89. Headache Disorders Flashcards

Question

Who CANNOT have sumatriptan?

Answer 1

coronary artery disease and should not be used within hours of administration of an ergotamine containing meds

Answer 2

men >wo smoke almost always pre age 50 defined time interval (can last wk - mo) precipated by etoh

Answer 3

abnormal activation of the trigeminal nerve contrib- utes to headache nociception. Typically, secondary parasympathetic activation causes ipsilateral lacrimation and rhinorrhea, a characteris- tic of cluster headache syndrome.

Answer 4

multiple episodes can occur within a 24-hour period. Each headache lasts from 15 minutes up to 3 hours, with a mean duration of about two hours.

Answer 5

unilateral sharp, stabbing pain in the eye, which may awaken the patient from sleep. The attacks occur exclusively in the territory of the trigeminal nerve. Unlike the patient with migraine, the patient with cluster headache presents agitated and anxious, rocking, rubbing the head, and pacing. The attack subsides rapidly, often leaving the patient exhausted. Accompanying the headache are ipsilateral autonomic symptoms, such as ptosis, miosis, and forehead or facial sweating. The eye often is injected and tearing, and many patients have unilateral nasal conges- tion or rhinorrhea.

Answer 6

First-Line Sumatriptan 6 mg SQ Oxygen At least 6–12 L/ min until h/a gone

Answer 7

Octreotide 100 micrograms SQ GI symptoms Metoclopramide 10 mg IV Dystonic reaction

Answer 8

Dexamethasone 10 mg IM or IV Most efficacious dose unknown, some notes also say 10d predn taper starting with 60mg for at least 2d Verapamil 240–480 mg/day PO in 2–4 divided doses May cause constipation, use cautiously if BP or HR are low Melatonin 10 mg qHS Well tolerated

Answer 9

carotid a dissection trigeminal neuralgia rare trigeminal autonomic cephalagias

Answer 10

CA diss: particu- larly neck pain, Horner syndrome, or unilateral neurologic deficit, should undergo neurovascular imaging

Answer 11

tight, bandlike discomfort or pressure around the head that is nonpulsating and dull. They also may experi- ence tightening of the neck muscles. headache does not worsen with physical activity, and accompanying symptoms (such as nausea, vomiting, phonophobia, and photophobia)

Answer 12

activation of meningeal nociceptors

Answer 13

ruptured saccular/berry aneurysm (sm <15mm) near or at major junction of cerebral vessels (particularly circle of Willis)

Answer 14

posterior circ - basilar a

Answer 15

a benign form of SAH, in which a localized hemorrhage occurs anterior to the midbrain, with- out extension, and with no vascular abnormalities on cerebral vascular imaging. These hemorrhages resolve spontaneously and do not require intervention.

Answer 16

age (typ 40-60) rate of growth of the aneurysm and increases with aneurysmal size hypertension, smoking, excessive alcohol consumption, and use of sympathomimetic drugs. Both genetic and familial associations of cerebral aneurysms Marfan, Ehlers Danlos syndrome type IV/CTD AD polycystic kidney disease Coarctation of aorta

Answer 17

0 Unruptured aneurysm 1 Asymptomatic or minimal headache and slight nuchal rigidity 2 Moderate or severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy 3 Drowsiness, confusion, or mild focal deficit 4 Stupor, moderate to severe hemiparesis 5 Deep coma, decerebrate posturing, moribund appearance

Answer 18

Age ≥ 40 years Neck pain or stiffness Loss of consciousness Onset during exertion Thunderclap (instantly peaking) headache Limited neck flexion on examination

Answer 19

stratifies pt according to clinical sx and signs at presentation, predictive of outcome ie 1-2 good px; grade 4-5 do poorly; 3 are just at risk for clinical deterioration

Answer 20

cervical artery dissection (CAD), cere- bral venous thrombosis (CVT), reversible cerebral vasoconstriction syndrome, hemorrhagic or ischemic stroke, and primary headache disorders, including migraine and cluster headache

Answer 21

high (near 100%) sensitivity is achieved, but with low (less than 20%) specificity.

Answer 22

acute hemorrhages less than 24 hours old, the sensitivity of third-generation multidetector row CT scanners in identifying hemorrhage is greater than 90%; however, sensitivity decreases to approximately 50% by the end of the first week, as blood is resorbed. ensitivity of non–contrast- enhanced head CT performed within 6 hours of headache onset approaches 100%

Answer 23

patient preference, local availability, and what else is on the differen- tial diagnosis. xanthochromia secondary to metabolism of hemoglobin to pigmented oxyhbg and bilirubin - which takes 12h to go SAH cannot be ruled out if a substantial number of RBCs persist in tube 4; however, an RBC count of less than 100 in tube 4 indicates that aneurysmal SAH does not need to be pursued further

Answer 24

cardiac arrh Typical electrocardiographic findings include ST-T wave changes, U waves, and QT prolongation.

