Headache Answers 361setting include carbonic anhydrase inhibitors (ie, acetazolamide) and loop
diuretics (ie, furosemide). Transient visual loss, pain, or blurring occurs
frequently and can be permanent in up to 10% of patients. Treatment of the
headache itself often employs the same agents used to treat migraines;
ergots, antiemetics, and occasionally steroids. The headache is often refrac-
tory and difficult to manage. The condition is associated with obesity and
weight loss is sometimes helpful.
Papilledema(a)in the setting of intermittent frontotemporal headaches
and an otherwise normal neurologic examination is consistent with IIH. Its
presence does not rule in or out other intracranial pathology. It is not by itself
a risk factor in patients with IIH for neurologic deterioration. A history of
pulsatile tinnitus (b)is often associated with IIH but its prognostic signifi-
cance is unclear. An empty sella (c)is frequently seen on CT scan of IIH
patients. It is likely caused by herniation of arachnoid CSF into the sellar
space and is sometimes reversible with lowering of CSF pressure. Another
finding to look for on CT scan is an occluded venous sinus, which indicates
a secondary cause of elevated ICP. Minocycline, oral contraceptive pills, vita-
min A, and anabolic steroids (e)have been associated with the development
of IIH.
327.The answer is b.(Manno, pp 347-366.)The patient presents with a
clinical history that is consistent with a SAH.Brain CT without contrast is
the procedure of choice for diagnosing SAH and should be done in any
individual with a new onset of a severe or persistent headache. It has a sensi-
tivity of 95% for detecting SAH. If the CT is negative, an LP should be per-
formed because some patients with SAH have a normal CT scan. A yellow
supernatant liquid (xanthochromia), obtained by centrifuging a bloody CSF
sample, can help distinguish SAH from a traumatic tap. If the diagnosis is still
in question, an angiography may be required.
Administration of metoclopramide and ketorolac (a)is useful in man-
aging pain as a result of a migraine syndrome. Because of their antiplatelet
activity, ketorolac (Toradol) and other NSAIDs are contraindicated in
patients who may be actively bleeding. Treatment of meningitis (c)with IV
antibiotics should not be delayed if the diagnosis is suspected. However,
the patient’s clinical history is inconsistent with this diagnosis (he is afebrile
and without constitutional symptoms) and LP is readily available. Infusion
of IV mannitol (d)lowers ICP acutely via osmotic diuresis. It is indicated
in patients displaying symptoms of increased ICP or when impending her-
niation is suspected. Angiography (e)is the gold standard for diagnosis of