 My repertoire, two new pies for the repertoire this year, a pecan pie, and a banana cream. A pie for the winner, is that what you're suggesting? The winning person gets a pie. The key is to attend all these and do the quiz, that's the key to winning the pie. So is everybody done? Pretty much. Brad, are you done? Yes. I hope everybody either read the focus points or watched Brad's lecture because that helps you understand what I'm going to be talking about. These are not just a general heading, this is not a general heading case. This is talking about some of the atypical heading patients, and every one of the patients that I'm presenting here came into neuro-ophthalmology. So these are not like neurology cases or anything like that. So I'm going to start with this, and I sent you the cases ahead of time too so that you could think about them. So we're going to just kind of both, I've got quite a few, I don't know how many we'll get through and we'll leave a few minutes at the end to talk about the quiz. So this is a 22 year old man who has pain over his left eye and during the episode he notices that he has little ptosis and tearing and the pain lasts 30 to 45 minutes. He feels like he needs to pace and sometimes it awakens him at night and his exam is normal except for this. Okay, and I don't know if you can see that. Anybody want to say what's going on with his exam? Okay, so what do you think that is? Pointers. Pointers. Alright, so let's just talk about what is in your differential diagnosis first of all? Cluster. Cluster? Is there anything else or are you going to just say cluster? Any one of the trigeminal autonomic filters and can you name all of them? I'm not sure, like Sunt, Hemicrania, Continua and Paroxysmal, Hemicrania. Good, that's good. If you know those, that's really good. Cluster is your number one but it could be one of the other trigeminal autonomic filters. Do you need to evaluate this? Do you need to scan this person? This person's never had any imaging. And you're saying yes, why do you need to scan them? Horner's Syndrome and it is associated with the headaches so you worry about infection? Okay, maybe his pain is not actually from a headaches syndrome, maybe it's from a dissection, even though he's a younger patient. Okay. In general, the tax are the ones that you have to scan. Alright, and then what would you do for treatment? What are the ones we have to scan? Tax, the trigeminal autonomic filters, you know, migraine, you can do a, you can see 100 patients with migraine and if they have a completely normal exam, one or two of them will have something funny on their MRI or maybe more but most of them are not going to be relevant. The rest, you know, like 10% may have some weird thing but only one or two will be relevant. But a tax, if you take 100 people with one of the trigeminal autonomic filters, of any flavor that you listed, you've got a 30 to 40% chance of finding something secondary. So it's a much higher yield for imaging and so the first time you see somebody with one of these, you do have to image them. What would be the scan of choice? MR. In general, all headache types of any kind, except for, so I'm not saying the worst headache of your life, that could be an aneurysm, rupture, hemorrhage, it's an MR. And in choosing wisely, the choosing wisely campaign where they were trying to give you three things to remember to choose wisely about going headache, one of them is don't, image with an MR, if you need to image get an MRI scan, except for acute hemorrhage. And then treatment, I know you won't get into treatment but you should at least know something about treatment. Oxygen? Oxygen for the acute cluster and because they're so brief, you could use injectable Sumitriptan or Imagex. And then preventatively, there's some prevention out there of rapamil and the new calzotone and gene-related peptide antibodies, Imgalidir, Galkanizumab has been approved for cluster. All right, I just wanted, if you didn't remember about the different tax, I just wanted to remind you that the cluster is in that 45 minutes to a couple hours. And most of these are by, the longer the name, the shorter the headache. So, like sucked short lateral neural deform headaches with congenitival ejection and tearing is two to ten seconds very brief. Episodic hemicrania can be brief but hemicrania is continuous and then paroxysmal hemicrania is a little bit longer than episodic hemicrania. All right, good job. So, next case, and all these are from my clinic, okay? Eighty-four-year-old physician, family history of migraine, had migraine in his 20s intermittently. In fact, we saw somebody somewhat like this yesterday. And in his 40s, he had migraine aura without headache and the aura was a visual scintillating scatoma, sometimes fortification spectra. He could draw out a zigzaggy line for 20 minutes and every once in a while when the aura was off to the right, he would have speech difficulty, word finding difficulty, mild headache, rarely, occasionally. And sometimes the speech problem would last 