that subserve both pain and autonomic functions _______________
dilatation of the superior temporal artery
posterior cortical blood flow
(the
“trigeminovascular” complex).
Activation of the TRIGEMINOVASCULAR SYSTEM releases __________ and other peptides into
the vessel wall, which serves to sensitize the trigeminal
system to the pulsatility of cranial vessels, and to increase
their permeability; thereby promoting an i__________
substance P, calcitonin
gene-related peptide (CGRP),
Inflammatory
response
the
trigeminal pathways are in a state of ____________
in the migraine patient and that they discharge
periodically, perhaps in response to hypothalamic stimulus
acting on the endogenous pain control pathways
persistent hyperexcitability
Patients with waning visual auras should be advised
to wait to self-administer ____________
until the headache begins
_______ are ineffective in preventing headache if given
during the aura
subcutaneous serotorun agoNISts
triptans
the slower acting nasal spray or oral formulations
are often ineffective if given too long after the start of
headache and patients have learned to administer them
_____________ and, again, this seems safe.
during the aura
A single____________ or its equivalent,
given subcutaneously, is an effective and well-tolerated
treatment for migraine attacks
6-mg dose of sumatriptan
Sumatriptan is available as a nasal spray, which is useful in patients with nausea and vomiting.
The response rate after ___________
2 h is similar to that of the
orally a
_______ is an equally effective agent, but its
peripheral and coronary vasoconstricting side effects
have reduced its use.
This is an______________
with strong serotorun receptor affinity and vasoconstrictive action.
The drug is taken as an uncoated ________________, held under the tongue until
dissolved (or swallowed), or in combination with caffeine
Ergotamine
alpha-adrenergic agonist
1- to 2-mg
tablet of ergotarnille tartrate
A single oral dose of ___________
or of metoclopramide 20 mg, given with the ergotarnille,
relaxes the patient and allays the potential nausea and
vomiting from ergotamine
promethazine 50 mg,
___________is thought, on slim evidence,
to potentiate the effects of ergotamine and other
medications for migraine
Caffeine, 100 mg,
____________
are generally avoided if there is an ongoing and prolonged
aura of any type, including visual, but particularly
with hemiparesis, aphasia, or features such as vertigo,
drowsiness, or diplopia, referable to the basilar artery
serotorun agonists and ergots
___________ are contraindicated in
symptomatic and asymptomatic coronary artery disease
and poorly controlled hypertension.
Ergot drugs and triptans
The
sympathomimetic drug _________ combined with
a sedative, and __________(Midrin) has been useful
for some patients and probably acts in a similar way to
ergotamine and sumatriptan.
isometheptene
acetaminophen
_____________have been
found anecdotally to be useful in refractory cases and
as a means of terminating migraine status, but they
should not be given continuously
Intravenous and oral corticosteroids
approximately ____________
were appropriate for some form of prophylactic treatment on the basis of the frequency and severity of their
headaches, usually more than one severe episode per
week
one-fourth of patients
migraine prophylaxis
Considerable success has been obtained with __________
beginning with_____________and increasing the dosage gradually to as much as
240 mg daily; probably best given as a long-acting preparation
in the higher dosage range
propranolol
10 to 20 mg two to three times
daily
migraine prophylaxis
In patients
who do not respond to these drugs over a period of 4 to 6 weeks, _________taken three to four times
daily, other antiepileptic drug such as __________
valproic acid 250 mg
topiramate, or
amitriptyline, 25 to 125 mg nightly may be tried
__________ as already mentioned;
____________; and _______________, 4 to 16 mg/nightly are found to be helpful
in some patients and may be particularly useful in preventing
predictable attacks of perimenstrual migraine.
Isometheptene (Midrin)
indomethacin, 150 to 200 mg /d
cyproheptadine
(Periactin)
The newest putative treatment for chronic or frequently repeating headaches,
both migraine and tension, is the injection of ______________and other cranial
Botulinum toxin (Botox) into sensitive temporalis
__________ an ergot derivative that was
more widely used in the past, in doses of 2 to 6 mg daily for several weeks or months is effective in the prevention
of migraine.
____________are
rare but serious complications that can be avoided by
discontinuing the medication for 3 to 4 weeks after every
5-month course of treatment
Methysergide (Sansert),
Retroperitoneal and pulmonary fibrosis
example of Indomethacine responsive HA
These include orgasmic migraine, chronic paroxysmal hemicrania (see
further on), hemicrania continua, exertional headache,
hypnic headache, brief head pains (jabs and jolts and “icepick”
headaches), and some instances of premenstrual
migraine.
Other names for cluster:
paroxysmal nocturnal
cephalalgia, migrainous neuralgia, histamine cephalalgia
(Horton’s headache), and others.
Cluster HA
This headache pattern occurs predominantly
in adult men (age range: 20 to 50 years; maleto-
female ratio approximately 5 : 1 ) and is characterized
by a _________
severe consistent unilateral orbital localization
Cluster HA
Its denominative feature is the ___________, or
several times during the night for several or more consecutive days;
nightly recurrence, between 1 and 2 h after the onset of sleep
Cluster HA
The headache has been called the _______
because it may recur with remarkable regularity each
night for periods extending as long as many weeks, followed
thereafter by complete freedom for many months
or even years.
