Chapter 3 Neurological Disorders (Headache)

15. Indicators that a headache can be the presenting symptom of a serious underlying illness and consideration for neuroimaging include all of the following except: A. similar headaches that occur periodically in clusters. B. increasing frequency and severity of headaches. C. headache causing confusion, dizziness, and/or lack of coordination. D. sudden, abrupt onset.

A. similar headaches that occur periodically in clusters.

136. Therapeutic intervention for Mrs. Lewis should include: A. systemic corticosteroid therapy. B. addition of an ACE inhibitor to her antihypertensive regimen. C. warfarin therapy. D. initiation of topiramate (Topamax®) therapy.

A. systemic corticosteroid therapy.

23. In tension-type headache, which of the following is true? A. Photophobia is seldom reported. B. The pain is typically described as "pressing" in quality. C. The headache is usually unilateral. D. Physical activity usually makes the discomfort worse.

B. The pain is typically described as "pressing" in quality.

In older adults with new-onset headache, especially if different from previous headache, a CRP test can be ordered to rule out:

giant cell arteritis.

The beta-blockers ____ and ____ have the strongest evidence demonstrating preventive effects for migraine.

metoprolol; propranolol

CGRP is a small neuropeptide found at the ends of nerves and embedded in blood vessels and can play a role in vasodilation and pain signaling. Several monoclonal antibodies that block CGRP or its receptor have been developed to prevent____ episodes. CGRP inhibitors are administered via subcutaneous injection (given monthly or every 3 months), though oral formulations of CGRP inhibitors are also in development.

migraine

In ____, headache is described as usually at a unilateral location, although occasionally bilateral, with a pulsating quality, moderate to severe in intensity, and aggravated by normal activity such as walking or other lighter physical activity.

migraine

Photo- and phonophobia are reported, as well as nausea and often vomiting.

migraine

What type of primary headache? -Focal dysfunction of cerebral cortex or brainstem causes one or more aura symptoms to develop over 4 minutes, or two or more symptoms occur in succession -Symptoms include feeling of dread or anxiety, unusual fatigue, nervousness or excitement, GI upset, visual or olfactory alteration -No aura symptom should last greater than 1 hour. If this occurs, an alternative diagnosis should be considered -Positive family history in 70% to 90%

migraine with aura

Sometimes called the "____ headache" because of the severity of the associated pain, cluster headache occurs periodically in clusters (hence its name) of several weeks.

suicide

Patients, while working with the health-care provider, can consider ____ prophylaxis once headaches are better controlled and lifestyle modifications are in place to minimize headache risk.

tapering

Classically, ____-type headache presents in a band-like pattern, often with mild nausea but not vomiting, and photophobia or phonophobia is reported, but not both.

tension

In ____-type headache, cephalgia (head pain) is usually described as a pressing, nonpulsatile pain, mild to moderate in intensity, and usually bilateral in location.

tension

An autoimmune vasculitis involving medium and large vessels with resulting arterial inflammation that affects just part of an artery with sections of normal artery in between. Inflammation and swelling of the arteries cause decreased blood flow resulting in the condition's associated symptoms.

Giant cell arteritis (GCA)

As soon as the diagnosis is made, indeed, even as the diagnostic process is ongoing, high-dose systemic corticosteroid therapy should be initiated. This therapy typically involves prednisone (when neurological or visual symptoms are present) until the disease appears to be under control, followed by a careful dose reduction until the lowest dose that can maintain clinical response can be determined. This dose is continued for 6 months to 2 years.

Giant cell arteritis (GCA)

CRP and erythrocyte sedimentation rate (ESR), although nonspecific tests of inflammation, are usually markedly elevated. One of these tests is usually done prior to arterial biopsy to confirm the presence of an inflammatory process.

Giant cell arteritis (GCA)

Color duplex ultrasonography of the temporal arteries has been used as an alternative or complement to superficial temporal artery biopsy. This technique has a high specificity when a classic halo sign is observed about the vessel, but results are user dependent.

Giant cell arteritis (GCA)

Diagnosis should include a confirmatory arterial biopsy as this is the standard for diagnosis. Because the disease frequently skips portions of the vessel, biopsy specimens of multiple vessel sites should be obtained.

