2 Headache, pt 1

Question 1

First step in the management of headaches

Answer 1

Identifying those at high risk for a secondary headache

Question 2

Features associated with high-risk headaches

Answer 2

Age >50y
*Thunderclap headache
Onset on exertion
Fever
Immunocompromised state

**defined as pain that reaches 7 out of 10 in less than 1 minute*

Question 3

Medication overuse is defined as

Answer 3

Use of >10 times a month

Question 4

Features suggestive of migraine

Answer 4

Photophobia/phonophoboia, Pulsatile/throbbing
lasts hOurs (4-72 hours)
Unilateral
Nausea/vomiting
Debilitating, moderate/severe intensity

Question 5

Feautures suggestive of Cluster Headache

Answer 5

At least 5 attacks that meet the following:
- Severe
- Unilateral
- Lasts 15-180 mins (untreated)
- circadian/circannual pattern

associated with *ipsilateral symptoms (at least 1)
- lacrimation
- conjunctival injection
- nasal congestion/rhinorrhea
- ptosis and/or miosis
- edema of the eyelid and/or face
- sweaeting of the forehead and/or face

Question 6

Classic triad of meningitis

Answer 6

Fever
Neck stiffness
Altered mental status
Headache makes this a tetrad
~95% of patients with bacterial meningitis present with at least 2 of these 4 findings

Question 7

can be used to assess for papilledema

Answer 7

optic nerve sheath
normal is <5 mm
>6 mm is abnormal
5-6 mm is controversial

Question 8

Remarks on papilledema

Answer 8

The presence of papilledema requires CT imaging before lumbar puncture

Question 9

Lumbar puncture (LP) can be a therapeutic tool in

Answer 9

idiopathic intracranial hypertension

Question 10

Perform LP in what position?

Answer 10

lateral decubitus position
to allow for the accurate measurement of opening pressure

Question 11

It is safe to proceed with LP without imaging prior in patients with

Answer 11

normal sensorium,
no focal neurologic deficit, and
without a history of immunosuppression

Question 12

Imaging prior to LP is appropriate in patients with

Answer 12

Altered or deteriorating level of consciousness (particularly a GCS ≤11)
Brainstem signs (pupillary changes, posturing, irregular respirations)
Czure (recent seizure)
Deficit (Focal neurologic deficit)
*Emmunocompromised state
Freexisting neurologic disorder

but NEVER delay antibiotic administration while imaging is obtained

Question 13

Remarks on subarachnoid hemorrhage (SAH)

Answer 13

10% to 14% of those complaining of the “worst headache of their life” have SAH.
Acute onset of a severe headache is SAH until proven otherwise.

Question 14

prognosis of SAH

Answer 14

SAH resulting from rupture of an intracranial aneurysm carries only a 50% 30-day survival rate

Question 15

remarks on antiplatelets and ICH

Answer 15

The antiplatelet agent clopidogrel increases risk of acute iCH immediately after trauma, so patients receeiving antiplatelet agents and anticoagulants should be screened using head CT, regardless of symptoms

Question 16

Should be considered cerebellar hemorrhage until proven otherwise

Answer 16

Acute headache with associated vestibular symptoms (vertigo or ataxia)
- especially if patient suddenly could not walk
- may require prompt surgical evacuation of the hematoma to prevent rapid progression to severe disability or death

Question 17

Features suggestive of brain tumor

Answer 17

Headache worsened by Valsalva maneuver
Headache causing awakening from sleep
seizures

Question 18

Study of choice for detecting brain tumors

Answer 18

MRI with and without gadolinum

Question 19

Remarks on cerebral venous thrombosis (CVT)

Answer 19

Mean age of 39 years
More common in women
May present with a “thunderclap” headache
Diagnosed definitively with magnetic resonance venography
LP can safely be performed in patients with CVT