Headache case 5

Headache case 5

A forty-year-old woman presents to the emergency department complaining of two days of severe headache, fever, and stiff neck. On examination, the patient displays nuchal rigidity and Brudzinski's sign.

Q1

Which of the following is the most likely diagnosis?
/ A. Embolic stroke
/ B. Guillain-Barré syndrome
/ C. Hemorrhagic stroke
/ D. Meningitis
/ E. Vascular headache

Q 2

Lumbar puncture is performed and the cerebrospinal fluid is examined. The fluid is turbid, and laboratory findings include elevated opening pressure, neutrophilic pleocytosis, markedly elevated protein, and decreased glucose. Which of the following is the most likely etiologic
agent?
/ A. Cryptococcus neoformans
/ B. Herpes simplex
/C. Listeria monocytogenes
/D. Mycobacterium tuberculosis
/E. Streptococcus pneumoniae

Q 3
Cerebrospinal fluid glucose concentration is normally approximately what fraction of serum glucose concentration?
/ A. 1/3
/ B. 1/2
/ C. 2/3
/ D. 1
/ E. 4/3

Q 4
Which of the following would be the most appropriate pharmacotherapy?
/ A. Acyclovir
/ B. Ceftriaxone
/ C. Cephazolin
/ D. Penicillin
/ E. Valicyclovir


Q 5
Which of the following best describes the order of meningeal layers from the skull to the cerebral cortex?
/ A. Arachnoid, dura mater, pia mater
/ B. Arachnoid, pia mater, dura mater
/ C. Dura mater, arachnoid, pia mater
/ D. Dura mater, pia mater, arachnoid
/ E. Pia mater, dura mater, arachnoid

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Headache case 5 answers
A1
The correct answer is D. Meningitis is characterized by fever, headache, nuchal rigidity, and CNS dysfunction including confusion, delirium, lethargy, coma, and cranial nerve dysfunction. Brudzinski's sign indicates meningeal irritation: as the patient's neck is flexed, the patient flexes the hip and knee.
Choices A and C are incorrect. A stroke is a vascular accident and would thus have an acute onset. Focal neurologic findings would be elicited. Fever would not be found in stroke.
Guillain-Barré syndrome (choice B) is a peripheral neuropathy, and thus peripheral, rather than central nervous system findings, would be present.
Vascular headache (choice E) presents as severe headache, often throbbing, which is accompanied by nausea and photophobia. Visual aura may precede the headache, and focal neurologic findings may complicate the course. Fever is not present.

A2
The correct answer is E. The CSF analysis greatly aids in finding the etiology of meningitis. In bacterial meningitis, the CSF has decreased glucose, elevated protein, and a proliferation of neutrophils. In addition, a Gram's stain should be performed and will often reveal and allow characterization of the bacteria. S. pneumoniae is a common bacterial pathogen seen in this patient's age group. Antibiotic therapy to cover this organism can now be started pending cultures and sensitivity.
Cryptococcus neoformans(choice A) is responsible for chronic fungal meningitis. The CSF would have lymphocytes with only a slight elevation in protein, with normal or slightly decreased glucose.
Viral meningitis, from e.g., Herpes simplex (choice B), would produce a slight elevation in CSF lymphocytes, normal glucose, and slightly elevated protein.
Listeria monocytogenes(choice C) is a bacterial pathogen, but it is found in the pediatric population, and thus would be extremely unlikely in this patient.
Tuberculous meningitis (choice D) has an indolent course and a delayed onset. The CSF in TB meningitis would have slight lymphocytic elevation, markedly elevated protein, and slightly decreased glucose.

A3
The correct answer is C. CSF glucose is derived from serum, and is a reflection of the serum concentration during the previous 2-4 hours. Glucose is often abnormally low in cases of bacterial meningitis. In normal-pressure hydrocephalus, CSF glucose is usually normal. Normally, CSF glucose is about 2/3 of the serum glucose concentration.

