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Flashcards in 7. Headache Deck (18):

A 24 year-old female presents with a three year history of headaches. They are present for most of the day and are described as a dull pain throughout her head. She denies auras or any specific trigger. She notes that when she sneezes, she loses vision for several seconds after opening her eyes. A CT of the brain is normal and the physical exam is significant for bilateral papilledema.

  1. The most likely diagnosis is...
  2. The next appropriate step is...
  3. Which medicine functions as a carbonic anhydrase inhibitor and is used to decrease CSF production in these patients?
  4. Excess intake of which vitamin has been shown to lead to this condition?

  1. Idiopathic intracranial hypertension (pseudotumor cerebri)
  2. Lumbar puncture
    • The point is to document an opening pressure (which will be elevated)
    • This will temporarily relieve symptoms
  3. Acetazolamide
  4. Vitamin A

Idiopathic intracranial hypertension

  • Young, obese women
  • Due to impaired absorption of CSF
  • Signs
    • Episodes of vision loss due to transient increase in ICP, often brought on by sneezing or coughing
    • Papilledema
  • Diagnosis
    • LP - to confirm increased ICP
    • Imaging is usually normal but may show small "slit-like" ventricles
  • Treatment
    • Acetazolamide to reduce CSF production
    • Optic nerve sheath fenestration to relieve pressure on optic nerve
    • Ventricular shunt or repeated LPs
    • Weight loss and possible bariatric surgery = best treatment!


A 76 year-old man develops a dull pain on the side of his head. The pain is fairly constant, but worsened with chewing.

  1. The best diagnosis is...
  2. Best initial treatment is...
  3. Most feared complication of untreated condition is...

  1. Temporal arteritis
  2. Prednisone
  3. Unilateral vision loss

Temporal arteritis

  • Arteritis of extracranial carotid artery and its branches
  • Age > 60
  • Signs
    • Indolent headache in the temple
    • Jaw claudication (pain with chewing)
    • Associated with polymyalgia rheumatica (pain and stiffness in hip or shoulder)
    • Unilateral vision loss
  • Diagnosis
    • Elevated ESR & CRP
    • Biopsy of temporal artery
      • There may be "skip lesions" of temporal artery so several areas need to be biopsied
      • Giant cells are seen within blood vessels
  • Treatment
    • Prednisone


A 21 year-old man wakes up in the middle of the night with a sharp stabbing pain behind his eye and forehead. The has been going on for about 2 weeks, and he had a similar episode as a teenager. The episodes last 30-60 minutes before abating. He looked in the mirror during one of these events and saw the his eye looked red and swollen, there was some ptosis in that eye, and his pupils were not the same size.

  1. This presentation is most consistent with...
  2. What is the best treatment?

  1. Cluster headaches
  2. 100% oxygen

Cluster headaches

  • Criteria:
    • At least 5 attacks of severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 mins to 3 hours untreated, with at least 1 of the following:
      • Conjunctival injection
      • Lacrimation
      • Nasal congestion
      • Rhinorrhea
      • Forehead and facial sweating
      • Miosis
      • Ptosis
      • Eyelid edema
    • Frequency of attacks from one every other day to eight per day
  • Treatment
    • Inhaled oxygen for 10 minutes
    • Prophylaxis:
      • Verapamil (CCB)
      • Steroids
      • Lithium


A 32 year-old woman reports seeing flashing lights like fireworks that move across her visual field. This lasts for 20 minutes, and the patient then develops a pounding headache and vomits. She goes and lies down in a dark, quiet room to avoid the bothersome lights. She has a normal neurological exam.

  1. She most likely has...
  2. She has had dozens of such headaches over several years. She should have what study to evaluate her headaches...
  3. What are the typical qualities of such a headache?
  4. What is the treatment?
  5. What condition is a contraindication for treatment?
  6. Which medications are used as prophylaxis?

