Case 34

Chunhai Charlie Hao, MD, PhD

Associate Professor
Neuropathology
Emory University

Case 34: Part 1

A 33-year-old woman presents with a complaint
of headaches. She has had headache since she
was a teenager but they have become more
debilitating recently. The episodes occur once or
twice each month and last for up to 2 days. The
pain begins in the right temple or at the back of
the right eye and spreads to the entire scalp over
a few hours. She describe the pain as a sharp,
throbbing sensation that gradually worsens and
is associated with severe nausea.

Case 34: Part 2

Several factors aggravate the pain including load
noises and movement. She has taken several overthe-counter medications for the pain, but the only
thing that works is going to sleep in a quiet and
darkened room. A thorough history reveals that he
mother suffers from migraine headaches. Her vital
signs, general physical examination, and a
thorough neurologic examination are all within
normal limits.

The Key Questions

What is the most likely diagnosis?
What imaging study is most appropriate at
this time?
What are the most appropriate therapeutic
options?

Summary
A 33-year-old woman presents with headaches
that are throbbing and over here right eye. The
episodes occur once or twice each month and last
for up to 2 days. Her headaches have occurred
since she was a teenager and have progressively
worsened. She has not found relief from overthe-counter preparations.

Answers to the Key Questions

What is the most likely diagnosis?
- Migraine without aura
What imaging study is most appropriate at this time?
- No imaging is indicated at this time as there are no
red flag symptoms or signs.
What are the most appropriate therapeutic options?
- A triptan medication given in a mean
that does not have to be swallowed (eg, subcutaneous,
intranasal, or orally dissolving tablet)

Objectives
Know the differential diagnosis of chronic headache
Learn the red flag symptoms and signs that should
prompt rapid, specific diagnostic and treatment interventions.
Know how to manage common headache syndromes.

International Headache Society

Classification
Part 1:
Primary headache disorders
- no other causative disorder

Part 2:
Secondary headache disorders
- caused by another disorder

Part 3:
- cranial neuralgias
- central and primary facial pain and
other headaches

International Headache Society

Classification
Part 1: The primary headaches
1. Migraine
2. Tension-type headache
3. Cluster headache
4. Other primary headaches

International Headache Society: Classification

Part 2: The secondary headaches
5. Headache attributed to head and/or neck trauma
6. Headache attributed to cranial or cervical vascular disorder

7. Headache attributed to non-vascular intracranial disorder

8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of cranial structures
12. Headache attributed to psychiatric disorder

Part 3:
13. Cranial neuralgias and central causes of facial pain
14. Other headache, cranial neuralgia, central or primary facial pain

International Headache Society

Classification
Part 1: The primary headaches
1. Migraine
- vascular headaches typically throbbing
unilateral in character
- Female > male
- Common triggers
- menses
- fatigue
- hunger
- stress

International Headache Society

Classification
Part 1: The primary headaches
1. Migraine
1.1 Migraine without aura (common
migraine)
1.2 Migraine with aura (classic migraine)
1.3 Childhood periodic syndromes that are
commonly precursors of migraine
1.4 Retinal migraine
1.5 Complications of migraine
1.6 Probable migraine

1.1 Migraine without aura

A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 h
C. Headache has > 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine
physical activity (eg, walking, climbing stairs)
D. During headache > 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder

E. Not attributed to another disorder means

- history and physical/neurological examinations do not

suggest any of the disorders listed in groups 5-12,

- or history and/or physical/ neurological examinations
do
suggest such disorder but it is ruled out by appropriate
investigations,
- or such disorder is present but headache does not
occur
for the first time in close temporal relation to the
disorder

1.2 Migraine with aura

A. At least 2 attacks fulfilling criterion B
B. Migraine aura fulfilling criteria B and C
for one of the subforms
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with non-migraine headache
1.2.3 Typical aura without headache
1.2.4 Familial hemiplegic migraine (FHM)
1.2.5 Sporadic hemiplegic migraine
1.2.6 Basilar-type migraine
C. Not attributed to another disorder