A4
The correct answer is B. When selecting an antimicrobial, it is important to select an agent that is effective against the likely organisms and will also penetrate the blood-brain barrier. Ceftriaxone will be effective against the likely organisms causing bacterial meningitis in a 40-year-old (Neisseria meningitidis and Streptococcus pneumoniae). In addition, it can cross the blood-brain barrier and access the CNS.
Acyclovir (choice A) and valicyclovir (choice E) are antivirals and would be inappropriate in bacterial meningitis.
Cephazolin (choice C) and penicillin (choice D) are effective against gram-positive organisms, but they do not cross the blood-brain barrier.

A5
The correct answer is C. The dura mater is the most substantial layer of the meninges and is the most distal from the brain. The next layer is the arachnoid layer. The pia is a thin tissue layer applied directly to the surface of the brain. Cerebrospinal fluid is found between the arachnoid and pia layers.

Headache case 4

Headache case 4

A 39-year-old woman presents to the emergency department after collapsing at a party. An interview with her boyfriend indicates that she complained of a severe headache prior to her collapse. He states that she has no significant past medical history and takes occasional
vitamin supplements. Her blood pressure is 200/120 mm Hg, pulse is 37/min, and respirations are 5/min. The patient is unresponsive to commands or painful stimuli. There is moderate papilledema. The remainder of the examination is unremarkable. An electrocardiogram
demonstrates normal sinus rhythm without T wave inversions or ST segment changes.
Q 1
Which of the following is the most likely diagnosis?
/ A. Anterior communicating artery aneurysm rupture
/ B. Atonic seizure
/ C. Cocaine induced myocardial infarction
/ D. Posterior inferior cerebellar artery aneurysm rupture
/ E. Vein of Galen malformation


Q 2
Which of the following conditions would predispose this patient to having this condition?
/ A. Atherosclerosis
/ B. Diabetes
/ C. Hemophilia
/ D. Marfan syndrome
/ E. Protein C deficiency
/ F. Protein S deficiency

Q 3
A CT scan would most likely demonstrate blood in which of the following areas?
/ A. Fourth ventricle
/ B. Lateral ventricles
/ C. Subarachnoid space
/ D. Subdural space
/ E. Superior sagittal sinus
/ F. Third ventricle


Q4
Which of the following drugs could have precipitated this patient's condition?
/ A. Cocaine
/ B. Hashish
/ C. Lysergic acid diethylamide (LSD)
/ D. Morphine
/ E. Pindolol

Q5
Which of the following is more likely to be present in patients with this condition than in normal persons?
/ A. Early AIzheimer disease
/ B. Fronto-temporal brain atrophy
/ C. Medullary thyroid carcinoma
/ D. Osteosarcoma
/ E. Renal cysts

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Headache case 4 answers

A1
The correct answer is A. This patient is presenting with a loss of consciousness, bradycardia, hypertension, and decreased respirations. While loss of consciousness has a wide differential diagnosis, the triad of bradycardia, hypertension, and decreased respirations is known as Cushing's triad, and is indicative of increased intracranial pressure. The finding of papilledema confirms that there is increased intracranial pressure. The differential diagnosis at this point is a spontaneous hemorrhage due to aneurysm rupture, trauma, vascular malformation rupture, or possibly a massive ischemic stroke. Of the choices given, anterior communicating artery aneurysm rupture is the most likely diagnosis. Aneurysms are outpouchings of the arteries of the Circle of Willis that occur most commonly at the anterior communicating artery, middle cerebral artery, or posterior communicating artery. They most commonly present with hemorrhage or headache. In this case, there is likely hemorrhage and increased intracranial pressure leading to secondary brain herniation. Treatment of this patient consists of lowering intracranial pressure and treating the aneurysm surgically.
An atonic seizure (choice B) is a fainting spell in which the patient becomes hypotonic, but recovers over a short interval. There would be no signs of increased intracranial pressure.
Myocardial infarction (choice C) from cocaine or other etiology would usually have electrocardiogram abnormalities and there would be no signs of increased intracranial pressure.
Posterior inferior cerebellar artery aneurysm rupture (choice D) is a possibility but these aneurysms are rare, compared to anterior communicating artery aneurysms.
Vein of Galen malformations (choice E) are a remnant of the fetal circulation that presents in children as a posterior fossa mass. Actual hemorrhage of these lesions is relatively rare.

