CN LANGE - Headache & Facial Pain II Flashcards Preview

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Flashcards in CN LANGE - Headache & Facial Pain II Deck (98):

Seizures - Headaches - Migrainous features:

Throbbing, nausea/vomiting, photophobia, phonophobia) are common and similar to patient's non-ictal headaches.


Seizure headaches - It may be important to differentiate these headaches from ...?

SAH or meningitis.


Seizure headaches - If doubt exists:

--> Mild CSF pleocytosis (up to approx. 10 cells after single seizures or up to approx. 100 cells after status epilepticus).
--> CSF glucose content is normal.


Post-LP headache:

1. Characteristically a postural headache.
2. Marked increase in pain in the upright position and relief with recumbency.
3. Pain is typically occipital.
4. Comes on within 48-72h after the procedure.
5. Lasts 1-2days.


Post-LP headache is caused by ...?

Persistent leak of CSF from the spinal SAH space, with resultant traction on pain-sensitive structures at the base of the brain.


Post-LP headache - The risk can be reduced by ...?

1. Using a small-gauge needle (22 gauge or smaller) for the puncture.
2. Lying flat afterward, for any length of time, DOES NOT LESSEN THE RISK.


Headache similar in character to that caused by LP can be produced by ...?

Spontaneous intracranial HYPOTENSION.


Spontaneous intracranial hypotension - T1-weighted, gadolinium-enhanced MRI may show ...?

Smooth enhancement of the pachymeninges + a "sagging" brain.
--> The enhancement may be confused with that associated with meningitis.


Most coital headaches are ...?



Most coital headaches occur in ...?



Coital headache:

1. Can be dull, bilateral pain occurring during sexual excitement.
2. Can be severe, sudden headache occurring at the time of orgasm, presumably caused by a marked increase in BP.


Persistent headache after orgasm - worse in the upright posture - has also been described. Reminiscent of:

Post-LP headache --> Associated with low opening pressures at LP.


Patients reporting severe headache in association with orgasm should be evaluated for possible ...?



Pain about the eye may occur in migraine and cluster headache - Also the presenting feature of ...?

1. Iritis.
2. Glaucoma.


Acute iritis produces ...?

Extreme eye pain with photophobia.


Angle-closure glaucoma produces pain ...?

Within the globe that radiates to the forehead.


The new onset of headache in middle or late life should always raise concern about ...?

A mass lesion such as:
1. Brain tumor.
2. Subdural hematoma.
3. Brain abscess.
--> These may NOT produce headache, depending on proximity to pain-sensitive intracranial structures.


About ...% of patients with brain tumor complain of headache although symptoms vary to some extent with tumor type.



Headaches associated with brain tumors - Features:

1. Nonspecific in character.
2. Mild to moderate in severity.
3. Dull and steady in nature.
4. Intermittent.
5. Characteristically BIFRONTAL, worse ipsilaterally.
6. Aggravated by change in position or by maneuvers that increase ICP.
7. Classically maximal on awakening in the morning.


Relative incidence of primary central nervous system tumors:

34.4% --> Meningioma.
16.7% --> Glioblastoma.
13.1% --> Pituitary.
8.6% --> Nerve sheath.
7.0% --> Astrocytoma.
5.1% --> Other neuroepithelial.
2.4% --> Lymphoma.
2.0% --> Oligodendroglioma.
1.8% --> Ependymoma.
1.0% --> Embyonal (medulloblastoma).
0.7% --> Craniopharyngioma.
0.5% --> Germ cell tumor.
6.6% --> Other.


Symptoms of brain tumors - Headache:

50% --> Malignant glioma.
40% --> Low-grade glioma.
36% --> Meningioma.


Symptoms of brain tumors - Seizure:

65-95% --> Low-grade glioma.
40% --> Meningioma.
15-25% --> Malignant glioma.


Symptoms of brain tumors - Hemiparesis:

30-50% --> Malignant glioma.
22% --> Meningioma.
5-15% --> Low-grade glioma.


Symptoms of brain tumors - Altered mental status:

40-60% --> Malignant glioma.
21% --> Meningioma.
10% --> Low-grade glioma.