Migraine aura symptoms

- precede migraine symptoms
- occurs within an hour before head pain begins
- lasts less than 60 minutes before disappearing
- migraine aura may occur with little or no headache
Visual signs and symptoms
Other sensory disturbances

Migraine aura symptoms

Visual signs and symptoms
- blind spots (scotomas), outlined by geometric designs
- zigzag lines, gradually float across your field of vision
- shimmering spots or stars
- changes in vision
- flashes of light

Other sensory disturbances

- feelings of numbness, tingling in one hand or on face
- difficulty with speech or language
- muscle weakness

2. Tension-type headache
- Typically presenting with peri-cranial
muscle tenderness and a description of
a bilateral band-like distribution of the pain.

2.1 Infrequent episodic tension-type headache

2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
2.4 Probable tension-type headache

2.1 Infrequent episodic TTH

A. At least 10 episodes occurring on <1 d/mo (<12 d/y)
and fulfilling criteria B-D
B. Headache lasting from 30 min to 7 d
C. Headache has > 2 of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E. Not attributed to another disorder

2.2 Frequent episodic TTH

As 2.1 except:
A. At least 10 episodes occurring on >1 but
<15 d/mo for > 3 mo (>12 and <180 d/y) and
fulfilling criteria B-D

2.3 Chronic TTH

As 2.1 except:
A. Headache occurring on >15 d/mo (>180
d/y)
for >3 mo

3. Cluster headache and other trigeminal

autonomic cephalalgias
- unilateral headaches, male > female
- in orbital, supraorbital, or temporal region
- deep, excruciating pain
- last from 15 min to 3 hours

3.1 Cluster headache

3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache
attacks with conjunctival injection and tearing
3.4 Probable trigeminal autonomic cephalalgia

3 Cluster headache
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min if untreated
C. Headache is accompanied by > 1 of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
6. a sense of restlessness or agitation
D. Attacks have a frequency from 1/2 d to 8/d
E. Not attributed to another disorder

Part 2: The secondary headaches

Diagnostic criteria for secondary headaches
A. Headache with one (or more) of the following [listed]
characteristics and fulfilling criteria C and D
B. Another disorder known to be able to cause headache
has been demonstrated
C. Headache occurs in close temporal relation to the other
disorder and/or there is other evidence of a causal
relationship
D. Headache is greatly reduced or resolves within 3 mo
(shorter for some disorders) after successful treatment
or spontaneous remission of the causative disorder

Important general rules

The last criterion for most secondary headaches
D. Headache is greatly reduced or resolves within
[specified time] after successful treatment or
spontaneous remission of the causative disorder
is part of the evidence of causation
Before treatment or spontaneous resolution,
- criterion D is not fulfilled; code as
- Headache probably attributed to [the disorder]

Primary or secondary headache

Primary:
- no other causative disorder
Secondary
(ie, caused by another disorder):
- new headache occurring in close temporal
relation to another disorder that is a known
cause of headache
- coded as attributed to that disorder

Primary or secondary headache

A pre-existing primary headache made worse in
close temporal relation to another disorder:
either as the primary headache only
or as both the primary headache and a
secondary headache attributed to the other disorder

Diagnosis:

Primary
Primary
headache only + secondary

Temporal relation of
other disorder to
Headache exacerbation
Degree of exacerbation

Loose Close
Slight

Other evidence that other

disorder can cause
Weak
secondary headache
Other disorder eliminated
Headache
unchanged

Close
Marked
Strong
Headache
returns to
previous pattern

Clinical Approach to Headaches

General Practitioners:
- make accurate diagnosis of the cause
- rule out secondary causes (red flags)
- provide appropriate acute management
- assist with headache prevention when needed

Clinical Approach to Headaches

Take a good medical history:
- headache characters:
intensity, nature, quality, features and location
- associated symptoms
- age of onset, frequency, duration
- disability and distress
- a focal neurologic deficit, red flag