30 minutes or so but it was never severe. He was sitting in a boardroom. He's on a lot of boards because he's retired. And he couldn't understand the slide so he got up to leave and he wanted to tell them that he was wanted to leave or he was going to leave because he didn't feel well but he couldn't get his words out. This lasted three to four hours. He had no headache. He had another spell a week later. He was hospitalized. He had an MR. This was negative. He had a little slowing of his EEG. He does have a lot of past medical history. Diabetes, hypertension, gout, and a little peripheral neuropathy. So what is his diagnosis? Okay so but what kind of migraine? Complex migraine with aura without headache. Okay so it's migraine aura without headache. And does anybody know why somebody older would be getting this? It's outpatient yesterday or whatever who would have grown the pain of the migraines but continued to have aura. So I think you mentioned that that can be seen. Exactly. Late onset migraine. So aura. So C. Miller Fisher wrote about this and it happens in individuals as they get older they get the aura and they don't have the headache. And so this was aura without headache. And there is a form of this called which is typical aura and no headache follows it. And this was a wonderful review. I don't know if any of you are around when we had a visiting doctor from Thailand who wrote this paper up that these migraine accompaniments so people can come in with a history of aura. They used to get migraine and now they get aura and they don't get the headache. And most of these are visual, 23%. Sometimes blindness like losing vision in one eye. Hematomous hemianopia, blurred vision, trouble focusing. But I wanted you to note that 12% can have visual and speech disturbances. And obviously in brain stem symptoms that would be like diplopia and vertigo with the aura. I wanted to bring this up to you because a lot of people come in with this when they get older. And the question is to ask, did you ever have migraine when you were younger? You do have to work these up. I mean this isn't a headache type that you can just say oh well it's probably aura. Late onset aura. He needed an MR. He got a full evaluation on the neurology service. But it is something to be aware of. And there is a sub variety of this called late onset migraine accompaniments or LOMA. And most of these are visual but they can have speech and up to a third. And the big difference is you have to tell it apart from a transient of ski make attack. So can somebody tell me how do you tell a difference between migraine and a TIA? Wake up. I'm not awake in the morning so you. You guys should be. Okay so how what is the onset of a TIA? What's the onset of a migraine? It's kind of slow. It starts in the center and it moves out. There's a movement that comes with it, right? And that's really a critical piece of information. And then the duration. What about the duration of a TIA? It's about an hour. It could be up to an hour. What's the duration of an aura? It could be up to an hour. So that duration doesn't help you very much. TIAs can be brief. Like totally brief. Aura usually has a build up and it goes over time. And auras often will be accompanied by other symptoms of migraine. What are the other symptoms of migraine? Photophobia. Photophobia. Maybe nausea. Maybe cloudy thinking. Usually doesn't have the cloudy thinking. Migraine is usually a positive phenomenon. Meaning that it's going to be white or sparkly. Or whereas what is the TIA? It's going to be a loss of function, right? It's going to be like either weakness or blindness. You're going to have a amaurosis, a few gags with a blindness over one eye, right? This is critical though. You have to know the difference between a TIA and a migraine. And because I mean they will come into the ophthalmology clinic. And but migraine can be associated with the speech and motor and sensory. That's why you have to spend a few more seconds getting a little bit more history out of somebody before you just say, oh, well, that's a migraine. And I always work these auras without headache and these older people up. Because there can be other things like you can have a migraine phenomenon coming from a tumor, for example. Or a occipital lobe seizure, okay? Usually those are usually associated with movement or some kind of kaleidoscopic movement in the field. And it doesn't sound like the typical aura with the little onset in the center moving out or onset outside moving in. Has anybody ever had an aura? I've had one. It's pretty amazing, right? And you look at it and the other thing about auras is everybody thinks it's in one eye. And of course, you know, because it looks like it's in one eye, right? But if you cover each eye, that person's page can still, you can still see the aura on the page even if you cover up the eye. So it's always, it's usually in both eyes. And when you say a work of the aura, do you get an MR brain and an EEG on them? I would get an MR for sure. This guy needed an MR to rule