A2
The correct answer is D. Connective tissue diseases, such as Marfan syndrome, weaken blood vessel walls and predispose to aneurysms of any blood vessels in the body. Marfan syndrome is an autosomal dominant disorder that has been linked to the FBN1 gene on chromosome 15. FBN1 encodes the protein fibrillin, which is involved in the formation of elastic fibers found in connective tissue. Without the structural support provided by fibrillin, many tissues are weakened, with severe consequences, e.g., aneurysm formation.
Atherosclerosis (choice A) is not thought to be associated with intracranial aneurysms, which are believed to form from congenitally weak areas at the junctions of blood vessels. Aortic aneurysms are closely associated with atherosclerosis.
Diabetes (choice B) is not thought to be associated with intracranial aneurysms. However, diabetes leads to an increased incidence of atherosclerosis, which may lead to aortic aneurysms.
The hemophilias (choice C) are blood clotting disorders that do not predispose patients to aneurysms. These patients bleed profusely from even minor vessel trauma, however.
Protein C deficiency (choice E) and protein S deficiency (choice F) are blood clotting disorders leading to thrombosis of arteries and veins. This does not predispose a patient to aneurysms, however.

A3
The correct answer is C. The subarachnoid space consists of the space between the pia, which adhere to the brain, and the arachnoid membrane. The circle of Willis, including the anterior communicating artery, lies in the subarachnoid space. Subarachnoid hemorrhage is a common presenting symptom of ruptured intracranial aneurysms. Aneurysmal subarachnoid hemorrhage is usually within the basilar cisterns, where the circle of Willis lies, while posttraumatic subarachnoid hemorrhage is usually over the cerebral convexities. Hemorrhage into the epidural or subdural space is usually secondary to trauma. Epidural hematomas occur from injury to the middle meningeal artery and subsequent hematoma formation, and are usually associated with a fracture of the temporal bone.
Intraventricular hemorrhage (choices A, B, and F) is a much less common presentation of a ruptured aneurysm. Usually there will be subarachnoid hemorrhage and intraventricular hemorrhage, rather than isolated intraventricular hemorrhage. Intraventricular hemorrhage often leads to ependymitis and hydrocephalus from dysregulation of the normal cerebrospinal fluid production and resorption physiology.
Subdural hematomas (choice D) are usually secondary to trauma, not bleeding aneurysms. Subdural hematomas form from injury to the bridging veins between the venous sinuses and the cortical draining veins. Subdurals are common in elderly patients because they usually have some degree of brain atrophy and these bridging veins are stretched thin.
There is normally blood present in the superior sagittal sinus (choice E), which drains the cortical veins from the top of the cerebrum.

A4
The correct answer is A. The key here is to find the drug that leads to hypertension, and thus is likely to cause an aneurysm to rupture. Cocaine leads to episodic hypertension due to its sympathomimetic effects. It may be snorted, smoked, or injected. Cocaine use is associated with cardiac arrhythmia, myocardial infarction, stroke, and cerebral or aortic aneurysm rupture. Although not a cause of intracranial aneurysm formation, it may lead to aneurysm rupture. Cocaine is used for its central effects on dopaminergic neurons, and the sympathomimetic effects described above are unwanted side effects.
Hashish (choice B) and marijuana contain delta-9- tetrahydrocannabinol (THC), which is used for its effects on the central nervous system. Other physical effects include reddening of the eyes, dryness of the mouth and throat, moderate increase in the heart rate, tightness of the chest (if the drug is smoked), drowsiness, unsteadiness, and muscular incoordination. Hypertension is not a common effect of THC.
Lysergic acid diethylamide (LSD) (choice C) is a psychotropic amide with many poorly-understood central nervous system effects. Significant hypertension does not generally occur with LSD.
Morphine (choice D) is an opiate analgesic, and would tend to lower blood pressure, rather than increase it.
Pindolol (choice E) is a nonselective beta-adrenergic receptor blocker. In addition, pindolol has partial agonist activity, with significantly greater agonist than antagonist effects at beta-2 receptors. It has negative inotropic and chronotropic effects and thus is used as an antihypertensive agent. It would help prevent hypertension.

