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Flashcards in Headache and Facial Pain Deck (25):

What are the important historical questions to ask a patient during evaluation of a headache?

Headache tempo and evolution (onset and progression)
What is their behavioral response to the HA?
How often does it recur?
Associated with n/v, photophobia, phonophobia?
What visual symptoms do you have? Paresthesias, difficulty walking? weakness, difficulty concentrating or speaking?


The examination is usually normal in HA patients, but what are some important things to look for to rule out secondary causes of headache?

temporal artery tenderness
nuchal rigidity
visual field defects
eye movement abnormalities


Describe the classic presentation of a migraine.

unilateral and throbbing, often accompanied by nausea, photophobia, phonophobia

can be with or without an aura, which is usually visual (scintillating scotoma)

typically lasts from several to 72 hours


What is the proposed pathophysiologic mechanism for migraine?

cortical spreading depression - a wave of hyperpolarizationi followed by a wave of depolarization that spreads across a region of the cortex at a rate of 2-3 mm/minute

probably leads to release of chemical substances that activate the trigeminal nerve afferents


What drugs are mainstays for abortive treatment of migraine?

the triptans

but also ergotamine derivatives, caffeine-containing compounds, metoclopramide and prochlorperazine


What are the drugs typically used for prophylactic prevention of migraine?

beta blockers, TCAs and anticonvulsants


What is the most common type of headache?



Describe the classic presentation of a tension headache.

recurrent attacks of bilateral or holocranial headaches of a pressing, squeezing or tightening sensation, duration of which may be from 30 minutes to several days

not accompanied by nausea or neurologic symptoms and not exacerbated by physical activity


Describe the classic presentation of cluster headaches.

unilateral headache usually over the orbital or temporal region accompanied by autonomic signs like lacrimation, conjunctival injection, facial swelling, eyelid edema, rhinorrhea, and horner's syndrome


What are some of the management options for cluster headaches?

triptans and oxygen for abortive therapy

steroids to shorten the duration of and HA frequency in a cluster

Verapamil and lithium for long-term prophylaxis


Describe the classic presentation of paroxysmal hemicrania?

strictly unilateral HA with accompanying autonomic signs, differing from cluster headaches in that the headaches are typically of much shorter duration (typically 10-30 minutes) and occur with greater frequency (several to 40 attacks a day)


What medication do paroxysmal hemicrania headaches respond to?



What is the typical headache that occurs with a subarachnoid hemorrhage?

a HA that begins suddenLy and peaks in intensity within seconds of its onset - a thunderclap headache


What is the characteristic feature of a low-pressure headache?

it gets worse in the upright position and alleviated by recumbency (so opposite of an increased intracranial pressure headache)

this happens because the brain descends due to low CSF volume when you're in an upright position and pulls/pushes on the dura, causing pain


Describe the management of a low-pressure headache.

recumbency, aggressive fluid replacement, caffeine and occasionally an epidural blood patch


Describe the HA that occurs with idiopathic intracranial hypertension.

headaches that are worse when laying down, and in the mornings

often associated with pulsatile tinnitus and transient visual obscurations


What might exam reveal in the workup for intracranial hypertension headaches?


sixth nerve palsies


What are some possible etiologies of idiopathic intracranial hypertension?

impaired resorption of the CSF throguh damaged arachnoid granulations

clot formation within the dural venous sinuses


What are some treatment options for IIH?

repeated LPs
optic nerve fenestration
lumboperitoneal shunting


What is the most worrisome complication of IIH?

visual loss due to a compressive optic neuropathy


A new headache in a patient over 50 yo should raise concern for what?

temporal arteritis


What will a temporal artery biopsy reveal in temporal arteritis?

a vasculitis with mononuclear cell infiltration and granulomatous changes, segmental


What is the likely etiology of trigeminal neuralgia?

compression of the trigeminal nerve root at the cerebelopontine angle, most often by an aberrant vascular loop


What is the treatment of choice for trigeminal neuralgia?



What is the typical treatment for postherpetic neuralgia?

TCAs or gabapentin