CN LANGE - Headache & Facial Pain I Flashcards Preview

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Flashcards in CN LANGE - Headache & Facial Pain I Deck (135):
1

Headache etiology - Acute onset - Common:

1. SAH.
2. Other cerebrovascular diseases.
3. Meningitis/encephalitis.
4. Ophthalmic disorders (glaucoma, acute iritis).

2

Headache etiology - Acute onset - Less common causes:

1. Seizures.
2. LP.
3. HTN encephalopathy.
4. Coitus.

3

Headache etiology - Subacute onset:

1. Temporal arteritis.
2. Intracranial mass (tumor, subdural hematoma, abscess).
3. Pseudotumor cerebri.
4. Trigeminal neuralgia (tic douloureux).
5. Glossopharyngeal neuralgia.
6. Postherpetic neuralgia.
7. Persistent idiopathic facial pain.

4

Headache etiology - Chronic:

1. Migraine.
2. Medication overuse headache.
3. Cluster headache.
4. Tension-type headache.
5. Icepick-like pain.
6. Cervical spine disease.
7. Sinusitis.
8. Dental disease.

5

Pathophysiology of headache - Headache is caused by ...?

1. Traction.
2. Displacement.
3. Inflammation.
4. Distention.
of the pain-sensitive structures in the head or neck.

6

What does NOT produce headache?

Isolated involvement of the:
1. Bony skull.
2. Most of the dura.
3. Most regions of brain parenchyma.

7

Pain-sensitive structures within the cranial vault:

1. Venous sinuses (eg sagittal sinus).
2. Anterior + middle meningeal arteries.
3. Dura at the base of the skull.
4. Trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves.
5. Proximal portions of the ICA and its branches near the circle of Willis.
6. Brainstem periaqueductal gray matter.
7. Sensory nuclei of the thalamus.

8

Radiation or projection of pain - The trigeminal nerve carries sensation from intracranial structures in the ...?

Anterior + middle fossa of the skull (above the cerebellar tentorium).
Discrete intracranial lesions in these locations can produce pain that radiates in the trigeminal nerve distribution.

9

Radiation or projection of pain - The IX and X nerves convey sensation from the ...?

POSTERIOR FOSSA - Pain originating in this area may also be referred to the ear or throat, as in IX neuralgia.

10

Radiation or projection of pain - The upper cervical (C2-C3) nerves transmit stimuli from ...?

Infratentorial and cervical structures.
--> Pain from posterior fossa lesions often projects to the 2nd and 3rd cervical dermatomes.

11

Characteristics of pain - Pulsating or throbbing pain is frequently ascribed to migraine, but may also occur in patients with ...?

Tension-type headache.

12

A steady sensation of tightness or pressure is commonly seen with ...?

Tension-type headache.

13

The pain produced by intracranial mass lesions is typically ...?

Dull and steady.

14

Icepick-like pain may be described also by patients with ...?

1. Migraine.
2. Cluster headache.
3. Giant cell arteritis.

15

Headache of virtually any description can occur in patients with ...?

Migraine or brain tumors; therefore, the character of the pain alone does NOT provide a reliable etiologic guide.

16

Location of pain - Unilateral:

1. Invariable feature of cluster headache.
2. Majority of migraine attacks.

17

Bilateral pain - Most patients with ...?

Tension-type headache report bilateral pain.

18

Ocular or retroorbital pain suggests ...?

1. Primary ophthalmic disorder such as acute iritis or glaucoma.
2. Optic nerve disease (eg optic neuritis).
3. Retroorbital inflammation (eg Tolosa-Hunt syndrome).
4. It is also common in migraine or cluster headache.

19

Paranasal pain localized to one or several sinuses, often associated with ...?

Tenderness of the overlying periosteum and skin, occurs with acute sinus infection or outlet obstruction.

20

Focal headache may result from ...?

Intracranial mass lesions, but even in such cases it is replaced by bioccipital + bifrontal pain when the intracranial pressure becomes elevated.

21

Bandlike or occipital discomfort is commonly associated with ...?

Tension-type headache.

22

Occipital localization can also occur with ...?

1. Meningeal irritation from infection or hemorrhage.
2. With disorders of the joints, muscles, or ligaments of the upper cervical spine.

23

The pharynx and external auditory meatus are the ...?