A5
The correct answer is E. Patients with adult polycystic kidney disease have a much higher incidence of berry aneurysms than the general population. Hypertension that may accompany the eventual renal failure can contribute to aneurysm rupture and subarachnoid hemorrhage.
Early Alzheimer-like changes (choice A) are observed in patients with Down syndrome.
Fronto-temporal brain atrophy (choice B) is seen in Pick disease.
Medullary thyroid carcinoma (choice C) is seen with increased frequency in multiple endocrine neoplasia (MEN) IIa and IIb.
Osteosarcoma (choice D) is more frequent in patients with familial

Headache case 3

Headache case 3

A 69-year-old man presents to the emergency department with a headache. He states that the headache is the worst headache he has ever had and has been constant for the past three hours. The patient has a past medical history of hypertension and benign prostate hypertrophy.
Review of systems reveals a possible seizure two months ago. Medications include atenolol and occasional ibuprofen. Vital signs are normal.
Physical examination is notable for papilledema bilaterally and a clumsy gait.
Question 1 of 4
Which of the following is the most likely diagnosis?
/ A. Arteriovenous malformation
/ B. Ganglioglioma
/ C. Glioblastoma multiforme
/ D. Meningococcal meningitis
/ E. Metastatic renal cell carcinoma

Q 2
A CT scan with intravenous contrast shows a large, enhancing mass of the left temporal, frontal and parietal lobes. Biopsy of this lesion would
most likely show which of the following?
/ A. Atypical astrocytes with mild pleomorphism
/ B. BIepharoplasts in a sheet configuration
/ C. Normal astrocytes
/ D. Pseudopalisading astrocytes with necrosis
/ E. Tubules and rosettes of blepharoplasts



Q3
Besides surgery, which of the following would be the most appropriate pharmacotherapy in this patient?
/ A. Aspirin
/ B. Coumadin
/ C. Dexamethasone
/ D. Doxycycline
/ E. Heparin


Q 4
If this patient was left untreated for six months, what would be the most likely new presenting symptom?
/ A. Anosmia
/ B. Cardiac arrhythmias
/ C. Left hemiparesis
/ D. Right hemiparesis
/ E. Sudden death

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Headache case 3 answers

A1
The correct answer is C. Glioblastoma multiforme is the most common brain tumor in adults. In adults, glioblastomas are noted most frequently in the frontal lobe with the temporal lobe second in frequency. Childhood glioblastomas of the cerebral hemispheres are also located most often in the frontal lobe; with the second most frequent site being the parietal lobe. Glioblastomas account for 50% of all gliomas and arise after age 50 in most patients. Younger patients tend to have a better prognosis than the elderly. Radiation and chemotherapy appear to extend the life of the patient.
Glioblastoma multiforme is the highest grade of astrocytoma, and may present with papilledema, headaches, seizure, or personality changes. The next step is to obtain diagnostic imaging studies such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. The tumor would typically be a large, irregular, necrotic, enhancing mass within the brain parenchyma.
Arteriovenous malformations (choice A) are relatively uncommon brain lesions that often present with seizures in patients less than forty years of age.
Gangliogliomas (choice B) are rare, benign brain tumors that present with seizures in patients less than forty years of age.
Meningitis (choice D) usually presents with photophobia, fever, and headache. Meningitis would be on the differential diagnosis in this case.
Metastatic disease (choice E) is common in this older age group. Usually there are signs or symptoms from the primary neoplasm first, but an isolated brain metastasis may be the initial presentation. Renal cell carcinoma is a much less common cause of a brain mass than glioblastoma multiforme.