  1. Migraine with aura
  2. Nothing
  3. Pulsating quality, lateralized, photophobia, phonophobia, vomiting, pain worse with physical activity, normal physical exam
  4. Sumatriptan
  5. Coronary artery disease
  6. Topiramate, amitriptiline, depakote, propanalol, riboflavin

Migraine headache

  • Criteria
    • At least 5 headaches lasting 4 to 72 hours untreated, which has at least 2 of the following:
      • Unilateral location
      • Pulsating
      • Moderate or severe intensity (prevents daily activities)
      • Aggravated by routine physical activity
    • During headache, at least 1 of the following:
      • Phonophobia and photophobia
      • Nausea and/or vomiting
    • At least 1 of the following aura features establishes migraine with aura:
      • Homonymous visual disturbance
      • Unilateral paresthesias and/or numbness
      • Unilateral weakness
      • Aphasia or unclassifiable speech difficulty
  • Types of migraine
    • Common migraine
      • Migraine WITHOUT aura
    • Classic migraine
      • Migraine WITH aura
    • Basilar migraine
      • Symptoms of basilar artery
        • Visual disturbance, vertigo, confusion, brainstem dysfunction
    • Familial hemiplegic migraine
      • Autosomal dominant
      • Hemiparesis during aura, ataxia, changes in level of consciousness
    • Ophthalmoplegic migraine
      • Retro-orbital pain
      • Cranial nerve palsies (CN III, IV, VI)
  • Treatment
    • Triptan medications
      • Contraindicated in CAD because they have vasoconstrictive properties
  • Prophylaxis
    • Indications
      • More than 2 per month
      • When it is causing disruption to daily life
    • Antiepileptics, tricyclic antidepressants, riboflavin (B2), CCB, beta blockers
      • Topirimate is most commonly used medication


A 56 year-old man, with no history of headaches until two months ago, reports having dull, moderate headaches over that time period. They are primarily over his right temple. They are usually worse in the morning or after he lays down for an afternoon nap. He has some mild photophobia, but no phonophobia. Neurological examination is unremarkable, but his wife feels he is not a cognitively sharp as he used to be. He most likely has...

CNS neoplasm

Headache red flags

  • Old person without prior history
  • Associated with focal neurological deficits or personality changes
  • In immunocompromised person
  • Worse in the morning
  • Associated with signs of systemic disease
    • Fever, weight loss, etc.



What are the two categories of CNS neoplasms?

Glial and nonglial


  • Glial cells include astrocytes, oligodendrocytes, and ependymal cells
  • Astrocytes
    • Provide structural and nutrient support for neurons, maintain extracellular ion balance, repair CN injuries
    • Types of tumors:
      • Juvenile pilocytic astrocytoma
      • Subependymal giant cell astrocytoma
      • Pleomorphic xanthoastrocytoma
      • Diffuse astrocytoma
      • Anaplastic astrocytoma
      • Gliobastoma
  • Oligodendrocytes
    • Form the myelin sheath around axons in the CNS
    • Types of tumors:
      • Oligodendroglioma
      • Anaplastic oligodendroglioma
  • Ependymal cells
    • Line the walls of the ventricles, choroid plexus is formed by a network of ependymal cells and capillaries, secrete and circulate CSF
    • Types of tumors
      • Ependymoma
      • Anaplastic empendymoma
      • Choroid plexus papilloma
      • Choroid plexus carcinoma


  • Meningiomas
  • Primary CNS lymphomas


How are tumors classified according to the WHO?

WHO Grade

WHO Grade I

  • Tumor type
    • Juvenile pilocytic astrocytoma
    • Subependymal giant cell astrocytoma
      • Associated with tuberous sclerosis
    • Pleomorphic xanthoastrocytoma
  • Lifespan
    • Curative with complete resection
    • Common in children

WHO Grade II

  • Tumor type
    • Diffuse or fibrillary astrocytoma
    • Oligodendroglioma
  • Lifespan
    • 7-8 years


  • Tumor type
    • Anaplastic astrocytoma
    • Anaplastic oligodendroglioma
  • Life span
    • 2-3 years

WHO Grade IV

  • Tumor type
    • Glioblastoma multiforme (GBM)
      • Comprise of 2/3 of astrocytomas
      • Necrosis, vascular proliferation, pleomorphic cells
  • Life span
    • 9-12 months

A single tumor may have different histological features at different sites. Tumors that appear as low-grade tumor in one location might have features of higher grade tumor in another location.

Immunochistochemical staining can indicate the degree of mitotic activity, which also correlates with overal tumor prognosis.


What are the 4 different symptoms of CNS tumors?