out any kind of stroke because of that prolonged memory. I said this went on for hours and lasts a long time. So absolutely that person needs a work up with an MR. Now a typical aura without a headache in somebody who's had previous migraine without anything else on their exam, I would, I would. Unless there's something funny. All right, so 39 year old woman, sudden onset, almost explosive pain behind her head and behind her eyes and in her head. She was diagnosed with migraine. She went to the emergency room and the CT was negative and it got better out over a couple days. But four days later, she had another explosive headache. She has mild photophobia. She has previous migraine. So putting down a differential diagnosis, what, what, what kinds of things would be most likely in this situation? Primary thunderclap headache. Well, it is a thunderclap headache. Okay, but, but it could be primary. It could just be a simple primary thunderclap headache. But this is kind of the aneurysm. Benign is an exertional orgasmic headache. So orgasmic headache is usually seen in men, often middle-aged men at, at orgasm. And then they get this sudden onset of the worst headache of their life. Reversible cerebral vasoconstriction syndrome. RCVS is pretty common. And this is characterized by recurrent thunderclap onset, sudden onset of the worst headache of one's life. Obviously aneurysm is always at the top of somebody's mind with somebody with that. Press, posterior reversible encephalopathy syndrome. Usually that's seen with hypertension, eclampsia. This is kind of atypical for migraine. And then sometimes you can get headaches with drug use and probably that's related to the RCVS, like pseudoephedrine, cocaine, marijuana. Marijuana can cause this thunderclap onset headache. And I even saw somebody who was doing those jolt shots or know what are those, those energy drinks. You know the, whatever they're called. Yeah, like that, that five hour or whatever it is. Anyway, they were doing those and they got one of these. So the valuation is imaging. You got to image these people. And so there are primary thunderclap headaches like benign exertional headaches, cough headache, exertional, orgasmic. And then you can just see the big long list of secondary. These headaches are ones you don't take, you call up your neurology colleagues and say, I'm going to, you guys work this up. And then if they still have eye pain, send them back to me. But I want you to recognize this one is not something that you just sit there and go, oh, that's interesting. Wow, yeah. No, you call up your neurology colleagues and let them work them up. And especially if it's repetitive, you know, thunderclap onset headaches. Because there's a whole bunch of these things. And why would pituitary tumor be on the list? Apoplexy, right? And that's another cause of a thunderclap onset headache. Any question about this one? Okay, this is another patient we had in clinic. 18-year-old, senior high school, strong family history of migraine, mother and sister. He used to get a few headaches. He'd taken a sedaminophen and lay down and rest and he was fine. But after a usual weightlifting exercise, he had tingling in his body, chest, arms, couldn't speak for 30 minutes, fell asleep. His mother, of course, waked out and took him to the ER and he had a CT scan that was normal. And he was pretty normal, so they left to go home. But on the way home, he couldn't speak anymore. So he got back to the emergency room and they did TPA on him. And he had a normal MR, normal TTE with bubble. He did get a very bad headache afterwards and he was just diagnosed with complicated migraine. Now there's no such diagnosis as complicated migraine in the international classification of headache disorders. So this would be migraine with aura if it were a migraine. So his primary care put him on amytryptolin. He had a third of phasic episode and a horrible headache. He was given codeine and butyl butol and then he was sent to ophthalmology and he was found to have disc swelling. He had elevated opening pressure and he had 112 white cells. He was started on a cytosolamide for the pressure. Then he got a post-LP headache, a blood patch. Then he was started on to pyramid. Does this sound like a neuroophthalmology case or what? And then this is his exam at neuroophthalmology. So then we saw him. I don't know which one of you guys saw this guy, Rachel. Okay, so Rachel, you can't tell everybody what's going on. So this, he was 2030 in the right eye, 2060 in the left. He had no APD. His fields were really normal except for the big blind spot and he had a big esotropia. Because he had bilateral six nerve palsies. So this was his workup. He had a positive RPR but he was seen by an infectious disease that was false positive and negative FDA. And he had a big, big workup. He did have a positive ANA and he had all those white cells and elevated protein and all the meds were stopped. He got new glasses and so anybody have a thought about this case? Was it heading with neurologic deficits, CSF, lymphocytes