Migraine

Tension

Cluster

Prevalence

10% M, 22% F

40-50%,

1/1000, rare

Headache

moderate-severe

mild-moderate

severe

pulsating

pressing/tightening

unilateral

bilateral

Associated

nausea +/- vomiting

Frequency

median 1-2/m
over min-hr onset

Aura

in 15-33%

Disability

yes

Aggravated

daily activities

Sensitivity

light

Family history

often

unilateral
1-8/day
rapid onset
restless during

Clinical Approach to Headaches

General and neurologic examination and Lab Tests
- Non focal neurological deficits
- no tests necessary
- Focal neurologic deficits (red flags)
- CT/MRI, lumbar, CBC, serology and/or others

Red Flag Symptoms and Sings in Evaluation of headaches

Red Flags

Differential Diagnosis

Workup Migraine

Sudden onset

Subarachnoid hemorrhage
Pituitary apoplexy
mass+/- hemorrhage
vascular malformation

CT/MRI
if negative, lumbar

Increased severity
& frequency

mass, subdural hematoma

medication overuse

CT/MRI
drug screen

Begin > 50 yr old

mass, temporal arteritis

CT/MRI, ESR test

Immunocomprised

meningitis, abscess

CT/MRI, lumbar

+ systemic illness
(fever, stiff neck)

infections
collagen vascular diseases

CT/MRI, lumbar
serology

Papilledema

Mass, pseudotumor, infection

CT/MRI, lumbar

After trauma

hemorrhage, pos-traumatic

CT/MRI

Focal neuro sign

neurologic diseases

neurologic work-out

Clinical Management of Migraine Headaches

The US headache Consortium Guidelines
- Educate migraine patients:
- their conditions, treatments, participation of treatments
- Use migraine-specific agents:
- triptans, dihydroergotamine, ergotamine
- patients with severe migraines, poorly responsive to
aspirin and acetaminophen, alone or in combination
- Select a non-oral route for patients with nausea or
vomiting
- Consider using a rescue medication to severe migraine
- Guard against medication-overuse or rebound
headaches
- prophylactic treatment to patients > 2 tx / week

Clinical Management of Tension-Type Headaches

- Initial medical therapy of episodic :
- aspirin, acetaminophen, and NSAIDs
- Management of chronic tension-type
headaches:
- treatments of migraine headaches
- prophylactic treatment
- guard against medication-overuse

Clinical Management of Cluster Headache

- Acute treatments:
- 100% oxygen at 6 L/min
- dihydroergotamine, triptans
- Prophylactic treatment:
- verapamil 240-960 mg
- Referral:
- Cluster headaches are rare and require referral

International Headache Society

Classification
8. Headache attributed to a substance or
its withdrawal
8.1 Induced by acute substance use or exposure
8.2 Medication-overuse headache
8.3 Adverse event attributed to chronic medication
8.4 Headache attributed to substance withdrawal

8.2 Medication-overuse headache

- The most common cause of migraine-like and TTH-like
headaches on >15 d/mo is overuse of symptomatic
migraine drugs and/or analgesic
- Patients with migraine or TTH who develop new
headache or whose migraine or TTH is made markedly
worse during medication overuse should be coded for
that headache + 8.2 Medication-overuse headache
- Diagnosis of MOH is important because patients rarely
respond to preventative medications until withdrawn

International Headache Society

Classification
8.2 Medication-overuse headache
8.2.1 Ergotamine-overuse headache
8.2.2 Triptan-overuse headache
8.2.3 Analgesic-overuse headache
8.2.4 Opioid-overuse headache
8.2.5 Combination analgesic-overuse headache
8.2.6 Attributed to combination of acute medications
8.2.7 Attributed to other medication overuse
8.2.8 Probable medication-overuse headache

8.2 Medication-overuse headache

A. Headache present on 15 d/mo fulfilling criteria C and D
B. Regular overuse for >3 mo of one or more drugs
that can be taken for acute and/or symptomatic treatment
of headache
C. Headache has developed or markedly worsened
during medication overuse
D. Headache resolves or reverts to its previous pattern
within 2 mo after discontinuation of overused
medication

8.2.1 Ergotamine-overuse headache

- intake on >10 d/mo on a regular basis for >3 mo
8.2.2 Triptan-overuse headache
- intake (any formulation) on >10 d/mo on a regular
basis for >3 mo
8.2.3 Analgesic-overuse headache
- Intake of simple analgesics on >15 d/mo on a regular
basis for >3 mo

Homework Case 34.1:

A 28-year-old man presents for evaluation of headaches.
He has had several episodes of unilateral throbbing
headaches that last 8 to 12 hours. When they occur, he
gets nauseated and just wants to go to bed. Usually they
are relieved after he lies down in a dark, quiet room
for the remainder of the day. He is missing significant
work time due to the headaches. He has a normal
examination today.

