10-21 Headaches

Question 1

primary vs. secondary HA

Answer 1

1°: head pain syndrome occurring w/o cranial or systemic pathology (e.g. migrant, tension-type, cluster, others)
2°: occurs in temporal association w/ cranial, extracranial pathology (infx, hemorrhage, incr ICP, tumor, etc.)
**pts can have both au même temp

Question 2

Red flags: mnemonic

Answer 2

SNOOPER isn’t PC:
S - Systemic symptoms (fever, wt loss) or Secondary risk factors (cancer, HIV)
N - Neuro sx or abnl s’s
O - Onset: sudden
O - Older: new onset and/or progressive HA
P - Previous HA hx (if HA is 1st, different, or ∆ing)
E - Effort-induced
R - Recent trauma

P - Positional
C - Change in personality

Question 3

RED FLAG ETIOLOGY: Meningitis/encephalitis

Answer 3

—Usually have fever (grace à IL-1), could be
—Mental status ∆s, stiff neck (Brudzinski/Kernig’s signs (lost in deep coma))
—Develop focal neurologic deficits
—May have seizures
—Headache often diffuse, may be pulsatile. May have N/V

Question 4

RED FLAG ETIOLOGY: HSV encephalitis

Answer 4

Most common sporadic encephalitis
—Fever, cognitive ∆s (loss of smell), evolving neuro deficits (necrotizing)
—MRI abnormal early
—EEG with abnl periodic complexes
—CSF......get PCR
—Treatable (acyclovir)

Question 5

RED FLAG ETIOLOGY: Brain Tumor/Mass Lesion

Answer 5

—Primary or metastatic
—HA often not initial sx
—Raised ICP
—Focal deficits, seizures, diplopia (VIth nerve palsies), papilledema
—Progressive HA, may be worse w/ recumbency
—HA can be focal, holocranial, various features
—Neuroimaging (esp MRI w/ Gd)

Question 6

RED FLAG ETIOLOGY: Stroke and TIA’s

Answer 6

— Pt has risk factors
—If hemorrhage, N/V more likely (blood irritates meninges)
—Deficit
—A chance to prevent a stroke
—HA: localized or holocranial

Question 7

RED FLAG ETIOLOGY: SAH (subarch hem)

Answer 7

—Sudden, dramatic (worst HA of my life) maybe s/p exertion
—N/V
—Severe HA
—May have sz
—Aneurysm, AVM, other
—Fever, stiff neck, stupor, coma
—Brudzinski/Kernig signs
—Imaging (non contrast head-CT; see blood in Sylvian fissure), LP, angiography
—Sentinel (warning) leak = sudden HA w/ n/v & sz

Question 8

RED FLAG ETIOLOGY: trauma

Answer 8

—causes epidural hematoma (crescent-shaped)
—Often s/p concussion
—Lucid interval
—Rapid arterial bleeding (middle meningeal artery) →rapid ↑ in ICP as there is no “epidural space”
—Neurosurgical emergency

Question 9

RED FLAG ETIOLOGY: subdural hematoma

Answer 9

—Generally slow/venous bleeding (bridging/emissary veins) (acute subdural as in boxing)
—May have no hx of head trauma
—Blood accumulates in the (potential) subdural space therefore slower increase in ICP
—Mental status changes, headache, evolving neurologic deficits

Question 10

RED FLAG ETIOLOGY: Giant Cell Arteritis (a.k.a Horner’s Dz, Temporal arteritis)

Answer 10

—Think 50! Age > 50, ESR >50
—High CRP
—Any type of NEW headache, or worsening of a pre-existing HA type
—Risk of blindness, stroke
—tx w/ Steroids
—dx w/ Temporal a. biopsy

Question 11

RED FLAG ETIOLOGY: Intracranial HTN

Answer 11

*presents like mass lesion
—Often idiopathic
—Risk to vision
—Headache, diplopia, papilledema, VIth n palsies
—Risk of visual loss
—Obesity, venous sinus thrombosis
—Post-partum, infection, dehydration, head trauma
—Image first (“symptomatic” vs. “idiopathic”)
—If no contraindication, then LP for opening pressure

