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Course # 90213 • Diagnosing and Managing Headaches


Click on any objective to view test questions.
  1. Illustrate the epidemiology and economic impact of headaches.
  2. Demonstrate the pathophysiology of headaches.
  3. Recognize the signs and symptoms of headaches, focusing on history and physical exam, and discuss the role of an interpreter in assessing non-English-proficient patients.
  4. Identify the appropriate imaging modalities for headaches and their specific indications.
  5. Describe the epidemiology, diagnosis, and treatment of migraine headaches.
  6. Differentiate the signs and treatments for cluster and tension headaches.
  7. Identify the secondary causes of headaches.
  8. Compare and contrast the differences between acute and chronic headaches.
  9. Recognize indications for specialist referral.
  10. Analyze medico-legal issues surrounding headache diagnosis and management.
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1. All of the following statements regarding the epidemiology of headaches are true, EXCEPT:
A) Women have a greater incidence of headaches than men.
B) Three-fourths of adults experience some type of headache each year.
C) About 25% of patients with headache seek medical attention.
D) More than $2 billion is spent annually on over-the-counter medications to treat headache.

EPIDEMIOLOGY

Almost everyone experiences a headache at some point in their life. In fact, approximately three-fourths of all adults in the United States experience some type of headache each year. The prevalence of headache varies by gender, with women having a greater incidence of headaches than men. It has been estimated that nearly nine out of ten women, and seven out of ten men, have a headache at least once during her/his lifetime [4]. In developed countries, tension-type headache is more common in women, usually by a factor of about two to one [3].

In the overwhelming majority of cases, headaches are transient and benign. People simply treat the headache with either rest and/or relaxation, or they utilize various over-the-counter analgesics. In fact, the public spends more than $2 billion annually on over-the-counter medications to treat headaches [5]. Less than 5% of adults with headaches actually seek medical attention. Even with this small percentage, however, headaches are one of the most common complaints addressed by primary care physicians and clinicians and represent the reason for nearly 3% of all visits to the emergency department [1].


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2. People tend to seek medical care for headaches when they experience
A) increased frequency.
B) persistent symptoms.
C) an unusually intense headache.
D) All of the above

EPIDEMIOLOGY

People typically seek medical care when they have increased headache frequency, an unusually intense headache, or persistent symptoms. Headaches can be one of the most difficult and challenging disorders to accurately diagnose and treat, so it is important for physicians and other clinicians to become familiar with the latest evidence on headache diagnosis and management.


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3. How much do headaches cost in direct and indirect expenditures annually?
A) $12 billion
B) $14 billion
C) $16 billion
D) $18 billion

EPIDEMIOLOGY

Headaches are a costly condition. It has been estimated that headaches are responsible for nearly 30 million days of lost productivity, both in terms of lost days at work, as well as decreased effectiveness while at work. Headaches cost an estimated $18 billion in both direct and indirect expenditures yearly. Most costs are indirect as the majority of headache sufferers do not seek medical attention [2,7,8,9].


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4. Secondary headaches account for what percentage of headaches?
A) 5%
B) 10%
C) 15%
D) 20%

BASIC PATHOPHYSIOLOGY

Secondary headaches, as the name indicates, occur secondary to another cause (i.e., they are a symptom of other diseases). These may include vascular, traumatic, neoplastic, infectious, pressure, and metabolic disorders [11]. Secondary headaches account for only 10% of headaches. Although some causes of secondary headache are common, others are important to recognize because they are dangerous and may require specific treatment [12]. For example, patients with chronic tension headaches may present with an epidural hematoma, and patients with migraine may actually have a brain tumor. Primary and secondary headaches should not be considered mutually exclusive when evaluating a patient with headache. It is helpful to consider secondary headaches in terms of etiologic categories. Some of the more common causes of secondary headaches are as follows [13]:

Traumatic

  • Epidural hematoma

  • Subdural hematoma

Vascular

  • Subarachnoid hemorrhage

  • Giant cell arteritis

  • Arterial dissection

  • Stroke

Neoplastic

  • Primary brain tumor

  • Metastatic brain tumor

Infectious

  • Meningitis

  • Encephalitis

  • Sinusitis

  • Abscess

Pressure

  • Hypertension

  • Idiopathic intracranial hypertension

Metabolic

Other

  • Syringomyelia

  • Dental and myofascial

  • Cervicogenic

  • Medication overuse

  • Herbal medications


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5. Which of the following is considered a "red flag" when assessing the patient with headaches?
A) Gradual onset
B) Accelerating pattern
C) Normal systemic findings
D) Onset around 20 years of age

WORK-UP OF HEADACHES

Although most headaches are benign, clinicians should be aware of the following "red flags" or warning signs that should prompt an immediate and exhaustive work-up and possible referral to an appropriate specialist for further assessment [5,13,20,21,23]:

  • Onset in or after middle age (>50 years of age)

  • Sudden onset, rapid time to peak headache intensity (i.e., seconds to five minutes)

  • First or worst sudden, severe headache

  • Accelerating pattern, progressively worsening

  • Fever

  • Seizure

  • Change in level of consciousness

  • Abnormal neurologic, physical, or systemic findings

  • New headache in patients with cancer, immunosuppression, or pregnancy


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6. The use of electroencephalogram (EEG) is
A) useful when patients present with encephalopathy.
B) not recommended for routine work-up of headaches.
C) of limited value in determining structural causes of headache.
D) All of the above

WORK-UP OF HEADACHES

Electroencephalogram (EEG) is not frequently used and not recommended in the routine work-up of headaches. It has minimal value in determining any structural causes of headaches. It may be useful, however, when patients present with encephalopathy, focal neurologic deficits, atypical aura symptoms, or altered consciousness [21,22,24].


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7. All of the following statements regarding imaging for patients with headache are true, EXCEPT:
A) Most patients tolerate CT scans easily.
B) MRI is preferred for cervical spine lesions.
C) Most CT scans for headache are done with contrast.
D) CT scans are more sensitive than MRI for posterior fossa lesions.

WORK-UP OF HEADACHES

CT scans may be performed either with or without contrast. Unless there is a contraindication to the use of contrast agents, most scans are performed with contrast in the diagnostic work-up of headaches. A contrast-enhancing CT scan can be an effective test for identifying several serious lesions that may be causing headaches [33,34].

In general, CT scans are widely available, quickly performed, and well-tolerated by patients. The technology has been around for quite some time, and most patients are familiar with it [34]. In addition, there are "open" CT scanners that help minimize the feeling of claustrophobia some patients experience. This scan detects most space-occupying lesions such as brain tumors, subdural hematomas, and CNS abscesses. It can also show fluid from hydrocephalus and cerebral edema, and it can reveal bleeding and structural abnormalities such as some arteriovenous malformations. However, CT scanning can miss aneurysms, and it also does not provide adequate views of the sphenoid sinus. Adding "bone windows" on CT provides much better detection of skull fractures, especially as compared to plain films.

MRI is the diagnostic test of choice for most patients [27]. However, it is not as readily available as CT [34]. MRI is more sensitive for detecting lesions within the posterior fossa (specifically because of bony artifacts that limit CT's visualization), pituitary area, paranasal sinuses, and leptomeninges [34,35]. It has also proven effective in identifying some otherwise occult tumors and infarcts. MRI is also more sensitive for detecting vascular abnormalities, although it is not as sensitive as CT in revealing early subarachnoid bleeding. In addition, special MRI images can evaluate problems with the orbit or optic nerve areas. When abnormalities of the cervical spine are suspected, MRI is the preferred imaging technique, especially compared to plain films. "Open" MRI scanners may be used to help diminish claustrophobia or to accommodate obese patients [34].


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8. The U.S. Headache Consortium developed which of the following management principles for neuroimaging in patients with nonacute headache?
A) Testing should be completed even if the test results will not lead to a change in management.
B) Testing that may not normally be recommended as a population policy may make sense at the individual level.
C) Testing is recommended even if the individual is not significantly more likely than anyone else in the general population to have a significant abnormality.
D) All of the above

WORK-UP OF HEADACHES

The U.S. Headache Consortium has issued guidelines relating to neuroimaging in patients with nonacute headache. The guidelines include three consensus-based general principles of management [22]:

  • Testing should be avoided if the test results will not lead to a change in management.

