Which of the following has been shown to be of benefit in treating generalized anxiety disorder (GAD)?
D. Cognitive-behavioral therapy
E. All of the above
The answer is E. Generalized anxiety disorder (GAD) is often treated acutely with benzodiazepines, but these medications may be associated with the development of tolerance, psychomotor impairment, cognitive changes, physical dependence, and a withdrawal reaction on abrupt discontinuation. Medications used to treat depression may be effective in patients with GAD. The serotonin and noradrenaline reuptake inhibitors, including venlafaxine XR (Effexor XR) and duloxetine (Cymbalta), have demonstrated efficacy over placebo in randomized long-term and acute treatment trials. Paroxetine (Paxil) and other selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of GAD. Buspirone (BuSpar) is an azapirone, a group of drugs that work at the 5-HT1A receptor, which has been used for short treatment of patients with GAD. Cognitive-behavioral therapy (CBT) shows the greatest benefit of the psychological therapies, with evidence of durable treatment gains in patients with GAD. In many patients distressed by GAD, treatment with a combination of medication and nonpharmacological intervention is necessary. (Allgulander, Bandelow, Hollander, et al., CNS Spectr 2003)
Which of the following is the most common trigger of an acute migraine headache?
A. Change in weather
B. Stress or relief from stress
D. Specific foods
E. Change in sleep
The answer is B. In a study of 1, 207 patients with migraine headaches, 76% reported headache triggers, usually associated with a more severe migraine headache. The triggers included stress or stress relief (80%), hormonal changes in women (65%), hunger (57%), change in weather (53%), change in sleep (50%), smells (44%), neck pain (38%), light (38%), alcohol (38%), and smoke (36%). Other triggers include heat, food, exercise, and sexual activity. Although patients may be concerned that food is a migraine trigger, specific foods are generally not reliable or reproducible triggers, especially in the absence of other precipitants of headaches. A confluence of triggers, “a perfect storm” (e.g., staying out late during a thunderstorm to drink cheap red wine the night after the headache medicine board examination), may be needed to precipitate a migraine, whereas a single trigger might be insufficient. (Kelman, Cephalalgia 2007)
A 52-year-old woman describes 10 months of a coaster-sized headache over her right parietal region. The pain is a mild to moderate aching sensation that is almost always present to some degree, never switching sides or changing location. The area is described as sensitive to touch, and she does not like to brush her hair on the right side. Nausea, vomiting, photophobia, phonophobia, and autonomic features are not denied She is postmenopausal, with a past history of menstrual headaches and currently has mild untreated depression. Which of the following etiologies for headache best describes her symptoms?
A. Giant cell arteritis (GCA)
B. Tension-type headache (TTH)
C. Nummular headache
E. Cluster headache (CH)
The answer is C. This woman’s description of a round, constant area of pain and sensitivity best fits with nummular headache, a round or oval area of mild to severe head pain. The pain is continuous, but periods of spontaneous remission may last weeks to months. A distortion of sensation is commonly noted in the area of the pain, but symptoms that accompany migraine headaches are generally absent. The patient’s relatively young age and the location of the pain are not consistent with GCA. The pattern and the location of the pain are not characteristic of cluster headaches or TTH. The pain characteristics and lack of accompanying symptoms make migraine headaches unlikely in this woman. (Grosberg, Solomon, & Lipton, Curr Pain Headache Rep 2007)