Giant cell arteritis (GCA)

Extracranial branches of the carotid artery are often involved; this results in a tender or nodular, pulseless vessel, usually the temporal artery.

Giant cell arteritis (GCA)

SNOOP=

Presence of Systemic symptoms Neurological signs, symptoms Onset, abrubt or with exertion, sexual activity, coughing, and sneezing is suggestive of increased intracranial pressure; age onset less than 5 or greater than 50 Prior headache history Positional Papilledema - visual problems

____ headaches are not associated with other diseases.

Primary

58. Which of the following is a likely candidate for the use of a CGRP inhibitor? A. A 57-year-old man who experiences a migraine about once every 2 to 3 months B. A 45-year-old woman who experiences about 15 migraine days per month despite propranolol therapy C. A 32-year-old woman currently experiencing an acute migraine with severe GI upset and vomiting D. A 46-year-old man with a history of cluster headaches for the past 7 years

B. A 45-year-old woman who experiences about 15 migraine days per month despite propranolol therapy

33. The use of neuroleptics such as prochlorperazine (Compazine®) and promethazine (Phenergan®) in headache therapy should be limited to less than three times per week because of their: A. habituation potential. B. EPM risk. C. ability to cause rebound headache. D. activating effect.

B. EPM risk. Due to their antiemetic effects, the neuroleptics are sometimes used as adjunctive therapy in migraine therapy. However, use should be limited to 3 days per week because of the risk of EPMs.

24 to 28. Indicate if each of the following is a risk factor for cluster headaches (yes or no). ______ 24. onset at age 65 years or older ______ 25. heavy alcohol use ______ 26. tobacco user ______ 27. male gender ______ 28. recent increase in life stressors

24. no 25. yes 26. yes 27. yes 28. no

43 to 45. Match the female-to-male ratio for each type of primary headache listed: ______ 43. Tension-type headache ______ 44. Migraine without aura ______ 45. Cluster headache A. 1:3 to 1:8 B. 2:1 C. 5:4

43. C. 5:4 44. B. 2:1 45. A. 1:3 to 1:8

46 to 48. Match each patient with the most appropriate triptan formulation. ______ 46. A 34-year-old man with rapid-onset migraine headache that typically lasts 3 to 4 hours with nausea but no vomiting ______ 47. A 44-year-old woman with a slowly developing migraine that typically lasts 6 to 8 hours with little GI upset ______ 48. A 38-year-old woman with rapid-onset migraine that is often accompanied with significant nausea and vomiting A. oral naratriptan B. oral sumatriptan C. intranasal zolmitriptan

46. B. oral sumatriptan 47. A. oral naratriptan 48. C. intranasal zolmitriptan When considering a triptan medication for abortive migraine treatment, it is important to match the type of triptan with the patient and migraine characteristics. For patients with rapid-onset migraines of shorter duration, a rapid-onset triptan such as sumatriptan is most appropriate as it will be effective when the migraine is most debilitating. Similarly, for patients with migraines that are slower onset and longer duration, a triptan with a slow onset, such as naratriptan, will be more effective. Oral formulations are appropriate for patients without GI upset and vomiting. Otherwise, injection or intranasal formulations can be considered.

49 to 54. Indicate the appropriate course of action (head CT scan, head MRI, or neither) for each of the following patients: ______ 49. A 45-year-old man who presents with a sudden, abrupt headache. Upon questioning, he appears somewhat confused with decreased alertness to his surroundings. ______ 50. A 48-year-old woman with a history of breast cancer who presents with a 3-month history of progressively severe headache and bulging optic disk. ______ 51. A 24-year-old man who presents in the emergency department (ED) following a motor vehicle accident. He exhibits confusion and falls in and out of consciousness.

49. ct 50. mri 51. ct

The oral ____ ____ class (-ditan suffix, lasmiditan) is helpful in the treatment of migraine with or without aura and noted to improved pain as well as nausea and sensitivity to light and sound. Aside from sedation, this medication class is generally well tolerated, though cost is considerable. As a result, the oral 5-HT-1 agonists are typically used when other less expensive medications are ineffective and/or not tolerated.