Answer 25

1. airway management of hunt and hess 3 or more 2. sbp <160 or map 95-130 (labetalol, nicardipine 60mg po/ng q4h if high) 3. antinausea prn 4. agitated - sedate fentanyl/midaz 5. seizure - keppra 6. definitive: endovascular coil embolization vs neurosurg clip

Answer 26

Metastatic: Breast Lung Gastrointestinal Melanoma Meningioma Glioblastoma Primary CNS lymphoma Pituitary adenoma

Answer 27

present for weeks to months. The headache may have been present initially only on awak- ening (most likely in patients with increased ICP), gradually becoming continuous. The classic triad of brain tumor headache—sleep distur- bances, severe pain, and nausea and vomiting any valsalva makes it worse

Answer 28

dex 10mg IV then 4mg q6h

Answer 29

inflammatory vasculopathy that occurs in medium and large arteries with well-developed wall layers and adventitial vasa vaso- rum. It typically involves the major branches of the aorta and has a predilection for the extracranial branches of the carotid artery (e.g., temporal and occipital arteries). It can involve the ophthalmic, verte- bral, and distal subclavian arteries,

Answer 30

wo mean age 71 (so think of if over 50)

Answer 31

inflammatory infiltrate in the arterial wall resulting in intimal hyperplasia and subsequent stenosis and occlusion, leading to a variety of ischemic complications

Answer 32

loss of vision is due to anterior ischemic optic neuropathy.

Answer 33

Headache is the most common initial manifestation and occurs in more than 70% of patients. The headache often is of 2 to 3 months’ duration and can be continuous or intermittent; it can worsen at night or on exposure to cold. The pain may be described as sharp, throbbing, boring, or aching and usually is localized to the temporal region but may occur anywhere in the head. The physical examination may reveal tenderness over the scalp in the area of the temporal artery, with exacerbation of the pain by wearing a hat or resting the head on a pillow. Patients also can experience jaw claudication secondary to vascular insufficiency of the masseter and temporalis muscles. Systemic signs and symptoms are often present, including fever, anorexia, and weight loss. Approximately 40% of patients develop symptoms of polymyalgia rheumatica, pain in their large proximal joints,

Answer 34

Age ≥ 50 years old New headache type, particularly in association with visual loss or jaw clau- dication Temporal artery tenderness or tenderness of other extracranial arteries ESR ≥ 50 mm/h or CRP ≥ 10 mg/L Positive imaging finding or temporal artery biopsy

Answer 35

amarosis fugax

Answer 36

amarosis fugax AION peripheral neuropathies, transient isch- emic attacks, and stroke.

Answer 37

elative afferent pupillary defect

Answer 38

Takayasu arteritis can affect the aorta and its primary branches as well, but it affects younger patients and visual loss is uncommon. Polyarteritis nodosa, microscopic polyangiitis, and granulomatosis with polyangiitis (formerly known as Wegener gran- ulomatosis) can rarely affect the temporal artery but have different histopathology and vascular involvement. Ischemic stroke can cause headache with visual loss or amaurosis fugax. Pituitary apoplexy clas- sically presents with thunderclap headache and bitemporal visual field loss.

Answer 39

we recommend methylprednisolone 1000 mg per day for 3 consecutive days to optimize immunosuppression and sup- press tissue edema. For patients without visual symptoms, lower doses of steroids, in the range of 40 to 60 mg/day of prednisone should be used.

Answer 40

tocilizumab

Answer 41

cervical a dissection

Answer 42

sudden neck movement or trauma preceding the event. Reported mechanisms include neck torsion, chiro- practic manipulation, coughing, minor falls, heavy lifting, various sports including basketball and volleyball, sexual intercourse, childbirth, and motor vehicle collisions.

Answer 43

intramurla hemorhage within media of arterial wall - The hematoma can be localized or extend circumferentially along the length of the vessel, resulting in partial or complete occlusion. Damage to the intima results in platelet aggregation and thrombus formation further compromis- ing vessel patency or causing distal embolization.

Answer 44

(1) unilateral headache or neck pain, sometimes radiating to the ipsilateral eye; (2) ipsilateral ptosis and miosis (a partial Horner syndrome) ; and (3) either blindness, due to retinal ischemia, or contralateral motor deficits, caused by cerebral ischemia. However, this complete triad is only present in a minority of patients.

Answer 45

older age, occlusive disease on angiography, and stroke as the initial presenting symptom.

Answer 46

relatively young person with severe, unilateral posterior headache and a rapidly progressive neurologic deficit with symptoms of brainstem and cerebellar ischemia. Common findings include vertigo, severe vomiting, ataxia, diplopia, hemiparesis, unilateral facial weakness, and tinnitus.