or lymphocytosis? Yep. No, it could be something else. It could be something else. I mean, he could have just had encephalitis or meningitis. His red count and the CSF. That white count can be, that can be. What was his red count though? His red count was not that bad. No, he had leukocytosis. He had clearly leukocytosis. What's interesting about this case is, you know, it's migraine-like with these neurologic deficits. And then the white count in the CSF, it's almost always over 15. And in his case it was quite high and in the literature it's also quite high. And then the heading comes along with the neurologic deficits and then you work them up and you really don't find anything and it goes away. But what was interesting was when we looked this up in the literature, papillodema can be present, which my headache colleagues had never heard of papillodema with handle. So this case could be written up, Rachel. Another case to write up, right? 90% of pressure is over 400. I'll give you a great differential when you ask us. And sometimes they have a viral pro-drone. Their MRs are usually normal and everything gets done and everything is normal. But it's something to be aware of and it was listed in your focal points, right? Wasn't it? Yeah, mentioned in focal points. So I figured you might get one right on the Ocamp exam with the handle. Alright, so this person is a 15-year-old sophomore in high school. And she had an ear infection when she was really little and lost her hearing. She has a family history of migraine and she came in talking about having ocelopsia with intermittent headaches. And she feels pale, her vision's blurred, sometimes gets double. She sleeps and it goes away. Now, unfortunately, because my thumb drive wasn't even recognized, you know, we have to carry encrypted thumb drives. And if our thumb drives are not encrypted, they could take them away from us. This wouldn't even recognize my thumb drive. But just imagine this kid sitting there and her eyes are beating to the right intermittently. And that's what she looks like. And then in between, she's completely normal. So you're seeing her because she's coming in with ocelopsia, kind of these spells. And it isn't that much headache. It's more of this EEG normal. Do you have an MRI? MRI normal. This infection she had was when she was a little kid, she lost her hearing. Her hearing isn't good in the right ear, but that's been evaluated and it's sought to be an idiopathic hearing loss in a childhood. Any changes with position? No, no change with position. And it's only intermittently at school. She turns pale, she looks like this. She gets a little bit of double vision and her eyes are beating to the right. She had like social problems at school? None. She's a good student. Functional. That would be really interesting. But her mom brought this video in to show me what she looked like when she was in the middle of this. So I would take it seriously. It wasn't. Well, I bring this one up because we see vertigo in our clinic, right? Because one of the symptoms of vertigo sometimes is ocelopsia and diplopia. But if you see a kid with vertigo in childhood, there is a benign vertigo of childhood. Benign positional vertigo that Shravu is getting at doesn't change with position. Vertiginous migraine, cyclic vertigo. And then migraine with brainstem aura. And yes, you have to, you do work it up. Everything was negative. Now benign paroxysmal vertigo are brief attacks and otherwise healthy children. Comes on without warning. They often have nystagmus, ataxia, vomiting, pallor, fearfulness, and their otherwise normal exam. And there is a relationship between vertiginous migraine and this benign paroxysmal vertigo of childhood. Some people think this benign paroxysmal vertigo is like a precursor, just like car sickness for migraine or cyclic vomiting in children with migraine. It's a precursor. Instead of getting migraines, they get abdominal pains or cyclic vomiting or this benign paroxysmal vertigo. So this is completely separate from BPPB? It's completely separate from benign positional vertigo. You could flip your head around in the clinic all day long and nothing would happen. And then vestibular migraine, this is not rare. This is probably one of the most common causes of vertigo that we see in our clinic is vertiginous migraine. And they almost always have a headache. But the headache does not always have to come with the vertigo. It can be intermittent. And so they often have a headache. They most often have photophobia or phonophobia. Sometimes they have an aura. But vestibular migraine is way more common than thought. I showed this video to three pediatric neurologists who do migraine and they all said vertiginous migraine. So important to realize that intermittent nystagmus, pallor, photophobia, feeling sick, nauseated, et cetera, that are episodic could just be vertiginous migraine. But obviously you have to work it up. She'd sleep and then she'd be fine. So she'd go home, go to bed, sleep. And she was getting like one every