buzz

Question 1

imaging findings of CSF leak

Answer 1

pachymeningeal enhancement, “sagging brain” can look like Chiari I with crowded posterior fossa, big pituitary, small vents, engorged venous sinuses, can see subdural hematomas/hygromas too

Question 2

most common location of spontaneous CSF leak

Answer 2

thoracic spine

Question 3

causes of low pressure CSF headache

Answer 3

trauma, LP, neurosurgery, dural tear from spondylosis, meningeal diverticula

Question 4

symptoms associated with CSF leak

Answer 4

low pressure headache (positional), neck pain, tinnitus/hearing changes, nausea, photophobia

Question 5

SUNCT

Answer 5

short unilateral neuralgiform HA with conjuctival injection + tearing

20+ attacks, mod-severe pain, lasting 1-600 seconds, occuring 1x+ daily

MRI w/wo contrast is warranted to exclude secondary cause like pituitary or posterior fossa tumors/abnormalities

Question 6

headache red flags

Answer 6

NEW HEADACHE > 50 years old

systemic sx, hx cancer/immunocomp, focal neuro sx, thunderclap HA

Question 7

name the TACs (trigeminal autonomic cephalalgias)

Answer 7

cluster headache
hemicrania continua
paroxysmal hemicrania
SUNCT/SUNA

Question 8

difference between paroxysmal hemicrania versus SUNCT/SUNA

Answer 8

paroxysmal hemicrania = 20 attacks lasting 2 - 30 MINUTES, >5 x per day

vs

SUNCT/SUNA = 20 attacks lasting 1-600 SECONDS, >1 x per day

Question 9

how long does cluster headache last

Answer 9

15 minutes - 3 hours in duration

Question 10

temporal arteritis management

Answer 10

check ESR, but don’t wait for biopsy to start prednisone, to prevent vision loss

Question 11

hemicrania continua management

Answer 11

indomethacin 150 mg daily, up to 225 mg x 1 week (MUST RESPOND TO DIAGNOSE)

MRI/MRA w/wo to look at trigeminal nerve

Question 11

hemicrania continua management

Answer 11

indomethacin 150 mg daily, up to 225 mg x 1 week (MUST RESPOND TO DIAGNOSE)

MRI/MRA w/wo to look at trigeminal nerve

Question 12

MOA of triptans

Answer 12

agonists at 5HT1B (vasoconstricts) and 5HT1D (inhibits trigeminal inflammatory peptide release, treats N/V)

Question 13

pathophy of autonomic sx in TACs

Answer 13

parasympathetic outflow from superior salivatory nucleus of facial nerve –> activates lacrimal and nasal mucosal glands.

noxious stim to trigeminal distribution –> trigeminal-autonomic reflex via brainstem connection between TNC and SSN

Question 14

pathophys of migraine

Answer 14

1. activation of super sensitive central generator
2. cortical spreading depression
3. blood vessel dilation + activation of trigeminovascular system
4. release of vasoactive neuropepties (CGRP!!) –> inflammation
5. worsening vasodilation, more neuropeptides, more pain
6. pain signals to trigeminal nucleus caudalis –> thalamus –> cortex
7. more pain signals –> N/V/photo/phono
8. more TNC firing –> central sensitization and allodynia - triptans useless at this stage

Question 15

absent venous pulsations

Answer 15

suggests increased ICP

Question 16

options for cluster HA prevention

Answer 16

VERAPAMIL

+ valproic acid, lithium, high dose melatonin…

Question 17

CADASIL gene and chromo

Answer 17

NOTCH3 gene

chromo 19

Question 18

MRI findings for CADASIL

Answer 18

confluent deep white matter changes, extend to anterior temporal lobes

Question 19

3 types of autosomal dominant familial hemiplegic migraine

Answer 19

FHM1 - CACNA1A gene on chromo 19 - P/Q calcium channel defect. cerebellar involvement, coma, prolonged hemiplegia

FHM2 - ATP1A2 gene on chromo 1 - defect in Na/K ATPase - can be seen with seizures/IDD

FHM3 - SCN1A gene on chromo 2, VG Na channels

Question 20

idiopathic cranial pachymeningitis

Answer 20

dx of exclusion

healthy person with headache, other neuro sx, MRI shows leptomeningeal enhancement but infectious/inflamm studies negative. CSF may show lymphocytic pleocytosis, biopsy shows inflammation

Question 21

the only FDA approved preventative for CHRONIC migraine (not just episodic) - or the first one at least

Answer 21

Botox

Question 22

hypnic headache

Answer 22

headaches occurring only during sleep, waking patient up. >10 days for > 3 months. no restlessness or autonomic stuff.

more common in elderly

treatment: lithium, indomethacin, caffeine, melatonin

Question 23

migraine with monocular visual aura

Answer 23

retinal migraine

Question 24

migraine with aura and stroke risk

Answer 24

women younger than 45 years - increased stroke risk if aura

increases further with OCPs, smoking

in women with migraine with aura who smoke, OCPs with estrogen are contraindicated.

women who don’t spoke, ok to use OCPs if under 35 years but over that do not use

Question 25

chronic migraine and medication overuse headache

Answer 25

it is thought that med overuse can convert episodic to chronic migraine (fioricet, opioids, triptans, NSAIDs)