  • Testing is not recommended if the individual is not significantly more likely than anyone else in the general population to have a significant abnormality.

  • Testing that normally may not be recommended as a population policy may make sense at the individual level, resources notwithstanding. For example, exceptions might be made for patients who are disabled by their fear of serious pathology.


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9. A migraine aura without headache
A) is the most common type of migraine.
B) most commonly occurs in young women.
C) is often described as the worst pain one can experience.
D) predominately occurs in older individuals with a history of migraine with aura.

PRIMARY HEADACHES

Approximately 3% to 5% of patients with migraine experience an aura without headache. This presentation, formerly known as a "migraine equivalent," tends to occur in older individuals who have had a history of migraines with aura in their earlier years [45]. They predominantly occur in men of advanced age.


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10. Which of the following factors may act as a trigger for migraine headaches?
A) Stress
B) Caffeine withdrawal
C) Low barometric pressure
D) All of the above

PRIMARY HEADACHES

Many different factors work to trigger migraines. These factors vary greatly from one individual to another and often no precipitating events can be clearly identified. Trigger factors increase the probability of a migraine attack in the short term (i.e., usually in less than 48 hours) in a person with migraine. Some of the more common triggers include stress, sleep disturbances, depression, low barometric pressure, food, hormonal variations, and caffeine withdrawal. Some trigger factors have been reasonably well studied epidemiologically (e.g., menstruation) or in clinical trials (e.g., chocolate, aspartame); however, causal attribution in individual patients may be difficult [43].


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11. All the following statements regarding the acute treatment of migraine are true, EXCEPT:
A) Triptans are contraindicated in the setting of ischemic heart disease.
B) Ergotamine derivatives tend to increase the likelihood of rebound headaches.
C) Opioids are among the most commonly used class of drugs in treating migraine.
D) Both the triptan and ergotamine classes of drugs work to alleviate migraine headaches, in part, by their vasoconstrictive properties.

PRIMARY HEADACHES

Acute attack pharmacologic options are used at the onset of the attack. They can be divided into nonspecific and specific drugs. The nonspecific therapies are single or combination analgesics. Routes of administration include oral, nasal, parenteral, and rectal. Appropriate situations for use, including potential side/adverse effects, drug-drug interactions, and patient-specific contraindications, should be addressed. Opioids are generally avoided, if possible, due to concerns about tolerance and dependence [54,173].

The specific therapies include ergotamines and triptans. The ergotamines and triptans both work as vasoconstrictors. Ergotamine derivatives, although less expensive, are more nonspecific and tend to increase the likelihood of rebound headaches after their use [53,67].

Although many of the serotonin 5-HT1B/1D receptors are located in the brain, some 5-HT1B receptors are located in the heart, as determined by anatomical studies using selective antibodies [70]. Triptans have been shown to constrict coronary arteries and prevent the release of pro-inflammatory neuropeptides [71]. In rarer circumstances, they may actually cause myocardial infarction [72]. Because of this, it is contraindicated to use these drugs in the setting of ischemic heart disease, uncontrolled hypertension, pregnancy, and cerebrovascular disease, such as ischemic stroke [36,38,53,73]. They should also be avoided in the treatment of FHM and basilar migraine. Triptans should not be prescribed to patients who are also taking monoamine oxidase inhibitors (MAOIs), nor should they be given within 24 hours of use of ergotamines [73]. No evidence has supported the use of triptans during the aura phase of a migraine attack [53].


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12. Which of the following is TRUE regarding cluster headaches?
A) The pain is often bilateral.
B) They may induce lacrimation.
C) Bilateral conjunctival injection may occur.
D) They are commonly mild to moderate in pain intensity.

PRIMARY HEADACHES

Cluster headaches are one of several types of trigeminal autonomic cephalalgias, primary headaches characterized by unilateral pain in the trigeminal nerve region. As defined by the IHS, cluster headaches are attacks of severe unilateral pain in the orbit and/or the surrounding region of the eye that last 15 to 180 minutes [43,53]. The term "cluster" refers to the headache attacks occurring in daily episodes. The patient is headache-free in between the clusters.