“alarm clock headache”
cluster HA
There are several associated vasomotor phenomena
by which cluster headache can be identified: ____________________, all lasting
on average for 45 min (range: 15 to 180 min).
a blocked
nostril, rhinorrhea, injected conjunctivum, lacrimation,
miosis, and a flush and edema of the cheek
A somewhat similar syndrome as cluster HA is produced by the
________ of eye pain and ocular motor paralysis
Tolosa-Hunt syndrome
Cases of paroxysmal pain behind the eye or nose or in
the upper jaw or temple-associated with blocking of the
nostril or lacrimation and described in the past under the
titles of _________________ (Charlin or Harris)-probably represent variants
of cluster headache.
sphenopalatine (Sluder), petrosal, vidian, and ciliary
neuralgia
These
are of much shorter duration (2 to 45 min) than cluster
and usually affect the temporoorbital region of one side,
accompanied by conjunctival hyperemia, rhinorrhea, and
in some cases a partial Homer syndrome.
respond dramatically
to the administration of ________
Chronic paroxysmal hemicrania
indomethacin, 25 to 50 mg tid.
similar to paroxysmal
hemicrania in which the supraorbital or temporal
pain lasts up to 4 min or so and frequent; it does not usually
respond to indomethacin
SUNCT (short-lasting unilateral neuralgiform
attacks with conjunctival injection and tearing)
flushing of the face on the side of a ________
and pallor in _________;
increased intraocular pressure in
__________, normal pressure in________;
increased skin temperature over the forehead, temple, and cheek in cluster headache, decreased temperature in migraine
cluster headache, migraine
cluster headache, migraine
Cluster may be triggered in sensitive patients by
the use of _______ and, as mentioned, by alcohol.
nitroglycerin
mechanism of cluster
paroxysmal parasympathetic discharge mediated
through the _______ and ________
pain arises from the __________, in the canal through which it ascends in the _________
greater superficial petrosal nerve and
sphenopalatine ganglion
internal carotid artery
petrous portion of the temporal bone
The cyclic nature of the attacks has been linked to
a hypothalamic mechanism that governs the circadian
rhythm. At the onset of the headache, the region of the
_________ appears to be active on PET
suprachiasmatic nucleus
_____________has also been found
in migraine, SUNCT, chronic paroxysmal hemicrania,
and hemicrania continua
Hypothalamic activation
treatment of cluster
Inhalation o f 100 percent oxygen via mask for 1 0 to 1 5 min
at the onset of cluster headache may abort the attack,
but this is not always practical
Termination of a cycle
of cluster can also be achieved with ____________ but
__________monitoring is recommended in
the older individual.
verapamil, starting
with 80 mg qid and increasing the dose over days,
electrocardiogram (ECG)
The usual nocturnal attacks of cluster
headache can be treated with a single anticipatory dose of ______________) or with possibly lesser efficacy; an equivalent dose of serotonin agonist
ergotamine at bedtime (2 mg orally
prevention of cluster
verapamil, up to 480 mg per day
prevention of cluster
A course of _________ and then reducing the dose at 3-day intervals, has been beneficial in many patients
prednisone, beginning with 75 mg daily
for 3 days
This, said to be the most common variety of headache,
is usually bilateral, with occipitonuchal, temporal, or
frontal predominance, or diffuse extension over the top
of the cranium
Tension Headache
In a substantial group of patients with chronic daily
headache, the pain, when severe, develops a pulsating
quality, to which the term _________ has been applied
tension-migraine or tensionvascular headache
______________are hardened in patients
with tension headaches
pericranial
and trapezius muscles
a headache syndrome in older
patients that shares with cluster headache a nocturnal
occurrence _______
successfully treated a number of his patients with________________
at bedtime
(hypnic headache).
300 mg
of lithium carbonate or 75 mg of sustained-release indomethacin
The most common cause of generalized persistent headache,
both in adolescents and adults, is probably mild
____________ in one of its several forms
depression or anxiety
Odd cephalic pains, e.g., a sensation of having
a nail driven into the head____________ may occur
in hysteria or psychosis and raise perplexing problems in
diagnosis.
(clavus hystericus),
the patient develops an increasingly intense throbbing
or nonthrobbing headache, often with superimposed
sharp, stabbing pains.
The _____________ and other scalp arteries are frequently thickened and tender and without pulsation.