other week. And she was a bright kid. In between she looked great. But this is how she looks in the middle of it. You can tell she doesn't feel good. I mean, she's like, uh, great. So. Right. Probably older kids or older people are brainstem aura. Now brainstem aura can be tricky too. Brainstem aura is like an aura. It happens before the headache. But when they say brainstem, they mean things like double vision, a little ataxia, um, you know, uh, dizziness, vertigo. I mean, there's a whole list of brainstem symptoms that people can have that often come before the headache occurs. It used to be called basilar migraine, but we don't call it that. Now we call migraine with brainstem aura. Okay. Does that. Okay. Now this one is another one. I don't know who saw this one. Um, this is another one. So 49 year old woman, hypertension, hyperlipidemia type two diabetes. No previous history of migraine. She had headaches really before. Um, for the last two years though, she's been having headaches, especially at night. And she noticed her pupil would dilate and she was diagnosed with migraine. She used Cetaminophen. She was having spells once every three to four months. Then they slowly increased to once every two weeks. And then her pupil would come back to normal in between the spells. And sometimes her pupil dilated without a headache that could last minutes to hours. She never had a headache without a dilated pupil, but she could have a dilated pupil without a headache. And she had associated light sensitivity and nausea, severe enough that she had to go lie down. And remember she's 49. Uh, one day she left for work. Uh, she left work because she had a fever and a cough. And she had a headache for 44 hours with a red left eye. Then she had wavy colors in her vision, especially when she closed her eyes. Then she went to the ER two days later, was given morphine, which made her throw up and made her headaches actually worse. Morphine is a terrible drug for migraine because it dilates your blood vessels, makes the whole thing worse. Uh, she was admitted to the hospital for pneumonia and treated with antibiotics. She got two shots of Sumitriptan and her headache got better, but her pupil enlarged bigger and didn't go down and her red eye was a little bit better. Now, um, she's got some family history of aneurysm, lung cancer, stroke. She's on, you know, the usual medicines. And she has two children. She's been a smoker. She does drink some alcohol. Then 10 days later she had a seizure. Then her left pupil dilated again and she was sent to the ER. And then they life-flighted her to the university because they couldn't find out what was wrong. And she was noted to have ptosis, amyretic, unreactive pupil on the left. Here's her, here's her MRI scan. Anybody see anything on the MR? That's a problem. What do you see, Rachel? Yeah, this is what you're talking about, right? So, and do you know what that's kind of associated with? Press. Yeah, posterior reversible encephalopathy syndrome was exactly. Most of her blood vessels looked pretty good. Her diffusion was basically negative. So she was diagnosed with a press. But this is what she looked like. Did anybody here take care of her? Oh, okay. Rachel again. Another case you can write up, Rachel. And Kendra. Okay, so Kendra saw this patient too. So she had ptosis. She had a little bit of an exo. And she was diagnosed with a press. This is her pupil over here. And you can see a normal pupil here. Okay. We're all on her attack side, looked. To the left side. All the attacks were on the left eye. You mean one eye being big or the other eye being big? Sometimes it can be in one eye. Sometimes it can just be one eye. That's not painful enough. No. No, it's migraine. Well, what happens with... Benign episodic medriasis? They get their usual migraine. And then they get anisecoria. You don't see that in press. So that's something that... This is not typical press. Press is usually just seizure and then this MR finding. And it's, you don't usually get this kind of thing. Dilated pupil. And her evaluation was, her vision was down a little bit. And you can see that her pupil, her vision was down a little bit. And you can see that her pupils were terrible. She had an afferent defect in the left by reverse afferent technique. She did have good color vision. Eye movements were grossly full, but she did have this large exiphoria. She had one cotton wool spot on the left. So here's her OCT. All right, so here's... So I wanted to give you kind of an idea of what should you be thinking about, but I want you to tell me what you think this is. So, straw brings up migraine, benign episodic medriasis of migraine. The neurologist on the service thought it was a third nerve palsy with pupil involvement. The other causes of enlarged pupil could be an 80s pupil, pupillary block, seizure-induced medriasis. And that was brought up. Could this be seizure-induced medriasis? Because you can't see seizures giving induced medriasis. So what did you want to know that? Okay, so her meds... her