Homework Case 34.1:

Which of the following statements is accurate regarding this
situation?
A. He needs a CT scan of his head to revaluate for the
cause of his headache.
B. When he gets his next headache, he should breathe in
100% oxygen and use a triptan medication.
C. If he has not already done so, he should use aspirin 650
mg orally every 4 hours as needed and take a stressmanagement class.
D. An injectable or nasal spry triptan is most appropriate.

Homework Case 34.1:

Answer: D
This patient gives a history every consistent with common
migraine headaches. There are no red flags found on
history or examination, so no further testing is necessary at
this point. As he has significant nausea, he may benefit
from non-oral medications. A triptan delivered by injection
or nasal spry is a reasonable starting point for him.

International Headache Society

Classification
1.1 Migraine without aura
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 h
C. Headache has > 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by physical activity
D. During headache > 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder

Clinical Management of Migraine Headaches

The US headache Consortium Guidelines
- Educate migraine patients:
- their conditions, treatments, participation of treatments
- Use migraine-specific agents:
- triptans, dihydroergotamine, ergotamine
- patients with severe migraines, poorly responsive to
aspirin and acetaminophen, alone or in combination
- Select a non-oral route for patients with nausea or
vomiting
- Consider using a rescue medication to severe migraine
- Guard against medication-overuse or rebound
headaches
- prophylactic treatment to patients > 2 tx / week

Pharmacological Management of Migraine (1)

A. Acute treatment
- treatment needs to be taken asap to maximize efficacy:
- NSAIDs
- acetaminophen (1g), mild-moderate, not specific
- aspirin (900mg)
- ibuprofen (400)

Pharmacological Management of Migraine (2)

A. Acute treatment
- Triptans (serotonin [5-HT1B/1D] agonists)
- oral agents
- almotriptan (12.5 mg), cheapest
- sumatriptan (25, 50, 100 mg)
- eletriptan (40-80 mg)
- naratriptan (1-2.5 mg)
- rizatriptan (5-40 mg)
- if no response, worth trying a different
- subcutaneous
- almotriptan
- sumatriptan (6 mg)
- nasal sprey
- sumatriptan (10-40 mg)

Drug

Guide to Triptan Therapy

Dose
Repeat
dose

sumatriptan oral
50-100 mg
tabs
sumatriptan nasal
5 and 20 mg
spray
sumatriptan
6 mg
injection
zolmitriptan tabs
2.5-5 mg
zolmitriptan ZMT
2.5 mg
zolmitriptan nasal
2.5 mg
spray
rizatriptan tabs*
5 and 10 mg
naratriptan
1 and 2.5 mg
almotriptan
6.25 and 12.5 mg
frovatriptan
2.5 mg
eletriptan
20 and 40 mg

Maximum
dose/24 hrs

2 hrs

200 mg

2 hrs

40 mg

1 hr

12 mg

2 hrs
2 hrs

10 mg
10 mg

2 hrs

10 mg

2 hrs
4 hrs
2 hrs
4 hrs
2 hrs

30 mg
5 mg
25 mg
5 mg
80 mg

*If patient is taking propranolol, only a 5-mg dose should be used.

