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.