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Flashcards in headache and fascial pain Deck (17):
1

A 22-year-old woman reports a scotoma progressing across her left visual field over the course of 30 min, followed by left hemicranial throb-bing pain, nausea, and photophobia. Her brother and mother have similar headaches. Which of the following is present in classic migraine but not in common migraine?
a. Photophobia
b. Familial pattern
c. Visual aura
d. Hemicranial pain
e. Nausea

The answer is C. (Victor, pp 180–181.) Classic migraine, but not com-mon migraine, is preceded by an aura of neurologic dysfunction. The aura is most often visual in nature, consisting of bright flashing lights, scintillat-ing scotomas, or field cuts. Both kinds of migraine are most often charac-terized by a hemicranial throbbing headache associated with nausea, vomiting, photophobia, and phonophobia (aversion to sound). Familial
patterns are not unusual with either classic or common migraine, although with classic migraine the probability that another family member will have a similar problem approaches 80%

2

Basilar migraine differs from classic migraine in the
a. Sex of the persons most often affected
b. Resistance of the visual system to involvement
c. Severity of symptoms
d. Duration of the aura
e. Sequence of neurologic deficits and headach

The answer is c.( Victor, pp 183–184.) As with classic migraine, with basilar migraine women are more susceptible than men, disturbances of vision are common, the aura usually resolves within 10 to 30 min, and the headache invariably follows, rather than precedes, the neurologic deficits; however, the character and severity of neurologic deficits associated with
basilar migraine are distinct. The visual change may evolve to complete blindness. Irritability may develop into frank psychosis. Rather than a mild hemiparesis, the patient may have a transient quadriplegia. Stupor, syn-cope, and even coma may appear and persist for hours.

3

A 43-year-old woman complains of lancinating pains radiating into the right side of her jaw. This discomfort has been present for more than 3 years and has started occurring more than once a week. The pain is paroxysmal and routinely triggered by cold stimuli, such as ice cream and cold drinks. She has sought relief with multiple dental procedures and has already had two teeth extracted. Multiple neuroimaging studies reveal no structural lesions in her head. Assuming there are no contraindications to the treat-ment, a reasonable next step would be to prescribe
a. Clonazepam (Klonopin) 1 mg orally three times daily
b. Diazepam (Valium) 5 mg orally two times daily
c. Divalproex sodium (Depakote) 250 mg orally three times daily
d. Indomethacin (Indocin) 10 mg orally three times daily
e. Carbamazepine (Tegretol) 100 mg orally three times daily

The answer is e.( Patten, p 375.) This woman probably has trigemi-nal neuralgia (tic douloureux). The treatment options for this facial pain disorder include carbamazepine (Tegretol). Although carbamazepine is a
potent antiepileptic medication, other antiepileptic medications, such as
phenobarbital and divalproex sodium (Depakote), are usually ineffective
in blunting the pain. Phenytoin (Dilantin) is another antiepileptic useful in the management of trigeminal neuralgia, and recently gabapentin (Neu-rontin) has had some success as well. Analgesics and anti-inflammatory
drugs, such as indomethacin (Indocin), are notably ineffective in manag-ing this disorder.

4

A 23-year-old woman has had 1 week of worsening facial pain. She describes it as an intense shooting pain that comes and goes. It is only present on her right face. Which of the following is most likely to be this patient’s underlying problem?
a. Multiple sclerosis
b. Tolosa-Hunt syndrome
c. Migraine
d. Anterior communicating artery aneurysm
e. Falx meningioma

The answer is a.( Victor, p 971.) Multiple sclerosis is often associated with trigeminal neuralgia, which is then termed symptomatic trigeminal neuralgia because it occurs as a symptom of another illness. Other causes of
symptomatic trigeminal neuralgia include basilar artery aneurysms, acoustic schwannomas, and posterior fossa meningiomas, all of which may cause
injury to the fifth cranial nerve by compression. The Tolosa-Hunt syndrome is a presumably inflammatory disorder that produces ophthalmoplegia as-sociated with headache and loss of sensation over the forehead. Pupillary function is usually spared, and the site of pathology is believed to be in the
superior orbital fissure or the cavernous sinus. It is usually not associated with trigeminal neuralgia.