5-HT-1F agonist

The goal of headache prophylactic/prevention therapy is a minimum of a __% reduction in the number of headaches, along with easier-to-control headaches that respond more rapidly to standard therapies and likely require less medication.

50

49 to 54. Indicate the appropriate course of action (head CT scan, head MRI, or neither) for each of the following patients: ______ 52. A 57-year-old woman with a prior history of a brain tumor that was removed 8 years ago. She complains of headaches that have been increasing in frequency and intensity over the past month. ______ 53. A 37-year-old man diagnosed with cluster-type headache 10 years ago that is consistently alleviated with high-dose oral NSAID and injectable triptan ______ 54. A 27-year-old woman with migraines occurring consistently for the past 10 years around 2 to 3 days prior to onset of menses, accompanied by photo-/phonophobia, nausea, and vomiting, with partial relief with ibuprofen; normal neurological examination

52. mri 53. neither 54. neither

34. Which of the following statements about ergotamines is false? A. This drug class is effective in the treatment of tension-type headaches. B. They act as 5-HT1A and 5-HT1D receptor agonists. C. With its use, this drug class carries a potential vasoconstrictor effect. D. Use should be avoided in the presence of coronary artery disease.

A. This drug class is effective in the treatment of tension-type headaches. Ergotamines can be an effective option for the treatment of migraines and cluster headaches. However, they are not recommended in the treatment of tension-type headaches.

55. In counseling a patient who experiences migraines, you recommend all of the following lifestyle changes to minimize the risk of triggering a headache except: A. avoiding eating within 1 to 2 hours of morning awakening. B. limiting exposure to cigarette smoke. C. avoiding trigger physical activities. D. implementing strategies to reduce stress.

A. avoiding eating within 1 to 2 hours of morning awakening.

31. Triptans should be used with caution with the concomitant use of: A. high-dose SSRI. B. calcium channel blockers. C. fluoroquinolones. D. high-dose statin.

A. high-dose SSRI.

16. Prophylactic treatment for migraine headaches in a 28-year-old woman with no chronic health problems who uses a levonorgestrel-releasing intrauterine device (LNG-IUD) for contraception includes the use of: A. nortriptyline. B. ergot derivative. C. naproxen sodium. D. clonidine.

A. nortriptyline.

37. A first-line prophylactic treatment option for the prevention of tension-type headache is: A. nortriptyline. B. verapamil. C. carbamazepine.

A. nortriptyline.

41. When evaluating a patient with acute headache, all of the following observations would indicate the absence of a more serious underlying condition except: A. onset of headache with exertion, coughing, or sneezing. B. history of previous identical headache. C. supple neck. D. normal neurological examination results.

A. onset of headache with exertion, coughing, or sneezing.

139. Concomitant disease often seen with GCA includes: A. polymyalgia rheumatica. B. acute pancreatitis. C. psoriatic arthritis. D. reactive arthritis.

A. polymyalgia rheumatica.

135. Mrs. Lewis is a 74-year-old woman with well-controlled hypertension. She is taking HCTZ and presents with a 3-day history of unilateral throbbing headache with difficulty chewing because of jaw pain. On physical examination, you find a tender, pulseless, noncompressible temporal artery. Blood pressure (BP) is 160/88 mm Hg, apical pulse is 98 bpm, and respiratory rate is 22/min; the patient is visibly uncomfortable. The optimal technique to confirm a diagnosis of GCA is: A. to check serum creatine kinase (CK). B. biopsies of likely affected arteries. C. CT scan of the head without contrast. D. MRI of the head.

B. biopsies of likely affected arteries.

39. A 68-year-old man presents with new-onset headaches. He describes the pain as bilateral frontal to occipital and most severe when he arises in the morning and when coughing. He feels much better by mid-afternoon. The history is most consistent with headache caused by: A. vascular compromise. B. increased ICP. C. brain tumor. D. tension with atypical geriatric presentation.

B. increased ICP.

30. Which of the following oral agents has the most rapid analgesic onset? A. plain naproxen (Naprosyn®) B. liquid ibuprofen (Motrin®, Advil®) C. immediate-release diclofenac (Voltaren®) D. enteric-coated naproxen (Naproxen EC®)

B. liquid ibuprofen (Motrin®, Advil®)

138. For a patient receiving standard therapy for GCA, the use of all of the following concomitant therapies should be considered except: A. aspirin. B. nitrate. C. bisphosphonate and calcium/vitamin D. D. a proton pump inhibitor.

