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NMSK Exam 2: Neuro > HA > Flashcards

HA Flashcards

1
Q

What are Primary HA (Benign HA disorders)?

A
  1. Common migraine
  2. Classic migraine
  3. Chronic migraine
  4. Tension HA
  5. Cluster HA
  6. Other: drug-rebound HA, trigeminal neuralagie
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2
Q

Secondary headaches are a sign of?

A

Organic disease

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3
Q

What are the 10 worrisome signs which may indicate headache of pathologic origin (secondary HA)?

A
  1. “Worst HA”
  2. Onset of HA after 50 YO
  3. Atypical HA for patient
  4. HA w/ fever
  5. Abrupt onset (max. intensity in sec. to min.)
  6. Subacute HA w/ progressive worsening over time
  7. Drowsiness, confusion, memory impairment
  8. Weakness, ataxia, loss of coordination
  9. Paresthesias/Sensory loss/ Paralysis
  10. ABNL medical/ neuro exam
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4
Q

When taking a HA history, what important topics do you want to ask?

A
  1. HA history
  2. Pain
  3. Prodrome
  4. Assoc’d Symptoms
  5. Triggers
  6. Current and Previous medications tried: for prophylactic and abortive therapy
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5
Q

As a general rule, many physicians (including neurologists) believe that any person with HA should do what?

A

One-time, thorough neuroimaging study (CT head with and w/o contrast or MRI of the head).

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6
Q

Any patient presenting with a headache who has a “worrisome history” or abnormal examination needs what?

A
  1. Urgent CT of the head
  2. If CT is NL = L.P. and possibly arteriogram because CT can miss 5-10% of SAH
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7
Q

When are imaging studies NOT warrent for HA?

A
  1. Adult patients with recurrent HA: migraine, including aura,
  2. No recent change in pattern,
  3. no history of seizures,
  4. no focal neurological signs
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8
Q

Differentiate a common migraine from a classic migraine.

A
  1. Common migrarine = without aura
  2. Classic migraine = with aura
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9
Q

What do you perform for a HA exam?

A
  1. Vitals (esp BP and pulse)
  2. Cardiac status
  3. Extracranial structures
  4. ROM and prescence of pain in C-spine
  5. Neuro exam
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10
Q

Describe the most common cause of bacterial meningitis in an adult and in a child.

A

Most common cause in infants, young children and adults: Strep. pneumoniae

  • Progresses VERY quickly to bcome serious and complications like: hearing loss, memory problems, learning disabilities, brain damage, gait problems, death.
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11
Q

Describe the appropriate initial treatment for suspected bacterial meningitis.

A

If you suspect a bacterial meningitis:

  1. If you can blood cultures and spinal tap STAT => do it.
  2. If not DO NOT DELAY TX: draw blood cultures STAT => then, treat with ABX
    1. IV STEROIDS (dexamethasone= give to decrease complications) +
    2. IV vancomycin
    3. IV 3rd generation cephalosporin (ceftriaxone or rosephine).
    4. If herpes or suspect, give acyclovir.
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12
Q

What drugs do you give someone with bacterial meningitis?

A
  1. IV STEROIDS (dexamethasone= give to decrease complications)
  2. IV vancomycin
  3. IV 3rd generation cephalosporin (ceftriaxone or rosephine)
  4. If herpes, give acyclovir.
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13
Q

_________ used to be the most common cause in children, but vaccine has decreased this substantially.

A

Hemophilus influenza

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14
Q

__________ is a highly contagious cause in teenagers and young adults.

A

Nisseria meningitidis

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15
Q

___________ is a consideration in causing meningitis in elderly.

A

Listeria monocytogenes

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16
Q

Pt with T1DM, over 50, who never had HA before => __________ better be a differential!!!!