5

Both trigeminal neuralgia and atypical facial pain involve pain that may be
a. Lancinating
b. Paroxysmal
c. Associated with anesthetic patches
d. Abolished with resection of the gasserian ganglion
e. Unilateral

he answer is e. ( Victor, pp 196, 200–201.) Unlike patients with trigeminal neuralgia, who complain of paroxysmal, lancinating pains, pa-tients with atypical facial pain usually complain of a constant, deep pain. Although atypical facial pain is often bilateral, it may be unilateral and fairly limited in its distribution. The cheek, nose, or zygomatic regions are often affected by this idiopathic pain syndrome. The pain is often sensitive to antidepressant medication, a characteristic that has led some to suggest
that the syndrome is invariably caused by depression. Progressive loss of sensation in the distribution of the fifth cranial nerve should prompt a care-ful search for an underlying malignancy invading the nerve either intracra-nially or in the face

6

A 26-year-old graduate student presents to the emergency room with a severe left-sided throbbing headache associated with nausea, vomiting, and photophobia. She has tried taking ibuprofen without relief. On further
questioning, she relates that she has been having similar headaches three to four times per month for the past year. Her mother had a similar problem. Her exam is normal. Appropriate therapy for this patient’s present headache might include which of the following drugs?
a. Ergotamine tartrate
b. Nitroglycerine
c. Verapamil
d. Amitriptyline hydrochloride
e. Phenobarbital

The answer is a. ( Victor, pp 187–189.) This patient has common migraine. Of the agents listed, only ergotamine tartrate is generally consid-ered of use to abort a headache. Verapamil and amitriptyline hydrochloride
may be used as prophylactic (preventative) therapy. Phenobarbital is an anticonvulsant and is not typically used to treat migraine. Nitroglycerine can actually precipitate headaches in susceptible individuals. Nausea is a frequent accompaniment of migraine. Metoclopramide hydrochloride (Reglan) may be effective in relieving the nausea, but it also reduces gastric stasis, which can retard absorption of oral medications. Certain antiemet-ics, such as prochlorperazine, may relieve nausea and also provide relief from the headache itself. Additional agents that might be of benefit in abortive therapy include ibuprofen, aspirin, acetaminophen, isometheptene (Midrin), ergotamine, or a triptan. The triptans are a group of medica-tions that act as agonists at serotonergic receptors (specifically, the 5HT-1 receptors), and they have been found to be very effective at stopping migraine headaches

7

A 26-year-old graduate student presents to the emergency room with a severe left-sided throbbing headache associated with nausea, vomiting, and photophobia. She has tried taking ibuprofen without relief. On further
questioning, she relates that she has been having similar headaches three to four times per month for the past year. Her mother had a similar problem. Her exam is normal. Appropriate long-term management might include a prescription for daily use of which of the following medications?
a. Metoclopramide hydrochloride
b. Sumatriptan
c. Oral contraceptives
d. Amitriptyline hydrochloride
e. Ergotamine tartrate

The answer is d.( Victor, pp 187–189.) Several medications are effective as prophylactic agents in the treatment of migraine. These include amitripty-line hydrochloride, propranolol, verapamil, and valproate. Most experts rec-ommend initiating prophylactic therapy only when headaches occur at least
one to two times per month. Metoclopramide hydrochloride, sumatriptan, and ergotamine tartrate are appropriately used to treat an acute attack of migraine, and should not be prescribed on a daily basis. Daily use of these
medications can establish a rebound syndrome that results in a daily head-ache. Oral contraceptives may be associated with either an increase or de-crease in the frequency of migraines, but are not generally used as a treatment for migraine. Some experts recommend not prescribing OCPs for patients
with migraine for fear of increasing the risk of a stroke, although OCPs are probably safe to use in most patients with common migraine