meds, let's go back to her meds. Cetaminophen, Atorvastatin, Estradiol, Isinopril, Metformin, Triampherin, Casper. Okay. So I'm not going to... So she had narrow angles on exam, and her eye pressure was 49. In our clinic, unfortunately, she hadn't been checked until... And she'd been seen by an ophthalmologist, and she didn't... In between, when her pupil was normal, she had normal pressure, but when her pupil dilated, she had that... So I bring this case to you for number one. I mean, you're always going to check a pressure no matter what. Even in those little black bags that you carry around, you always have a tonal pen and you check the pressure. You could see somebody with a dilated pupil, almost isolated, and a red eye. You've got to check the pressure. So that's really critical that... But it should be in your thinking. And whoever brought up what drug she's on, you should know this list because there are a whole lot of drugs that can cause changes in the angle, especially things like to pyramid, acetazolamide, can all change the angle, pressure, and... angle and give people a closed angle. That have got a narrow angle. But I think that was really an instructive case for a lot of people. And, you know, benign episodic medriasis often comes with the migraine and so we lowered her pressure. The reason she had breasts was they stopped all her anti-hypertensives when they treated her pneumonia in the hospital. Fortunately, she really lost vision related to the angle closure. I was going to show you a nice picture of the benign episodic medriasis with a humongous pupil. Well, maybe I'll do that later. I may have one for you. Okay, any questions about this one? Just something to always think about those pupils. Check the pressure. Don't forget block. Okay, so 58-year-old woman and she had no previous headaches. And in January, she began with a new, dull, continuous right-sided headache around her eye. Her very sharp frontal temporal area, stabbing pains, radiating into the ear, jaw, and nostril. It would last 10 to 15 minutes, about five times a day. She was light sensitive, mainly in the right eye. She had tearing also in the right side. And here's her exam. And here's an apoclonitine test. And why did we do the apoclonitine test, Mike? It's just that we have three monitors. And can you see what happened here? She has a smaller pupil on the right. And when we put the apoclonitine in, you can see how the right pupil dilated. So, the diagnosis is... Okay, all right. So what do you think we should do here? So what, let's first do the headache phenotype. What's the phenotype of this headache? So it's continuous right-sided pain And they would last 10 to 15 minutes on top of a continuous right-sided pain. Hemi-crania continuum, okay? Good. So that's the phenotype of the headache. So what do we have to do about Hemi-crania continuum and all tacks that occur like this? Okay, so our next step, what's our next step? Do we want to just give her an endomethacin trial and see if the pain goes away? Get a carotid angiogram, CT, MR, what would you do? MR? Okay. And here's her field. I did a field, I chose to do a field. What do you think about the field? I mean, didn't you do fields yesterday? Anybody want to come on, you guys? It's almost like the junctional fields that we saw yesterday because what are you going to call this? It's kind of an incongruous, left-hemonomous Hemi-enopia. It's not, I mean, it's incongruous, right? It's more nasal on the right eye, a little bit of temporal, but there's something going on a little bit up there on the superior nasal quadrant of the left eye too, correct? Okay. All right. So, Teresa's already said we have to get a scan, get an MR scan, okay? And what do you think this is going to show? I picked this case for a couple of reasons, occipital stroke, okay? But remember that as the field gets more and more congruous and occipital lobes, you know, those are pretty congruous in the occipital lobe, you know? You can have incongruous kind of anywhere anterior to the occipital lobe. What was that? I think that you'll have a cavernous sinus syndrome. Cavernous sinus syndrome? Well, how are you getting the field defect? Now, get these guys over on this table that are sitting here, mute. Okay, so a carotid dissection throwing an embolic stroke, and where is the stroke then? It's a parietal. Okay. I forget which side you're... Is it left-sided? Yeah. Okay. Yeah. All right. Anybody else have other thoughts? Brown. Brown. What do you think? I agree. No, this was not an abrupt onset, you guys. Remember, this is a person coming in with a continuous right-sided headache with stabbing pains on the right side, and then we did a visual field and went, oh my goodness. She's got this kind of incongruous thing. Did you want to... Could it be pituitary mass? Where? In the... Just a small bit. Could it be pituitary mass? So does she... Could it be pituitary mass? Why? Why do you say pituitary? Because you've got a lot of crossing fibers there, so you could get it, depending on where it's