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50 Cards in this Set

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  • Back

Types of trigeminal autonomic cephalalgia (TAC)? (3)

1. Cluster headache

2. Paroxysmal hemicrania

3. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome

Peak incidence of cluster headache

Between 20 and 40 years old

Main two aspects of CH (2)

1. Cluster attack - the individual episode of pain, which can last minutes to hours

2 .The cluster bout - the period, usually weeks to months, when a person is susceptible to cluster attacks

Criteria A to get the diagnosis of cluster headache?

At least 5 attacks fulfilling the criteria for CH

Frequency of cluster headache attacks?


If more than the normal frequency of cluster attacks, which diagnosis should be considered?

SUNCT has up to 200 attacks daily, and paroxysmal hemicrania has 2-40 daily

How do patients with cluster headache usually describe the pain? (5)

1. Constant burning

2. Boring

3. Piercing

4. Tearing

5. Hot poker

Pain in cluster headache reaches peak intensity by

60 minutes

Autonomic features associated with cluster headache?

Horner syndrome;: restlessness and cannot sit or lie still, prefer to pace about a room or rock back and forth

____ is a key feature of cluster headache. During a cluster bout, most patients have ___ daily that occur at predictable times. For many times, the peak cluster attacks are when?

Circadian periodicity; 1-2; peak between 1 and 2 am, and between 1 and 3 pm, and around 9 pm

What should cluster patients be screened for?

Obstructive sleep apnea

Clinical course of cluster headacahe (4)

1. 80% episodic, recurrent bouts that last at least 1 week and are separated by at least 1 month

2. 25% have only a single bout of CH with no recurrence

3. CH generally occurs in bouts lasting 1 to 3 months, with each bout occurring every 6 to 24 months

4. 20% have chronic CH (remission lasting less than a month)

Cluster headache often has a circannual periodicity. Describe this phenomenon

Cluster bouts more frequently in the spring and autumn; correlates with the increasing and decreasing of daylight hours

Differential diagnosis of cluster headache (4)

1. Migraine

2. Paroxysmal hemicrania (PH)


4. Hypnic headache

When a patient presents with the symptoms of cluster headache, what's the next step in workup?

At the bare minimum an MRI with dedicated views of the pituitary gland should be done, even in the absence of atypical features because pituitary lesions can mimic TACs, including CH

One potentially effective treatment of CH?

100% oxygen adminsitered with a nonrebreather mask for 15 to 20 minutes at a rate of 7 to 15 L/min

First-line preventive treatment for CH?

Verapamil: 40 to 80 mg 3 times daily titrated to as high as 240 mg 3 times daily

Steroids in CH?

60 mg prednisone, tapered by 10 mg every 2-3 days

For how long is preventive treatment in CH usually administered?

For the duration of the typical duration of the bout and then for a 2-week pain-free period before it is slowly tapered

Consideration to be made in patients with treatment resistant cluster headache?

Paroxysmal hemicrania with a cluster headache phenotype; consequently, a trial of indomethacin should be offered

Main difference in PH compared to cluster headache?

Attacks tend to be shorter and can occur more frequently during a day; most have chronic, with daily or near daily attacks occurring for at least a year

When the diagnosis of paroxysmal hemicrania (PH) is suspected, what is the next step in management?

MRI with coronal gadolinium-enhanced sequences should be done because pituitary lesions can mimic PH

Treatment of paroxysmal hemicrania?

1. Indomethacin: 25 mg 3 times daily, and increasing the dosage every 3 to 5 days until a response occurs or to a max of 75 mg 3 times daily

2. Spontaneous remission of PH can occur, so periodically the dose should be decreased or tapered to zero

Clinical features of SUNCT? (4)

1. Similar to CH and PH

2. Unilateral pain

3. Associated autonomic features

4. Differs from PH and CH in that the attacks are much shorter, lasting from seconds to minutes, and can recur up to hundreds of times daily

Diagnosis of SUNCT? (3)

1. It's a TAC, but more likely to involve V1

2. Prominent autonomic symptoms

3. Use ICHD-III criteria

When SUNCT is suspected, what is the next step in management?

MRI of te brain with gadolinium-enhanced coronal cuts of the pituitary gland

Treatment of SUNCT? (4)

1. Least responsive to treatment

2. Lamotrigine

3. Gabapentin

4. Topiramate

Indomethacin should still be tried due to the overlap with PH

Hemicrania continua may be a secondary headache. To what? (5)

1. Pituitary lesions

2. Sphenoid sinusitis

3. Intracrnial tumors

4. Stroke

5. ICA dissection

Treatment of hemicrania continua?

