Neuro E2- HAs & facial pain

Lesions of the 2nd and 3rd cervical nerves can cause what type of headache?

occipital HA

Which classification of headaches is most likely to be a benign cause?

chronic

What headaches is I/L rhinorrhea and lacrimation seen in?

cluster HAs

What is the MCC of SAH?

trauma

What is the MC non-traumatic cause of SAH?

ruptured cerebral arterial saccular “berry” aneurysm

What condition?

• bleeding → increased ICP → HA (sudden onset = cardinal sx)

• increased ICP → decreased cerebral blood flow → LOC

• other sx: photophobia, N, V, neck stiffness + kernigs, sudden onset thunderclap, non-focal neuro exam

• “worst HA of my life” → sentinel bleed

subarachnoid hemorrhage (SAH)

What is the workup for SAH?

head CT w/o contrast (most accurate first day of bleed)

MRI, angiography when stable

if CT negative → CSF (inc ICP, bloody fluid, xanthochromia / yellow)

What is the treatment for SAH?

keep SBP less than 140/100 mmHg

prevent inc ICP→ strict bed rest w/ head elevated, possible sedation

IV fluids, analgesics (avoid ASA)

surgery- clip/coil ruptured aneurysm, ligate/embolize AVM

What condition?

• inflammation of brain/meningeal coverings d/t infection

• pain d/t inflammation of intracranial pain sensitive structures

• HA- throbbing & worse w/ sitting upright, B/L or occipital or nuchal

• photophobia

• mental status change

Meningitis

What bleed occurs w/in the skull (below the dura mater) but outside actual brain tissue due to a tear in a blood vessel (MC a vein)?

subdural hematoma/hemorrhage (aka intracranial hematoma or TBI)

What happens with a severe subdural hematoma?

body can’t absorb → buildup causes pressure on brain → breathing problems, paralysis, death

What type of subdural hematoma?

• most dangerous

• severe sx that appear right after head injury

• deteriorates quickly & can lead to death if not recognized early

acute

What type of subdural hematoma is common in older people & occurs with very subtle change?

chronic

What type of subdural hematoma has sx that occur hours-days after the injury (concussion)?

subacute

What are risks factors for SDH?

older adults (brain shrinks, space widens → veins stretch), athletes in contact sports, blood thinners, hemophiliacs, ETOH abuse, babies

What sx are seen with SDH?

HA that doesn’t go away, confusion, drowsiness, N/V, slurred speech & vision changes, dizziness, weakness on one side of body

may have a lucid period w/o sx immediately after

What is the workup for SDH?

complete hx, full neuro exam, STAT CT w/o contrast or MRI

What is the tx for large subdural hematomas?

surgical decompression, bore holes to drain blood, repeat surgery if blood/clots remain

What is the treatment for small subdural hematomas?

bed rest, medications & observation

What are possible complications of SDH?

brain herniation, repeated bleeding, seizures

What is the likely cause of this subacute HA?

• slower progressive onset of sx (over several wks-mos)

• HA worse in morning, w/ exertion or valsava

• N/V

• new onset HA later in life

• other sx: cluster type, abnormal neuro exam, aura, papilledema

brain tumor

What workup should be done for suspected brain tumor?

contrast CT or MRI; confirm w/ bx

(*avoid LP)

Who is giant cell arteritis MC in?

> 50 y/o (mean age 70) & females

What condition?

• subacute HA caused by inflammation of external carotid artery at the superficial temporal artery

• pain over scalp at temporal artery w/ dec pulse or nodules

• jaw/tongue claudication (pain or stiffness when chewing)

• pale optic disc, blindness if ophthalmic artery inflamed

Giant cell arteritis

How is giant cell arteritis dx?

bx of temporal artery, ESR elevated > 500mm/hr

What is the tx for giant cell arteritis?

urgent prednisone burst to avoid vision loss, slow taper over several mos

What is another name for idiopathic intracranial HTN?

pseudotumor cerebri

What are causes of idiopathic intracranial HTN?

idiopathic or tetracyclines, corticosteroid withdrawal, or venous sinus thrombosis

What patients is idiopathic intracranial HTN classically seen in?

middle aged. obese female

What condition?

• diffuse generalizes subacute HA made worse w/ straining

• Nausea, pulsation tinnitus, transient visual disturbances (diplopia, diminished acuity)

• papilledema; CN VI palsy

• elevated CSF pressure

idiopathic intracranial HTN

What is the workup for idiopathic intracranial HTN?

MRI or CT to r/o mass, LP

What is the tx for idiopathic intracranial HTN?

LP drainage + acetazolamide or furosemide (lasix)

What condition?

• pain in dermatomal (MC V1 of CN V) distribution ≥6 mos after shingles

• deep gnawing pain w/ superimposed sharp elements exacerbated by contrast

• if CN V → dec corneal sensation & impaired blink reflex → corneal scarring

• decreased pinprick sensation on exam

• sx usually subside in 6-12 mos but can persist

post-herpetic neuralgia

What is the treatment for post-herpetic neuralgia?

pain- amitriptyline, gabapentin, opioids, topical lidocaine (avoid pain), capsaicin cream (avoid face)

What can prevent post-herpetic neuralgia?

treat acute shingles w/ steroids or acyclovir

What is another name for trigeminal neuralgia?

tic douloureux

What condition?