Most frequent sites of pain caused by glossopharyngeal neuralgia.

24

Associated symptoms - Recent weight loss:

1. Cancer.
2. Giant cell arteritis.
3. Depression.

25

Associated symptoms - Fever and chills:

Systemic infection or meningitis.

26

Associated symptoms - Dyspnea or other symptoms of heart disease:

Raise the possibility of subacute IE and resultant brain abscess.

27

Associated symptoms - Visual disturbances suggest:

1. An ocular disorder (eg glaucoma).
2. Migraine.
3. Intracranial process involving the optic nerve (optic neuritis) or tract or central visual pathways.

28

Associated symptoms - Nausea and vomiting:

Common in migraine and post-traumatic headache and can also be seen with intracranial mass lesions.

29

Some patients with migraine report that ... or other ... symptoms accompany attacks.

Diarrhea or other GI symptoms.

30

Photophobia may be prominent in ...?

1. Migraine.
2. Acute meningitis.
3. SAH.

31

Myalgias often accompany ...?

1. Tension-type headache.
2. Systemic viral infections.
3. Giant cell arteritis.

32

Ipsilateral rhinorrhea and lacrimation during attacks typify ...?

Cluster headache.

33

Transient loss of consciousness may be seen in both ...?

1. Migraine (basilar migraine).
2. Glossopharyngeal neuralgia (due to cardiac syncope).

34

Temporal pattern of headache - Headaches from mass lesions are commonly maximal on ...?

Awakening, as are sinus headaches.

35

Cluster headaches frequently ...?

Awaken patients from sleep.
--> They often recur at the same time each day or night.

36

Tension-type headaches can develop whenever ...?

Stressful situations occur and are often maximal at the end a workday.

37

Migraine headaches are ...?

EPISODIC - May be worse during menses.

38

Conditions relieving headache - Migraine headaches are frequently relieved by ...?

1. Darkness.
2. Sleep.
3. Vomiting.
4. Pressing on the ipsilateral temporal artery.
5. Their frequency may diminish during pregnancy.

39

Post-LP + low pressure headaches are typically relieved by ...?

Recumbency, whereas headaches caused by intracranial mass lesions may be less severe with the patient standing.

40

Conditions exacerbating headache - Associated with an intracranial mass ...?

Discomfort exacerbated by rapid changes in head position or by events that transiently raise intracranial pressure, such as coughing and sneezing --> Intracranial mass.
--> Can also occur in migraine.

41

Anger, excitement, or irritation can precipitate or worsen both ...?

Migraine and tension-type headaches.

42

Stooping, bending forward, sneezing, or blowing the nose characteristically worsens the pain of ...?

Sinusitis.

43

Postural headachee (maximal when upright, nearly absent when lying down) occurs with ...?

1. Low CSF pressure caused by LP.
2. Head injury.
3. Spontaneous spinal fluid leak.

44

Fluctuations in intensity + duration of the headache with no obvious cause, especially when associated with similar fluctuations in mental status, are seen with ...?

Subdural hematoma.

45

Physical exam - Temperature:

Fever may suggest:
1. Viral syndrome.
2. Meningitis.
3. Encephalitis.
4. Brain abscess.
Headache from these causes can also occur without fever.

46

Blood pressure:

1. HTN per se rarely causes headache unless the BP elevation is acute, as with pheochromocytoma, or very high, as with early HTN encephalopathy.
2. Chronic HTN, however, is the major risk factor for hemorrhagic or ischemic stroke, which can be associated with acute headache.
3. SAH is commonly followed by marked acute elevation of BP.

47

Respiration:

Hypercapnia from respiratory insufficiency from any cause can elevate ICP and produce headache.

48

General physical exam - Weight loss suggests:

1. Cancer.
2. Chronic infection.
3. Polymyalgia rheumatica.
4. Giant cell arteritis.

49

General PE - Skin - Focal inflammation of the face or overlying the skull indicates ...?

Local infection, which may be the source of intracranial abscess or cause venous sinus thrombosis.

50

General PE - Skin - Neurofibromas or cafe-au-lait spots ...?

NF --> Benign or malignant intracranial tumors that can produce headache.

51

Skin - Cutaneous angiomas sometimes accompany ...?

AV malformations (AVMs) of the CNS, which may be associated with chronic headache - or acute headache if they bleed.

