Headache

Question 1

What proportion of migraine patients have a unilateral character?

Answer 1

2/3

Question 2

Identify which primary headache

1. Onset in the wee hours of the morning or in the daytime
2. Lasts for 4-24 hours
3. Appears after falling asleep as severe unilateral orbitotemporal pain

Answer 2

1. Onset in the wee hours of the morning or in the daytime: MIgraine
2. Lasts for 4-24 hours: Migraine
3. Appears after falling asleep as severe unilateral orbitotemporal pain lasting 30-45 minutes: Cluster

Question 3

Enumerate ALL the pain sensitive structures of the head:

Answer 3

1. Skin, subcutaneous tissue, muscles, extracranial arteries, external periosteum
2. Eye, ear, nasal cavity, paranasal sinuses
3. Intracranial venous sinuses and tributaries
4. Dura at the base of the brain, arteries in the dura– proximal ACA, MCA and intracranial ICA
5. MIddle meningeal and superficial temporal arteries
6. Cervical nerves 1, 2, 3 and cranial nerves as they pass the dura

Question 4

T or F: Pia arachnoid, parenchyma, and ependyma and choroid plexus LACK SENSITIVITY

Answer 4

T

Question 5

Identify where pain is referred in the following instances:

1. Pain from middle meningeal artery distention
2. Pain from intracranial ICA and proximal MCA and ACA
3. Supratentorial structures
4. Ingratentorial structures

Answer 5

1. Pain from middle meningeal artery distention: back of they eye and temporal area
2. Pain from intracranial ICA and proximal MCA and ACA: eye and orbitotempora regions
3. Supratentorial structures: V1 and 2 area
4. Infratentorial structures: referred to the vertex and back of the head and neck by the second cervical roots

Question 6

What nerves innervate?

1. Nasoorbital region
2. Inferior temtorium and posterior fossa
3. Forehead, orbit, anterior and middle fossae and upper part of the tentorium

Answer 6

1. Nasoorbital region: Spenopalatine branches of the CN7
2. Inferior temtorium and posterior fossa: CN9 and 10
3. Forehead, orbit, anterior and middle fossae and upper part of the tentorium: CN V1 and V2

Question 7

T or F: The tentorium roughly demarcates the trigeminal from the cervical-vagal-glossopharyngeal zones

Answer 7

T

Question 8

What are the only 2 structures that extracranial but have referred pain to the head?

Answer 8

Cervical portion ICA: pain in supraorbital region/ eyebrow

Upper cervical spine: pain at occiput

Question 9

Where are these vascular pain felt?

1. Vertebral artery dissection:
2. Basilar artery thrombosis
3. Carotid artery or MCA:

Answer 9

1. Vertebral artery dissection: Upper neck of post-auricular area
2. Basilar artery thrombosis causes pain to be projected to the occiput
3. Carotid artery or MCA: Forehead and ipsilateral brow

Question 10

Why are patients post LP encouraged to lay flat on their back?

What is the treatment for post LP headache?

Answer 10

They may develop post LP headache. There can be a persistent leakage of CSF into the lumbar tissues through the needle track.

Blood patch

Question 11

What types of headache are worse on recumbency?

Answer 11

Subdural
Tumor of the posterior fossa
Idiopathic intracranial hypertension

Question 12

What are the 2 types of migraine? Which is classic and which is common?

Answer 12

Migraine with aura and migraine without aura

Classic and common

1:5 incidence

Question 13

Which type of migraine has a strong familial tendency of about 60-80% inheritance?

Answer 13

Classic

Migraine with aura

Question 14

How to differentiate focal neurologic symptoms migraine from that of TIA or a seizure?

Answer 14

TIA: All body parts involved suddenly
Migraine: Slow spread from one body part to another over minutes
Seizure: Spread to body parts is over seconds

Question 15

What is the most common genetic pathology for familial hemiplegic migraine?

Answer 15

1. P/Q-type calcium channe alpha subunit CACNA1A
2. Less common second locus in the gene for Na/K ATPase channel
3. Rare: SCNA1 alpha subunit gene

Question 16

During in an aura what can be seen on PET scan?

Answer 16

Decreased blood flow to the occipital lobes– then there is a 2.2mm/min forward spreading cortical depression (oligemia)

Question 17

What theory is proposed by Moskowitz to explain migarine PP?

How about the Harold Wolff hypothesis?

How about the Woods and Lashley hypothesis?

Answer 17

Moskowitz: Activation of the unmyelinated fibers trigeminal nerve fibers innervating the extracranial and intracranial vessels (trigeminovascular complex) that results in the release of substance P, calcitonin related peptide on the vessel wall– sensitizing these vessels to the pulsatility of cranial vessels and to increase their permiability thereby promoting an inflammatory response

Wolff: Headache is caused by the distention and excessive pulsation of the branches of the external carotid artery

W and L: Spreading cortical depression from reduced blood flow

Question 18

What is the MOA of

1. Triptans
2. Ergotamines

Answer 18

1. Triptans: Serotonin agonists

2. Ergotamines: Alpha adrenergic agonist with strong serotonin receptor affinity and vasoconstricting action

Question 19

For preventive migraine therapy:

1. How is propranolol given?
2. What medications can be given for perimenstrual migraine?

Answer 19

1. Start 10mg to 20mg per tab 3x per day until 240mg per day

2. Isometheptene, indomethacin, cyproheptadine

Question 20

What are the serious complications with the use of Methysergide, an ergot derivative?