The attacks may occur anywhere from every other day to eight times per day and are accompanied by one or more of the following symptoms: ipsilateral conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, ptosis and/or miosis, eyelid edema, forehead/facial sweating, forehead/facial flushing, or sensation of fullness in the ear (Table 10). Attacks occur in series lasting for weeks or months separated by remissions lasting for months to years [43].


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13. Which of the following statements is TRUE regarding tension headaches?
A) Tension headaches are more common in men.
B) Tension headaches are solely due to muscle spasm in the head and neck region.
C) The lifetime prevalence for tension headaches ranges from 30% to 78%.
D) Tension headaches are the most extensively studied of the primary headaches.

PRIMARY HEADACHES

Tension headaches are among the most common headache type seen in practice today; however, it is the least studied of the primary headache disorders, despite the fact that it has the highest socioeconomic impact. The lifetime prevalence ranges from 30% to 78%, with a rate of 63% seen in men and 86% in women [21,43].

The etiology of tension headaches is multifactorial. Although once thought to be simply secondary to muscle spasm, it is now felt that other factors play important roles. In fact, although tension headaches may arise from sustained contraction of pericranial muscles, no correlation exists between muscle contraction and the presence of a tension headache. It seems that, just as in migraine headaches, tension headaches arise in part from centrally mediated neural dysfunction. This abnormality may in part be due to central sensitization in the trigeminal area [43,67].


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14. Which of the following medications should be avoided for the treatment of tension headaches?
A) Aspirin
B) NSAIDs
C) Narcotics
D) Acetaminophen

PRIMARY HEADACHES

Tension headaches also tend to respond well to medications. Some commonly used medications that are effective include aspirin, acetaminophen, and NSAIDs in the standard prescribed doses [114]. Combination treatments with the above medications and caffeine, butalbital, and muscle relaxants are also effective. However, overuse of these medications, especially those containing caffeine, may lead to rebound headaches. The use of butalbital also may result in dependency, and for this reason, it is not recommended for prolonged use [53,73]. In general, narcotics should be avoided because tension headaches are typically mild-to-moderate in pain intensity. Botulinum has also been suggested for the treatment of tension headaches; however, not all researchers agree that it should be used for chronic tension-type headache [11,116]. As discussed, however, more study regarding efficacy and safety is required.


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15. All of the following are considered etiologic categories for secondary headaches, EXCEPT:
A) Tension
B) Metabolic
C) Neoplastic
D) Traumatic

SECONDARY HEADACHES

As noted, it is helpful to think of secondary headaches in terms of etiologic categories, such as vascular, traumatic, neoplastic, infectious, pressure, metabolic/toxic ingestions, and medication overuse. A secondary headache may be diagnosed when another disorder known to cause headache has been demonstrated; headache occurs in close temporal relation to the other disorder and/or there is other evidence of a causal relationship; and headache is greatly reduced or resolves within three months (this may be shorter for some disorders) after successful treatment or spontaneous remission of the causative disorder. The IHS has divided secondary headaches into subtypes attributed to specific causes [43]. Table 15 shows a summary of several causes of secondary headache.


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16. Which of the following statements is TRUE regarding epidural hematomas?
A) Posterior fossa is most often involved.
B) MRI is more useful than unenhanced CT.
C) Characteristic white lenticular shapes are observed on CT.
D) All of the above

SECONDARY HEADACHES

Hemorrhages usually occur in the temporal fossa from middle meningeal artery tears; they may also occur in the posterior fossa as a result of a transverse sinus tear. Posterior fossa epidural hematoma may exhibit a rapid and delayed progression from minimal symptoms to even death within minutes. Overall mortality has been estimated to be as high as 50%, so prompt evaluation and treatment is critical [43].

With respect to diagnosis through neuroimaging, in the acute setting, unenhanced CT scan is more useful than MRI imaging. Epidural hematomas have a characteristic white lenticular shape adjacent to the bone, while focal hypodense or isodense areas on CT indicate active bleeding. Because the temporal fossa is often involved, one must be careful that bony artifacts do not obscure a hemorrhage [121].


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17. Subdural hematomas
A) are typically caused by metastases.
B) often present with focal neurologic signs.
C) are more common than epidural hematomas.
D) evolve more quickly than arterial hemorrhage.