Headaches of Tem pora l Arteritis ( G i a nt Cel l
Arteritis)
superficial temporal
In GCA, ________ and _________
on the scalp, with ulceration of the overlying skin, have
been described in severe cases
Jaw claudication and ischemic nodules
Usually
the sedimentation rate is greatly elevated (>50 mm/h and
typically >75 mm/h) but elevation of the ___________ level is a more sensitive indicator of this
inflammatory condition and is particularly helpful when
the sedimentation rate is only mildly elevated
C-reactive
protein (CRP)
in GCA, The importance o f early diagnosis relates t o the threat of blindness from thrombosis of the _______ and _________
ophthalmic
or posterior ciliary arteries
treatment of GCA
The administration o f prednisone, 4 5 t o 6 0 mg/ d in
single or divided doses over a period of several weeks,
is indicated in all cases, with gradual reduction to 10
to 20 mg /d and maintenance at this dosage for several
months or years, if necessary, to prevent relapse
Most typical is a feeling of _________that
is greatly worsened by lying down
some of them respond to medications
such as ___________ compounds
occipital pressure
propranolol and ergot
mechanism of catamenial HA
The relation of headache to a drop in estradiol levels during
the late luteal phase
Premenstrual headache, taking
the form of migraine or a combined tension-migraine
headache, usually responds to the administration of an
NSAID begun ___________before the anticipated onset of the
menstrual period;
oral sumatriptan (25 to 50 mg qid) and zolmitriptan (2.5 to 5 mg bid) are also equally effective
3 days
It can be stated
that _________
may be used safely in the small proportion
of women whose headaches persist or intensify during
pregnancy.
beta-adrenergic compounds and tricyclic antidepressants
As a rule, it follows the
initiating action within a second or two and lasts a few
seconds to a few minutes.Most often this syndrome is a benign idiopathic state
that recurs over a period of several months to a year or
two and then disappears.
______ is usually effective in controlling exertional
headaches; this has been confirmed in controlled
trials
Cou g h and Exertio n a l H eadache
Indomethacin
In cases of repeated coital headache, _________ has
been effective
indomethacin
Thunderclap headache, as pointed
out by Dodick, has also been a symptom of________
pituitary
apoplexy, cerebral venous thrombosis, cervical arterial
dissection, non-aneurysmal perimesencephalic hemorrhage,
or hypertensive crisis
An intense, generalized, throbbing headache may occur
in conjunction with flushing of the face and hands and
numbness of the fingers (erythromelalgia). Episodes
tend to be present on awakening from sound sleep
E ryth rocya n otic Headache
paroxysms of intense, stabbing pain in the
distribution of the mandibular and maxillary divisions
(rarely the ophthalmic division) of the fifth cranial nerve
Trigem i n a l Neura l g i a (Tic D o u l o u reux
It
has also become apparent that a proportion of ostensibly
idiopathic cases are caused by compression of the trigeminal
roots by a__________________
small tortuous branch of the basilar artery;
in TN, Carbamazepine is effective in _______
percent of patients, but half become tolerant over a
period of several years
70 to 80
In TN, _________ were relieved of pain by repositioning
a small branch of the basilar artery that was found to
compress the fifth nerve, and this benefit persisted with
a recurrence rate of less than 1 percent annually for
10 years.
70 percent
A procedure used more in the past for TN, was ____________
stereotactically
controlled thermocoagulation of the trigeminal
roots
The
pain is intense and paroxysmal; it originates in the throat,
approximately in the tonsillar fossa, and is provoked
most commonly by swallowing but also by talking, chewing,
yawning, laughing, etc.
G losso p h a ryngeal N e u ra l g i a
be accompanied by bradycardia and even by syncope,
presumably because of the triggering of cardioinhibitory
reflexes by afferent vagal pain impulses. There is no
demonstrable sensory or motor deficit
vagoglossopharyngeal
neuralgia.
Tx for vagoglossopharyngeal
neuralgia.
the
conventional surgical procedure had been to interrupt the
glossopharyngeal nerve and upper rootlets of the vagus
nerve near the medulla but recent observations suggest
that a vascular decompression procedure similar to the
one used for tic and directed to a small vascular loop
under the ninth nerve
Neuralgia associated with a vesicular eruption caused
by the herpes zoster virus may affect cranial as well as
peripheral nerves
Acute Herpes Zoster a n d Postherpetic
N e u ra l g i a
in herpes zoster,_________ during the early acute phase
may prevent persistent pain
amitriptyline
It is commonly the incipient symptom
of Bell’s palsy but there are a number of different
causes and mechanisms
Ota l g i a
Paroxysmal pain may occasionally occur i n the distribution
of the greater or lesser occipital nerves (suboccipital,
occipital, and posterior parietal areas ) .
Occipita l N e u ra l g i a
In occipital neuralgia, The finding of hypesthesia in the distribution of the
occipital nerves makes the possibility of an _________ more convincing
entrapment
neuropathy
This condition, a unilateral occipital and suboccipital
ache, may be a prominent symptom in patients with neck pain, particularly after neck injuries
“Third Occi pita l Nerve” Headache
degenerative or traumatic arthropathy involving the C2 and C3 apophysial joints with impingement
on the “third occipital nerve” __________________
(a branch of the C3
dorsal ramus that crosses the dorsolateral aspect of the
apophysial [facet] joint) .
special type of cervicofacial pain that could be
elicited by pressure on the common carotid arteries of
patients with atypical facial neuralgia.
Ca rotidyn i a a n d Extracra n i a l Artery
Dissection