B. nitrate.

29. Which of the following is most specific for abortive therapy of cluster headaches? A. NSAIDs B. supplemental oxygen C. opioids D. neuroleptics

B. supplemental oxygen

137. Headache associated with GCA is least likely to occur in the: A. frontal area. B. temporal area. C. vertex. D. occipital area.

B. temporal area.

134. In examining a 65-year-old woman who is undergoing evaluation for GCA, the NP considers the conditions clinical presentation is influenced by the diseases pathophysiology. Which of the following statements is false regarding GCA? A. It results in inflammation of temporal and other arteries. B. Normal arterial sections can be found in between affected sections. C. It primarily impacts smaller-sized vessels. D. GCA can result in a finding of a tender and/or nodular, pulseless vessel.

C. It primarily impacts smaller-sized vessels.

20. You are examining a 65-year-old man who has a history of acute coronary syndrome (ACS) and migraine. Which of the following agents represents the best choice of acute headache (abortive) therapy for this patient? A. verapamil B. ergotamine C. acetaminophen D. sumatriptan

C. acetaminophen For patients with a history of coronary artery disease, the use of agents with vasoconstrictor properties (triptans) should be avoided.

40. Short-term systemic corticosteroid therapy would be most appropriate in treating: A. monthly tension-type headache. B. migraines occurring on a weekly basis. C. acute intractable or severe migraines and cluster headaches. D. periodic migraines occurring during pregnancy.

C. acute intractable or severe migraines and cluster headaches. Systemic corticosteroids can be considered for patients with intractable or severe migraine pain or with cluster headache. Because of adverse effects, these agents should not be used more than once per month.

35. With appropriately prescribed headache prophylactic therapy, the patient should be informed to expect: A. virtual resolution of headaches. B. no fewer but less severe headaches. C. an approximately 50% reduction in the number of headaches. D. that lifelong therapy is advised.

C. an approximately 50% reduction in the number of headaches.

140. One of the most serious complications of GCA is: A. hemiparesis. B. arthritis. C. blindness. D. uveitis.

C. blindness.

42. The more common secondary headache etiology includes all of the following except: A. brain tumor. B. intracranial bleeding. C. cluster cephalalgia D. viremia.

C. cluster cephalalgia

13. A 27-year-old man presents with a 5-week history of recurrent headaches that awaken him during the night. The pain is severe, lasts about 1 hour, and is located behind his left eye. Additional symptoms include lacrimation and nasal discharge. His physical examination is within normal limits, and he is currently headache-free. This clinical presentation is most consistent with: A. migraine without aura. B. migraine with aura. C. cluster headache. D. increased ICP.

C. cluster headache.

32. Limitations associated with the use of butalbital with acetaminophen and caffeine (Fioricet®) include its: A. energizing effect. B. GI upset profile. C. high rate of rebound headache if used frequently. D. low clinical efficacy.

C. high rate of rebound headache if used frequently.

18. Antiepileptic drugs useful for preventing migraine headaches include all of the following except: A. divalproex. B. valproate. C. lamotrigine. D. topiramate.

C. lamotrigine.

14. A 22-year-old woman presents with a 3-year history of recurrent, unilateral, pulsating headaches with vomiting and photophobia. The headaches, which generally last 3 hours, can be minimized by resting in a dark room. She can usually tell that she is going to get a headache. She explains, "I see little 'squiggles' before my eyes for about 15 minutes before the headache starts." Her physical examination is unremarkable. This presentation is most consistent with: A. tension-type headache. B. migraine without aura. C. migraine with aura. D. cluster headache.

C. migraine with aura.

38. A 47-year-old woman experiences occasional migraine with aura and reports improvement in photophobia and phonophobia with zolmitriptan use and a small reduction in headache pain. You consider prescribing the addition of which of the following to help improve her overall migraine symptoms? A. gabapentin B. topiramate C. naproxen sodium D. magnesium

C. naproxen sodium

21. A 45-year-old man experiences rapidly progressing migraine headaches that are accompanied by significant GI upset. Appropriate acute headache (abortive) treatment includes all of the following except: A. injectable sumatriptan. B. dihydroergotamine nasal spray. C. oral naproxen sodium. D. zolmitriptan nasal spray.

