70 neuro Flashcards
red flags for HA? 3
sudden onset - thunderclap
Escalating in severity/frequency
Associated with systemic symptoms : weight loss, fever, and/or meningeal signs (meningitis); consider cerebellar hemorrhage if nausea and vomiting accompany these signs
thunderclap
headache-severe onset, reaches max intensity in seconds accompanied by vomiting
Escalating in severity/frequency eg?
intracranial lesion; headache that is worse in am with drowsiness or vomiting may reflect raised ICP
Associated with systemic symptoms? 3
consider what ddx?
weight loss, fever, and/or meningeal signs (meningitis); consider cerebellar hemorrhage if nausea and vomiting accompany these signs
tension headaches
triggers? 4
intensity?
how long?
neuro deficits?
s/s
mx
triggers- anxiety, depression, situational stress, secondary to muscle strain
Mild to moderate intensity, bilateral, generalized
“Band like “sensation around head
Lasts 30 min- days
No neuro deficits, poor concentration
mx - Mild analgesics
Acetaminophen, aspirin, *NSAIDS
Relaxation techniques. Explore causes of anxiety
Patients with chronic tension headaches need underlying distress to be addressed
Stress reduction
Amitriptyline 10-12.5mg at hs and increase the dose in 10-12.5 mg steps every 2-3 wks as tolerated and as needed for sleep, until there is improvement in headache.
Max dose 100 -125 mg hs
Takes 4-6 weeks before improvement seen and may be accrued up to 3 months
Maintain for at least 3-6 months then taper
Cluster headache
affects who?
SS mostly affecting
how often and how long?
middle-aged men.
s/s - Very painful H/A syndrome
Severe unilateral, periorbital pain and behind eye.
bilateral nasal congestion, eye redness, rhinorrhea and lacrimation
how often - clusters can last weeks to months, Lasts <2hrs but several may occur in 24hrs
which HA wakes people from sleep?
Which HA precipitated by alcohol ingestion?
Usually occurs at the same time of year?
which HA has focal neuro deficits?
Cluster
Cluster
Cluster
Migraine
Tx for clusters? 4
Prophylaxis? 4
O2
limit triggers
Sumatriptan 6mg SQ/intranasal
Ergotamine tartrate inhalation
pro: Prophylaxis
Verapamil 240mg daily
Tapering prednisone from 40mg/d
Ergotamine tartrate po/SQ/pr
POUND for what HA?
Migraine
P:pulsating O: lasts one day U: unilateral N: N & V D: disturbance of daily activity
which is more common of Migraine? aura or without?
s/s - 7
how long?
without aura
Unilateral,
Dull or throbbing
Visual disturbances, field deficits, hallucinations
Aphasia, numbness, tingling, clumsiness, weakness
N & V
Photophobia, phonophobia
Appears acutely ill
Build up gradually and lasts several hours
Triggers for Migraines
Lack of sleep, no food, alcohol, nitrate foods, menstruation, oral contraception, weather changes, motion sickness
Diagnostics for Migraines ? 4
CBC, syphilis screen, ESR, CT head
Temporal arteritis - inflam of temporal arteries
mx of Migraines?
prophylactic therapy?
acute attacks?
what drugs have contraindications, and what are they?
Avoidance of triggers: Relation/stress management Eliminate MSG/nitrates in diet Stabilize/wean caffeine intake Avoid alcohol
If 2-3x/month prophylactic therapy:
ASA, NSAIDS, propranolol (Inderal) 80-240mg/day
Can use amitriptyline 10-150mg/day but try propranolol first
Various ergotamines, MAO inhibitors
If acute attack: Rest in dark Analgesic (ASA) Serotonin agonists, triptans: containdicated in coronary artery disease, Uncontrolled HTN, pregnancy, Prinzmetal’s angina Sumatriptan 6mg SQ repeat in 1hr x3 Cafergot 1-2 tabs
common manifestation of Lyme meningitis?
Other causes of facial paralysis? 4
Facial nerve palsy
Injury to facial nerve from bacterial infection, Herpes Zoster, DM, sarcoidosis, Guillan-Barre syndrome
Stroke
MS
Bell’s palsy
def of bells palsy
common in what pts? 4
when occurs?
ss? 6
Abrupt paralysis of the facial muscles innervated by CN 7, due to inflammation - nerves compressed from inflam?
