Headaches

Question 1

3 Primary Headache Syndromes

Answer 1

Migraine
Tension headache
Cluster headache

Question 2

Migraine symptoms

Answer 2

Unilateral, throbbing/pulsatile headache
Lasts 4 - 72h
Nausea/Vomiting
Photophobia
Visual changes (aura)
Light headedness
Paresthesia
Vertigo
Triggered (eg, menses, fatigue, hunger, stress)

Question 3

Acute migraine treatment

Answer 3

NSAIDs/Analgesics (shouldn’t need ≥2x/w, or you get rebound headache)

AND/OR

-Triptans (eg Sumatriptan) - 5HT agonists
Non-PO route if vomiting

AND/OR

IV Anti-emetics (eg prochlorperazine, metoclopramide)

Question 4

Migraine prevention

Answer 4

Amitriptyline
β-blockers (Metoprolol, Propranolol, Timolol)
Divalproex Sodium
Valproic Acid
Topiramate

Question 5

Tension headache symptoms

Answer 5

Bilateral, bandlike headache
Lasts 30m - 7d
Pericranial muscle tenderness
Constant & steady
\+/- photophobia or phonophobia

Question 6

Acute tension headache treatment

Answer 6

NSAIDs/Analgesics (shouldn’t need ≥2x/w, or you get rebound headache)

AND/OR

-Triptans (eg Sumatriptan) - 5HT agonists
Non-PO route if vomiting

AND/OR

IV Anti-emetics (eg prochlorperazine, metoclopramide)

This is the same as migraine

Also Antidepressants + stress management may work

Question 7

Tension headache prevention

Answer 7

Calcium Channel Blockers

β-blockers (Metoprolol, Propranolol, Timolol)

Question 8

Cluster headache symptoms

Answer 8

Unilateral, excruciatingly painful headaches
Repetitive & brief
Localized to retroorbital/orbital/temporal region
lasting 15m - 3h
M>F predominance
+/- ipsilateral autonomic sx (Horner syndrome!!!)

Question 9

Acute cluster headache treatment

Answer 9

100% O2 & 6L/m + Sumatriptan

Question 10

Cluster headache prevention

Answer 10

Verapamil
Lithium
Divalproex sodium
Ergotamine
Prednisone

Question 11

Pseudotumor cerebri

Answer 11

Benign/idiopathic intracranial hypertension

Question 12

Pseudotumor cerebri Epi

Answer 12

Young, overweight female

Question 13

Pseudotumor cerebri Pathophys

Answer 13

Exposure to provoking agent (eg steroids, vitamin A/isoretinoin, OCPs, growth hormone, tetracyclines)

vs

Idiopathic –> impaired absorption of CSF by arachnoid villi

Question 14

Pseudotumor cerebri clinical presentation

Answer 14

Headache suggestive of brain tumor
(intermittent, persistent, associated N/V, worse when lying down)

Vision problems
(transient vision loss, visual field defects, diplopia, CN6 palsy)

Increased ICP
(increased opening pressure, papilledema)

Question 15

Pseudotumor cerebri diagnosis

Answer 15

Symptoms
Normal MRI
Opening pressure >200
Otherwise normal tap

Question 16

Pseudotumor cerebri treatment

Answer 16

D/c offending medication (if applicable)

Weight loss & acetazolamide +/- furosemide

If these fail, try VP shunt or optic nerve sheath fenestration

Question 17

How does acetazolamide treat pseudotumor cerebri?

Answer 17

Inhibits carbonic anhydrase in the choroid plexus
CSF production decreases
+/- Furosemide diureses them and all is well

Question 18

Pseudotumor cerebri complications

Answer 18

Blindness

Question 19

Etiologies of intracranial hypertension

Answer 19

Trauma
Space-occupying lesion
Hydrocephalus\
Impaired CNS venous outflow
Idiopathic

Question 20

Intracranial hypertension clinical presentation

Answer 20

Headache that is worse:
At night
When coughing/sneezing
When leaning forward
On valsalva

Nausea/Vomiting
Altered mental status
Focal neurologic symptoms
palippedema on fundoscopy
Enlarged blind spots & momentary vision loss with some head positions

Question 21

Intracranial hypertension workup

Answer 21

Ophtho exam
MRI/CT
LP