8

A 22-year-old dance instructor routinely develops headaches on the weekend. The headaches are almost always limited to the right side of her head and centered about the right temple. She knows that a headache is coming because of changes in her vision that precede the headache by 20 to 30 min. She sees scintillating lights just to the left of her center of vision. This visual aberration then expands and interferes with her vision. The blind spot that it creates appears to have a scintillating margin. As the blind spot clears, the headache starts. It rarely lasts more than 1 h, but is usually associated by nausea and vomiting. (SELECT 1 DIAGNOSIS)
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is a. ( Victor, pp 182–183.) Classic migraine is usually familial, involves a unilateral, throbbing head pain, and diminishes in fre-quency with age. The blind spot, or scotoma, that may develop as part of the aura of a classic migraine attack will involve the same visual field in both eyes. This defect usually changes over the course of minutes. It typi-cally enlarges and may intrude on the central vision. The margin of the blind spot is often scintillating or dazzling. If this margin has a pattern like the battlement of a castle, it is called a fortification spectrum, or teichopsia.
Homonymous hemianoptic defects of the sort that develop during the aura of a classic migraine indicate an irritative lesion that is affecting one part of the occipital cortex in one hemisphere of the brain. The changes in the sco-toma over the course of minutes indicate that the irritative phenomenon sets off a cascade of events in the visual cortex that temporarily disturbs vision in a progressively larger area. Other focal neurologic phenomena
may precede classic migraine; the most common are tingling of the face or hand, mild confusion, transient hemiparesis, and ataxia. Fatigue, irritabil-ity, and easy distractibility often develop before a migraine. Affected per-sons usually also have hypersensitivity to light and noise during an attack.

9

A 29-year-old woman comes to the emergency room with complaints of facial pain of new onset. She has stabbing pains on the left side of her face just below her eye. These last less than 1 s at a time, but are so severe that she winces involuntarily with each pain. The pain seems to be trig-gered by drinking cold fluids. The only other problems she has noticed are clumsiness in her right hand and blurred vision in her right eye. Both of these have been present for more than 2 years and have not interfered with her normal activities. (SELECT 1 DIAGNOSIS
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is d. ( Victor, pp 196–198.) Trigeminal neuralgia may develop in the context of multiple sclerosis—an association suggested by this woman’s other neurologic problems. The development of trigeminal
neuralgia (tic douloureux) indicates that demyelination has probably ex-tended to the brainstem and may be involving trigeminal nerve connec-tions. A more detailed history would probably reveal that the patient has
had pain in the eye that now has disturbed vision. This is expected with the optic neuritis, which is typically associated with multiple sclerosis. Other symptoms commonly reported at this age by patients with previously undi-agnosed multiple sclerosis include bed wetting (enuresis), changes in speech (dysarthria), and gait instability (ataxia).

10

A 35-year-old man complains of severe throbbing pain waking him from sleep at night and persisting into the day. This pain is usually centered about his left eye and appears on a nearly daily basis for several weeks or months each year. It occurs most prominently at night within a few hours of falling asleep and is associated with a striking personality change in
which the man becomes combative and agitated. He never vomits or devel-ops focal weakness. (SELECT 1 DIAGNOSIS)
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is b. ( Victor, pp 189–191.) The term cluster headache refers to the tendency of these headaches to cluster in time. They may be dis-tinctly seasonal, but the triggering event is unknown. The pain of cluster headache is usually described as originating in the eye and spreading over the temporal area as the headache evolves. In contrast to migraine, men are more often affected than women, and extreme irritability may accompany the
headache. The pain usually abates in less than 1 h. Affected persons routinely have autonomic phenomena associated with the headache that include uni-lateral nasal congestion, tearing from one eye, conjunctival injection, and
pupillary constriction. The autonomic phenomena are on the same side of the face as the pain. These phenomena are similar to those elicited by the local action of histamine and gave rise to the now largely abandoned term Horton’s histamine headaches

11

A 76-year-old man complains of dull left-sided head pain with some radiation of the discomfort to the right side of the head. He has no nausea
or vomiting with the pain, but has lost 10 lb over the previous 2 months. His erythrocyte sedimentation rate is 102 mm/h, and he is mildly anemic. An extensive investigation for malignancy reveals no signs of lymphoma,
carcinoma, or leukemia. (SELECT 1 DIAGNOSIS)
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is f.( Victor, pp 193–194.) Both men and women are at risk for temporal arteritis, and the greatest risk to both is loss of vision in association with the headache. The erythrocyte sedimentation rate is usu-ally dramatically elevated, and the abolition of symptoms with cortico-steroid therapy is equally dramatic. Temporal arteritis is largely nonexistent in persons under 50 years of age and rare in those under 60. Many patients
exhibit persistent fevers and progressive weight loss. The temporal arteries are likely to be pulseless or at least thickened. Biopsy of the artery often reveals a giant cell arteritis