Increasing incidence with age, associated with pregnancy (especially in 3rd trimester and 1 week postpartum), DM, hypothyroidism
Abrupt onset (hours-48hrs)
unilateral facial paralysis
Eyebrow sagging, inability to close the eye, disappearance of nasolabial fold, mouth drawn to the non affected side
Difficulty wrinkling forehead of affected side
2/3 of cases are accompanied by pain in or behind the ear
Drooling, alterations in taste or hearing
if have skin lesions especially external auditory meatus-consider?
HSV
consider Imaging in facial paralysis if:
slow progression beyond 3 wks, or if there is no improvement at 6 mo
Hx of a facial twitch or spasm that precedes facial weakness suggests nerve irritation from tumor and should also prompt imaging
tx for bells palsy? 2 drugs
do anything with eyes?
other tx? 1
Prednisone: 60-80 mg/d x1 wk (begin w/i 3 d of sx onset)
If believed to be caused by Herpes Simplex Virus then consider use Combo therapy with valacyclovir (1000 mg TID) X 1 week for patient with severe facial palsy at presentation
Prevent corneal injury
Artificial tears, methycellulose drops BID, and HS
Lid may need to be taped shut, especially at night to prevent keratitis
Physical Therapy: various options out there
diff btwn bells and trigeminity neuralgia?
bells - nerve 7
trigem - nerve 5 - Sudden, usually unilateral, severe, brief stabbing or lancinating recurrent episodes of pain in the distribution of one or more branches of the 5th cranial (trigeminal) nerve.
continuous dull pain
ss of neuralgia trigem
Headache, sudden, usually unilateral, severe, brief, stabbing or lancinating. Recurrent episodes of pain in the distribution of CN 5, may have continuous dull pain
Pain tends to occur in paroxysms and is maximal at or near onset
Facial muscle spasms can be seen
Pain described as electric, shock like or stabbing
Usually lasts from 1-several seconds but may occur repeatedly
Pain is out of proportion from the stimulus
triggers of nerualgia trigem
what to do for this pt? drugs? 3
Chewing Light touch Talking Brushing teeth Cold air Smiling/grimacing
refer to neurologist
Carbamazepine 100-200mg po BID. Can increase dose gradually in 200 mg increments as tolerated to total maintenance dose 600-800mg daily plus give prn pain managment
Baclofen: start at 15 mg daily given in 3 divided doses with gradual titration to maintenance dose of 50-60mg/day
Lamotrigine: start at 25mg daily x 2 weeks then increase to 50mg daily for weeks 3 and 4. Dose titrate to effect by increasing by 50mg daily every 1-2 weeks. Suggested total dose is 400mg daily given in 2 divided doses.
Headache with gradual onset stiff neck photophobia and fever may be due to?
A generalized headache that is worse in the morning and is associated with drowsiness or vomiting may reflect? eg?
meningitis
ICP (aneurysm, subarachnoid hemorrhange, tumor, encephalitis, meningitis, trauma, hydrocephalus, stroke)
mx of tension headache? what drug? max dose, taper when?,
how long it takes to work? think original therapeutic purpose
find underlying cause addressed Stress reduction
Amitriptyline 10-12.5mg at hs and increase the dose in 10-12.5 mg steps every 2-3 wks as tolerated and as needed for sleep, until there is improvement in headache.
Max dose 100 -125 mg hs
Takes 4-6 weeks before improvement seen and ay be accrued up to 3 months
Maintain for at least 3-6 months then taper
how long migraines last?
4 phases?
hours to days
Prodrome (60%)- lassitude, irritability, difficulty concentrating, nausea 24-48 hrs prior to onset of headache
+/-Aura (~25%)-visual (scintillations to scotoma), sensory (tingling on 1 side of the limb/face leading to numbness for up to 1 hr), less common are dysphagic aura (language) http://www.youtube.com/watch?v=ZrrviW0Od-w
http://www.youtube.com/watch?v=qVFIcF9lyk8
Headache-usually unilateral, throbbing/pulsatile quality. Termination-usually w/i 24 hr; sometimes 72 hr often during sleep without tx
Postdrome-fatigue, sleepiness, irritability