C. oral naproxen sodium.

133. Risk factors for GCA include all of the following except: A. older age. B. female gender. C. osteoarthritis. D. European ancestry.

C. osteoarthritis.

In older adults with new-onset headache, especially if different from previous headache, a ____ test can be ordered to rule out giant cell arteritis.

CRP

____ headaches involve severe or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain) that can last 15 to 180 minutes with a frequency ranging from once a day to eight times daily. Headaches are often accompanied by one or more of the following symptoms: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, or eyelid edema.

Cluster

____ headaches, also known as migrainous neuralgia, are most common in middle-aged men, particularly men with heavy alcohol and tobacco use.

Cluster

22. With migraine, which of the following statements is true? A. Migraine with aura is the most common form. B. Most migraineurs are in ongoing health care for the condition. C. The condition is equally common in both men and women. D. The pain is typically described as pulsating.

D. The pain is typically described as pulsating.

56. A 37-year-old woman complains of migraine headaches that typically occur within hours after eating in a restaurant. Potential triggers that can influence the onset and severity of migraine symptoms include all of the following except: A. cheese pizza. B. pickled or fermented foods. C. freshly baked yeast products. D. baked whitefish.

D. baked whitefish.

19. Evidence supports the use of all of the following vitamins and supplements for migraine prevention except: A. butterbur. B. riboflavin. C. feverfew. D. ginkgo biloba.

D. ginkgo biloba.

59. Which of the following is most closely linked to migraines? A. dyslipidemia B. completing at least one full-term pregnancy C. allergic reaction to shellfish D. motion sickness

D. motion sickness

57. Which of the following is incorrect regarding the CGRP inhibitor class? A. dosed once monthly or quarterly B. used for prevention of migraines C. dosed by subcutaneous injection D. nearly eliminates migraines for over 50% of individuals

D. nearly eliminates migraines for over 50% of individuals

17. Among the following beta blockers, which is the preferred agent to use in preventing migraine headache in a 40-year-old woman with a history of bilateral tubal ligation and no history of airway disease? A. acebutolol B. carvedilol C. atenolol D. propranolol

D. propranolol

36. A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers prescribing all of the following except: A. continuous monophasic combined oral contraceptive. B. phasic combined oral contraceptive with a 7-day-per-month withdrawal period. C. low-dose estrogen patch use during the premenstrual week. D. triptan prophylaxis.

D. triptan prophylaxis. Menses and ovulation can be potential triggers for migraine headaches. Estrogen supplementation, particularly during the premenstrual week, can be considered for migraine prevention. Triptans, however, are used as abortive therapy and not prophylaxis.

Often there is also a history of recent-onset respiratory tract symptoms (cough, sore throat, hoarseness). Jaw claudication, that is, pain in the jaw, is usually reported as well as acute reduction or change in vision. Approximately 50% of patients experience visual symptoms, including transient visual blurring, diplopia, eye pain, or sudden loss of vision; transient repeated episodes of blurred vision are usually reversible, but sudden loss of vision is an ominous sign and is almost always permanent. Occasionally, and most often noted in the frail older adult, there is a change in mental status and less report of headache.

Giant cell arteritis (GCA)

Treatment helps minimize the risk of blindness, which is one of the most serious complications of the disease, and also serves to minimize pain.

Giant cell arteritis (GCA)

When symptoms have been stable, and the corticosteroid therapy is to be discontinued, a slow taper with close monitoring is warranted because of the risk of adrenal suppression and/or disease resurgence. GI cytoprotection with misoprostol or a proton pump inhibitor and bone protection with a bisphosphonate plus calcium/vitamin D supplement should also be provided to minimize these corticosteroid-related adverse effects. Low-dose aspirin (81 mg per day) can also be considered to reduce the risk of stroke.

