NMS Q&A Family Medicine

Pain and Headache Management 29surgery is dramatically successful. Regardless, the initialtreatment should be conservative, to which 70% ofpatients will respond. CT scan and MRI are often negativein the foregoing syndromes; therefore, exploration hasbecome more common for making the diagnosis. Thefirst drug of choice is carbamazepine (Tegretol). Otherdrugs used are phenytoin, baclofen, lamotrigine (Lamictal),gabapentin (Neurontin), topiramate (Topamax), andclonazepam (Klonopin). Neither temporomandibularjoint syndrome nor maxillary sinusitis has sensory stimulatoryprecipitation. HZ acutely causes a typical rash.Postherpetic (zoster) pain is precipitated by sensory stimulation,but this patient had no preceding rash.9. The answer is C. Multiple sclerosis can be a cause oftrigeminal neuralgia. The common pathological pathwayof trigeminal neuralgia includes demyelination of thenerve root near the ganglion, which may be on a mechanicalbasis as described in Question 5 or by the mechanisminvolved in multiple sclerosis. Sepsis could not explain thesymptoms described without having more than one focus.Amyotrophic lateral sclerosis is entirely a motor degenerativeneurologic disease. Mechanical causes of compressionof the ganglion would not explain the urinary andthe ophthalmologic symptoms.10. The answer is B. Occipital neuralgia is caused bycompression of the greater occipital nerve, by underlyingentities such as posterior head trauma or compression ofthe occipital nerves by muscle tension (a possible cause ina “burned out” elementary school teacher). Tapping tostimulate electric shocklike pain is here called the Tinel’ssign, just as it is in relationship to carpal tunnel syndrome.Such muscle tension can be secondary to osteoarthritis ofthe cervical spine, and on occasion, the cause cannot befound. Tension headache is not characterized by local tendernessor other neuralgic traits, although some patientscomplain of generalized scalp tenderness; migraine andcluster headaches are not neuralgic in character. Giant cellarteritis does not produce nerve tenderness.11. The answer is A. Postherpetic neuralgia occursincreasingly with the age of the patient, rising from 9% inyounger people to as high as 70% in patients older than75 years. The other significant risk factor is acute HZinvolvement of the ophthalmic branch of the trigeminalnerve. Sacral involvement may result in bladder dysfunctionbut no particular risk for postherpetic neuralgia.Incidence in all settings is reduced by acute (within 72hours of onset) treatment with antiviral agents such asacyclovir and famciclovir.12. The answer is A. A CT scan of head without contrastshould be taken. Sudden severe headache, sometimescalled “the worst headache I’ve ever had,” should beassumed to be due to SAH until proven otherwise. A CTscan of the head without contrast is 90% sensitive indetecting SAH. Using a contrast agent or MRI confers nogreater sensitivity; these procedures require more timeand are more expensive. Cerebrospinal fluid examinationis not necessary if blood is visible in the ventricles on theCT scan. Such procedures should be resorted to in theevent of a negative CT study, when SAH is still suspected,to avoid brainstem herniation. Sedimentation rate elevationis sensitive for temporal arteritis, which occurs inthe age group of this patient. SAH is a neurosurgicalemergency.13. The answer is D. Giant cell arteritis is the cause oftemporal arteritis, which this patient has. The disease is amedical urgency because it can be the cause of blindness,based on occlusion of the ophthalmic artery. The jaw painis the ischemic pain of claudication. The diagnosis is confirmedby biopsy of the temporal artery. Giant cell diseasecan affect many other parts of the arterial vascularity,which accounts for various presentations other than theheadache of temporal arteritis. The disease responds dramaticallyto systemic glucocorticoids, and these do nothave to be continued indefinitely.14. The answer is D. A photosensitive, macular rash overthe facial cheeks is not known to be associated with temporalarteritis. Temporal arteritis may lead to the symptomsof polymyalgia rheumatica (or the symptoms ofboth may develop simultaneously). Unilateral vision lossis present in only about 7% of patients at the time of presentation,but it will develop in about 44% of patients ifthey are not treated. Temporal arteritis is characterized bya strikingly elevated sedimentation rate. Temporal arteritismust be considered as a potential source of fever inthose patients who are older than 50 years.15. The answer is B. There is an intracranial arteriovenousmalformation. Arteriovenous malformation maypresent with headache, seizures, or focal neurologic symptomor hemorrhage, but the latter is the most common,constituting the clinical presentation in 30% to 60% ofcases. Headaches are the presenting complaint in 5% to25% of the cases, and seizures in 20% to 40%. Bruits maybe heard over a mastoid bone or an optical orbit. Carotidatheromatous stenosis causes pulsations audible to thepatient on occasion but are not often heard by the stethoscope.Carotid atheromas would most likely occur in peoplewith risk factors such as hypertension, dyslipidemia,or diabetes, and nearly always in individuals in their fifthor sixth decades or older. Migraine headaches often recurduring various stages of the menstrual cycle, but the bruitwould have to be explained otherwise. The same is saidregarding cluster headaches, and these do not recurwith such wide ranges of periods between attacks. See