A few cases of headaches

Okay, another case. Sixty-seven-year-old woman with a new holocranial headache with exposure to cold, tenderness in her scalp and pain upon chewing. That’s a classic history of giant cell arteritis. Scalp pain. Bothers them to touch the scalp. If they chew, they get jaw claudication or tongue claudication, and they are very typically associated with worsening upon exposure to cold. Now fortunately everybody doesn’t walk in here with a little arrow at their superficial temporal artery saying, “Look here.” Many of these people actually don’t have pain or tenderness over their superficial temporal artery. Very few of these people are under 60. It’s rare, rare, rare under that age, but most of them have polymyalgia rheumatica. So they are not well people. They come in, they feel terrible, they are achy. They have this new scalp pain and often it’s worse when they chew. Now you do a sedimentation rate and it’s generally high. There are cases where sed rates are normal. Fortunately they are relatively rare. I generally recommend not just doing a sed rate, but a C-Reactive protein, and a serum viscosity, because what you often find is, as you are treating them, one of these or more than one of these becomes better markers for the activity of their disease. In other words, just counting on sed rates is often not as good. You will find an individual patient where their serum viscosity turns out to be a better marker of how they are doing.

Now I’ll tell you about another case. This is a case of a 46-year-old woman who came in with the abrupt onset of a severe frontal headache. She actually got better over a few hours. I’ll tell you a secret. Actually she was given sumatriptan, someone gave her sumatriptan and her headache went away so she was sent home, and someone did find that she had a stiff neck in the emergency room. The problem here is that she has a subarachnoid hemorrhage. All that white stuff is blood, she had a huge subarachnoid hemorrhage, responded beautifully to sumatriptan and she went home. Remember, 50% of these people die, 50% mortality, so you can imagine the problems. I will also mention in that, that I saw a patient with meningitis who came in with a fever and a stiff neck. Someone gave them DHE intravenously, it all went away. Sent home, did fine for about three hours and came in moribund. We’ll talk about that in these migraine drugs. But this is a subarachnoid hemorrhage and what makes a history is this: these are people who have the abrupt onset of a headache, terrible headache. It doesn’t come on gradually. It comes on apoplectically. So if someone comes in and says, “I have the abrupt onset of a terrible headache” you think of subarachnoid hemorrhage until proven otherwise. You get a CAT-scan. You don’t do an MRI, you do a CAT-scan and usually the blood will be seen. Occasionally it’s missed, so if you think about that, you do a lumbar puncture. Very, very important. Again, 50% mortality. You don’t want to miss this.

Subhyaloid hemorrhages are usually seen in the optic nerves. These are puddle-shaped hemorrhages and they are generally within a disc diameter, so you are not going to see them way out here, you are going to see them within a disc diameter.

This is a case of a 31-year-old male who came to see me who had a 15 year history of recurrent right-sided throbbing headaches, that were always preceded by distortions in his left visual field.

Now he should have had migraine, and I’ll tell you that the overwhelming majority of people like this have migraine. The only reason we thought anything else is because the headaches were always in the same place and the visual aura was always in the same place, so we did an MRI. This is a big arterial venous malformation in the occipital lobe. Now had he come in and said, “They are almost always on that side, but every once in awhile they switch to the other”, don’t scan them. It’s not worth it. I’ve never seen a person in 20 years of practice who had anything else that imitated migraine, where it shifted, even if it’s 1% or 2% of the time.

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