5 - Common Neurological Disorders 2 Flashcards
All dementia syndromes and stroke will be covered in detail in…..
OPIC
When somebody presents with a headache, what differentials should you think of?
IMPORTANT
How do you take a history for the present complaint of a headache?
(NB - OSCEs)
- Site: Band like, unilateral, temporal
- Onset: Sudden, gradual
- Character: Throbbing, stabbing
- Radiation: Ear, neck, back
- Associated Symptoms: Eye pain, blurred vision, jaw claudication, lacrimation, aura, photophobia, non-blanching rash, rhinorrhea, fever, N+V
- Timing: Recur? Seconds? Hours? Progressively worsen? Head trauma at the time? What else doing at time?
- Exacerbating/Relieving Factors: Analgesia, Sex, Food (e.g cheese, chocolate, coffee)
- Severity: 1 to 10
- RED FLAGS
- Systems Review: General, Neurological, Fundoscopy
- PMHx: Cancer, HTN, ADPKD
- DHx + Allergies: COCP
- FHx: Migraines
- SHx: Stress, smoking alcohol
- ICE
What differentials should you think of for a rapid onset headache and a gradual onset headache?
Rapid: SAH, Meningitis, Encephalitis
Gradual: Venous sinus thrombosis, Sinusitis
If a patient has a chronic progressive headache, what differential should you consider?
Raised ICP, especially if worse on waking/bending forward/coughing and papilloedema
LP contraindicated until CT
What are some red flags with a headache that mean there may be an underlying sinister pathology? e.g raised ICP or Intracranial Haemorrhage
SSNOOPPPP
- Fever, photophobia or neck stiffness (meningitis or encephalitis)
- New neurological symptoms (haemorrhage, malignancy or stroke)
- Dizziness (stroke)
- Visual disturbance (temporal arteritis or glaucoma)
- Sudden onset occipital headache (subarachnoid haemorrhage)
- Worse on coughing or straining (raised intracranial pressure)
- Postural, worse on standing, lying or bending over (raised ICP)
- Severe enough to wake the patient from sleep
- Vomiting (raised intracranial pressure or carbon monoxide poisoning)
- History of trauma (intracranial haemorrhage)
- Pregnancy (pre-eclampsia)
What examinations should you do when a patient presents with a headache?
General: Rashes, Bruising
Neurological: see image
Fundoscopy: May show Papilloedema if raised ICP from tumour, bleed or BIH
What are some primary and secondary headaches?
Secondary headaches give a similar presentation to a tension headache but with a clear cause. They produce a non-specific headache secondary to:
- Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
- Alcohol
- Head injury
- Carbon monoxide poisoning
What are the following for Cluster headaches (primary headache disorder):
- Symptoms
- Epidemiology
- Diagnosis/Ix
- Mx
- Prevention
Can also try steroids and lithium for prevention
If refractory after treatment can try deep brain stimulation, greater occipital nerve blocks and trigeminal nerve compression
What are trigeminal autonomic cephalalgias?
Collection of primary headache disorders with unilateral headache and parasympathetic autonomic features
Causes: cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache and hemicrania continua
What is the diagnostic criteria for cluster headaches?
What are the following for Tension Headaches:
- Symptoms
- Epidemiology
- Diagnosis/Ix
- Mx
- Prevention
What are some red flags associated with headaches?
What is a medication overuse headache?
Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped
What is a hormonal headache?
Related to low oestrogen and produce tension headache:
- Two days before and first three days of the menstrual period
- Around the menopause
- Pregnancy. It is worse in the first few weeks and improves in the last 6 months. Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.
COCP can improve!!!
What are the following for Trigeminal Neuralgia (Primary Headache Disorder)
- Symptoms
- Epidemiology
- Diagnosis/Ix
- Mx
Red flags requiring referral:
* Sensory changes
* Deafness or other ear problems
* History of skin or oral lesions that could spread perineurally
* Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
* Optic neuritis
* A family history of multiple sclerosis
* Age of onset before 40 years
What is primary, secondary and idiopathic Trigeminal Neuralgia?
Primary trigeminal neuralgia (80-95%)
- Vascular compression
- Compression leads to demyelination and abnormal electrical activity in response to stimuli.