52

Skin - VZV that affects the face and head most often involves the ...?

Eye and the skin around the periorbital tissue, causing facial pain.

53

Scalp tenderness is characteristic of ...?

1. Migraine.
2. Subdural hematoma.
3. Giant cell arteritis.
4. Postherpetic neuralgia.

54

Paget disease, myeloma, or metastatic cancer of the skull may produce head pain that is ...?

Boring in quality and associated with skull tenderness.

55

In Paget disease, AV shunting within bone may make the scalp feel ...?

Warm.

56

General PE - Neck - Cervical muscle spasm occurs with ...?

1. Tension-type + migraine headaches.
2. Cervical spine injuries.
3. Cervical arthritis or meningitis.
4. Carotid bruits may be associated cerebrovascular disease.

57

Neurologic exam - Mental status exam - Headache with dementia may be indicative of ...?

Intracranial tumor --> Particularly one in the frontal lobe or infiltrating across the corpus callosum.

58

Neurologic exam - Papilledema, the hallmark of increased intracranial pressure, may be seen with ...?

1. Space-occupying lesions.
2. Carotid artery-cavernous sinus fistula.
3. Pseudotumor cerebri.
4. HTN encephalopathy.

59

Superficial retinal hemorrhages (subhyaloid hemorrhages) are characteristic of ...?

SAH in adults.

60

Ischemic retinopathy may be found in patients with ...?

Vasculitis.

61

Progressive III nerve palsy, especially when it causes pupillary dilation, may be the presenting sign of an ...?

Expanding PCA aneurysm.
--> Alternatively, it may reflect increasing intracranial pressure and incipient brain herniation.

62

Decreased pupillary reactivity to light occurs in ...?

Optic neuritis.

63

Extraocular muscle palsies occur in ...?

Tolosa-Hunt syndrome.

64

Proptosis suggests ...?

1. An orbital mass lesions.
2. Carotid artery-cavernous sinus fistula.

65

Motor exam - Asymmetric motor function or gait ataxia in a patient with a history of subacute headache ...?

Demands complete evaluation to exclude intracranial mass lesions.

66

SAH - Rupture of a berry aneurysm accounts for approx. ...% of cases of SAH.

75%.

67

SAH - Annual incidence:

6 per 100.000.

68

SAH - Which families should have all members screened?

Families with two or more affected persons.
--> Both AD and AR patterns of inheritance occur.

69

SAH - Rupture of berry aneurysm occurs most often during ...?

40-60 - With approx. equal sex distribution.

70

Approx. ...% of autopsied individuals have cerebral aneurysms, and most have never experienced symptoms.

5%.

71

HTN has not been conclusively demonstrated to predispose to the formation of aneurysms, but acute elevation of BP ...?

Eg at orgasm --> May be responsible for rupture.

72

SAH - Fusiform aneurysms result from circumferential dilation of a cerebral arterial trunk. In contrast to saccular aneurysms, they are thought to be caused by ...?

1. Atherosclerosis.
2. Dissection.

73

SAH - Fusiform aneurysms affect preferentially the ...?

Vertebrobasilar system - Can present with symptoms from ischemia or mass effect, in addition to rupture.

74

Intracranial AVMs, a less frequent cause of SAH (...%).

10%.

75

AVMs occur twice as often in ...?

Men.

76

AVMs usually bleed in the ...?

10-40.
--> A significant incidence extends into the 60s.

77

Blood in the subarachnoid space can also result from ...?

1. Intracerebral hemorrhage.
2. Embolic stroke.
3. Trauma.

78

Berry aneurysms - Occur in ...% of patients, and are multiple in approx. ...% of cases.

2%.
20%.

79

Mycotic aneurysms account for ...-...% of aneurysmal ruptures.

2-3%.

80

Mycotic aneurysms are usually more ...?

DISTAL along the course of cerebral arteries than are berry aneurysms.

81

AVMs are most common in the ... distribution.

MCA distribution.

82

Frequency of distribution of intracranial aneurysms:

29% --> MCA.
16% --> ICA.
15% --> Acomm.
14% --> Basilar artery.
9% --> ACA.
6% --> Pcomm.
6% --> Vertebral artery.
3% --> PCA.

83

What is the pathophysiology that causes loss of consciousness at onset in approx. 50% of ruptured berry aneurysms?