compressing, you could get a pattern that's incongruous like that. Correct? Correct. You can get a tract lesion with a pituitary compression, and that's exactly what she had. So she's got a mass in her pituitary that is compressing the posterior aspect of the pituitary, giving her an incongruous. Now I'm telling you this case for several reasons. The first reason is that you should know that any hamonomous defect could come from the pituitary, and this is on old caps all the time. They love this question. They love to give you a hamonomous incongruous-like thing, and then have you try to pick parietal lobe, when it actually could be pituitary or chiasma. So they love doing that. Usually they throw in an RAPD to tell you that it's a tract lesion, to give you a clue. I also am giving you this because pituitary tumors can cause eye pain and give you these kinds of trigeminal autonomic cephalgias. So the phenotype of this headache, I treated her within the mouth and her headache went away. The phenotype of her headache, I treated the phenotype of the headache, and the headache went away. But it still didn't take away her pituitary tumor, which was probably related to the headache. So she had a pituitary adenoma. 46% will get a chronic migraine, or a sunk, or a cluster, or a hemicrainy continuum, or primary stabbing headache in studies where they've looked at headache and pituitary tumors. And these are people coming into your clinic all the time, not every day, but this is not going to be rare. If you're in general practice, you should at least remember, you know, you see somebody with that TAC, you want to be thinking about it. And then this is another study of the cranial autonomic symptoms associated with pituitary tumors. This hemicrania continuum in this series was up to 20%. So we treated her within the mouth of the son, then we took out her pituitary tumor and their headache came back and I gave her in the mouth of the son periodically. Okay, so this is a woman, let's see how much time do I have. This is a woman who has a family history migraine. And then she's had slowly developed increased headaches, most chronic daily headache with no light or sound sensitivity, no nausea. Some of the severe ones are positional and she has to lie down. Her pain is around her eyes and behind her eyes. And she came in saying, I think it's something to do with my eyes, her neuroexam is normal. She was just married, she had a baby six months before she's tried to go to law school and this is her imaging. And she was diagnosed in Boston as a Kiari male formation. Is this a Kiari? We just talked about this yesterday. We had one of these. We had one of these that thought they had a Kiari and it's... Right, and is this a Kiari? No. Why do you say no? Because it's like the posterior fossa, the cerebellum isn't sinking down. Okay, so there is tonsillotopia, but she's got a plump pituitary. Well, she's a young person, just had a baby, but she's lost her part of her ambient cistern around her midbrain. And when I saw the things that tipped me off was this ambient cistern is usually white all the way around. And the other thing that tipped me off is the pons. The pons is usually a nice little belly, you know, it's kind of got a little round belly and it's kind of flattened. And when you see a flattened pons, what should you be thinking of? Increased intracranial pressure. Decreased intracranial pressure. So this is one year later when I finally did sear myself and she'd gone from one year, she'd gone from that scan to this scan looking like she's going to herniate. So that's a year before I saw her and then when I saw her she looked like this. So she'd had an epidural with her, but you know sometimes the dura gets a little nicked and she had intracranial hypotension. And you know, all right, this I want to make sure we cover this case. This is a guy referred for anti-sacoria. So this is a guy 37 years old. He's had long-standing migraine family history, blah, blah, blah. And during his headache, he notes severe anti-sacoria during the headache. And this one, these are two different headaches. Both times his right pupil seemed to dilate. And then when he's headache free, he looks like this. So this one, OK, benign episodic medrices. But I wanted to show you how dramatic these can be. This one from the literature, where these pupils can be humongous. They usually work. They usually can, you can get them to work, but they can be really big. And just to be aware that this canker usually switched sides, but it can always be on one side. Why do people get it? People wonder if it's a parasympathetic deficiency or a sympathetic overaction. Nobody really knows for sure. And OK, this is the last one, and then we'll talk about the quiz. 45-year-old with brief eye pain, less 25 to 30 seconds, 50 attacks a day, slight ptosis in the right eye. His eye exam is normal, his neuro exam is normal, and he's got sunk. And these are really not common. Because I've only seen like maybe three in my whole career. But it's one that you're going to get