An UNCOMMON type of headache that suggests brain tumor is characterized by:

Sudden onset of severe pain that reaches maximal intensity within seconds, persists for minutes to hours, and subsides rapidly.
--> May be associated with altered consciousness or "drop attacks".
--> Classically associated with 3rd VENTRICULAR COLLOID CYSTS.


Idiopathic intracranial HTN - Headache:

1. Variable character.
2. Papilledema.
3. Pulsatile tinnitus.
4. Visual loss.
5. Diplopia (from VI nerve palsy).


Like visual loss from glaucoma, that due to idiopathic intracranial HTN is characterized by ...?

Gradually constricting visual fields with late loss of central acuity.


Symptoms of idiopathic intracranial HTN are generally ...?

SELF-LIMITED over several MONTHS + papilledema may disappear, but CSF pressure remains elevated for years, and recurrent symptomatic episodes occur in 10%.


Idiopathic intracranial HTN - Imaging studies may show:

Small ("slit-like") ventricles and demonstrate an empty sella turcica in 70% of instances.
--> The optic nerve sheath is characteristically dilated, and the back of the globe is flattened.


Trigeminal neuralgia:

Facial pain syndrome that develops in middle to late life and is more common in WOMEN than men.


Trigeminal neuralgia - In many instances, the trigeminal nerve roots are ...?

Close to a vascular structure, and microvascular compression followed by DEMYELINATION of the nerve is believed to cause the disorder.


Trigenimal neuralgia - Pain is ...?

UNILATERAL and typically confined to the area supplied by V2, V3.
--> V1 or BILATERAL disease occurs in LESS THAN 5% of cases.


Trigeminal neuralgia - Occurrence during sleep:



Trigeminal neuralgia - Pain-free intervals:

May last for MINUTES TO WEEKS.
--> Long-term spontaneous remission is rare.


Trigeminal neuralgia - PE:

Trigeminal sensory deficits or abnormal trigeminal (eg, corneal or jaw jerk) reflexes EXCLUDE THE DIAGNOSIS.


Trigeminal neuralgia - Rarely, similar pain may occur in ...?

1. MS.
2. Brainstem tumors.
--> Should be considered in young patients and in all patients who show neurologic abnormalities on exam or who experience BILATERAL symptoms.


Trigeminal neuralgia - Treatment:

Oxcarbazepine better than carbamazepine --> Equally effective without risk of blood dyscrasia.


Trigeminal neuralgia - Surgery?

Posterior fossa microvascular decompression surgery --> In patients who fail or cease to respond to drugs.


Glossopharyngeal neuralgia:

Rare syndrome --> Unilateral pain localized to the oropharynx, tonsillar pillars, base of the tongue, or auditory meatus.


Glossopharyngeal neuralgia - Rarely causes ...?

Cardiac syncope due to bradyarrhythmia.


Glossopharyngeal neuralgia - Trigger areas:

Usually around the tonsillar pillars, so symptoms are initiated by shallowing or talking.
--> Paroxysms of pain can occur many times daily.


Glossopharyngeal neuralgia - Men and women?

Equally affected.


Glossopharyngeal neuralgia sooner or later than trigeminal neuralgia?

Glossopharyngeal neuralgia typically occurs at a somewhat YOUNGER AGE than in trigeminal neuralgia.


Bilateral symptoms, abnormal signs, or other atypical features should prompt a search for disorders that can mimic glossopharyngeal neuralgia:

1. MS.
2. Cerebellopontine angle tumors.
3. Nasopharyngeal carcinoma.


Postherpetic neuralgia:

1. Not before 50.
2. Increasingly common with advancing age.
3. Observed in immunocompromised patients + leukemia/lymphoma patients.


Postherpetic neuralgia is characterized by ...?

1. Constant, severe, stabbing, or burning, dysesthetic pain.
2. V1 is MC affected.
3. Scarring may be present.
4. Careful testing of the painful area reveals decreased cutaneous sensitivity to pinprick.
5. The other major complication of herpes zoster in the trigeminal distribution is decreased corneal sensation with impaired blink reflex, which can lead to corneal abrasions, scarring, and ultimately loss of vision.


Persistent idiopathic facial pain:

Constant, boring, mainly unilateral, lower facial pain for which no cause can be found is referred to as persistent idiopathic or atypical facial pain.


Persistent idiopathic facial pain - This idiopathic disorder must be distinguished from similar pain syndromes related to ...?