Answer 47

Approximately 10% of patients who develop a vertebral dissection die during the acute phase, secondary to mas

Answer 48

thrombolytic therapy endovascular thrombectomy

Answer 49

Antiplatelet agents including aspirin, clopi- dogrel, or dipyridamole, and anticoagulation with unfractionated or low–molecular-weight heparin

Answer 50

Classically linked to the Virchow triad of blood stasis, blood vessel wall abnor- malities, and a hypercoagulable state. Both genetic and acquired prothrombotic conditions have been associated with CVT. Inherited thrombophilias such as antithrombin III, protein C and protein S defi- ciencies, and factor V Leiden mutation are the most common genetic causes. Acquired causes for CVT include pregnancy and the puerpe- rium, malignancy, head trauma, surgery, parameningeal infections, and exogenous hormones, such as oral contraceptives. Other causes include systemic inflammatory disorders, including vasculitis, inflam- matory bowel disease and connective tissue disorders, and neurosur- gical procedures.

Answer 51

1) Those that are related to increased ICP due to impaired venous drainage, and (2) those related to focal brain injury from venous occlusion resulting in ischemia, infarction, or hemorrhage.

Answer 52

diffuse headache increasing over days to weeks mc sx focal neuro findings seizure ocular: orbital pain, proptosis, chemosis, EOM paralysis, papilledema

Answer 53

cbc chem esr clotting studies - pt, ptt ddimer MRA vs MRI best but typically CTA and CTV faster to get

Answer 54

anticoagulated. with unfractionated heparin or w based LMWH tx seizure with antiepileptic drug as required tx underlying etiology for thrombus if possible

Answer 55

een primarily in young, obese women of childbearing age - unclear mechanism but perhaps imbalance between csf production and reabsorption

Answer 56

including anti- biotics (most commonly tetracyclines), vitamin A and retinoids, and human growth hormone. yo female obesity

Answer 57

Headache that remits with normalization of CSF pressure *worsened with valsalva Papilledema (may not be appreciable in all patients) May have CN VI palsy Increased CSF opening pressure: >250 mm in adults; >280 mm in children Normal CSF diagnostic studies Normal neuroimaging studies No other cause of increased ICP identified

Answer 58

diameter of the optic nerve sheath, 3 mm behind the optic disc, is consistent with elevated intra- cranial pressure if greater than 5 mm.

Answer 59

If neuroimaging is normal, an LP should be performed in the lateral decubitus position to measure CSF opening pressure and to obtain CSF diagnostic studies. An opening pressure of 250 mm H2O or more (normal is 70 to 180 mm H2O) is necessary to make the diagnosis. child >280mm

Answer 60

actually may not feel better with significant csf removal nsaids antidopa med - metoclopramide visual field loss - acetazolamide 250-500mg bid if not improving with this, consider optic nerve sheath decompression or csf diversion procedure

Answer 61

persistent CSF leak that exceeds CSF production, resulting in CSF hypotension. If sufficient CSF is lost, the brain descends in the cranial vault when the patient assumes the upright posi- tion, leading to increased traction on the pain fiber

Answer 62

noncutting needle use likea whitaker or sprotte postulated bevel up in LLDP LP, 20-22g needle use

Answer 63

rthostatic or positional headache that is precipitated by the upright position and relieved when the patient lies down. About 90% occur within the first 72 hours after the LP and typically resolve within 1 week, though headaches may persistent for months.

Answer 64

bed rest, hydration and analgesia within 5-7d if not: methylxanthine agents (such as caffeine 500 mg IV drip over 1 hour) and corticosteroids may be of benefit. For severe headaches that do not respond to these conservative measures, an epidural blood patch (EBP) should be used. This procedure involves the injection of 15 to 30 mL of autologous blood into the epidural space near the site of the original dural puncture resulting in a blood clot that seals off the dural hole.

Answer 65

PTH develops within 7 days of the injury or regaining consciousness. Acute PTH resolves within 3 months, whereas persistent PTH persists beyond 3 months.

Answer 66

preeclampsia *>20 weeks, proteinuria posterior reversible encephalopathy syndrome *abnormal MRI white matter changes hypertensive emergency ICH - abnormal neuroimaging

Answer 67

cerebral arteriopathy characterized by segmental areas of vasoconstriction within large- and medium-sized vessels. RCVS causes recurrent thun- derclap headache in susceptible patients and may cause ischemic or hemorrhagic stroke

Answer 68

thunderclap headache abrupt severe robbing and associated with nausea, vomiting, and photophobia. The headache may be provoked by use of vasoactive medications or substances such as recreational sym- pathomimetics or nasal decongestants

Answer 69

ct lp to r/o sah repeat neurovascular imaging/angio if recurs

Answer 70

prevention of ischemic and hemorrhagic stroke and elimination of headache. To date, the natural history of this disorder is incompletely understood. Treatment with calcium channel blockers, such as nimodipine 30 to 60 mg PO q4h, has been described and we recommend that it be offered to patients with progressive or refractory symptoms.

Answer 71

SAH RCVS CVT cervical a dissection hemorrhagic stroke pituitary apoplexy post coital headache

89. Headache Disorders Flashcards

(104 cards)