SECONDARY HEADACHES

As the name implies, subdural hematomas occur between the surface of the brain and the dura. The source of bleeding is the venous system (i.e., bridging veins) as opposed to the arterial system. Because the subdural space is continuous, these types of hemorrhage may have significant mass effect. Subdural hematomas are more common than epidural hematomas. They tend to evolve more slowly based on the slower rate of venous bleeding compared to arterial hemorrhage. As a result, there may be a progression of symptoms over two to four weeks; the rate of progression depends upon the severity of the injury [122].

Patients often present with a mild persistent headache. There may be drowsiness and confusion, although focal neurologic signs are often absent. Symptoms may be followed by a brief lucid interval with subsequent deterioration. Subdural hematomas are seen in approximately 15% of all head traumas. Automobile accidents are a typical cause of subdural hematomas [122].


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18. Which of the following may be used as a treatment for a subdural hematoma?
A) Diuretics
B) Antiepileptics
C) Surgical evacuation
D) All the above

SECONDARY HEADACHES

Prompt treatment is critical because mortality can reach 60%. Treatment may include diuretics to reduce swelling. Because there is a high frequency of seizures, antiepileptics are frequently used to either control or prevent seizures. For more serious hematomas, surgical evacuation may be necessary. The long-term prognosis is actually worse than that for epidural hematomas [122,123,124].


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19. Which of the following characteristics is commonly associated with a subarachnoid hemorrhage (SAH)?
A) Dull pain
B) Mild severity
C) Early focal deficits
D) Radiation of pain to the neck and back

SECONDARY HEADACHES

Typically, headache due to an SAH is described as a sharp pain that usually involves the entire head. Patients classically describe it as the "worst headache of their life." It often radiates into the neck and even into the back. There is usually nausea and vomiting. In general, there are no focal neurologic deficits early on, but as it progresses, there may be loss of consciousness and altered mental state. Seizures during the acute phase occur in 10% to 25% of patients [125].


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20. The mean age for an SAH is
A) 30 years of age.
B) 50 years of age.
C) 70 years of age.
D) 80 years of age.

SECONDARY HEADACHES

The prevalence of SAH increases with age in a linear relationship. The mean age is 50 years [125,126,127]. On physical examination, the patient is typically in severe pain. The pain is sometimes referred to as a "thunderclap" headache [126]. Symptoms of meningeal irritation, such as nuchal rigidity and pain, back pain, and bilateral leg pain, occur in as many as 80% of patients with SAH but may take several hours to manifest [126]. Focal neurologic deficits, such as facial droop or weakness in a specific extremity, are present in 25% of patients. However, if the hemorrhage is associated with infarction it will likely involve the brain parenchyma, which may lead to hemiparesis, aphasia, or visual field abnormalities. Loss of consciousness is transient [43,125].


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21. Giant cell (temporal) arteritis typically presents with
A) fever.
B) hyperactivity.
C) ache in neck.
D) All of the above

SECONDARY HEADACHES

On exam, the affected scalp artery is sometimes prominent. It may be tender and is often pulseless. The scalp itself is usually tender as well. Depending upon the progression, visual field defects and decreased acuity may be noted, although the patient does not usually exhibit focal neurologic deficits. Typically, the headache occurs in someone who is febrile, has malaise, and feels aches in the back and shoulders. Claudication of the jaw occurs commonly and is virtually pathognomonic for this condition when present during talking or chewing [129].


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22. Headache with a stroke is
A) atypical.
B) usually unilateral.
C) indicative of a hemorrhagic stroke.
D) more common in patients younger than 40 years of age.

SECONDARY HEADACHES

Headache, migraine, and stroke are common and can be temporally related, but a direct causal association has not been definitively proven in clinical studies. Headache may be coincidental with stroke (also referred to as cerebrovascular accident or stroke syndrome), including both ischemic and hemorrhagic stroke, or it may be a consequence of stroke. Headache or migraine may increase the risk of stroke [131]. Results of the Women's Health Study, presented at the 2013 International Headache Congress, reported that migraine with aura is a strong risk factor for any type of stroke [132,133,134]. Headaches associated with stroke are typically reported as dull but diffuse (35%) [135]. They are not localized to a particular side. In addition, headache presentation of a stroke is more common in patients younger than 40 years of age [135]. Headache is more likely to occur in combination with other signs and symptoms of stroke [132]. Depending upon the type of stroke, there may be a focal neurologic deficit, such as aphasia or dysarthria. Young patients should be evaluated carefully to avoid misclassification of stroke as a complicated migraine [135].


