Headaches (secondary HAs)- MJ

Question 1

The following are possible etiologies of what group of headaches?

• Trauma/injury to head/neck
• Cranial or cervical vascular disorder
• Non-vascular intracranial disorder
• A substance or its withdrawal
• Infection
• Disorder of homeostasis
• Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or cervical structure
• Psychiatric disorder

Answer 1

Secondary headaches

Question 2

Who does pseudotumor cerebri (AKA idiopathic intracranial HTN) primarily affect?

Answer 2

women of childbearing age who are overweight

Question 3

What is the eitiology of pseudotumor cerebri?

Answer 3

chronically elevated intracranial pressure (ICP)

Question 4

What are the 3 possible causative medications of Pseudotumor Cerebri?

Answer 4

1. Growth hormone
2. Tetracyclines
3. Hypervitaminosis A

Question 5

What are the 9 conditions that are possibly related to Pseudotumor Cerebri?

Answer 5

1. Addison Disease
2. Hypoparathyroidism
3. Anemia

4. Sleep apnea

5. SLE (Lupus)
6. Behcet’s syndrome

7. PCOS

8. Coagulation disorders
9. Uremia

Question 6

What is the MC presentign symptom of a patient with Pseudotumor Cerebri?

Answer 6

Headache (sxs vary)

Question 7

What can cause headache with vision loss?

Answer 7

Pseudotumor Cerebri

Question 8

The following are associated sxs of what condition?

• Transient visual obscurations
• Intracranial noises (pulsatile tinnitus)
• Photopsia
• Back pain
• Retrobulbar pain
• Diplopia
• Sustained visual loss

Answer 8

Pseudotumor Cerebri

Question 9

What are the 4 physical exam findings of someone w/ Pseudotumor Cerebri?

Answer 9

1. Obesity
2. Papilledema
3. Visual field loss
4. Abducens (CN VI) palsy

Question 10

How do you diagnose Pseudotumor Cerebri?

Answer 10

• Clinical presentation suggesting increased ICP
• LP- Opening pressure showing elevated ICP w/ normal CSF
• MRI w/ MR venography to r/o secondary causes

Question 11

What are the 6 treament options for a patient w/ Pseudotumor Cerebri?

Answer 11

1. Weight loss for obese patients
2. Decrease sodium intake
3. Acetazolamide (Carbonic anhydrase inhibitors)-> reduce rate of CSF production
4. Furosemide (Loop diuretics)–> adjunct to Acetazolamide
5. Serial LPs (can be bridge to sx)
6. Surgery (optic nerve fenestration, CSF shunting)

Question 12

What medication is no longer recommended for tx of Pseudotumor Cerebri?

Answer 12

Corticosteroids

Question 13

What 2 pharmacologic medications can be used to tx Pseudotumor Cerebri?

Answer 13

• Acetazolamide (carbonic anhydrase inhibitor)–> reduce rate of CSF production
• Furosemide (adjunct to acetazolamide)

Question 14

Which 3 acute symptomatic headache medications are most commonly realted to medication overuse headache?

Answer 14

• Opioids
• Butalbital / analgesic combinations
• Aspirin / acetaminophen / caffeine combinations

Question 15

What 3 underlying behavioral disorders should you consider when diagnosing a headache as a medication overuse headache?

Answer 15

1. Addictive personalities
2. Depression
3. Anxiety

Question 16

Medication overuse headache:

Although severity, location and HA pattern varies significantly, what 5 associated sxs may be present?

Answer 16

1. Nausea
2. Asthenia
3. Difficulty Concentrating
4. Memory Problems
5. Irritability

Question 18

The following is criteria for diagnosing which type of headache?

• HA occurring on 15+ days/month in a patient with a pre-existing HA disorder who is:
  
  • Taking combo meds or prescription meds (triptans, ergotamines, etc) for ≥10 days/month x >3 months OR
  • Regular intake of simple analgesics (ie, acetaminophen, aspirin, or NSAID) ≥15 days/month x >3 months

Answer 18

Medication Overuse Headache

Question 19

What are the 5 treatment options for Medication Overuse Headache?

Answer 19

1. Discontinue medication
2. Rescue abortive therapy ≤ 2 days/week with a medication class different than overused med
3. Prophylactic therapy for the original primary h/a disorder
4. +/- bridge therapy
5. Patient education

Question 20

• What age is it rare to see temporal arteritis?
• When is the peak incidence?