Pharmacological Management of Migraine (3)

A. Acute treatment
- Ergot Alkaloids and Derivatives
-

Ergotamine, PO, PR
higher incidence of adverse
only selected patients
moderate-severe migraine

- dihydroergotamine, SC, IV, IM

- relatively sfe and effective
- inability to tolerate or take oral
- nausea/vomiting patients

Pharmacological Management of Migraine (4)

A. Acute treatment
- Antiemetic, if nausea/vomiting is a problem
- metroclopramide, IV, IM
- Do not routinely use opioids
- rick of medication overuse headaches
- Discuss overuse with patients when initiating therapy

Pharmacological Management of Migraine (4)

B. Prophylaxis of migraine
- Beta-blockers
- propranolol, 80-240 mg/day
- Antiepileptics
- topiramate, 50-200 mg/day
- valproate 0.8-1.5 g/day
- gabapentin 1.2-2.4 g/day
- Non-pharmacological prophylaxis
- stress management
- acupuncture

Clinical Management of Migraine Headaches

The US headache Consortium Guidelines
- Educate migraine patients:
- their conditions, treatments, participation of treatments
- Use migraine-specific agents:
- triptans, dihydroergotamine, ergotamine
- patients with severe migraines, poorly responsive to
aspirin and acetaminophen, alone or in combination
- Select a non-oral route for patients with nausea or
vomiting
- Consider using a rescue medication to severe
migraine
- Guard against medication-overuse or rebound
headaches
- prophylactic treatment to patients > 2 tx / week

Clinical Management of Migraine Headaches

The US headache Consortium Guidelines
- Consider a self-administered rescue medication for
patients
with severe migraine that do not respond well to (or fail)
other treatments.
- a rescue medication is an agent that the patient can use at
home when other treatments have failed. While rescue
medications often do not completely eliminate pain and
return patients to nrmal activities, they permit the patient to
achieve relief wihout the discomfort and expense of a visit to
the physicianss office or ER. A cooperative arrangement
betwwen provider and patient may extend to the use of
rescure medication in appropriate situation.

Migraine Rescue Medications

Drug

Dose/Route

sumatriptan

6 mg subcutaneously

Chlorpromazine (thorazine, Largactil)

Anti- pyschotic

12.5 mg slow IV push q 20 min (maximum

50 mg)

Prochlorperazine, Anti -pyschotic

10 mg slow IV push

Droperidol, anti-dopaninergic, antipyschotic

2.5 mg slow IV push q 30 min (maximum

7.5 mg)

Depakon ( IV form sodium valproate)

Anti-epileptic
magnesium sulfate, Anti-epileptic in
pregnancy

1 gram IV push over 1 min

1 gram IV push over 1 min

DHE45 +
prochlorperazine

Mix DHE45 1 mg plus prochlorperazine 10

mg.
Give 1.5 ml slow IV push over 1-3 min.

Dexamethasone, steroid

6-8 mg IV push

Methylprednisolone, steroid

250-500 mg IV push

Olanzapine, anti-pyschotic

5-10 mg PO

Homework Case 34.2:

A 43-yearl-old man presents with headaches that he has
had daily for several months. Every morning at work,
usually between 9 and 10 am, he has to take 650 mg of
acetaminophen to relieve the headache. This has been
going on for the past 3 months and he is at the point of
looking for a new job, as he thinks that job stress is the
cause of his symptoms. His examination is normal.

Homework Case 34.2:

Which of the following is the most appropriate advice
for him?
A. Continue with the as-needed acetaminophen and
find a less stressful career.
B. He should start an antidepressant for headache
prophylaxis.
C. His headaches are most likely to improve if he
strops taking the acetaminophen.
D. A triptan is a more appropriate treatment for him.

International Headache Society

Classification
8.2.1 Ergotamine-overuse headache
- intake on >10 d/mo on a regular basis for >3 mo
8.2.2 Triptan-overuse headache
- intake (any formulation) on >10 d/mo on a regular
basis for >3 mo
8.2.3 Analgesic-overuse headache
- Intake of simple analgesics on >15 d/mo on a regular
basis for >3 mo

Homework Case 34.2:

Answer: C
This situation is typical of a medication-related headache.
While finding a new, less-stressful job may be beneficial,
the problem will not resolve until he discontinues the daily
use of his over-the-counter analgesic.