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23. Cerebrospinal fluid (CSF) analysis of patients with encephalitis demonstrates
A) monocytosis.
B) erythrocytosis.
C) decreased protein.
D) Both A and B

SECONDARY HEADACHES

CSF examination is critical to establish the diagnosis and reveals moderate monocytosis and erythrocytosis with a variably elevated protein level. EEG is sensitive but not specific, and contrast CT is only 60% sensitive. It may be used, however, to evaluate acute disease progression and to follow up on complications. MRI is more sensitive than CT scan [142]. MRI with gadolinium enhancement is the preferred imaging study. One should keep in mind certain seasonal and geographic issues when differentiating specific etiologic agents.


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24. An individual with sinusitis usually presents with all of the following, EXCEPT:
A) Fever
B) Nausea
C) Leukocytosis
D) Purulent nasal discharge

SECONDARY HEADACHES

In acute rhinosinusitis, the patient may present with purulent nasal discharge, which is frequently associated with fever and leukocytosis [43]. The pain is felt as a deep, dull, heavy fullness that sometimes may be pulsatile. Shaking or flexion of the head, coughing, and sneezing exacerbate the pain. Sinus headache is seldom associated with nausea. In addition, it does not reach the same pain intensity of cluster headache or migraine. The vast majority of patients with acute sinusitis respond to antibiotics [143]. Plain radiography is generally obsolete, but exceptions include its use in confirming air-fluid levels in acute sinusitis [144]. MRI is generally reserved for the evaluation of any complications of local sinus infections, particularly suspected intracranial extension. A CT scan is highly sensitive and is the examination of choice in the evaluation of sinusitis, particularly in cases of chronic sinus disease [144]. However, it is usually not useful in acute sinusitis, as diagnosis in these cases is primarily based on clinical findings. Coronal CT imaging is the preferred initial procedure [144].


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25. Which of the following would best aid in the diagnosis of a brain abscess?
A) MRI
B) CT scan
C) MR spectroscopy
D) Lumbar puncture

SECONDARY HEADACHES

The time course of an abscess is reflected in the symptoms and usually progresses over one to two weeks [147]. Diagnosis is aided by CT, MRI, and nuclear medicine studies. In general, MRI provides better brain parenchymal differentiation than CT and shows the edema from the abscess in better detail [147]. The abscess is also better demonstrated because the routine brain MRI generally is multiplanar, as opposed to the routine CT, which is usually axial. However, MRI may not be useful in an acutely ill patient [146]. MR spectroscopy and some nuclear medicine studies may also be helpful to differentiate abscess from brain tumor [146]. Diffusion weighted MR may also give early indication of an infarction because this may be part of the sequelae of the abscess. Lumbar puncture is contraindicated due to its poor diagnostic yield and possible risk of herniation of the cerebellar tonsils [146,147].


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26. All of the following are true regarding syringomyelia, EXCEPT:
A) It results in numbness of the extremities.
B) It is an uncommon presentation of headache.
C) It is most often related to a congenital abnormality of the brain.
D) It usually becomes symptomatic between 45 and 60 years of age.

SECONDARY HEADACHES

Syringomyelia is an uncommon presentation of headache. It is a condition in which a cyst forms within the spinal cord, either congenitally or due to trauma, malignancy, infection, or hemorrhage. In most cases, the disorder is related to a congenital abnormality of the brain called a Chiari malformation. This malformation occurs during the development of the fetus and causes the lower part of the cerebellum to protrude from its normal location in the back of the cranium into the cervical portion of the spinal canal [160].

The cyst, or syrinx, gradually expands and elongates over time, eventually resulting in destruction of the cord's center. As a result, patients may present with a variety of symptoms, although they typically present with headache, back pain and stiffness, and numbness of the extremities [160]. Symptoms usually begin between 25 and 40 years of age; they are more common in men than women and may worsen with straining (e.g., heavy lifting) or any activity that causes CSF pressure to fluctuate [160].