A

Cryptococcal meningitis (fungal) = common in pts with T1DM and immunocompromised

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17
Q

Signs/symptoms of meningitis in children over age 2 years

A
  1. –Sudden high fever + HA that seems different than normal ( can have N/V)
  2. –Stiff neck
  3. –Confusion or difficulty concentrating
  4. –Seizures
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18
Q

Common causes of infectious encephalitis?

A
  1. HSV 1 or 2
  2. HIV
  3. West Nile
  4. Varicella Zoster
  5. Treponema pallidum (shypillus)
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19
Q

Herpes Simplex 1 Encephalitis

  1. MRI and EEG show focal abnormalities in ______
  2. Treatment = _____
  3. Complication of HSV1 Encephalitis
A
  1. Temporal lobes
  2. Acyclovir
  3. Secondary NMDA autoimmune encephalitis
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20
Q
  • AI can cause encephalitis: Over the last 10 years, we have learned of AI causes of encephalitis, which can mimic infectious encephalitis. Most of these associated with _________.
A

Seizures

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21
Q

Autoimmune encephalitis should be considered in who?

A
  1. Rapidly progressive (usually < 6weeks) encephalopathy or psychiatric problems
  2. Seizures
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22
Q

If you suspect pt with AI encephalitis, what should you do?

A
  1. Prompt identification of cause + initiation of treatment is important. CSF and serum testing takes weeks,
  2. IF you suspect this in pt => draw blood and spinal fluid => treat !!
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23
Q

2 etiologies of autoimmune encephalitis

A
  1. NMDA Encephalitis (Anti-N-Methyl-D-Aspartate Encephalitis)
  2. LGI1 Encephalitis (Leucine-rich Glioma Inactivated 1 Encephalitis)
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24
Q

NMDA Encephalitis

  1. MC in:
  2. Presentation:
  3. ABNL labs
  4. Commonly associated with:
  5. Response to treatment:
A
  1. Middle-aged women
  2. Rapid onset (less than 3 months) of at least 4/6 symptoms:
    1. ABNL (psychiatric) behavior or cognitive dysfunction
    2. Speech dysfunction (pressured speech, verbal reduction, mutism)
    3. Seizures
    4. Movement disorder
    5. ⬇︎ level of consciousness
    6. Autonomic dysfunction or central hypoventilation
  3. ABNL labs
    1. Extreme delta brush on EEG
    2. CSF: pleocytosis (increase white cells), oligoclonal bands, NMDA-R AB
  4. Teratomas
  5. Present with severe deficits, but many will improve with aggressive treatment, but may take long time
25
Q

EEG with__________________ with methotrexate neurotoxicity supports NMDA receptorinvolvement.

26
Q

NMDA encephalitis is commonly associated with a ________

A

teratoma

27
Q

LGI1 Encephalitis

  1. MC in:
  2. Presentation:
  3. Complications
  4. Commonly associated with:
  5. Response to treatment:
A
  1. Men
  2. Faciobrachial dystonic seizures: brief, seizures involving one side of the face and the arm on the same side, often occurring frequently, sometimes hundreds of times per day. Does not respond to epileptic drugs and may require immunotherapy.
  3. Temporal lobe (esp. hippocampal) ABNLities: brain damage
  4. Sleep disturbances (50% of pts)
  5. 1/3 relapse
28
Q

Classic HA of ruptured aneurysm: sx and what do you do?

A
    1. Worst HA of life,
    1. Dilated pupil on side of aneurysm; down and out eye
    1. Grab head and fall over/ collapse suddenly ,
    1. stiff neck,
    1. HX of seizure.