Homework Case 34.3:

A 52-yearl-old woman presents to the office for an acute visit
complaining of 2 hours of headache. She says that it came on
suddenly with no account of trauma and is the worst
headache she has ever had. She has had migraines since she
was an early adult. The pain is described as stabbing and is
more severe on the left side. She takes no medications and
recently stopped taking oral contraceptive pills after going
through menopause. Her blood pressure is elevated at 145/95
mm Hg, but otherwise she has no focal neurologic
abnormalities on examination. She is alert and oriented to
person, place, time, and situation.

Homework Case 34.3:

Which of the following is the most appropriate
management at this time?
A. Prescribe a triptan medication.
B. Schedule a non-contrast head CT scan for tomorrow
morning.
C. Call 911 and transfer the patient to the nearest
emergency room.
D. Prescribe an antihypertensive medication and
follow-up in 2 weeks.

Homework Case 34.3:

Which of the following is the most appropriate
management at this time?
A. Prescribe a triptan medication.
B. Schedule a non-contrast head CT scan for tomorrow
morning.
C. Call 911 and transfer the patient to the nearest
emergency room.
D. Prescribe an antihypertensive medication and
follow-up in 2 weeks.

Red Flag Symptoms and Sings in Evaluation of headaches

Red Flags

Differential Diagnosis

Workup Migraine

Sudden onset

Subarachnoid hemorrhage
Pituitary apoplexy
mass+/- hemorrhage
vascular malformation

CT/MRI
if negative, lumbar

Increased severity
& frequency

mass, subdural hematoma

medication overuse

CT/MRI
drug screen

Begin > 50 yr old

mass, temporal arteritis

CT/MRI, ESR test

Immunocomprised

meningitis, abscess

CT/MRI, lumbar

+ systemic illness
(fever, stiff neck)

infections
collagen vascular diseases

CT/MRI, lumbar
serology

Papilledema

Mass, pseudotumor, infection

CT/MRI, lumbar

After trauma

hemorrhage, pos-traumatic

CT/MRI

Focal neuro sign

neurologic diseases

neurologic work-out

Subarachnoid Hemorrhage

Homework Case 34.3:

Answer: C
The acute onset of the most severe headache in a patients
life is concerning for the presence of a subarachnoid
hemorrhage. This is a medical emergency. This patient
should be transported by emergency medical services to
the nearest emergency facility for stabilization and
management (and imaging).

Case 34.4:
A 14-year-old previously healthy boy is brought to the office
because of a 1-month history of headaches. The headaches
usually occur when he is tying his shoes or picking up
something on the floor. They are some times accompanied by
nauseas and vomiting and are most intense in the morning.
They occasionally wake him up from sleep. He often
experiences tunnel vision when they are most intense.
There are no other neurologic symptoms associate with his
headaches.

Case 34.4:
The most likely underlying cause of his condition is
A. Intracranial hypertension
B. Intracranial hypotension
C. Psychologic tension
D. Vascular hypertension
E. Vascular hypotension

Case 34.4:
Answer: A
- History typical for headache of intracranial hypertension
- causes - intracranial masses
- idiopathic intracranial hypertension
- Headache of intracranial hypotension (B):
- worse with standing up, alleviated by lying down
- causes: - post-lumbar puncture
- spontaneous cerebrospinal fluid leaks
- Psychologic tension (C)- migraine, tension-type
- Vascular hypertension (D) - very rare and asymptomatic
- Vascular hypotension (E) - syncope

Case 34.5:
You are seeing a 43-yea-old obese woman for headaches.
She reports that she has had holoacranial headaches for
several months, which are present throughout most of the
day but often worse in the morning and when she strains.
She also notes a whooshing sound in her ears, and
reports seeing back spots in her vision when she bend
over or stains. She denies any nausea or photophobia, but
has had some blurry vision.