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27. All of the following are true regarding rebound or medication overuse headache, EXCEPT:
A) It has a well-understood pathophysiology.
B) Treatment is withdrawal from the medication.
C) It is caused by frequent use of analgesics or migraine medications.
D) It is most common in patients with frequent migraine headaches or chronic tension headaches.

SECONDARY HEADACHES

Medication overuse headache, also known as rebound headache, results from misuse of drugs, most notably over-the-counter analgesics or migraine medications. It is most common in patients with frequent migraine attacks or tension-type headaches [165]. Chronic tension-type headache is less often associated with medication overuse; however, episodic tension-type headache has commonly become a chronic headache through overuse of analgesics [43]. The headache is caused by frequent use of anti-headache medications for more than 15 days per month. Evidence suggests that this occurs sooner with triptan overuse than with ergotamine overuse [43,166]. The mean period of time that elapses before this type of headache evolves ranges from one to two years for the triptans, three to five years for ergotamines, and up to 5 to 10 years for over-the-counter analgesics [167]. The pathophysiology of this syndrome remains unknown.

The diagnosis of medication-overuse headache is clinically extremely important because patients rarely respond to preventative medications while overusing acute medications [43]. Treatment is withdrawal from the medication. If tapered, this may take more than two weeks, depending on the medication. Improvement should occur within two months after cessation of overuse in order for the diagnosis to be definite [43]. This is followed by prophylactic treatment of the primary headache [165,166].


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28. All of the following are true regarding chronic headaches, EXCEPT:
A) Chronic headache is not a separate syndrome.
B) Most chronic headaches are primary headaches.
C) Chronic daily headache occurs in 10% of the population.
D) Headaches occur on more than 15 days of each month, whether or not the person is taking any medications.

ACUTE VERSUS CHRONIC

Although chronic headache is a term often used by patients, as well as some clinicians, it is no longer a recognized diagnosis. Patients either have a chronic primary headache or a chronic secondary headache. Chronic daily headache occurs in approximately 4% to 5% of the population [170,171]. The overwhelming majority of chronic headaches are primary headaches, typically migraine or tension. Chronic headache is not a separate syndrome. The general time frame for chronic is when the headache occurs on more than 15 days of each month, whether or not the patient is taking any medication.


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29. Which of the following factors should trigger referral to a headache specialist?
A) Failure of the patient to respond to appropriate treatment
B) Dependence of the patient on opioids for headache management
C) Minimal expertise of the primary physician regarding headache management
D) All of the above

REFERRAL

One of the most important decisions in managing patients with headaches, especially chronic headaches, is when to continue care and when to refer care. In general, most patients with benign headaches can be managed by primary care physicians and other clinicians. There are several factors involved when one should consider referral to a specialist. These include, but are not limited to:

  • Minimal physician expertise in headache management

  • Unable to determine diagnosis

  • Failure of the patient to respond to appropriate treatment

  • Worsening symptoms

  • Development of rebound cycles

  • Dependence on opioids

  • Significant comorbidities


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30. Which of the following statements regarding medico-legal issues in headache management is TRUE?
A) Physicians are fearful of missing a catastrophic cause of headache.
B) A common claim for headache management is "failure to diagnose."
C) Injury is a necessary but not sufficient requirement for recovery of damages.
D) All of the above

MEDICO-LEGAL ISSUES

With rising malpractice premiums, the threat of malpractice remains high on the minds of many healthcare professionals. With respect to headaches, physicians are fearful of missing that rare brain tumor or other catastrophic cause of headache. When such a misdiagnosis occurs, a malpractice claim may ensue. Any malpractice action falls under tort law.

Tort law allows injured persons to recover damages through the civil (i.e., noncriminal) judicial system. It is important to note that injury is a necessary but not sufficient requirement for recovery and most injuries do not give rise to a legal action. In the context of medical malpractice suits, the most relevant aspect of tort law is negligence as that is the claim most plaintiffs raise. A common claim for headache management is "failure to diagnose."


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