Approach To Neuro Cases

Question 1

What are the basic types of primary HA?

Answer 1

Tension type, migrain, cluster HA, other

Question 2

What is the duration of a tension HA?

Answer 2

Minutes-days

Question 3

Where is a tension HA located?

Answer 3

Bilateral

Starts at posterior head and radiates anteriorly

Question 4

Describe characteristics and pt presentation of tension HA

Answer 4

Pressure that waxes and wanes

More of a nuisance, usually able to remain active

Question 5

What is the duration and location of a migraine?

Answer 5

4-72 hours 
Typically unilateral (temporal/frontal) in adults, can occur bilaterally (more common in peds populations)

Question 6

What are the characteristics and pt presentation of a migraine?

Answer 6

May have aura, gradual onset, with increase in pain sx from onset
Typically pulsatilla and severe
Pt is ill appearing, pt prefers room with no stimulus
Photo/photophobia, vomiting/nausea, vertigo, seizure like activity

Question 7

What is the duration and location of a cluster HA?

Answer 7

15mins-3 hours
Typically involves eye and/or temple region
Always unilateral

Question 8

What are characteristics and pt presentation of cluster HAs?

Answer 8

Quick onset, sharp stabbing pain of significant intensity, often see tearing of eye
Ice pick HA
Pt is active but in obvious discomfort

Question 9

What is the SNOOP mnemonic?

Answer 9

Systemic sx, illness or condition (fever, weight loss, cancer, pregnancy, immunocompromised)
Neuro sx or abnormal signs
Older onset (over 50)
Onset sudden (thunderclap HA)
Papilledema, precipices by valsalva, positional provocation, progression or change in HA history
Could represent a space occupying mass, vascular lesion, infection, metabolic disturbance or systemic problem
Danger

Question 10

What signs represent need for emergency evaluation?

Answer 10

Sudden thunderclap HA, acute or subacute neck pain or HA with Horner syndrome, HA with suspected meningitis or encephalitis, HA with global or focal neuro deficit or papilledema, HA with orbital or periorbital sx, HA and possible CO exposure

Question 11

What are examples of peripheral causes of vertigo?

Answer 11

Benign paroxysmal positional vertigo (BPPV), Meniere disease and otosclerosis

Question 12

What is benign paroxysmal positional vertigo (BPPV)?

Answer 12

Transient sx of vertigo due to canalith movement in the semicircular canals

Question 13

What is Meniere disease?

Answer 13

Spontaneous vertigo sx associated with unilateral hearing loss*
Caused by increased endolymphatic pressure in the inner ear

Question 14

What is otosclerosis?

Answer 14

Bony overgrowth of the stapes that results in spontaneous vertigo and conductive hearing loss

Question 15

What are examples of central causes of vertigo?

Answer 15

Vestibular migraine, cerebrovascular disease, mass at cerebellopontine angle

Question 16

What is a vestibular migraine?

Answer 16

Vertigo sx associated with migraine HA

Question 17

What is cerebrovascular disease?

Answer 17

Vertigo sx associated arterial occlusion

Question 18

What are other causes of vertigo?

Answer 18

Medication induced, psychiatric or orthostatic

Question 19

How do pts describe vertigo?

Answer 19

A sensation of self motion when they are not moving or a distorted self motion during normal head movement

Question 20

What is titrate the evaluation of dizziness?

Answer 20

Titrate consists of three distinct components of workup
Timing of the sx (onset, duration and evolution)
Triggers that provoke the sx (actions,movements or situations)
And a targeted examination

Question 21

What are the classifications of syncope?

Answer 21

Cardiac, orthostatic hypotension and neuro mediated

Question 22

What is orthostatic hypotension?

Answer 22

Positional changes that result in acute drop in BP
May be exacerbated my medication (beta blockers)
Volume depletion
Autonomic failure from primary (MS, Parkinson’s) or secondary (DM, spinal cord injury)

Question 23

What are the three causes of neuro mediated syncope?

Answer 23

Carotid sinus syndrome, vasovagal, situational

Question 24

What is carotid sinus syndrome?

Answer 24

Head rotation accompanied by pressure to the carotid artery resulting in stimulation carotid sinus resulting in reflexive ventricular pause and possible syncope

Question 25

What is vasovagal?

Answer 25

Occurs as an over correction to stimulus of SNS (panic, pain, sight of blood) resulting in rebound over stimulation of PNS, resulting in bradycardia and vasodilation
Most common cause for neuro mediated syncope

Question 26

What is situational syncope?

Answer 26

Occurs when a scenario (standing, coughing, micturition) triggers a neural reflex resulting in transient bradycardia and vasodilation resulting in syncope

Question 27

The history for syncope complaint should focus on which 3 things?

Answer 27

1. Is loss of consciousness attributed to syncope?
2. Is there a history of cardiovascular disease?
3. Are there clinical features to suggest a specific cause of syncope?