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
meds for migraines - 6
Sumatriptan 85mg/naproxen 500 mg tab
More effective than either agent as monotherapy
Rizatriptan (Maxalt) 5 or 10mg orally disintegrating tabs (may repeat in 2 hrs prn-max 30mg/day)
Antiemetics
Metoclopramide IV/IM can be used as montherapy for acute tx
Diphenhydramine IV is recommended to be given concurrently to prevent adverse events (utd)
Opioids shouldn’t be used for tx of migraine, except as a last resort d/t to potential for addiction and overdose
Prophylactic meds for migraines - 3 types
BBs-first line, reduce frequency and severity by 50%
Propranolol start at 40 mg BID; dose range 40-160 mg daily
Metoprolol start at 100 mg BID; dose range 100 -200 mg daily
Timolol start at 20 mg BID; dose range 20 to 30 mg daily
Not to be used in >60 y.o. or smokers (d/t risk of CV events)
Amitriptyline starting 10 mg at hs, dosage range 20 -50 mg at hs
Antiepileptic drugs: valproate, topiramate
NSAIDS (naproxen)
abortive mx for cluster HA? 2
Abortive
O2 5-8 L/minX10 min (12L/min non-rebreather mask x15 min
And/or SC sumpatripatan 6mg effective within 20 min
tx for cluster HA, SE what to do with follow up?
verapamil is associated with an increased incidence of ECG abnormalities, including heart block and bradycardia
Benign Paroxysmal Positional Vertigo, what is it, what to do?
ss?
positional vertigo, try physio
Attributed to calcium debri (otoliths) in the semicircular canal.
Clinical Manifestations Recurrent vertigo lasting ≤1min with head movement Wks-months without tx May be accompanied by n/v Nystagmus with provocation
how to dertermine if true vertigo
True vertigo can be reproduced. If it can’t it is unlikely to be vertigo.
If patient tells you they are continuously dizzy, it is not vertigo
Then try to determine if it central or peripheral.
Central will be accompanied by brainstem sx: diplopia, facial numbness, weakness, hemiplegia, dysphagia
Peripheral
Timing and precipitating factors help to elucidate most causes
Consider neuroimaging for vertigo with neurologic s/s risk factors for CV disease, or progressive unilateral hearing loss
Meniere’s
patho?
dx?
avoid?
tx?
Patho:
Results from idiopathic endolymphatic hydrops
Typically presents in 20-40 y.o.
Clinical Features:
Episodic vertigo (20min-24 hr duration and sensorinueral hearing loss (becomes permanent),tinnitus lasting min-hrs
Pain in the ear, aural fullness, nausea
dx - Clinical-no specific test
Audiometry
Refer early to ENT to do workup. MRI may be ordered to r/o CNS lesions
avoid - Avoid caffeine, nicotine, alcohol, MSG, nicotine
Salt restriction to 1-2 g/day
Stress reduction
tx -
HCTZ 50 mg BID
Surgery
MS clinical feautures
Clinical Presentation
Attacks typically a few hrs -days; last anywhere from >24 hours to a few months
Sensory Deficits
Visual and Occulomotor Deficits
nystagmus
Coordination issues
vision, numbness, nerve pain, dizziness, balance/ coordination, difficulty walking, muscle weakness, tremors, bowel/bladder, difficulty thinking
Paresthesisa/ sensation in the extremities
“Numbness, pin/needles, tightness, coldness, swelling”
Lhermitte phenomenon – classic, only when having an attack, 10%
Transient sensory sx-electric shock radiating down the spine or into the limbs with flexion of the neck
PEx:
Impairment of vibration and joint position sense
Decreased perception to pain and light
Lhermitte phenomenon
– classic, only when having an attack, 10%
Transient sensory sx-electric shock radiating down the spine or into the limbs with flexion of the neck