  1. Progressive, focal neurological deficits
    • Weakness, visual loss, aphasia, etc.
  2. Headaches that are characteristically worse in recumbency and associated with nausea/vomiting and other symptoms of increased ICP
  3. Seizures, if there is irritation of cerebral cortex
  4. Gradual cognitive slowing and personality changes


What are the differences between CNS tumors in adults vs. children?

  • Adults
    • 2/3 of tumors are supratentorial (brain)
  • Children
    • 2/3 of tumors are infratentorial (cerebellum or brainstem)


What is the lesion found in this imaging?

  • In children, a meduloblastoma
    • PNET = primitive neuroectodermal tumor
  • In adults, a metastatic tumor


In CNS tumors,

  1. If there is sudden onset of neurological symptoms, think...
  2. If there is fever and weight loss, think...

  1. Hemorrhage into the tumor
    1. This can sometimes occur without hemorrhage
  2. Metastatic disease rather than primary CNS tumor


What is the lesion found in this imaging?

Brainstem meningioma


  • Slow-growing, usually benign
    • Can become quite massive before causing clinical symptoms
  • Arise from arachnoid
  • On imaging
    • Enhance uniformly with contrast and often calcified
    • Often have a dural tail
  • Treatment
    • Cured with surgery
  • Multiple meningiomas = neurofibromatosis II


What are the lesions found in this imaging?

Metastatic tumors

  • 10 times more common than primary brain tumors
    • 50% of metastatic tumors present as solitary lesions
  • Spread hematogenously
  • Found at junction of gray and white matter
  • Primary source
    • Lung, breast, melanoma, renal, GI cancers
      • Lung tumors account for 2/3 of tumors
      • Melanomas, renal cancers, choriocarcinomas are bleeders
  • Treatment
    • Radiation
      • Life expectancy is 4-6 months


A 55 year old man presents to the ER with new onset aphasia. CT shows a left frontal hemorrhagic mass. A neurosurgeon decides to evacuate the mass and sends the margin for pathology. The report says Kernohan grade IV astrocytoma. Which is the most appropriate next step in therapy?



A 56 year-old man reports having moderate headaches 3-4 times per week. They are bilateral and of moderate intensity, though he can continue working. He has some mild photophobia, but no phonophobia. Neurological examination is unremarkable. He most likely has...

Tension headache

Tension headache criteria:

  • Headache lasting 30 mins to 7 days
  • At least 2 of the following:
    • Pressing/tightening (non-pulsatile) quality
    • Mild or moderate intensity
    • Bilateral location
    • No aggravation with routine physical activity
  • Both of the following:
    • No nausea or vomiting
    • Photophobia and phonophobia are absent, or one but not the other


A 34 year-old female, who received an epidural injection and is now postpartum, complains of a severe headache whenever she stands to get her child. As soon as she lies down, the headache resolves.

  1. The most likely diagnosis is...
  2. The best treatment is...

  1. Intracranial hypotension
  2. Autologous blood patch
  • Image A showing "brain sagging" and descent of cerebellar tonsils
    • Red arrow = crowding of the foramen magnum
    • Blue arrow = flattening of ventral pons against the clivus
  • Image B showing prominent enhancement related to venous engorgement of dural venous sinuses


A 46 year-old man develops a severe headache only in certain postures. At times, he loses consciousness. You worry about...

Intraventricular tumor

  • A variety of tumors can grow within the ventricles
    • Colloid cyst
    • Meningioma
    • Central neurocytoma
  • They cause symptoms by blocking flow of CSF
  • They cause positional headaches and loss of consciousness due to sudden increases in ICP if there is acute obstruction


A 55 year-old woman presents to the ER with the sudden onset of severe periorbital pain and headache. The pain is primarily surrounding her left eye. She reports that her vision is blurry and she is seeing halos of light. On exam, her pupil is dilated and poorly reactive to light. The most likely diagnosis is 

Closed angle glaucoma

  • Accounts for less than 10% of glaucoma cases in US
    • More common in Asia
  • Signs and symptoms
    • Sudden ocular pain
    • Seeing halos around lights
    • Red eye
    • Nausea/vomiting
    • Sudden decreased vision
    • Fixed, dilated pupil
    • Oval pupil
    • Very high intraocular pressure (> 30 mmHg)
  • Treatment
    • Emergency timolol drops to the eyes