Headache Answers 359people experience a constant, dull pain that is nonthrobbing and without
the ancillary features associated with migraines (visual phenomena, aura,
neurologic complaints, nausea, vomiting). There is often secondary con-
traction of the neck and scalp musculature. First-line treatment includes
NSAIDs and acetaminophen. If the headaches occur frequently enough to
cause dysfunction in daily activities, patients may benefit from preventive
therapy, such as amitriptyline, desipramine, or propranolol.
Migraine headaches (a)classically begin with visual phenomena or
another aura and are pulsatile, unilateral, associated with nausea, vomiting,
photophobia, and phonophobia. They may also have associated neurologic
phenomena. Cluster headaches (b)are more common in men and are uni-
lateral, boring, and may be associated with neurologic phenomena or auto-
nomic activation. They are short lived and generally recur daily at the same
time for days or weeks before the patient has remission of their symptoms.
Trigeminal neuralgia (c)is thought to result from microvascular compres-
sion of the trigeminal nerve roots. It presents as shooting facial pain, in the
distribution of the fifth cranial nerve, particularly the second and third
nerve roots. In less than 5% of cases, it involves the first division of the
trigeminal nerve and patients will present complaining of headache. Treat-
ment includes carbamazepine or other antiepileptic drugs. Postherpetic
neuralgia(d)is pain that continues after an eruption of herpes zoster. It is
often described as a burning or stabbing pain that is constant in the der-
matome originally affected by the zoster outbreak. In 50% of patients it
subsides after 6 months. In some patients it lasts for years. Treatment is
with gabapentin, phenytoin, or amitriptyline.
324.The answer is c.(Tintinalli et al, pp 1379-1381.)The patient is expe-
riencing a migrainevariant known as a basilar migraine.Its onset is simi-
lar to other migraines in that it can begin with scotomata or aura. The visual
symptoms are often bilateral and followed by a brief period of cortical blind-
ness. Symptoms related to the basilar circulation then predominate includ-
ing incoordination, dysarthria, vertigo, and numbness and tingling in the
arms or legs. These symptoms generally last 10 to 30 minutes then resolve.
Occasionally, transient coma or quadriplegia can develop but persist for
only several hours. The resulting headache is occipital and pulsating. The
symptoms may mimic a vertebrobasilar ischemic event. Treatment with first-
line agents for migraine is recommended. Threshold should be low to seek
neurologic consultation unless the diagnosis is certain.