• microvascular compression of CN V

• excruciating lancinating stabbing pain

• U/L over lower 2/3 of face

Trigeminal neuralgia

What is the treatment for trigeminal neuralgia?

spontaneous recover; carbemazepine, baclofen

When would a HA be considered acute & require immediate evaluation?

HA is different than previous HAs

What are the MC foods that precipitate migraines?

chocolate & cheese

What would intracranial vasoconstriction from inc serotonin during the aura phase result in?

hypoxia

What would rebound vasodilation during the HA phase result in?

drop in serotonin levels

Who are migraines most common in?

F>M, onset 20-30 y/o

At what age would onset of migraines be unusual and require further evaluation?

after age 50

What are the migraine characteristics (92% probability of having a migraine if 4 out of 5 are present)?

Pulsatile

Onset/duration 4-72 hrs

Unilateral

Nausea / Vomiting

Disabling in intensity- HA is severe

A migraine WITHOUT aura is a _____

common migraine

A migraine WITH aura is a _______

classic or complicated migraine

What is the workup for migraine HAs?

imaging not necessary outside of typical sx

normal exam outside of attack (appears very ill during attach but no focal neuro signs)

What are abortive symptomatic tx options for migraines?

simple analgesics, 5-HT agonists, ergots, antiemetics

(avoid recurrent use of narcotics unless refractory)

What drug?

• 5-HT agonist available SC, nasal spray, PO

• abortive tx for migraines - best if initiated early

• cause vasoconstriction of carotid arterial tree

• SE: flushing, chest tightness

• CI: cardiac dz, pregnancy

Sumatriptan (Imitrex)

What drugs?

• ergot preparations used for abortive migraine tx

• best if started early

• CI: cardiac dz, pregnancy

• risk of drug interactions (CYP3A4)

Cafergot (ergotamine + caffeine) & dihydroergotamine (DHE)

What antiemetics can be used for migraines?

Metoclopramide (Reglan) IV or Prochlorperazine (Compazine) IM

When is migraine prophylaxis indicated?

frequent attacks (>1 per week)

What drugs can be used for migraine prophylaxis?

BBs (propranolol), TCAs (amitriptyline), VPA, Topiramate

What should be avoided to prevent migraines?

caffeine, chocolate, red wine, cheese

Over use of analgesics or caffeine can cause ____

drug rebound HA

What is the treatment for drug rebound HAs?

abrupt withdrawal of meds & caffeine containing sources; sumatriptan or DHE IV/IM during transition

What kind of headache?

• Unilateral HA lasting few seconds to less than 2 hrs

• may start as burning over lateral aspect of nose or pressure behind eye

• common at night- awaken pt

• groups of brief, severe, constant, non-throbbing attacks that may remit for months at a time

• may be due to activation in hypothalamus

cluster HA

Who are cluster HAs more common in?

M » F; begin around 25 y/o

What is the treatment for acute relief of cluster HAs?

acute: 100% O2, sumatriptan, octreotide, lidocaine IN, ergotamine, DHE

prednisone to stop attacks

What are prophylactic options for cluster HAs?

verapamil (DOC), topiramate, glucocorticoids, lithium

What kind of headache?

• frequent episodic HAs - can last 30min to 1 wk (occur < 15 days per month for atleast 3 months)

• contraction of neck/scalp muscles is secondary phenomenon

• non-throbbing bandlike

• B/L forehead, temples, occiput

• no visual sx or N/V

tension HA

Who are tension HAs MC in?

F > M; onset after age 20

What is the workup for tension HAs?

normal exam b/t attacks (uncomfortable during attack but non focal/normal fundoscopic)

no studies if history typical

What is the treatment for tension HAs?

simple analgesics, NSAIDs (ibuprofen, naproxen), Tylenol, Ketorolac IM, Ergots (Cafergot)

What are prophylactic tx options for tension HAs?

TCAs (amitriptyline), CBT, lifestyle mods, exercise

What type?

• non throbbing HA

• hours - days

• occiput/bandlike

• no prodrome

• N/V rare

• +/- photophobia

• FHx not prominent

Tension HA

What type?

• throbbing HA

• hours

• U/L

• aura, N, V, photophobia, scotomas are common

• Fhx common

Migraine HA

What type of HA?

• HA w/in 24 hrs of injury; may worsen over few wks w/ gradual improvement

• constant dull ache that’s worse w/ head movement

• N/V, impaired concentration, altered mood

• non-focal exam

post-traumatic HA

What is the workup for post traumatic HAs?

CT/MRI, r/o SDH

What is the treatment for post traumatic HAs?

simple analgesics

if refractory → amitriptyline, propranolol, ergots

encouragement

What should be considered w/ a chronic HA & hx of URI or fever w/ sinus tenderness?

sinusitis

What should be considered if chronic HA & facial pain associated with/ chewing or temp changes?

TMJ dysfunction or tooth abscess

A chronic HA w/ pain localized to periorbital region indicates what non-neurological condition?

Glaucoma

What are concerns for chronic HAs requiring MRI or CT?

unexplained abnormal neuro findings, HA worse w/ valsalva, wakes pt form sleep, new HA in older pt, HA progressively worsening, exertion induces, seizures, “worst HA of my life, FHX aneurysms

Tension HA + normal exam =

insufficient evidence for imaging

Which imaging study has greater resolution?

MRI