1. Nasopharyngeal carcinoma.
2. Intracranial extension of SCC.
3. Infection at the site of a tooth extraction.


Migraine is common?

Prevalence = 12%.


The migraine attack begin with visual or other neurologic (usually sensory) symptoms in approx. ...-...% of patients (migraine with aura, or classic migraine), followed by the headache phase.

--> In MOST cases, NO AURA (migraine without aura, or common migraine).


Migraine - Before puberty:

Men and women are equally affected.
--> After puberty --> 2/3-3/4 occur in women.


Migraine - Onset is early in life:

25% --> 0-10.
55% --> By age 20.
>90% --> By age 40.


AD inheritance of migraine occurs in several well-recognized syndromes, including:

1. Familial hemiplegic migraine.
2. Cerebral AD arteriopathy with subcortical infarcts (CADASIL).


Migraine - Structural features:

Increase in MRI-detected:
1. White matter lesions.
2. Infarct-like lesions.
3. Volumetric changes in cerebral gray and white matter.
4. Patients with/without aura are affected equally.
--> Clinical significance of these findings is UNCERTAIN.


Migraine - Pathogenesis:

Intracranial vasoconstriction + extracranial vasodilation were long held to be respective causes of the aura + headache phases of migraine.


Migraine pathogenesis - Recent studies show:

A more complicated picture and suggest that a primary disturbance of central neuronal activity may be responsible for both the aura and headache phases.


Migraine pathogenesis - In many patients, migraine attacks are heralded by prodromal fatigue or cognitive, affective, or GI symptoms, which can last for up to 1 day. The basis for this PREMONITORY phase is poorly understood, but ...?



At the onset of the aura phase:

A decrease in cerebral blood flow is observed in the OCCIPITAL cortex --> Spreads anteriorly across the cortex according to CYTOARCHITECTURAL rather than vascular boundaries.
--> In this respect, and in its rate of propagation (2-5mm/min), it resembles the phenomenon of SPREADING DEPRESSION.


Spreading depression:

A slow wave of neuronal and glial depolarization decreases blood flow and inhibits neuronal activity in its wake.


2 principal mechanisms have been proposed to explain the headache phase:

1. Pain is triggered peripherally in primary sensory trigeminal neurons innervating the meninges and blood vessels, perhaps as a result of sterile inflammation --> These neurons project to the nucleus caudalis in the brainstem --> From there to the periaqueductal gray, sensory thalamic nuclei, and somatosensory cortex.
2. Primary disturbance of central pain pathways, so that normally innocuous sensory input is misinterpreted as signaling pain --> ALLODYNIA.


Migraine with aura (classic migraine) - The MC auras are:

Visual alterations --> Particularly hemianopic field defects and scotomas (blind spots) and scintillations (flickerings) that enlarge and spread peripherally.


Migraine with aura - The frequency of headache:

Varies, but more than 50% of patients experience no more than one attack per week.


Migraine with aura - The duration of episodes:

Greater than 2 hours and less than 1 day in most patients.


Migraine with aura - Remissions are common during ...?

The 2nd and 3rd trimesters of pregnancy and after menopause.


Migraine with aura - Although hemicranial pain is a hallmark of classic migraine ...?

Headaches can also be BILATERAL.
--> Can also be occipital in location - a characteristic commonly attributed to tension-type headaches.


What may occur in BASILAR migraine?

Light-headedness, vertigo, ataxia, or altered consciousness may occur in basilar migraine.


How to distinguish basilar migraine from stroke?

By both the gradual onset ("migrainous march") and spontaneous resolution of symptoms.


Migraine occasionally produces ...?

Neurologic deficits that persist into or beyond the pain phase (eg hemiplegic migraine) and may RARELY cause stroke.


Late-life migraine equivalents:

Especially after 50years of age, the aura may occur without headache.
--> Symptoms include:
1. Visual disturbance.
2. Hemiparesis.
3. Hemisensory loss.
4. Dysarthria.
5. Aphasia.
--> Usually lasts for 15-60min.


Migraine without aura (common migraine):

Much more common than migraine with aura and produces headache that is most often BILATERAL + PERIORBITAL in location.


Migraine without aura - If untreated?

Headache usually persists for 4-72hours and is occasionally terminated by vomiting.


In both common and classic migraine, what may reduce the severity of headache?