A2
The correct answer is D. Markedly pleomorphic astrocytes in a pseudopalisading configuration with necrosis is a classic appearance for glioblastoma multiforme. There are often multiple gemistocytes (large astrocytes) present as well.
Atypical astrocytes with mild pleomorphism (choice A) are characteristic of a low grade astrocytoma, not a high grade astrocytoma, like glioblastoma multiforme.
Blepharoplasts (choice B and E) are the key cells seen in ependymoma, a less aggressive tumor of the ependyma, which lines the ventricles. Typically, blepharoplasts are arranged in tubules and rosettes around blood vessels.
Astrocytes (choice C) are the most common cell in the normal brain. Normal astrocytes make up only a small portion of the cells in a glioma

A3
The correct answer is C. A high potency steroid like dexamethasone or prednisolone is indicated to lower intracranial pressure on the brain. A low potency steroid like cortisone would not be effective. Steroids interrupt the normal inflammatory cascade of the body, and thus reduce brain swelling from causes such as a tumor or trauma. A low potency nonsteroidal anti-inflammatory agent like aspirin or ibuprofen would not reduce intracranial pressure to any measurable extent.
Aspirin (choice A) is a low potency anti-inflammatory agent that also has an effect on platelets. It might help with headache, but would not relieve symptoms of increased intracranial pressure.
Coumadin (choice B) is an oral anticoagulant that is contraindicated in a patient with a brain tumor because of the risk of potentially fatal intracranial hemorrhage within the tumor.
Doxycycline (choice D) is an antibiotic with no known role in the treatment of brain tumors.
Heparin (choice E) is an intravenous anticoagulant that is contraindicated in a patient with a brain tumor because of the risk of potentially fatal intracranial hemorrhage within the tumor.

A4
The correct answer is D. Right hemiparesis is the most likely outcome, because a frontoparietal lesion on the left would likely affect the motor strip controlling the entire right side of the body. Specific body parts affected would depend on the exact neural circuits damaged. The patient would likely also experience sensory deficits on the right side of the body.
Anosmia (choice A) is characteristic of lesions in the inferior frontal lobes or the bones of the anterior cranial fossa interfering with the first cranial nerves, which convey the sense of smell.
Lesions affecting the autonomic centers of the medulla, or a lesion of the pituitary causing an electrolyte imbalance, could conceivably cause an arrhythmia, but cardiac arrhythmias (choice B) are most commonly caused by primary dysfunction of the cardiac conduction system or electrolyte imbalances, rather than brain lesions.
Left hemiparesis (choice C) would arise from a lesion of the right frontal region.
Sudden death (choice E) is a rare effect of brain tumors. A tumor would have to compress the medulla (directly, or via a mass effect) to stop respiration or cardiac activity. A posterior cranial fossa mass lesion could cause sudden death from cerebral herniation.

Headache case 2

Headache case 2

A 70-year-old woman of Scandinavian descent consults a physician because she has been having numerous headaches for the past several months. These headaches began abruptly and increased in severity and duration over a several week period. They are sometimes accompanied by facial pain on the lateral aspect of her forehead. During the period when the headaches first began, she experienced malaise and fever. Physical examination is notable for a tender, thickened blood vessel running cranially along her lateral temple anterior to and above her ear.
Q 1
The involved blood vessel is most likely which of the following?
/ A. Facial artery
/ B. Lingual artery
/ C. Occipital artery
/ D. Posterior auricular artery
/ E. Superficial temporal artery

Q 2
The involved blood vessel is a branch arising directly from which of the following blood vessels?
/ A. Basilar artery
/ B. Common carotid artery
/ C. External carotid artery
/ D. Internal carotid artery
/ E. Vertebral artery


Q 3
Biopsy of the involved blood vessel would be most likely to show which of the following?
/ A. Arteriolosclerosis
/ B. Giant cell arteritis
/ C. Polyarteritis nodosa
/ D. Takayasu arteritis
/ E. Wegener granulomatosis


Q 4
Which of the following is the most serious complication of this disease process?
/ A. Blindness
/ B. Face and neck pain
/ C. Jaw claudication
/ D. Skin necrosis
/ E. Widespread vessel tenderness


Q 5
The patient has also been experiencing severe morning stiffness, which causes her to have to "roll" out of bed in the morning. Her shoulder girdle and pelvic girdle are most strikingly involved. She experiences the pain as "muscle pain," but later serum studies show no elevation of the muscle marker creatine kinase. Physical examination for arthritis-related findings is unremarkable, but her erythrocyte sedimentation rate is found to be markedly high. Which of the following is the most likely diagnosis?
/ A. Gout
/ B. Osteoarthritis
/ C. Polymyalgia rheumatica
/ D. Rheumatoid arthritis
/ E. Still disease