Answer 20

• Rare < 50y/o
• Peak incidence= 70-79y/o

Question 21

What are the 4 most common symptoms of Temporal Arteritis (AKA “Giant Cell Arteritis”)

Answer 21

1. Temporal/occipital HA (throbbing/continuous)
2. Neck, torso, shoulder, and pelvic girdle pain (consistent with polymyalgia rheumatica)
3. Jaw claudication
4. Fever

(can also have constitutional sxs- malaise, weight loss, etc)

Question 22

The following is the clinical presentation of what condition?

• ~1/2 have tenderness over superficial temporal artery
• Nodularity/thickening of the superficial temporal artery
• Gentle pressure on scalp may elicit pain
  *

Answer 22

Temporal Arteritis

Question 23

If a patient has Temporal Arteritis, what would labs show?

Answer 23

• Elevated ESR and C-reactive protein
• ESR usually > 50 mm/h (but may be normal)
• ESR does not correlate well with severity of disease

Question 24

If you suspect a patient has Temporal Arteritis, what diagnostic procedure should be performed?

Answer 24

• Temporal artery biopsy (positive result is 100% specific)

Question 25

If you seriously suspect a patient has temporal arteritis, when should treatment be started?

Answer 25

**Before** temporal artery **biopsy** is performed (start tx right away b/c this condition is vision threatening- confirm w/ biopsy)

Question 26

What is treatment for Temporal Arteritis?

Answer 26

* **_High dose Corticosteroids_** (Prednisone) * Tx continued long enough for sxs to resolve * taper initiated when signs of clinical inflammation are suppressed and ESR/CRP remain low

Question 27

In a patient with Temporal Arteritis, when should you see **improvement of systemic symptoms** after being treated w/ high-dose corticosteroids (Prednisone)?

Answer 27

**72 hours** (if no improvement at this point then reconsider dx)

Question 28

What is Trigeminal Neuralgia?

Answer 28

•**Compression of trigeminal nerve root** * MC aberrant loop of an artery or vein (80 to 90% of all cases)

Question 29

* What ages is Trigeminal Neuralgia most common in? * Before what age is it uncommon?

Answer 29

* Peak incidence= **60-70y/o** * Uncommon \< 40y/o

Question 30

Trigeminal Neuralgia is 20x more prevalent in patients with what disease?

Answer 30

**_Multiple Sclerosis_** | (this will be on exam)

Question 31

Which branch of the Trigeminal Nerve is most commonly affected in Trigeminal Neuralgia?

Answer 31

V3

Question 32

In what condition will the patient complain of severe "sharp" pain with benign tactile stimuli like light touch, shaving, wind blowing?

Answer 32

**Trigeminal neuralgia** (hyper excitability over select Trigger Zones

Question 33

The following are clinical features of what condition? * **Sharp electric shock pain** lasting few seconds to several minutes (V2 and/or V3, less likely V1) * Pain may be **triggered by simple actions** (chewing, brushing teeth, puffs of air…) * Overtime duration of remission periods shortens * No clinically evident neurologic deficit

Answer 33

Trigeminal Neuralgia

Question 34

How is the diagnosis of Trigeminal Neuralgia made?

Answer 34

* **Clinical diagnosis** based upon history physical exam * **MRA with gadolinium** visualize neurovascular compression

Question 35

What are the 3 red flags for Trigeminal Neuralgia indicating a worse prognosis/difficulty treating?

Answer 35

1. Trigeminal Sensory loss 2. Bilateral Sxs 3. \<40y/o

Question 36

The following is criteria for what condition? A. **\>3 attacks of unilateral facial pain:** * Occurring in **1+ divisions of the trigeminal nerve,** with **no radiation beyond the trigeminal distribution**

Answer 36

Trigeminal Neuralgia

Question 37

What is first line tx for Trigeminal Neuralgia

Answer 37

**Carbamazepine** (titrate slowly)

Question 38

What type of medications are rarely effective in treating trigeminal Neuralgia?

Answer 38

Narcotics

Question 39

Which treatment for Trigeminal Neuralgia has the best long-term outcome? (70% pain free in 10 years)

Answer 39

Surgery- **Microvascular decompression**