Case 34.5:
On physical examination there is most likely to be
A. Bilateral optic disc edema
B. Generalized weakness
C. Hyperactive reflexes
D. Hypoactive reflexes
E. Normal findings

Case 34.5:
Answer: A
- History typical for headache of intracranial
hypertension
- idiopathic intracranial hypertension
- most commonly in obese females
- pulsatile tinnitus, transient visual obscurations
- occasionally sixth nerve palsies
- otherwise, normal neurologic examination

Case 34.6:
A 15-year-old female comes to the office complaining of a
bad headache for the past year. The onset of the
headache was preceded by an inability to clearly visualize
an area of his right outer visual field and eventually his left
eye, too. It was associated with some difficulty speaking
and walking, and his hands, and mouth felt weird. The
pain is on both sides of his head and it is not the worst
headache in his life. He is on the wrestling team at school
and has ha to concussions over the past 2 years. He has
never had to lose weight in order to meet his weight class
on the wrestling team and denies any recreational drug use.

Case 34.6:
When assessing the presence of raised intracranial pressure, the
most specific question to ask would be which of the following:
A. Are your headaches similar from attack to attack?
B. Do you get headaches when you wake up in the morning?
C. Do you have any neck pain?
D. Do you have nay problems with bright light with these
headaches?
E. Have you ever been told that you have an unpredictable
personality?
F. Have you ever had any seizures or loss of consciousness?

Case 34.6:
Answer: B
- Critical in history taking
- raised intracranial pressure
- headaches on rising in the morning
- red flags focal neurologic symptoms
- blurred right outer visual field
- difficulty speaking and walking motor
- weird feeling of hands and mouth sensory
- A: migraine type headache
- similar from attack to attack
- C/D: neck pain, or stiffness, bright light - meningitis:
- E: personality change
- F: seizures

Case 34.7:
A 19-year-old man has probable migraine headaches that
you decide to treat with a combination of butalbital,
acetaminophen, and caffeine and a trail of sumatriptan
nasal spray 20 mg once daily. You ask him to return in 1
week for follow-up. Before leaving the office, he says,
before I shove anything up my nose I want to know how
this thing can help me.

Case 34.7:
You explain that sumatriptans method of action in the treatment
of migraine headaches is most likely by:
A. Antagonizing certain peripheral actions of serotonin
B. Causing vasoconstriction by acting as an agonist to
dopamine receptors in the CNS
C. Initiating platelet aggregation in the CNS
D. Inhibiting the reuptake of serotonin
E. Selectively activating a particular subpopulation of
serotonin receptors, thereby rectifying serotonin depletion

Case 34.7:
Answer: E
- Pathophysiology of migraine headaches is unknown
- may relate to serotonin
- Sumatriptan of Triptans are serotonin receptor agonists
- activates serotonin receptors 1A and D
- A: it is not antagonist
- B: it does not activate directly dopamine receptors
- C: it does not cause platelet aggregation
- D: it is not a serotonin reuptake inhibitor

Case 34.8:
A 60-year-old woman presented to the headache clinic with three
episodes of visual symptoms. The first episode occurred after she
had been on the computer for several hours. She described her
symptoms as a bright semi-circle in her visual field on the right
side of both eyes. She was still able to see, but there was a black
spot around the bright zig-zag lines. The episode lasted for 30
minutes. She had two more episodes, which lasted 15 minutes
each, and she became concerned because they came on within the
same week. Her neurological examination was normal. She had a
family history of migraine with aura and previously got headaches
with her menstrual period, which fit the criteria for migraines.

Case 34.8:
What is the likely diagnosis?
A. Migraine without aura
B. Migraine with aura
C. Tension-type headache
D. Typical aura with non-migraine headache
E. Typical aura without headache

International Headache Society

Classification
1.2 Migraine with aura
A. At least 2 attacks fulfilling criterion B
B. Migraine aura fulfilling criteria B and C
for one of the subforms
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with non-migraine headache
1.2.3 Typical aura without headache
1.2.4 Familial hemiplegic migraine (FHM)
1.2.5 Sporadic hemiplegic migraine
1.2.6 Basilar-type migraine
C. Not attributed to another disorder

Case 34.8:
Answer: E
- typical aura without headache
- a very uncommon condition
- sometimes referred to as ophthalmic migraine
- since she had never had aura before
- an MRI was ordered and the results were normal
- treatment of typical aura without headache.
- educate the patient that the disorder was benign
- if the aura come on frequently and was disabling to her
- medications that could prevent the aura
- neuromodulators: valproate, gabapentin, topiramate
- clinical follow-up