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Headache case 2 answers

A1
The correct answer is E. The artery is the superficial temporal artery, which is often just called the temporal artery. It runs from the parotid gland upward in front of the tragus of the ear together with the auriculotemporal nerve, and divides into anterior and posterior branches that supply the temporal area of the scalp.
The facial artery (choice A) arises below the corner of the jaw and then crosses the mandible to run diagonally toward the nose.
The lingual artery (choice B) arises below the corner of the jaw and supplies the tongue.
The occipital artery (choice C) and the posterior auricular artery (choice D) both course backward behind the ear.

A2
The correct answer is C. The temporal artery is a terminal branch (together with the posterior auricular artery) of the external carotid artery. The external carotid artery supplies the external aspect of the face and head, and its branches include the lingual artery, the facial artery, the superficial temporal artery, the posterior auricular artery, and the occipital artery.
The basilar artery (choice A) arises from the union of the two paired vertebral arteries (choice E); both supply the brainstem and the rest of the brain through the Circle of Willis.
The common carotid artery (choice B) gives rise to the internal and external carotid arteries.
The internal carotid artery (choice D) supplies the brain via the Circle of Willis.

A3
The correct answer is B. The most likely diagnosis is giant cell arteritis, which is characterized microscopically by granulomatous destruction, with giant cell formation, of the wall of the vessel. The condition is also commonly known as temporal arteritis, although this term is presently being discouraged because the inflammatory process may involve many other similar sized arteries both within and outside of the head. The clinical presentation illustrated in the case summary is typical. The condition is fairly uncommon (18 cases per 100,000 in the population aged 50 years or more), and so will be suspected more often than proved. The diagnosis is established by biopsy of a fairly long segment (2 cm or more) of the temporal artery, since the lesion is spotty and may be missed with smaller biopsies. (There is enough collateral blood supply to the scalp that distal infarction of scalp tissues does not occur.)
Arteriolosclerosis (choice A) involves arterioles rather than larger vessels, and is most commonly diagnosed in the kidney.
Polyarteritis nodosa (choice C) produces localized inflammation of blood vessels in many sites in the body, and while it might possibly involve the temporal artery, it does not have a particular predilection for doing so.
Takayasu arteritis (choice D) is a granulomatous involvement of the aorta and its branches, and is most common in Asia or in people of Asian descent.
Wegener granulomatosus (choice E) would characteristically also produce prominent lung involvement.

A4
The correct answer is A. Visual symptoms that can be seen in giant cell arteritis include blurred vision, diplopia, visual hallucinations, and transient or permanent blindness. These symptoms are thought to be related to the involvement of the ciliary arteries and/or the central retinal artery. In large part, because of the fear of recurrence with the possibility of permanent blindness, temporal arteritis is treated with a prolonged steroid course that may run for a year or longer. The conditions listed in the other choices can also occur, but are not usually as serious as the risk of blindness.

A5
The correct answer is C. There is a known association between giant cell arteritis and polymyalgia rheumatica, and in fact, some authors claim that the two conditions are actually different ends of the same disease spectrum. The clinical description given in the question is typical. Polymyalgia rheumatica appears to be much more common than giant cell arteritis, so patients with giant cell arteritis are much more likely to have coexisting polymyalgia rheumatica than vice versa.
Gout (choice A) usually appears clinically quite different, with obvious involvement of one or a small number of joints.
While polymyalgia rheumatica is often misdiagnosed as osteoarthritis (choice B), rheumatoid arthritis (choice D), or adult-onset Still disease (the adult form of juvenile rheumatoid arthritis, choice E), the prominence of the muscle complaints, the absence of obvious joint deformity, and the predilection for involvement of shoulder and pelvic girdles should suggest the correct diagnosis.