Giant cell arteritis (GCA)

Headache red flag mnemonic:

SNOOP

____ headaches are associated with or caused by other conditions, generally does not resolve until specific cause is diagnosed and addressed

Secondary

Available in various types, including rapid-onset ____ (effect within minutes to a few hours depending on route; e.g., sumatriptan [Imitrex®], rizatriptan [Maxalt®]) and slow-onset ____ (effect up to 24 hours; e.g., naratriptan [Amerge®], zolmitriptan [Zomig®]).

Triptans

Select ____ drugs, such as divalproex sodium, sodium valproate, and topiramate, have also demonstrated effectiveness in preventing migraines.

antiepileptic

Migraine ____ is a recurrent neurological symptom that arises from the cerebral cortex or brainstem. Typically, the ____ develops over 5 to 20 minutes, lasts less than 1 hour, and is accompanied or followed by unilateral cephalgia.

aura

Treatment includes a reduction of triggers, such as tobacco and alcohol use, and initiation of prophylactic therapy and appropriate abortive therapy. In ____ headache, abortive treatments can include high-flow oxygen therapy, triptans, ergot alkaloids, and local anesthetics, including lidocaine nasal spray. Preventive/prophylactic agents can include the use of calcium channel blockers, mood stabilizers (e.g., lithium), and anticonvulsants.

cluster

What type of primary headache? -Tendency of headache to occur daily in groups or clusters, hence the name -Usually last several weeks to months, then disappear for months to years -Usually occurs at characteristic times of year -Headache is often located behind one eye with a steady, intense ("hot poker in the eye" sensation), severe pain in a crescendo pattern lasting 15 minutes to 3 hours, with most in the range of 30 to 45 minutes. -Most often occurs with ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, and nasal stuffiness -Female-to-male ratio approximately 1:3 to 1:8 (depending on source) Family history present in approximately 20%

cluster

What type of primary headache? -Lasts 4 to 72 hours with two or more of the following characteristics: • Usually unilateral location, although occasionally bilateral • Pulsating quality, moderate to severe in intensity • Aggravation by normal activity such as walking, or causes avoidance of these activities -During headache, one or more of the following: • Nausea/vomiting, photophobia, phonophobia • Female-to-male ratio 2:1 • Positive family history in 70% to 90%

migraine without aura

The ____ headaches, including migraine, tension-type, and cluster, are the most common chronic pain syndromes seen in health care.

primary

Use of ____ therapy for migraine and tension-type headache should be considered if abortive or acute headache therapy is used frequently or if inadequate symptom relief is obtained from appropriate use of these therapies.

prophylactic

What type of primary headache? Lasts 30 minutes to 7 days (usually 1 to 24 hours) with two or more of the following characteristics: • Pressing, nonpulsatile pain • Mild to moderate in intensity • Usually bilateral location • Notation of 0 to 1 of the following (greater than 1 suggests migraine): nausea, photophobia, or phonophobia • Female-to-male ratio 5:4 • Significant family history of similar headache usually reported

tension

Select antidepressants, including the ____ antidepressants such as nortriptyline and amitriptyline, as well as the selective ____, including venlafaxine, can also be considered for migraine prophylaxis.

tricyclic; SNRIs

Because of a potential vasoconstrictor effect, ____ use is contraindicated in patients with Prinzmetal angina, with established or high risk for coronary artery disease, with uncontrolled hypertension, in pregnant women, or with recent ergot use.

triptan

Because of the risk of serotonin syndrome, ____ should be used with caution with monoamine oxidase inhibitors (MAOIs), high-dose selective serotonin reuptake inhibitors (SSRIs), or selective serotonin and norepinephrine reuptake inhibitors (SNRIs).

triptans

The selective serotonin receptor agonists, better known as the ____, are a medication class specifically used for the relief of migraine headache.

triptans

These agents are often effective in reducing migraine-related symptoms, such as photophobia and phonophobia, but are more limited in complete relief of migraine pain. Adjunctive therapy is often used for pain relief, typically with an NSAID.

triptans

Migraine ____ ____ is found in about 20% of patients with migraine disorders.

with aura

Migraine ____ ____ affects about 80% of persons with migraine. On careful questioning, many patients report a migraine warning, such as agitation, jitteriness, disturbed sleep, or unusual dreams, prior to onset.

without aura