12

An 81-year-old man with chronic lymphocytic leukemia develops pain and burning over the right side of his face. Within a few days, he develops a vesiculopapular rash in the distribution of the first division of the trigeminal
nerve. The vesicles become encrusted, and the burning associated with the rash abates. Within 1 month the rash has largely resolved, but the man is left with a dull ache over the area of the rash that is periodically punctuated by shooting pains. Imipramine 100 mg nightly helps reduce the intensity of the chronic pain. (SELECT 1 DIAGNOSIS)
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is j. ( Victor, pp 198–199.) The rash preceding the facial pain was probably caused by herpes zoster, a virus that erupts in the severely ill elderly and in immunosuppressed persons. The virus is manifested earlier in life as chickenpox and remains dormant for decades in most people. Tricyclic drugs, such as imipramine hydrochloride, are often more useful than analgesics in suppressing the pain associated with this postviral syndrome.

13

An 81-year-old man with chronic lymphocytic leukemia develops pain and burning over the right side of his face. Within a few days, he develops a vesiculopapular rash in the distribution of the first division of the trigeminal
nerve. The vesicles become encrusted, and the burning associated with the rash abates. Within 1 month the rash has largely resolved, but the man is left with a dull ache over the area of the rash that is periodically punctuated by shooting pains. Imipramine 100 mg nightly helps reduce the intensity of the chronic pain. (SELECT 1 DIAGNOSIS)
a. Classic migraine
b. Cluster headache
c. Common migraine
d. Trigeminal neuralgia
e. Sinusitis
f. Temporal arteritis
g. Vertebrobasilar migraine
h. Hemiplegic migraine
i. Atypical facial pain
j. Postherpetic neuralgia

The answer is j. ( Victor, pp 198–199.) The rash preceding the facial pain was probably caused by herpes zoster, a virus that erupts in the severely ill elderly and in immunosuppressed persons. The virus is manifested earlier in life as chickenpox and remains dormant for decades in most people. Tricyclic drugs, such as imipramine hydrochloride, are often more useful than analgesics in suppressing the pain associated with this postviral syndrome.

14

A 22-year-old woman reports a scotoma progressing across her leftvisual field over the course of 30 min, followed by left hemicranial throb-bing pain, nausea, and photophobia. Her brother and mother have similar headaches. Which of the following is present in classic migraine but not in common migraine?
a. Photophobia
b. Familial pattern
c. Visual aura
d. Hemicranial pain
e. Nausea

The answer is c.( Victor, pp 180–181.) Classic migraine, but not com-mon migraine, is preceded by an aura of neurologic dysfunction. The aurais most often visual in nature, consisting of bright flashing lights, scintillat-ing scotomas, or field cuts. Both kinds of migraine are most often charac-terized by a hemicranial throbbing headache associated with nausea, vomiting, photophobia, and phonophobia (aversion to sound). Familial
patterns are not unusual with either classic or common migraine, although with classic migraine the probability that another family member will have a similar problem approaches 80%

15

103. An obese 37-year-old woman complains of daily headache, worse in the morning, for 1 year. She has episodes of transient visual obscurations affecting each eye, and also complains of pulsatile tinnitus. Examination
is notable for bilateral papilledema. There are no other abnormalities. (SELECT 1 DIAGNOSIS)
a. Carotid artery dissection
b. Pseudotumor cerebri
c. Glioblastoma multiforme
d. Thunderclap headache
e. Analgesic rebound headache
f. Paroxysmal hemicrania
g. Raeder syndrome
h. Intracranial hypotension
i. Posttraumatic headache
j. Aseptic meningitis