Headache case 1

Headache case 1

A 28-year-old graduate student presents to the university health center complaining of headache. She has had multiple episodes of severe headache over the past three years. She describes the headache as a pounding pain behind her eyes and along the lateral aspects of her
head. Prior to the headaches, she almost always sees small flashes of bright light that form enlarging patterns, then clear over time. She often feels nauseated during the headache and occasionally vomits. She has tried multiple over-the-counter pain medications with minimal relief.
She has no other medical problems and takes no other medications. She denies fever, weakness, or loss of sensation. Her vital signs are normal. Physical examination, including a full neurologic examination, is normal.

Q 1

Which of the following is the most likely diagnosis?
/ A. Cluster headache
/ B. Meningitis
/ C. Migraine headache
/ D. Sinusitis
/ E. Tension headache

Q 2
A CT of the head in this patient would most likely show which of the following?
/ A. Air fluid levels in the sinuses
/ B. Contrast enhancement of the meninges
/ C. Normal findings
/ D. Posterior fossa tumor
/ E. Subarachnoid hemorrhage

Q 3
The visual symptoms this woman experienced are thought to be the result of localized decreased blood flow to the visual cortex. The visual cortex is located in which of the following parts of the brain?
/ A. Brainstem
/ B. Frontal lobe
/ C. Occipital lobe
/ D. Parietal lobe
/ E. Temporal lobe

Q 4
The patient's headache is interrupted using sumatriptan. This drug acts by activation of which of the following?
/ A. Alpha adrenergic receptors
/ B. Beta adrenergic receptors
/ C. Cholinergic receptors
/ D. Dopamine receptors
/ E. Serotonin receptors

Q 5
A potential side effect of sumatriptan is which of the following?
/ A. Angina
/ B. Arrhythmia
/ C. Bradycardia
/ D. Gastrointestinal bleeding
/ E. Hypotension

Q 6

The patient returns to the clinic three months later and reports that the sumatriptan works well. She says, however, that her headaches are occurring more frequently and asks if there is a medication that can prevent the headaches. An effective drug for prophylaxis is which of the
following?
/ A. Caffeine
/ B. Ergotamine
/ C. Meperidine
/ D. Prednisone
/ E. Propranolol

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Headache case 1 answers

A1
The correct answer is C. This patient is describing signs and symptoms of classic migraine headache or migraine with aura. The aura is an episode of transient neurologic symptoms that precede the headache. Auras are most commonly visual, and include scotomas, scintillations, and visual field defects. During the headache, common symptoms include nausea, vomiting, and photophobia.
Cluster headache (choice A) describes a syndrome of a brief, very severe, unilateral headache that lasts from ten minutes to less than two hours. The headaches affect men more commonly than women and occur at night, often awakening the patient from sleep. It typically starts as a burning sensation over the lateral aspect of the nose and is associated with ipsilateral conjunctival injection, lacrimation, nasal stuffiness, and Horner syndrome.
Meningitis (choice B) often presents with headache. The lack of fever, however, suggests that the patient's headaches are not due to an infectious etiology. In addition, the chronic nature of the headaches is not typical of meningitis. Meningitis classically presents with an acute onset of headache associated with fever, nuchal rigidity, and neurologic signs.
Sinusitis (choice D) is an inflammatory process that presents with headache and pressure or pain typically over the frontal or maxillary sinuses. Percussion of these sinuses can exacerbate the pain. Inflammation of the ethmoid or sphenoid sinuses presents as a deep midline pain behind the nose. Sinusitis is not associated with visual symptoms or nausea.
Tension headache (choice E) is a general term used to describe chronic headaches of unclear pathophysiology that lack characteristic features of migraine or cluster headache. Tension is thought to be the cause of these headaches and may be related to contraction of neck and scalp muscles. It is described as a nonthrobbing, bilateral, occipital head pain, which is not associated with nausea or visual disturbances.