tested on. It's even in your focal points, right? So they test you on it. So OK, oh darn, I want to show you these two, too. OK, this one's a 24-year-old with severe pain on the right eye. And she has a history of rheumatoid arthritis. She's got a quiet eye, normal eye exam. And it's especially worse when looking down. Anybody have a thought about that one? Trochleitis, OK, trochleitis. Severe pain, 75-year-old with rheumatoid arthritis, normal eye exam, eye quiet, normal eye exam, except for some mild cervical spasm. Any thoughts about this one? Revert pain from the neck. Pardon? Revert pain from neck muscle. From her cervical spasm, could be. Is this somebody would you just say, OK, it's your cervical spasm going to physical therapy? An 84-year-old woman with pain. I don't think so. Maybe that's not. I don't think so. I think you're going to work it out. Cervical spasm is very common and ends up being a waist basket. But this lady actually had been to several ophthalmologists and neurologists. And nobody went and looked at her adontoid that was compressing her cervical, upper cervical. They get panace. And this huge panace just pushes on a spinal nucleus of five, which gives you eye pain. And she came in with eye pain. That was two, like, three ophthalmologists, three neurologists. And then they just forgot to look at her. All right, we've got to go through the quiz. The cure is innervated by the upper cervical nerves to the pulse. Oh. Oh. Oh. A man has pain over his right eye. That last 45 minutes, he has tearing rhinorrhea on the right side. His clinical diagnosis is most consistent with the next step is oxygen, MRCT, cocaine, MR. You can give him oxygen, but you've got to do an MR. You can give him oxygen first. The next step. And that's oxygen. The next step. Yeah, a lot of you have a caution in your nose. The next step is the MR. All right. All right. Thank you. Thank you. But he needs an MR. I want you to use the attack. They need an MR, OK? They don't need 20 MRs. If they've had an MR, that's all they need. They don't need 20. They don't need to come into my office with 20 CDs. They just need one. OK, so the headache in this case would be responsive to endomethacin, true or false. Good. A dilated pupil associated with migraine could be? All right. What does sunk stand for? Sure. Steel, iron, lateral, neural, subcontinue, injection, bacteria, and high-tech. The average duration is two to 10. What are the three questions to ask to diagnose migraine? Votaphobia. Wait a minute. Votaphobia. Nasia. Nasia. Where's the physical activity? And severe and moderate to severe pain. Those are the three key questions in ID migraine. If you only have one second to do a migraine history, ask, does this disable you or keep you from doing whatever you want to do or moderate to severe? Do you have photophobia and do you have nausea? And if they have two out of the three, it's migraine. If it's long as it's not something else. That's a great thing to ask. It's making sure it's not something else, right? Yeah. That's the part that you always have to think about. Even though most of it's migraine. OK, name the nerve that innervates the dura. OK, trigeminal is not good enough. It has to be either V1. And if anybody gets the actual nerve that does this, then they get an even extra point. The recurrent nerve of, nobody knows this. Current nerve of aren't. Well, that's why it was actually credit. I mean, I'm going to give you a credit if you got a trigeminal. First vision. You can't just say trigeminal though, because it's the first division. And that's the key about why the eye is the center of attention for all weird stuff. Because in pain, it's because it's that first division of five that innervates the outer. And so that's why all pain leads to the eye in the trigeminal. All right, so if you just either turn it in or give me your scores, just turn in your papers. It's all you have to do. And then I'll give you credit. And if your name is at the top, it'll move Arnold. 2 to 10 seconds. Recurrent nerve of Arnold, good. It's been thought, it's been forgotten. And it's a, did Arnold say it? Maybe we need to rename it. Huh? We need to rename it in literature so it doesn't be forgotten. Maybe. I wouldn't be surprised at all. It's probably Arnold. It's probably the same. OK, so now, did this work for you? Yeah, it was awesome. It was great. This is what you're talking about, right? Yeah. I am lecturing you next week. I am going to give a lecture because it's my troubling thirds. I've gone across universities of the United States to ophthalmology departments and given this lecture. And for some reason, every time I've given it in this room, this stupid thing didn't work. So this is my third or fourth attempt to try to give this lecture to you guys because I want it on core so that next year, when we do third nerve, we can just watch the lecture and then do cases like this. But I need to do one of these so you're going to get a lecture. But it is one that I've given to a lot of other professors. Thank you. Thank you.