Question 12

RED FLAG ETIOLOGY: central venous sinus thrombosis

Answer 12

yup that too

Question 13

RED FLAG ETIOLOGY: intracranial hypotension

Answer 13

—CSF leak
—Classic example: post-LP headache
—Seen after trauma, spontaneously, after surgery
—Positional HA (early on)
—LP, MRI, myelography —Isotope (Indium 111) cisternography.
—Tx: bedrest, analgesia, IV caffeine; mod/severe—> epidural blood patch

Question 14

1° HA’s: Tension-Type Headache

Answer 14

**Bad name
—Defined as what migraine is not
—Lasts 30 minutes-7 days
—Often bilateral, non-pulsating, mild or moderate, not worse with activity
—No N/V
—Either or neither photo- phonophobia

Question 15

1° HA’s: Migraine dx criteria

Answer 15

—recurrent: 5 or more attacks lasting 4-72 hours
—2 or more of: a) unilateral b) pulsating c) moderate/severe, d) worse with activity
1 or more of: a) n or v B) photo-AND phonophobia

Question 16

1° HA’s: migraine prodrome

Answer 16

hypothalamus involved

Question 17

1° HA’s: childhood precursors to migraine

Answer 17

motion sickness, episodic vomiting, vertigo

Question 18

sleep helps…?

Answer 18

migraines!

Question 19

T/F Migraines are hereditary

Answer 19

true, they USUALLY are

Question 20

Auras

Answer 20

—10-15% have it
—before, during, after or all by itself
—short neuro deficit includes: visual ∆s, paresthesias, hemiplegia or aphasia
—visual aura: Scintillating scotoma = most common visual aura preceding migraine; ask “Do you see anything in the dark?”; originates in occipital lobe; no response to meds

Question 21

Cheiro-oral aura

Answer 21

numbness rises up the arm to face over 10-15 mins

—originates in sensory cortex

Question 22

Why is migraine often misdiagnosed?

Answer 22

Connections though trigeminal nucleus caudalis and superior salivatory nucleus cause confusion:
—With TTH (neck symptoms) something about radiating to face, causing tension in the neck?
—With “sinus” headache b/c migraine radiates into sphenopalatine ganglion

Question 23

Cluster HA’s

Answer 23

—Less frequent
—More common in males (vs. migraine more common in females)
—Most severe pain known
—tearing and runny nose
—Up to 8 attacks per day
—Attacks last 15-180 minutes
—Ipsilateral autonomic signs
—Patients often restless
—Gratifying to treat

Question 24

Post-traumatic HA: causes? DDX? prognosis?

Answer 24

—causes: s/p concussion, whiplash
—DDx: r/o brain bleed
—prognosis: 70% remission w/in 1 yr; rest likely never will recover
—cognitive ∆s, mood disturbances and sleep problems can co-occur w/ post-concussive syndrome

Question 25

drug-induced HA

Answer 25

—Analgesic rebound: occur in migraineurs; limit analgesic to 2 days/wk; washout can take 3 months!
—Vasodilators (hydralazine, isosorbide, nifedipine)
—IVIg
—Many others

Question 26

TMJ-dysfunction induced HA

Answer 26

Pain on use

Question 27

Sinus HA’s

Answer 27

—Acute sinusitis does cause headache
—Recurrent acute sinusitis unusual (think migraine)
—Chronic sinusitis often asymptomatic
—Most “sinus” headache is migraine
—“Sinus” problems
—order CBC, plain films and/or MRI/CT

Question 28

occipital neuralgia

Answer 28

—positive Tinel’s sign (tapping)

—may respond to nerve block/e-stim

Question 29

Trigeminal neuralgia

Answer 29

—Aka tic doloureux
—Lancinating pains (can’t shave, wind hurts!)
—V2 especially
—Trigger points, refractory period
—R/o: Idiopathic, compressive lesions; MS (bilateral, young pt) —> Get MRI
—Tx w/ Carbamazepine

Question 30

HA during sex

Answer 30

SAH or benign “orgasmic headache”

Question 31

status migranosus

Answer 31

migraine lasting >72 hrs

Question 32

migraine pathophys

Answer 32

serotinergic transmission problem; trigeminovascular system