Stroke Wrap up/ Headache - Rothrock

Question 1

what are the two subtypes of hemorrhagic stroke/

Answer 1

SAH

ICH

Question 2

what are the two types of ischemic stroke?

Answer 2

embolic

thrombotic

Question 3

A (thrombotic/emoblic) stroke may be characterized by the size of vessel it originates in

Answer 3

thrombotic

Question 4

HA can be secondary to…

Answer 4

SAH
Meningitis
Abnl ICP
Intracranial hematoma
Ischemic stroke
Tumor
Abscess
other

Question 5

what is the hallmark of a low ICP HA?

Answer 5

okay lying flat, bad HA when standing up

Question 6

what are some of the causes of thunderclap HA?

Answer 6

Aneurysmal rupture
Cerebral sinus thrombosis
Acute intracranial hypotension/CSF oligemia
Carotid artery dissection
Pituitary apoplexy
Unruptured aneurysm (?expansion,thrombosis)
Sexual headache (“explosive” type)/exertional
Crash migraine
Benign (idiopathic) thunderclap headache

Question 7

what are the cuases of primary thunderclap headache?

Answer 7

sexual HA

exertional HA

Question 8

what is the most common cause of thunderclap HA?

Answer 8

crash migraine

Question 9

can you Dx headache over the phone or via proxy?

Answer 9

no

Question 10

What things should you do on physical exam for HA?

Answer 10

check eyes: fundi, pupils, visual fields
BP
gait

Question 11

(side-locked/global) HA is concerning

Answer 11

side-locked

Question 12

what is the most common Dx for pts present with a CC of HA?

Answer 12

migraine

Question 13

if a pt. meets the ICHD criteria for migraine and there are no red flags and the neuro exam is normal, what will imaging show?

Answer 13

a normal brain

Question 14

what are the causes of primary headache?

Answer 14

tension-type headache
migraine
cluster
paroxysmal hemicrania
hemicrania continua
hypnic (“alarm clock”) headache
others

Question 15

what are the things to look for when trying to figure out if someone has a secondary headache?

Answer 15

acute onset or thunderclap
>55
occipto-nuchal location
abnormal exam

Question 16

what is the ICHD criteria for migraine?

Answer 16

5 or more attacks: unprovoked, 4-72hr duration, prohibit/significantly inhibit routine activities, nausea and/or photo/sonophobia

Question 17

what causes migraine?

Answer 17

genetically induced neuronal hypersensitivity

Question 18

the (blank) nucleus receives afferent messages and acts as a sensory relay center

Answer 18

trigeminal nucleus caudalis

Question 19

pain receptors on the (blank) vessels activate primary afferent neurons of the trigeminal nerve

Answer 19

dural blood vessels

Question 20

PANs coming from the dural blood vessels first pass through the (blank) before synapsing in the TNC

Answer 20

pons

Question 21

After synapsing in the TNC, pain signals then synapse where?

Answer 21

posterior third of the thalamus

Question 22

After synapsing in the thalamus, pain signals go where?

Answer 22

post central gyrus, cingulate gyrus, and hypothalamus

Question 23

Is the pain pathway in migraine wired in series or in parallel?

Answer 23

series

Question 24

what part of the cortex is sensitized in migraine?

Answer 24

occipital cortex

Question 25

What are the kinds of things that can cause the neurons to depolarize in migraine?

Answer 25

sleep deprivation stress change in barometric pressure menstrual cycle

Question 26

After neurons depolarize, what happens in migraine?

Answer 26

they hyperpolarize and go electrically silent First you get a aura like a flash, then as it moves across your vision you get a blind spot in its wake. Positive phenomena from depolarizing and black spot from hyperpolarized

Question 27

what is it called when you get a black spot following a aura like flash/

Answer 27

cortical spreading depression

Question 28

Cortical spreading depression causes pain in (anterograde/retrograde)

Answer 28

retrograde

Question 29

cortical spreading depression releases (blank) at the dural vessel receptors

Answer 29

neuropeptides

Question 30

release of neuropeptides at the dural vessel receptors causes the vessels to release (blank and blank)

Answer 30

bradykinin and histamine

Question 31

the release of histamine and bradykinin causes (anterograde/retrograde) pain transmission back up the brain

Answer 31

anterograde

Question 32

what are the two determining factors in the development of migraine?

Answer 32

the combo genetics and epigenetics (aka childhood abuse)

Question 33

when are migraines the worst in females?

Answer 33

menarche pregnancy just before menopause

Question 34

if the sensitization process of migraine is allowed to advanced unchecked, (blank) will be increasingly difficult to attain

Answer 34

stabilization

Question 35

Where would you want to have a drug target in the CNS to act on migraine?

Answer 35

trigeminal nucleus caudalis

Question 36

what types of receptors are in the TNC?

Answer 36

5-HT

Question 37

what stops cortical spreading depression?

Answer 37

GABA

Question 38

(blank) is an AED that can be used for migraine prophylaxis

Answer 38

topiramate

Question 39

what are the pharmacologic characteristics you need to consider when using a drug to treat migraine?

Answer 39

``` inherent efficacy of drug stage of attack when drug is administered drug’s T max drug’s C max drug’s ability to reach receptors drug’s affinity for those receptors ```

Question 40

What drugs are best used for acute Tx of migraine?

Answer 40

[NSAIDS, triptans, ergotamines/dihydroergotamine, opiates/opioids]

Question 41

What are the drugs you should consider for preventative migraine Tx?

Answer 41

``` beta blockers, specifically propanolol TCAs AEDs Botox gabapentin ```

Question 42

What is the only FDA approved drug for chronic migraine Tx?

Answer 42

botox