Neurology-Headache

Question 1

primary headache syndrome

Answer 1

means the headache is the disease

Question 2

Short-lived attacks; unilateral pain in V1 distribution of trigeminal nerve (around eye) with autonomic features

Answer 2

Trigeminal autonomic cephalalgias (TACs)

Question 3

most common subtype of TACs

Answer 3

Cluster headache

Question 4

Primary headache classification

Answer 4

Migraine 
Tension-type
    - Episodic
    - Chronic
Trigeminal autonomic cephalalgias (TACs)
    - Cluster

Question 5

Differentiate migraine from tension-type

Answer 5

Migraine: Crescendo pattern, Pulsating, Moderate to severe pain, dark, quiet room
Tension-type: Pressure, Waxing/waning, remains active
Migraine: + associated sx
Tension-type: no associated sx

Question 6

Cluster headache specific features

Answer 6

Ipsilateral parasympathetic overactivity:

Ptosis, miosis, lacrimation, conjunctival injection
Rhinorrhea,

Question 7

Food and red wine induced headache

Answer 7

Migraine

Question 8

At least five attacks fulfilling the following criteria:
Untreated headache lasting 4–72 hr
Group A (2 of 4):
1. Unilateral
2. Throbbing or pulsating pain
3. Moderate to severe pain that inhibits ability to function
4. Pain aggravated by routine physical activity
Group B (1 of 2):
1. Nausea or vomiting
2. Photophobia and phonophobia

Answer 8

Diagnostic criteria: migraine without aura

Question 9

Monocular blindness with disk edema

Peripapillary hemorrhage and slow resolution of the vision loss

Answer 9

Retinal migraine

Question 10

Migraine: pathophysiology

Answer 10

• starts in brainstem
• trigeminal vascular system
• release of neurotransmitters
• dilation of blood vessels

Question 11

Rx: acute migraine

Answer 11

NSAID
Metoclopramide
Triptan
Ergotamine
Dihydroergotamine
Acetaminophen/dichloralphenazone/isometheptene

Question 12

Migraine prophylaxis

Answer 12

Antihypertensives: β-Blockers demonstrate best evidence
Antidepressant
Botulinum
Riboflavin

Question 13

A 23-year-old female with a 10-year history of migraines is having headaches five times a month that keep her from working. She asks you for something to help prevent the headaches. Which of the following would not be an appropriate first option?

Atenolol 50 mg by mouth daily
Start a migraine diary to identify triggers
Dietary modifications
Amitriptyline 50 mg by mouth at bedtime
Nifedipine 30 mg by mouth daily

Answer 13

Nifedipine has not shown efficacy for this indication. It is a dihydropyridine and has the side effect of causing headaches. The other options are all reasonable first steps for headache prevention.

Question 14

A 50-year-old female with a 25-year history of migraine headaches with visual auras presents for her clinic visit. She has never taken prophylaxis for the migraines because she “didn’t want to take any medicines.” When you ask her how her headaches have been, she reports that, over the past month, she has been having them more frequently (once a week) and has a new “ringing” in her ears when she gets the headaches. She is on no medications, and physical exam is entirely normal. What would you suggest next?

1. Start a β-blocker as prophylaxis for the headaches
2. Refer for magnetic resonance imaging of the brain
3. Send her for audiology testing
4. Ask her to discontinue any nonsteroidal anti-inflammatory drug or aspirin she is taking

Answer 14

The change in headache character in a patient above age 50 and new neurologic symptoms (tinnitus) would be considered “red flags”

Question 15

A patient presents with stable migraine headaches on 12 to 16 days of the month and is taking acetaminophen combined with ibuprofen at least three times weekly. The patient gets good relief of symptoms with this combination. She does not have daily headaches. Neurologic exam is normal. What would be your next suggestion?

Continue current treatment regimen since it has good efficacy
Magnetic resonance imaging (MRI) if last imaging was greater than 3 years ago
Refer for urgent head computed tomography (CT)
Add PRN triptan and limit acetaminophen/ibuprofen use to less than 3 times weekly

Answer 15

Add PRN triptan and limit acetaminophen/ibuprofen use to less than 3 times weekly

The frequency of this patient’s medication use places her at high risk for developing chronic daily headache from medication overuse. Adding an alternative abortive medication such as a triptan and limiting the amount of acetaminophen/ibuprofen to less than 3 times/wk can prevent this complication. Alternatively, a migraine prophylactic medication could be considered. Continuing the current treatment regimen is risky for progression to chronic daily headaches. MRI and/or CT are not warranted at this time with stable headache features and normal neurologic exam.