LE 3: Approach to a Patient with Headache

Question 0

ushered in by an evident disturbance of nervous function, most often visual, followed in a few minutes by hemicranial or in about 1/3 of cases by bilateral headache, nausea, and sometimes vomiting, all of w/c last for hrs or as long as day or 2

Answer 0

Migraine w/ aura

“classic” or Neurologic migraine

Question 1

familial d/o, periodic, unilateral, often pulsatile, begin with childhood or early adulthood and diminishing in frequency during advancing years

Answer 1

Migraine

Question 2

unheralded onset over mins or longer of hemicranial headache or less often, by generalized headache w/ or w/o nausea and vomiting, w/c then follows the same temporal pattern as the migrain w/ aura

Answer 2

Migraine w/o aura

“common” migraine

Question 3

1:5

male: 4-6%
female: 13-18%

asians: lower prevalence

Answer 3

Migraine

Question 4

is an instrument often used for verbal assessment of pain

Answer 4

The McGill Pain Questionnaire

Question 5

common clinical complaint w/c rivals backache as a reason to seek medical help

Answer 5

Headache

Question 6

headache:

medical vs neurologic dses

Answer 6

medical > neurologic dses

Question 7

epidemiology: young women w/ family hx of migraine

s/sx: 
    vertigo
    incoordination
    staggering
    incoordination of limbs
    dysarthria

visual phenomena: whole visual field of OU (temp. cortical blindness)

duration: 10-30mins followed by headache

Answer 7

Basilar Migraine

Question 8

s/sx: recurrent unilateral headache assoc w/ weakness of EOM

CN affected w/ manifestion :
transient 3rd nerve palsy w/ ptosis w/ or w/o pupillary involvement
6th nerve rarely affected

duration: paresis often outlast the headache by days or weeks

Answer 8

Opthalmoplegic Migraine

Question 9

most common variety of headache, frontal, temporal or occipitonuchal predominance, pain is dull and aching, sometimes described as fullness, tightness/pressure, does not interfere w/ ADL

middle age w/ anxiety, fatigue, and depression

Answer 9

Tension-Type Headache (TTH)

Question 10

Frequency:

least 10 previous headaches fulfilling crit B-D

Answer 10

Frequent TTH

Question 11

frequency:
ave. > or = to 15d/mo. (180d/yr) for > = 6 mos fulfilling crit. C-D

at least 2 pain char:

1. Pressuring/tightening (nonpulsating) quality
2. Mild-moderate intensity
3. Bilateral location
4. no aggravation by walking stairs or similar routine, physically activity

both of the ff:

1. no vomiting
2. no more than one of the ff:
   a. nausea
   b. photophobia
   c. phonophobia
3. not attributed to any d/o

Answer 11

Chronic TTH

Question 12

Paroxysmal hemicrania, short-acting unilateral neuralgiform headache attacks w/ conjunctival infection and tearing(SUNCT)

young adult men (20-50yo)
M:F 5:1
occur regularly each day for 6-12 weeks

Answer 12

Cluster headache and other trigeminal autonomic cephalgias

Question 13

severe, chronic, intermittent
days or weeks
r/t injury

Answer 13

post-traumatic

Question 14

headache w/:
   Drowsiness
   Confusion
   Stupor
   Hemiparesis

Answer 14

Post-traumatic:

Acute/Chronic

Question 15

Headache is a prominent ft. complex syndrome:
  Giddiness
  Insomnia
  Fatigability
  Irritability
  Nervousness
  Inability to concentrate
  Trembling
  Tearfulness

Answer 15

Post-traumatic nervous instability

Question 16

unilateral/bilateral retroauricular or occipital pain d/t stretching or tearing of the ligaments and muscles of occipitonuchal junxn

Answer 16

Post-traumatic:

whiplash injury

Question 17

severe, episodic, throbbing, unilateral headache sometimes accompanied by ipsilateral mydriasis and excessive sweating of the face

Answer 17

Post-traumatic:

dysautonomic changes

Question 18

infrequent headache
deep seated
non-throbbing
aching
nocturnal awakening
inc. ICP
dependent on tumor site

Answer 18

Brain tumor:

non specific features

Question 19

Increasingly intense throbbing or non-throbbing, unilateral and localized to the affected artery, pain persistent throughout the day and severe at night, ESR >50mmH, elderly pt (60yo) Biopsy of affected vessel is granulomatous or giant cell arteritis, tx w/ steroids improvement in 1-2days. failure to improve will bring dx into question

Answer 19

Temporal Arteritis

Question 20

headache assoc w/ greatly reduced pressure of CSF compartment and probably caused by traction of cranial blood vessels

Answer 20

Low pressure and spinal puncture headache

Question 21

headache d/t drop in estradiol levels

Answer 21

Menstrual migraine

Question 22

Generalized headache may occur in conjunxn w/ flushing of the face and hands and numbness of fingers

Answer 22

Erythrocyanotic

Question 23

follows in initiating action within a second or two, last a few seconds to few minutes

Answer 23

Cough and exertional headache

Question 24

headache w/ sexual excitement - TTH headache w/c occur at time of orgasm - explosive, severe and throbbing type

Answer 24

Headache r/t sexual activity

Question 25

danger signals on Examination VSP RPM LART

Answer 25

``` VSP RPM LART abnormal V/s altered Sensorium Pupils unequal and/or poorly reactive Retinal hemorrhage or Papilledema signs of Meningeal irritation Lateralized deficits Ataxia of gait and/or mov'ts abnormal Reflexes Tender and poorly-pulsating cranial arteries ```

Question 26

danger signals on Hx SPF O MMS WFC

Answer 26

SPF O MMS WFC ``` Sudden onset of new severe headache Progressively worsening headache First headache in an adult Onset w/ exertion, coughing, straining and sexual activity Memory loss Myalgia Sensorium alteration Weakness Fever Clumsiness ```

Question 27

pt. w/ serious headache PACISSCHM

Answer 27

PACISSCHM ``` Pheochromocytoma Acute glaucoma Cns infexn, ischemia, hemorrhage Inc. icp Sah Secondary to metabolic disturbance Cranial arteritis Head trauma Malignant hpn ```

Question 28

pt. w/ benign headache TOMBC

Answer 28

TOMBC ``` Tth Orgasmic headache Migraine Benign exertional headache Cluster ```

Question 29

what modality? ``` r/o structural d/o recurring or progressive headache focal slowing on EEG comorbid seizures persistent unilateral headache assure anxious pt or his relatives ```

Answer 29

Neuroimaging

Question 30

what modality? Loss of consciousness Depressed sensorium or alertness Seizure Suspected metabolic encephalopathy

Answer 30

Electroencephalogram

Question 31

what modality? Cervical spine Spine Parasinuses

Answer 31

X-ray

Question 32

what modality? Vertebral Intracranial Carotid Echogram

Answer 32

Ultrasound

Question 33

what modality? suspected MS, infiltrative or inflammatory process, inc or reduced icp

Answer 33

Lumbar Tap (CSF Analysis)