Headache Medicine: Questions and Answers

Headache Medicine Q U E S T I O N S â•‹ A N D â•‹ A N S W E R S

The ultimate preparation guide helps you pass and excel on exams!

•

Includes 500 board-type questions, answers and explanations

• P rovides in-depth, multi-question patient management problems

DARA G. JAMIESON

Headache Medicine questions and answers

Headache Medicine questions and answers

Dara G. Jamieson, MD Associate Professor of Clinical Neurology New York–Presbyterian Hospital Weill Cornell Medical College New York, New York

New York

AC QU I SI T I ON S E D ITOR: R. Craig Percy C OV E R D E SI G N : Cathleen Elliot C OP Y E D I TOR : Joann Woy C OMP O SI TOR : Patricia Wallenburg P R I N T E R : Victor Graphics

Visit our website at www.demosmedpub.com © 2009 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. L I BR A RY OF C ON G R E SS C ATA LO G I N G - I N- P U BL I C ATI ON DATA

Jamieson, Dara G. Headache medicine : questions and answers / Dara G. Jamieson. p. ; cm. Includes bibliographical references. ISBN-13: 978-1-933864-36-5 (pbk. : alk. paper) ISBN-10: 1-933864-36-2 (pbk. : alk. paper) 1. Headache—Examinations, questions, etc. I. Title. [DNLM: 1. Headache Disorders—Examination Questions. 2. Headache— Examination Questions. WL 18.2 J32h 2009] RC392.J36 2009 616.8'4910076—dc22 2008046928 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact:

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M A D E I N T H E U N IT E D STAT E S OF A ME R I C A

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Contents

Preface vii Acknowledgments ix

1 2 3 4

5 6

Headache Epidemiology and Comorbidity 1 Headache Anatomy and Physiology 34 Headache Classification and Diagnosis 73 Headache Evaluation and Diagnostic Testing 143 Headache Treatment 213 Clinical Headache Scenarios 307

References 333 Abbreviations 359

Preface

H

with most people noting at least one headache in a lifetime. Most headaches are mild and transient, and do not warrant a visit to a healthcare provider. However, almost thirty million Americans suffer from chronic disabling headaches that impact their quality of life. Individuals of all ages, from young children to the elderly, may suffer from headaches with certain headache types present at a specific age. Most headaches are primary, not associated with any underlying anatomic or physiologic abnormality. Rarely a headache is secondary to a disease or disorder with risk of neurologic injury or even death. Patients with headaches may consult a variety of different medical specialists, including neurologists, internists, emergency medicine physicians, otorhinolaryngologists, family practitioners, gynecologists, psychiatrists, and pediatricians. Many specialists must evaluate these patients and distinguish between trivial or troubling headaches types. In an effort to assess the ability of medical specialists to treat headaches, the United Council of Neurologic Subspecialists (UCNS) has designated headache medicine as a subspecialty concerned with the diagnosis and treatment of head and face pain. The UCNS has developed an examination with 200 multiple-choice questions to certify physicians who have exhibited expertise in headache medicine either through completion of a headache medicine fellowship or through extensive E A DAC H E S A R E A N A L MO ST U N I V E R SA L E X P E R I E N C E

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P R E FAC E

clinical experience. Headache Medicine: Questions and Answers is an interesting and informative way to study for the UCNS headache medicine examination as the contents of the book parallels the UCNS headache medicine examination categories. Medical students and neurology residents will also find this book to be useful to assess and expand their knowledge of headache medicine prior to medical school examinations and the resident in-service examinations. Self-assessment through the multiple questions in this book is also a motivating way for established practitioners to appreciate their familiarity with headache treatment and to acquire new information. I have been able to use the enormous amount of information gleaned in writing this book in my clinical practice and I have enjoyed every minute of researching and writing. I hope that those who use this book to learn more about headache medicine will find the information useful and intriguing. And for those of you using this volume to study for examinations covering headache topics, I wish you the best of luck. Dara G. Jamieson, MD New York, New York

Acknowledgment

My husband, Ehud Lavi, MD is the inspiration for my interest in headache medicine. I have been trying for over a quarter of century to cure his headaches and I look forward to many more decades of learning from him about neuropathology and headaches. Dr. Lavi kindly supplied the neuropathological images for this book. A. John Tsiouris, MD of Weill Cornell Medical Center was most generous in supplying me with neuroradiologic images. I thank both of them so very much for their help with this book.

Headache Medicine questions and answers

1

Headache Epidemiology and Comorbidity ╇

questions

1.╇ Which of the following statements best describes the association between migraine and cardiovascular risk?

A. Migraineurs have not been proven to be at increased cardiovascular risk. B. Male migraineurs are at increased cardiovascular risk only when they have multiple traditional vascular risk factors. C. Women who have ever had a migraine headache are at increased risk of cardiovascular disease. D. The risk of myocardial infarction (MI) is increased in women with active migraine with aura. E. The increased cardiovascular risk in men with migraine with aura is a contraindication to their use of triptans.

2.╇ Which of the following causes of vestibular symptoms is associated with migraine?

A. Perilymph fistula B. Vestibular neuronitis C. Labyrinthitis D. Benign paroxysmal positional vertigo (BPPV) E. Medications

3.╇ ID Migraine is a simple, brief, easy-to-use, well-validated symptom-based di-

agnostic screener. Which of the following headache features of ID Migraine is the best predictor of a diagnosis of migraine? A. Pain on one side B. Moderate to severe pain C. Phonophobia D. Throbbing pain E. Disability

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HE A DAC HE E PID E MI OLO G Y A N D COM OR B I DI T Y: Q U E S T I O N S

4.╇ Which of the following is not a risk factor for the development of chronic daily headache (CDH)? A. Obesity B. Snoring C. High socioeconomic status D. Head injury E. Stressful life events

5.╇ Which of the following cardiac conditions is most closely linked to migraine? A. Coronary artery disease B. Patent foramen ovale (PFO) C. Spontaneous echo contrast D. Coarctation of the aorta E. Long Q-T syndrome

6.╇ Which of the following best describes gastric stasis in migraine patients? A. Migraine patients may suffer from gastric stasis both during and between acute migraine attacks. B. Gastric stasis delays the gastrointestinal absorption of all triptans during a migraine. C. Migraine patients rarely experience clinically relevant delayed gastric emptying during an attack. D. Gastric stasis is the main underlying mechanism of nausea. E. All of the above

7.╇ What is the approximate prevalence of PFO in patients with migraine with aura?

A.