Which of the following has been shown to be effective in the acute treatment of CH, but not in migraine?
A. Serotonin receptor agonists
B. Calcitonin gene-related peptide (CGRP) receptor antagonists
C. Somatostatin receptor agonists
D. Nitric oxide synthase (NOS) blockers
E. Adenosine A: receptor agonists
The answer is C. The subcutaneous somatostatin receptor agonist, oct-reotide, was superior to placebo in a trial of cluster headaches patients, but not in a trial of patients with migraine. Serotonin receptor agonists are the current foundation of acute migraine treatment. Early results of (CGRP) receptor antagonists in the treatment of acute migraine are encouraging and these agents are projected to be a treatment without vascular risk. The benefits from nitric oxide synthase (NOS) blockers and adenosine A: receptor agonists are still theoretical. (Goadsby, Curr Opin Neurol 2005)
A subdural hematoma:
A. Is generally associated with arterial hemorrhage.
B. Always needs surgical evacuation.
C. May be associated with metastatic cancer.
D. Appears as a lens-shaped collection crossing the midline
E. All of the above
The answer is C. Subdural hematomas are acute, subacute, or chronic collections of blood that generally accumulates after traumatic rupture of bridging veins. Depending of the age of the blood, they are hyper-, hypo-, or isodense crescent-shaped collections on computed tomography (CT) scanning that do not cross the falcine divide of the brain. Small chronic subdural hematomas are found not infrequently on neuroimaging of elderly individuals who are prone to falls or on chronic anticoagulation; surgical evacuation may not be required. Meta-static disease to the dura may hemorrhage, causing nontraumatic, spontaneous subdural hematomas in the setting of cancer. (Osborn, Blaser, Salzman, et al., Diagnostic Imaging, 2004)
Which statement best describes a thunderclap headache (TCH)?
A. A thunderclap headache (TCH) is a headache of very severe intensity that comes on over 5 minutes.
B. A TCH cannot be classified as a primary headache.
C. The most common secondary cause of TCH is subarachnoid hemorrhage (SAH).
D. A TCH is almost always due to underlying vascular disease.
E. A TCH should be evaluated with conventional angiography.
The answer is C. Thunder clap headache (TCH) describes a severe and explosive headache that is either maximal in intensity at its onset or reaches peak intensity in less than a minute. It can be a primary headache, such as “crash migraine”, without identified underlying anatomic abnormality. A benign, explosive, headache may be precipitated suddenly by cough, exercise, or orgasm. Secondary causes of TCH are usually vascular, such as SAH, cerebral venous thrombosis or intraventricular hemorrhage. Nonvascular causes include intracranial hypotension, infection, and acute hydrocephalus. Almost all acute, unexplained TCHs should be evaluated with at least an uncontrasted computed tomography (CT) scan of the brain to rule out SAH, the most common and life-threatening cause of secondary TCH. (Matharu, Schwedt, & Dodick, Curr Neurol Neurosci Rep 2007)