1. Indomethacin: 25 mg 3 times daily for 3 days, then 50 mg 3 times daily for 3 days, and then 75 mg 3 times daily

2. Every 3 to 6 months should the dosage be slowly tapered or discontinued to evaluate for the possibility that HC has gone into spontaneous remission

Clinical features of primary stabbing headache? (3)

1. Sudden, severe headache

2. Lasting on the order of seconds

3. Generally in the ophthalmic division of the trigeminal nerve

Differential diagnosis of primary stabbing headache (PSH)?


2. Trigeminal neuralgia

Difference between PSH and SUNCT?

1. SUNCT syndrome must include autonomic symptoms, whereas PSH has no associated features

2. PSH occurs spontaneously and lacks cutaneous triggers

Treatment of PSH?

Indomethacin, 25 to 75 mg 3 times daily. Given the short duration of the attacks, short-term therapy is not feasible

Criteria for diagnosing cough headache? (4)

B. Brought on by and occurring only in association with coughing, straining, or other Valsalva maneuver

C. Sudden onset

D. Lasting between 1 s and 2 hrs

E. Not better accounted for by another ICHD-III diagnosis

If cough headache is suspected, what should be the next step in management?

MRI with and without gadolinium (and other imaging studies if indicated) is important to rule out secondary causes; at least 50% of cases are associated with a Chiari Type I malformation

Treatment of cough headache?

Indomethacin: typically respond to prophylactic doses of 25 to 75 mg 3 times daily; given the short duration of attacks, short-term therapy is not pragmatic

Clinical features of primary exertional headache (6)

1. Only occurring during physical exertion

2. More common in men

3. Typically affects people younger than 50

4. Bilateral or unilateral

5. Can have migrainous features

6. Usually subsides when the activity ceases, but it can sometimes persist up to 2 days

Hoes does primary exertional headache differ from migraine?

Exertion precipitates the onset of primary exertional headache, whereas migraine is aggravated by activity

Treatment of primary exertional headache (3)

1. Transient exercise moderation or abstinence

2. Indomethacin before exercise

3. Propranolol

ICHD-III criteria for primary exertional headache? (3)

B. Brought on by occurring only during or after strenuous physical exercise

C. Lasting <48 hrs

D. Not better accounted for by another ICHD-III diagnosis

Lifetime prevalence of primary headache associated with sexual activity?

1%; most commonly occur at orgasm

Treatment of primary headache associated with sexual activity (2)

1. Preemptively with indomethacin 30 to 60 minutes before sexual activity

2. Prophylactically with a beta-blocker or indomethacin on a daily basis

Clinical features of hypnic headache? (4)

1. Nocturnal headache, lasting 10 to 180 minutes

2. Occurs exclusively during sleep and at least 15 nights per month

3. Nearly at the same time every night

4. Generally 2 to 4 hours after falling asleep, and may recur up to 6 times during the night

Differential diagnosis of hypnic headache? (3)

1. Consider other TACs

2. MRI of the brain must be done

3. Sleep evaluation to exclude the possibility of a sleep-related breathing disorder or nocturnal hypertension

Treatment of hypnic headache? (3)

1. Caffeine, either as a cup of coffee at bedtime or with caffeine tablets (60-200mg)

2. Melatonin 3-12 mg at bedtime

3. Indomethacin 25-75 mg at bedtime

Clinical features of new daily persistent headache (4)

1. Chronic

2. Spontaneous

3. Daily within 72 hours after onset

4. Phenotype resembles that of either chronic tension-type headache or chronic migraine, but patients tend to recall the exact moment the headache began and can describe that moment, down to the date of onset, with clarity

Underlying cause of new daily persistent headache?

Unknown, but in about a third of cases, it follows a recent infection or flulike illness

How is the diagnosis of new daily persistent headache made?

By exclusion

Which secondary causes must be ruled out when the diagnosis of new daily persistent headache is considered? (6)

1. CBC to exclude anemia and chronic infection

2. Thyrotropin level (to exclude hypothyroidism)

3. ESR and CRP for older patients

4. MRI of the brain with and without gadolinium (to exclude space-occupying lesions and spontaneous intracranial hypotension)

5. MR venography to exclude venous sinus thrombosis

6. LP to exclude disorders of increased or decreased CSF pressure and chronic meningitis

Treatment of new daily persistent headache?

No known effective treatment for new daily persistent headache, but standard acute and prophylactic treatments for chronic migraine and chronic tension-type headache can be tried; rarely, patients may also respond to doxycycline