The answer is b.( Victor, p 194.) Pseudotumor cerebri, or idiopathic intracranial hypertension, is a condition of unknown cause that results in
increased intracranial pressure, predominantly affecting obese women in their childbearing years. Symptoms include headaches, transient visual ob-scurations, progressive visual loss, pulsatile tinnitus, diplopia, and shoulder and arm pain. Neurological examination shows papilledema or optic atro-phy if the syndrome has been long-standing, and occasionally sixth-nerve palsies may be present. Neuroimaging must be performed to exclude mass lesion or venous sinus obstruction, which can also lead to a similar syn-drome of intracranial hypertension. Spinal fluid examination should be normal except for an elevated opening pressure. Additional causes of intracranial hypertension include systemic lupus erythematosus, renal disease, hypoparathyroidism, radical neck dissection, vitamin A intoxication, and steroid withdrawal. Treatment options include lumbar puncture, ven-triculoperitoneal shunting, and optic nerve sheath fenestration.

16

A 42-year-old man presents with a sudden and severe headache asso-ciated with nausea. The headache reaches maximal intensity within 5 s. He has no prior history of headache. Examination is unremarkable. Computed
tomography and spinal fluid examination show no evidence of blood. He later admits that he had been engaged in sexual activity when the headache occurred. (SELECT 1 DIAGNOSIS)
a. Carotid artery dissection
b. Pseudotumor cerebri
c. Glioblastoma multiforme
d. Thunderclap headache
e. Analgesic rebound headache
f. Paroxysmal hemicrania
g. Raeder syndrome
h. Intracranial hypotension
i. Posttraumatic headache
j. Aseptic meningitis

The answer is d.( Bradley, p 1837.) Thunderclap headache refers to the syndrome of the sudden onset of a very severe headache with no appar-ent structural cause. When a patient presents with “the worst headache of
my life,” the initial concern should always be for a subarachnoid hemor-rhage, particularly in the presence of meningismus, focal deficits, or a
change in the level of consciousness. Computed tomography scanning is indicated to exclude hemorrhage, but because CT may be negative in up to 5 to 10% of cases of subarachnoid hemorrhage, lumbar puncture is neces-sary if CT is negative to exclude small amounts of blood. Some reports have suggested that even in the absence of blood on a lumbar puncture, an un-derlying aneurysm may still be the cause of acute, severe headache, because sudden changes in the wall of the aneurysm may provoke severe pain. These reports would suggest that angiography should be performed in all such patients to exclude aneurysm. It remains unknown, however, whether these cases represent coincidental occurrence of thunderclap headache and an incidental, asymptomatic aneurysm. Several series have shown that many patients with thunderclap headache tend to go on to develop more typical migraine, raising the possibility that the thunderclap headache is simply the initial presentation of their migraine.

17

A 29-year-old man relates that he has had recent headaches only when standing up. The headaches resolve quickly when he lies down, and are accompanied by mild nausea. His examination is normal. (SELECT 1 DIAGNOSIS)
a. Carotid artery dissection
b. Pseudotumor cerebri
c. Glioblastoma multiforme
d. Thunderclap headache
e. Analgesic rebound headache
f. Paroxysmal hemicrania
g. Raeder syndrome
h. Intracranial hypotension
i. Posttraumatic headache
j. Aseptic meningitis

The answer is h. ( Victor, pp 670–671.) Headaches that occur on standing indicate the presence of intracranial hypotension. Most often, this is the result of recent lumbar puncture, either for diagnostic purposes or after
spinal anesthesia. The hole in the dura created by the spinal tap presumably allows fluid to continue leaking out, and this creates a condition of decreased pressure within the spinal canal, which causes traction on the pain-sensitive meninges of the brain. Other causes of intracranial hypotension include con-tinued leak of CSF from the subarachnoid space after head trauma, neuro-surgery, or even pneumonectomy (thoracoarachnoid fistula); occult pituitary tumor; a leak from a dural tear in the spinal root sleeves; traumatic nerve root
avulsion; or systemic illness such as dehydration, diabetic coma, uremia, or
meningoencephalitis. With leakage of CSF into nasal passages, the patient may complain of rhinorrhea. In some cases, no cause is apparent even after a thorough evaluation.