A2
The correct answer is C. There are no anatomic abnormalities associated with migraine headaches, with or without aura. If a CT of the head were performed in this patient, it would most likely demonstrate normal findings.
Air fluid levels in the sinuses (choice A) are seen in the setting of acute sinusitis. It is not an expected finding in a patient with migraine headaches.
Contrast enhancement of the meninges (choice B) can be seen in the setting of acute meningitis, other inflammatory processes involving the meninges, and metastatic disease to the meninges. In many instances, however, the head CT will be unremarkable. MRI of the brain is a more sensitive diagnostic test to evaluate for meningeal enhancement in suspected meningitis. There is no reason to expect this finding in a patient with migraine headaches.
Posterior fossa tumors (choice D) are the most common brain tumors of childhood and are much less common in adults. These tumors can present with headache, nausea, and vomiting. This is not an expected finding in a patient with classic signs and symptoms of migraine headache.
Subarachnoid hemorrhage (choice E) can be secondary to ruptured aneurysm or trauma to the head. Patients with subarachnoid hemorrhage present with acute onset of headache that they usually describe as the worst headache of their life. There is no reason to expect this finding in a patient with migraine headaches.

A3
The correct answer is C. While the mechanism for the development of migraines is still not well defined, it has been shown that the various types of aura appear to be related to decreased blood flow to different areas of the brain. Auras are transient, reversible neurologic defects that may produce visual, somatosensory, motor, or language alterations. Visual auras are the most common form, and may include flashing lights, scintillating scotoma, and fortification spectrums. In the case of visual aura symptoms, decreased blood flow to the visual cortex, located in the occipital lobe, at the occipital pole of the cerebral hemispheres, has been demonstrated.
Associate the frontal lobe (choice B) with control of movements; the parietal lobe (choice D) with receptive speech and the interpretation of sensation; the temporal lobe (choice E) with hearing; and the brainstem (choice A) with a large variety of basic body functions and reflexes.

A4
The correct answer is E. Sumatriptan is a prototype abortive drug used to interrupt migraine headaches acutely. It activates serotonin receptors (5-HT1d subtype) and has a 70% success rate in interrupting migraine headaches. Sumatriptan ameliorates the entire symptom complex of migraine, including headache, aura, nausea, vomiting, and photosensitivity.
Drugs with direct effects on alpha adrenergic receptors (choice A) and cholinergic receptors (choice C) are not usually used in migraine therapy.
Beta blockers, but not agonists (choice B), such as propanolol are sometimes used in migraine prophylaxis.
Dopamine antagonists, but not agonists (choice D), including metoclopramide and prochlorperazine are sometimes used for abortive therapy of migraines.

A5
The correct answer is A. Angina is a known side effect of sumatriptan and the frequency of occurrence is reported to be approximately 5%. Sumatriptan is a selective serotonin receptor agonist but can cause vasoconstriction in a number of different parts of the body, including the extracranial vessels as well as coronary arteries. As such, sumatriptan is contraindicated in patients with ischemic heart disease and Prinzmetal's angina.
Arrhythmia (choice B) is not a known side effect of sumatriptan. It is a side effect of amitriptyline, which is a drug used in the prophylaxis of migraine.
Bradycardia (choice C) is not a known side effect of sumatriptan. It is a side effect of beta blockers, which are used in the prophylaxis of migraine.
Gastrointestinal bleeding (choice D) is not a known side effect of sumatriptan. It is a side effect of nonsteroidal anti-inflammatory medications, which are used for analgesia in migraine.
Hypotension (choice E) is not a known side effect of sumatriptan. It is a side effect of some calcium channel blockers, such as verapamil, which can be used in the prophylaxis treatment of migraines.

A6
The correct answer is E. There are a number of effective migraine prophylactic agents. These include beta blockers such as propranolol, antidepressants such as amitriptyline, and anticonvulsants such as valproic acid. Prophylactic medications should be considered for patients who experience headaches two or more times a month, patients who experience prolonged headaches, and for patients who are intolerant to their medications for acute attacks.
Caffeine (choice A) is an ingredient that is found in several drugs that treat the acute onset of migraine headache. It has no known role in the prevention of migraine headaches.
Ergotamine (choice B) is a serotonin agonist and partial alpha agonist used to treat migraine headaches, in the acute setting, by a similar mechanism to sumatriptan. It has no known role in the prevention of migraine headaches.
Meperidine (choice C) is a narcotic analgesic that is used to treat the acute onset of migraine headaches. It has no known role in the prevention of migraine headaches.
Prednisone (choice D) is a corticosteroid that can be used to treat cluster headaches. It has no known role in the prevention of migraine headaches.