1. Intracranial pressure may reach systemic perfusion pressure + acutely decrease cerebral blood flow.
2. The concussive effect of the rupture.

84

Among patients presenting with the abrupt onset of an unusually severe headache, only ...-...% will have SAH.

8-10%.

85

SAH - The absence of headache ...?

Essentially precludes the diagnosis.

86

SAH - ... of patients present with headache alone.

33%.

87

SAH - The most significant feature of the headache is that it is ...?

NEW.

88

SAH - Milder but otherwise similar headache (sentinel headache) may have occurred in the weeks prior to the acute event and probably ...?

Represent small prodromal hemorrhages or aneurysmal stretch.

89

SAH - The headache is NOT always severe, especially if ...?

Hemorrhage is from a ruptured AVM rather than an aneurysm.

90

Although the duration of the hemorrhage is brief, the intensity of the headache may remain ...?

UNCHANGED for several days and may subside slowly over approx. 2 weeks.

91

SAH - Recurrence of the headache usually signifies ...?

REBLEEDING.

92

SAH - Meningeal irritation may induce ...?

Temp elevations up to 39C during the first 2 weeks.

93

SAH - Preretinal globular subhyaloid hemorrhages (found in ...-...% of cases) are most suggestive of the diagnosis.

20-40%.

94

SAH - Bilateral extensor plantar responses and VI palsies are frequent nonlocalizing signs that result from ...?

Increased ICP.

95

Ruptured AVMs tend to occur within ...?

Brain tissue + accordingly produce focal neurologic signs, such as hemiparesis, aphasia, or visual field defects.

96

In patients with a normal neurologic exam, a normal CT scan within 6 hours of symptom onset is held by some authorities to ...?

EXCLUDE SAH.

97

SAH - CT scans that are technically inadequate or delayed, or that otherwise fail to confirm the diagnosis of SAH, necessitate ...?

LP.

98

Why is the CSF xanthochromic in SAH:

Heme is degraded, first (by heme oxygenase) to the green pigment, biliverdin, and then (by biliverdin reductase) to the yellow pigment, bilirubin --> The supernatant of the centrifuged CSF becomes xanthochromic within 12hours after hemorrhage.

99

Chemical meningitis by blood in the SAH may produce ...?

A pleocytosis of several thousand WBCs during the first 48h + a reduction in CSF glucose 4 to 8 days after hemorrhage.

100

SAH - The ECG may reveal ...?

A host of abnormalities, including peaked or deeply inverted T waves, short PR intervals, or tall U waves.

101

Once the diagnosis of SAH is confirmed by CT or LP, what is the next step?

4-vessel cerebral arteriography is undertaken.

102

SAH - Complications - Recurrence of aneurysmal hemorrhage occurs in approx. ...% of patients over 10 to 14 days.

20%.
--> The major acute complications - Roughly doubles the mortality rate.

103

Acute recurrence of hemorrhage from AVM is ...?

Less common.

104

SAH - Complications - Intraparenchymal extension of hemorrhage:

1. Common with AVMs - Rare with aneurysms.
2. The ACA or MCA aneurysms may direct a jet of blood into the brain with resultant intracerebral hematoma producing hemiparesis, aphasia, and sometimes transtentorial herniation.

105

SAH - Complications - Vasospasm:

Delayed arterial narrowing (vasospasm) occurs in vessels surrounded by subarachnoid blood and is associated with ischemic neurologic deficits in more than 1/3 of cases.

106

SAH - Arterial vasospasm - Clinical ischemia typically does NOT appear before day ... after the hemorrhage, peaks at day ... to ..., and then resolves SPONTANEOUSLY.

4, 7-8.

107

The severity of vasospasm is related to the ...?

Amount of subarachnoid blood + vasospasm is less common when less blood is present, such as after traumatic SAH or rupture of an AVM.

108

Is vasospasm the only element in the genesis of delayed ischemic neurologic deficits following SAH?

Appears to be ONLY ONE element --> 1/3 of patients with delayed ischemia clinically do NOT have demonstrable vasospasm.

109

SAH - Complications - Acute or subacute hydrocephalus:

1. May develop during the first 3 days - or after several weeks - as a result of impaired CSF absorption in the subarachnoid space.
2. Progressive somnolence, nonfocal findings, impaired upgaze due to downward pressure on the midbrain should suggest the diagnosis.