Answer 20

Retroperitoneal and pulmonary fibrosis

Question 21

Give examples of indomethacin responsive headaches.

Answer 21

Valsalva related headaches
Trigeminal autonomic cephalgias
Short lasting unilateral neuralgiform attacks with conjunctival injection and tearing (SUNCT)
Stabbing headaches

Question 22

What is aka as: paroxysmal nocturnal cephalgia, migranous neuralgia, histamine cephalgia (Horton’s headache)?

Answer 22

Cluster headache

Question 23

What vasomotor phenomena are associated with cluster headaches?

Answer 23

Blocked nostril
Rhinorrhea
Injected conjunctivum
Lacrimation
Miosis
Flush and edema of the cheek
Ptosis

Lasting 45mins

Question 24

Describe the sxs:

1. Tolosa Hunt
2. Paratrigeminal syndrome of Raeder

Answer 24

1. Tolosa Hunt: eye pain and ocular motor paralysis caused by dural granuloma at the orbital apex
2. Paratrigeminal syndrome of Raeder: Paroxysms of pain somewhat like that of tic douloureux in the distribuition of the ophthalmic and maxillary (V1 and V2) divisions of the fifth nerve in association with unilateral Horner syndrome (Ptosis and miosis)– may be associated with ICA dissection

Compare with trigemnial neuralgia that affects V2 and V3 more commonly

Question 25

What is Gardner's theory regarding the PP of cluster headache?

Answer 25

Paroxysmal parasympathetic discharge mediated through the greater superficial petrosal nerve and sphenopalatine ganglion

Question 26

What are the "shorter" versions of cluster headache?

Answer 26

1. Chronic paroxysmal hemicrania | 2. SUNCT (Short lasting unilateral neuralgiform attacks with conjunctival injection and tearing)

Question 27

What is the treatment for cluster headache?

Answer 27

1. 100% O2 via face mask for 10 to 15 mins 2. Verapamil 3. Sumatriptan and ergots can also be used to abort attacks 4. Preventive therapy is anticipatory dose of ergotamine at bedtime

Question 28

What is the most common variety of headache?

Answer 28

Tension headache

Question 29

What is the PP of tension headache?

Answer 29

Hardened pericranial and trapezius muscles

Question 30

What drugs can be given on top of NSAIDs for tension type headaches?

Answer 30

Amitryptyline. Given as a single dose at night.

Question 31

Where is pain felt for tumors: 1. Supratentorial 2. Infratentorial

Answer 31

S: Anterior to the interauricular circumference of the skull P: Posterior to this line

Question 32

What is the most serious complication of giant cell temporal arteritis?

Answer 32

Blindness from thrombosis of the ophthalmic or posterior ciliary arteries

Question 33

The earliest suspicion of cranial arteritis should lead to administration of?

Answer 33

Corticosteroids and then biopsy of the scalp artery

Question 34

What can be given 3 days before the onset of catamenial migraine?

Answer 34

1. NSAIDS | 2. Sumatriptan 25mg QID

Question 35

What is recommended for exertional headaches and repeated coital headache?

Answer 35

Indomethacin

Question 36

What are the causes of thunderclap headache besides SAH or accelerate hypertension (DBP>120)?

Answer 36

``` Diffuse cerebral vasospasm (aka Call Fleming syndrome/ REVERSIBLE cerebral vasconstrictino syndrome) Pituitary apoplexy Perimesencephalic non-aneurysmal SAH CVT Migraine ```

Question 37

What is the common location for trigeminal neuralgia?

Answer 37

V2 and V3

Question 38

T or F: Sensory and motor deficits are not seen in trigeminal neuralgia

Answer 38

T-- only in a minority of cases are they invovled Pain is only a few seconds or up to a minute so that the patient winces hence "tic" douloureux

Question 39

What percentage of TN patients benefit with CBZ alone? At what does?

Answer 39

70-80% | 600-1200mg per day

Question 40

What areas hurt in glossopharyngeal neuralgia? AKA as vagoglossopharynteal neuralgia

Answer 40

Throat and ear (by auricular branch of the vagus nerve) May be accompanied by bradycardia and syncope by triggering the cardioinhibitory reflexes by afferent vagal pain impulses

Question 41

What is the etiology of the Ramsay Hunt Syndrome?

Answer 41

Herpes zoster auricularis Varicella Herpes shingles rash of the external auditory meatus, pinna with or without deafness, tinnitus and vertigo-- COMBINED WITH FACIAL PARALYSIS

Question 42

Where is the most common location of herpes zoster of the gasserian ganglion?

Answer 42

Ophthalmic division (V1) Pain 4-5 days before onset of rash Compare with paratrigeminal syndrome of Raeder that affects V1 and V2 primarily and trigeminal neuralgia that affects V2 and V3.

Question 43

What can be given with acyclovir for herpes zoster?

Answer 43

Amitriptyline and fluoxetine

Question 44

What should symptom should be suspected with focal neck pain, localized headache over an eye and corresponding neuro signs: Horner's, ischemia?

Answer 44

Arterial dissection

Question 45

What is Costen syndrome?

Answer 45

Temporomandibular joint pain

Question 46

What are the symptoms of Tolosa Hunt Syndrome?

Answer 46

Pain behind the eye with invovlement of the CN 3,4,6,V1 | caused by dural granuloma at the orbital apex