Compressing the ipsilateral carotid or superficial temporal artery.


Chronic (transformed) migraine:

Episodic migraine can change its clinical features over months to years, evolving into a chronic headache syndrome with nearly DAILY PAIN.
--> The headache often loses its classic migrainous features.


Chronic (transformed) migraine - Risk factors:

1. Obesity.
2. Prior headache frequency.
3. Caffeine.


A common subgroup of chronic migraine is that of ...?

Headache from medication overuse:
1. Most patients are women.
2. Headache is characteristically present at least 15 days per months for at least 3 months.


A new class of antimigraine drugs:

Calcitonin gene-related peptide receptor antagonists (eg telcagepant, olcegepant).


Ergot alkaloids and triptans are contraindicated in patients with ...?

HTN or other cardiovascular disease and should not be used together.


Cluster headache:

Presents as clusters of brief, very severe, unilateral, constant, nonthrobbing headaches that last from 15min to 3 hours.
--> ALWAYS UNILATERAL and usually recur on the same side in any given patient.


Cluster headaches occur most often ...?

At night, awakening the patient from sleep.
--> Recur daily, often nearly the same time of day (circadian periodicity) for a cluster period of weeks to a few months.


Cluster headache - The cause is unknown, but fMRI during attacks has shown ...?

Hypothalamic activation.


Cluster headache occurs much more frequently in ...?



Cluster headaches typically begin at a somewhat ...?

LATER AGE than migraine (mean onset at 25y).


Cluster headaches - Family history:



Cluster headache may begin as a ...?

Burning sensation over the lateral aspect of the nose or as pressure behind the eye.


Cluster headache - The pain is ...?

Throbbing, sharp, or stabbing.


Cluster headache - What is commonly associated with the attack?

1. Ipsilateral conjunctival injection.
2. Lacrimation.
3. Nasal stiffness.
4. Horner syndrome.
are commonly associated with the attack.


Cluster headaches - Episodes may be precipitated by ...?

The use of ALCOHOL or vasodilating drugs, especially if used during a cluster siege.


Cluster headache variants:

1. Chronic rather than episodic cluster headaches may occur.
2. A BILATERAL variant is HYPNIC headache --> Lacks the autonomic components of cluster headache and occurs in the elderly.
3. Multiple, brief 10 to 20min episodes of recurrent pain for approx. 5 days are called paroxysmal hemicrania --> More common in women.
--> Each of these syndromes responds dramatically to indomethacin 25-50mg/3x daily.


Tension-type headache:

Term used to describe chronic or recurrent headache of inapparent cause that lack features of migraine or other headache syndromes.
--> Underlying pathophysiologic mechanism is unknown - "Tension" is unlikely to be primarily responsible.


In its classic form, tension headache is a chronic disorder that begins after ...?

Age 20.


Tension headache - Features:

1. Nonthrobbing, bilateral occipital head pain --> Not associated with nausea, vomiting or prodromal visual disturbance.
2. Duration = Hours-days.
3. Pain is sometimes likened to a tight band around the head.


Tension headache - Women or men?

Women more likely to be affected than men.


Icepick-like pain:

Very brief, sharp, severe pain located in the scalp OUTSIDE of the trigeminal distribution is called icepick-like pain.


Icepick-like pain - Features:

1. Paroxysms of pain are single or repetitive or occur in clusters, either at a single point or scattered over the scalp.
2. Pain is experienced as an electric-like jab that reaches maximal intensity in less than 1 second, resolves rapidly, and is severe enough to cause involuntary flinching.


Icepick-like headache is more common in ...?

Those with migraine or cluster headache, BUT MAY OCCUR IN INDIVIDUALS WHO ARE HEADACHE-FREE.


Cervical spine disease:

Injury or degenerative disease processes involving the upper neck can produce pain in the occiput or orbital regions.
--> Most important source of discomfort is irritation of the C2 nerve root.


Sinusitis - Patients who complain of chronic "sinus" headache ...?

RARELY has recurrent inflammation of the sinuses --> They are much more likely to have primary headache syndrome.


Other causes of acute headache - Seizures:

Preictal, ictal, and postictal headaches occur but only the LATTER are common.
--> Most often associated with generalized tonic-clonic seizures but also occur following seizures of simple and complex partial phenomenology.