110

SAH - Seizures:

1. In fewer than 10% of cases.
2. Only after damage of the cortex.
3. Decorticate/decerebrate posturing is common acutely --> May be mistaken for seizures.

111

SAH - Complications - Summary:

1. Recurrence of hemorrhage.
2. Intraparenchymal extension of hemorrhage.
3. Arterial vasospasm.
4. Acute or subacute hydrocephalus.
5. Seizures.
6. SIADH/DI (uncommon).

112

Clinical grading of patients with aneurysmal SAH - Grade I:

Level of consciousness --> Normal.
Associated clinical features --> None or mild headache and stiff neck.
Surgical candidate --> Yes.

113

Clinical grading of patients with aneurysmal SAH - Grade II:

Consciousness --> Normal.
Clinical features --> Moderate headache and stiff neck, minimal neurologic deficit (eg cranial nerve palsy) in some cases.
Surgical candidate --> Yes.

114

Clinical grading of patients with aneurysmal SAH - Grade III:

Consciousness --> Confusional state.
Clinical features --> Focal neurologic deficits in some cases.
Surgical candidate --> Yes.

115

Clinical grading of patients with aneurysmal SAH - Grade IV:

Consciousness --> Stupor.
Clinical features --> Focal neurologic deficits in some cases.
Surgical candidate --> NO.

116

Clinical grading of patients with aneurysmal SAH - Grade V:

Consciousness --> Coma.
Clinical features --> Decerebrate posturing in some cases.
Surgical candidate --> NO.

117

Treatment of associated UNRUPTURED aneurysms is individualized. Surgery is favored by:

1. Young age.
2. Previous rupture.
3. Family history of aneurysmal rupture.
4. Observed aneurysmal growth.
5. Low operative risk.
--> Decr. life expectancy and asymptomatic small (

118

AVM - Surgery:

Because the risk of an early 2nd hemorrhage is much LESS with AVMs than with aneurysms, surgical treatment can be undertaken electively at a convenient time after the bleeding episode.

119

SAH - Prognosis - Approx. ...% of patients die before reaching a hospital.

20%.

120

SAH - Prognosis - ...% die subsequently from the initial hemorrhage or its complications.

25%.

121

SAH - Prognosis - ...% die from rebleeding prior to surgical correction.

20%.

122

SAH - The probability of survival is related to the ...?

Patient's state of consciousness and the time elapsed since rupture.

123

SAH - On DAY 1, the probability of survival is ...% for symptom-free and ...% for somnolent patients.

60% for symptom-free.
30% for somnolent patients.

124

SAH - At 1 month, symptom-free have ...% and somnolent have ...%.

90% and 60%.

125

Among survivors of aneurysmal SAH, approx. ...% have permanent brain injury.

50%.

126

Nearly ...% of patients recover after ...?

SAH from ruptured AVM.

127

Cerebral ischemia - Headache occurs at onset of stroke or TIA in ... of patients and may persist for ... .

33% - May persist for hours to several days.

128

Cerebral ischemia - Headache is more common with ...?

1. Younger age.
2. Female gender.
3. Cerebellar location.
4. History of migraine.

129

Headaches associated with ischemic stroke are typically ...?

Mild to moderate in intensity + non throbbing in character.

130

Carotid lesions usually produce ...?

Frontal (trigeminal distribution) pain.

131

Posterior fossa strokes usually present with ...?

Occipital headache.

132

Headache accompanying retinal artery embolism or PCA spasm or PCA occlusion may be erroneously diagnosed as ...?

Migraine because of the associated visual impairment.

133

Meningitis or encephalitis - Headache is commonly ...?

1. Throbbing in character.
2. Bilateral.
3. Occipital or nuchal in location.
4. Severity is increased by sitting upright, moving the head, compressing the jugular vein, or performing other maneuvers (eg sneezing, coughing) that transiently increase ICP.
5. RARELY presents suddenly --> Developing instead over hours to days.

134

Brain abscess - Headache:

The most frequent presentation but the classic triad of headache with fever and focal neurologic signs occurs in less than 20%.

135

Headache - Epidemiology:

In all age groups and accounts for 1-2% of emergency department evaluations and up to 4% of medical office visits.