Secondary trigeminal neuralgia
- Compression may be caused by other lesions (e.g. vestibular schwannoma, meningioma, cysts)
- MS can also lead to secondary trigeminal neuralgia due to demyelination of the trigeminal nerve.
Idiopathic trigeminal neuralgia
- Unidentifiable cause.
What are some important eye pathology headaches you need to look out for?
- GCA
- Glaucoma
What is the diagnostic criteria for a migraine?
Clinical
Aura: Confirms diagnosis. At least 2 attacks
No Aura: 5 or more headaches lasting 4-72h with nausea/vomiting or photo/phonophobia AND 2 of: unilateral headache, pulsating character, impaired or worsened by daily activities.
What are the following in migraine:
- Symptoms
- Epidemiology
- Diagnosis/Ix
- Mx
- Prevention
Acupuncture can be done over 10 session if propranolol and topiramate not working
Transcutaneous Nerve Stimulation may help
What are some examples of aura?
- Scotoma
- Paraesthesia from fingers to face
- Dysarthria and ataxia
- Hemiparesis
- Dysphasia
What is the definition of chronic migraine?
Headache on more than 15 days of each month, 8 of which have features of migraine.
What is a hemiplegic migraine?
Can mimic stroke. It is essential to act fast and exclude a stroke
- Typical migraine symptoms
- Sudden or gradual onset
- Hemiplegia (unilateral weakness of the limbs)
- Ataxia
- Changes in consciousness
If a headache is triggered by Valsalva manoeuvre what pathologies should you consider?
“Cough Headache”
Could indicate raised ICP from Chiari or Posterior Fossa Lesion
What are the 5 stages of a migraine?
Some patients may only experience one or two of the stages
- Premonitory or prodromal stage (can begin 3 days before the headache with yawning, fatigue, mood changes)
- Aura (lasting up to 60 minutes)
- Headache stage (lasts 4-72 hours)
- Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
- Postdromal or recovery phase
What is the mechanism of action of triptans?
5HT serotonin receptor agonists that act on:
- Smooth muscle in arteries to cause vasoconstriction
- Peripheral pain receptors to inhibit activation of pain receptors
- Reduce neuronal activity in the CNS
What vitamin supplement can be even as prophylaxis for migraines?
Riboflavin (B2)
What prophylaxis can be given for menstrual migraines?
NSAIDs (e.g. mefanamic acid) or Triptans(frovatriptanorzolmitriptan)
Taken 2 days before bleeding and up to 3 days after starting bleeding
Why should you not take COCP if you have migraines with aura?
Risk of ischaemic stroke, use POP instead
ONLY IF AURA!!! If no aura can use low dose COCP
What are some complications with a migraine?
- Status migrainosus: longer than 72 hours.
- Persistent aura without infarction: refers to symptoms of aura for one week or longer with no evidence of infarction of imaging.
- Migrainous infarction: describes a cerebral infarction that occurs during an aura whose symptoms then persist, imaging demonstrates an ischaemic infarction.
- Migraine aura-triggered seizure: migraine with aura that leads to a seizure.
- Ischaemic stroke: migraines are risk factor for stroke, avoid COCP, lose weight
What often happens with migraine disorders during pregnancy?
Often improves, if not seek help as may be pre-eclampsia
Give paracetamol, AVOID NSAIDs and Triptans
What is the likely underlying pathology?
Small Cell Lung Cancer
SCLC - SIADH, Cushings, LEMS, Cerebellar degeneration
This is Lambert-Eaton Myasthenic syndrome. Ascending weakness that gets better on use of the muscles
What autoantibodies are often found in GBS?
Anti-GM1
(Anti-ganglioside)
What mnemonic can you use to remember the features of Wallenburg Syndrome?
PICA Infarct
DANVAH
D - Dysphagia
A - Ataxia Ipsilateral
N - Ipsilateral Nystagmus
V - Vertigo
A - Anaesthesia (Ipsilateral facial numbness and contralateral loss of pain)
What anti-emetic should you prescribe alongside a triptan for a migraine?
Metoclopramide
Always prescribe a pro-kinetic as enhances the analgesia
What are the four grades of hypertensive retinopathy?
What are some primary and secondary headaches?
