Mehl. Headaches + drugs 04-14 (1)

Question 1

M. 11/10 lancinating, knife-like pain that occurs as episodes lasting usually <1 minute. Dx?

Answer 1

Trigeminal neuralgia

Question 2

M. Classically brought on by minor stimuli, such as brushing one’s hair/teeth, or a gust of wind. Dx?

Answer 2

Trigeminal neuralgia

Question 3

M. Trigeminal neuralgia, cause?

Answer 3

Thought to be caused by trigeminal nerve irritation or impingement (i.e., at the exit points from the skull).

Question 4

M. Trigeminal neuralgia.

There is an NBME Q where they ask what part of the brain is fucked up (i.e., they don’t list any nerves), and the answer is pons, since CN V originates from the pons.

Question 5

M. Trigeminal neuralgia. what part of brain is ,,fucked up”? no peripheral nerves mentioned

Answer 5

Pons, since CN V originates from the pons.

Question 6

M. Trigeminal neuralgia. prophylaxis?

Answer 6

carbamazepine.

Question 7

M. Trigeminal neuralgia. Tx?

Answer 7

There is no Tx for acute episodes since pain lasts such short duration.

Question 8

M. Trigeminal neuralgia. confused with what?

Answer 8

Often confused with cluster headache if occurring in the V1 (ophthalmic branch of trigeminal nerve) distribution.

Question 9

M. Cluster headache. Duration?

Answer 9

Episodes last minutes to half hour (longer than trigeminal neuralgia), where the Q will say the guy wakes up from sleep + paces around his room until pain eventually goes away.

Question 10

M. Male 20s-40s who wakes up from sleep with 11/10 lancinating, knife-like headache; often associated with ipsilateral lacrimation, rhinorrhea, and sometimes pupillary changes (I’ve seen NBME say ipsilateral miotic pupil). Dx?

Answer 10

Cluster headache

Question 11

M. Episodes last minutes to half hour (longer than trigeminal neuralgia), where the Q will say the guy wakes up from sleep + paces around his room until pain eventually goes away. Dx?

Answer 11

Cluster headache

Question 12

M. Cluster headache. Prophylaxis?

Answer 12

Verapamil

Question 13

M. Cluster headache. Acute Tx?

Answer 13

Tx for acute episodes is oxygen (bizarre, unless patient has O2 tank lying around).

Question 14

M. Unilateral throbbing/pounding headache that lasts hours. Dx?

Answer 14

Migraine

Question 15

M. Migraine. Duration?

Answer 15

• Unilateral throbbing/pounding headache that lasts hours.

Question 16

M. Migraine. Assoc with what?

Answer 16

Can be associated with prodromal visual aura or sounds.

Question 17

M. Migraine. prophylaxis?

Answer 17

Prophylaxis is propranolol.

Question 18

M. Migraine. Tx? first –> followed?

Answer 18

Tx is NSAIDs first, followed by triptans (e.g., sumatriptan).

Question 19

M. Migraine. Triptans group?

Answer 19

Serotonin (5HT) receptor agonists.
Triptans are not prophylactic meds; they are only used as abortive therapy.

Question 20

M. Migraine.
USMLE will give 30s female with hypertension who has migraine Hx, and the treatment is “beta blockade” for her HTN management.

Answer 20

.

Question 21

M. Migraine. what is contraindicated if aura present?

Answer 21

Estrogen-containing contraceptives are contraindicated in patients who have migraine with aura.

Question 22

M. Bilateral, dull, band-like headache. Dx?

Answer 22

Tension headache

Question 23

M. Tension headache. Tx?

Answer 23

Treated with sleep and acetaminophen.

Question 24

M. Temporal arteritis. aka giant cell arteritis.

Answer 24

.

Question 25

M. 9/10 Qs will be painful unilateral headache in patient over 50. I’ve seen one Q on NBME where it’s bilateral.

Answer 25

M. Temporal arteritis. aka giant cell arteritis.

Question 26

M. Temporal arteritis. Flares - what blood findings?

Answer 26

low-grade fever and high ESR.

Question 27

M. Temporal arteritis. MSK CP?

Answer 27

Patients can get proximal muscle pain and stiffness. This is polymyalgia rheumatica (PMR). The two do not always go together, but the association is HY. (Do not confuse PMR with polymyositis. The latter will present with ­ incr. CK and/or proximal muscle weakness on physical exam. PMR won’t have either of these findings. I talk about this stuff in detail my MSK notes.)

Question 28

M. Temporal arteritis. can get pain when doing what?

Answer 28

Patients can get pain with chewing. This is jaw claudication (pain with chewing).

Question 29

M. Temporal arteritis. Highest yield point?

Answer 29

Highest yield point is we give STEROIDS BEFORE BIOPSY in order to prevent blindness.

Question 30

M. Temporal arteritis. what complication we’re trying to prevent by giving STEROIDS BEFORE BIOPSY!!

Answer 30

An NBME has “ischemic optic neuropathy” as the answer

Question 31

M. Temporal arteritis. what steroid?

Answer 31

IV methylprednisolone is typically the steroid given, since it’s faster than oral prednisone.

Question 32

M. Temporal arteritis. It’s to my observation many 2CK NBME Qs will give the answer as something like, “Steroids now and then biopsy within 3 days,” or “IV methylprednisolone and biopsy within a week.” Students ask about the time frames, but for whatever reason USMLE will give scattered/varied answers like that.

Answer 32

.

Question 33

M. Temporal arteritis. Another 2CK Neuro CMS Q gives easy vignette of temporal arteritis and then asks next best step in diagnosis -> answer = biopsy. Steroids aren’t part of the answer. Makes sense, since they’re asking for a diagnostic step.

Answer 33

.

Question 34

M. drugs. Migraine. abortive therapy?

Answer 34

Abortive therapy: NSAIDs first, then sumatriptan (serotonin receptor agonist).

Question 35

M. drugs. NSAIDs first, then sumatriptan (serotonin receptor agonist). Dx?

Answer 35

Abortive therapy for migraine

Question 36

M. drugs. Migraine. prevention?

Answer 36

Prevention: propranolol (beta-blockade).

Question 37

M. propranolol (beta-blockade). Dx?

Answer 37

Migraine. prevention

Question 38

M. drugs. Cluster. abortive Tx?

Answer 38

Abortive therapy: oxygen.

Question 39

M. drugs. Cluster. prevention Tx?

Answer 39

Prevention: verapamil (non-dihydropyridine calcium channel blocker).

Question 40

M. drugs. verapamil (non-dihydropyridine calcium channel blocker). Dx?

Answer 40

Cluster. prevention

Question 41

M. drugs. oxygen. Dx?

Answer 41

Cluster. abortive

Question 42

M. drugs. tension Tx?

Answer 42

Rest + acetaminophen.

Question 43

M. drugs. Rest + acetaminophen. Dx?

Answer 43

tension headache

Question 44

M. Trigeminal neuralgia. Abortive?

Answer 44

Abortive: goes away on its own because episodes last maximum 30-60 seconds.

Question 45

M. Trigeminal neuralgia. Prevention?

Answer 45

Prevention: carbamazepine (sodium channel blocker).

Question 46

M. drugs. goes away on its own because episodes last maximum 30-60 seconds. Dx?

Answer 46

Trigeminal neuralgia. abortive

Question 47

M. drugs. carbamazepine (sodium channel blocker). Dx?

Answer 47

Trigeminal neuralgia. prevention