1st thing you do => PUT IN CT SCANNER IMMEDIATTELY!!!! => LP in case CT scan misses SAH

29
Q

Common migraines

  1. Intensity:
  2. Disability:
  3. Age of onset:
  4. Gender MC in:
A
  1. Moderate to severe
  2. Inhibits or prohibits daily activities; pain aggravated by activity
  3. Late teens => early 20’s; prevalence peaks between 35-40 years.
  4. F
30
Q

Common migraine

  1. Location:
  2. Description of pain:
  3. Patient behavior:
A
  1. Unilateral or bilateral
  2. Throbbing/sharp/pressure that last 4-72 hrs (usually 12- 24) with NO aura; afterwards, fatique, “fog”
  3. Retreat to dark, quiet room
31
Q

MC associated symptoms with Common migrane

A
  1. Nausea (90%)
  2. Vomiting (33%)
  3. Photophobia/ phonophobia
32
Q

How long does the aura associated with Classic Migraines usually last?

A

15-30 mins, but sometimes longer

33
Q

What are the common visual symptoms associated with Classic Migraines?

A
  1. Scintillations: flashes of light
  2. Scotoma: blind spots
  3. *Often hemianopic
34
Q

To be defined as a chronic migraine which criteria must be met?

A

HA that last 4+ hours for 15 or more days/month for at least 3 months

35
Q

The most widely discussed theory about the cause of migraines says that they are caused by?

A

Neurogenic inflammation: trigmeninal nerve is irritated => releasing neuropeptides => pain in meninges

36
Q

Tension HA

  1. Intensity
  2. Disability
  3. Age of onset
  4. Gender
A
  1. Mild to Moderate
  2. May inhibit, but does not prohibit daily activities
  3. Variable; generally peak incidence 20-40 yr.
  4. F:M = 3:2
37
Q

Tension HA:

  1. Location:
  2. Description:
  3. Behavior:
A
  1. Bifrontal, bioccipital => radiate to neck, shoulders
  2. Dull, aching, squeezing, pressure with no prodrome or aura
  3. No affect on behavior
38
Q

Which type of HA has an association with sleep apnea?

THIS WILL BE ON EXAM!

A

CLUSTER HA

39
Q

Cluster HA

  1. Intensity
  2. Disability
  3. Age of onset
  4. Gender
A
  1. Severe, excruciating
  2. Prohibits daily activities
  3. 20’s - 50’s
  4. F:M = 1:6
40
Q

Cluster HA:

  1. Location:
  2. Description:
  3. Behavior:
A
  1. 100% unilateral; generally orbitotemporal
  2. Excruciating, penetrating, sharp, boring, that does NOT throb; prodrome = brief mild burning in ipsilateral inner canthus or internal nares; no aura
  3. Frenetic, pacing, rocking
41
Q

How long do cluster HA last?

A

30 minutes - 2 hours

42
Q

What are some of the associated symptoms of Cluster HA’s?

A
  1. Ipsilateral ptosis
  2. Miosis
  3. Conjunctival injection
  4. Teary-eyed
  5. Stuffed / runny nose
43
Q

Acute Treatment of Migraines

A
  1. OTC analgesics / NSAIDS
  2. Isometheptene (Midrin)
  3. Butalbital (Fiorinal, Fioricet)
  4. Opioids
  5. DHE nasal spray
  6. Triptans (5HT1 agonists)
44
Q

CI for the use of Triptans in the acute treatment of migraines

A
  1. Ischemic heart disease
  2. Cardiovascular, cerebrovascular, or peripheral vascular disease
  3. Uncontrolled HTN
  4. Severe renal/ hepatic impairment
  5. Raynaud’s syndrome
  6. Hemiplegic or basilar migraine
  7. Use within 24 hr. of taking: ergotamines, MAOI’s, or other 5-HT1 agonists.
45
Q

If one triptan doesnt work for migraines, what should we do?

A

Try another! Consider nasal spray or injectable

46
Q

If nausea/vomiting are a major feature of migraine, consider using an ______

A

Antiemetic (metoclopramide, prochlorperazine), often before analgesic medication

47
Q

If insomnia is a major feature of migraine, consider using a ___________ to help the patient “sleep off” the migraine

A
  1. Sedative/ hypnotic (e.g. diazepam or temazepam)
  2. Major tranquilizer (e.g. thorazine)
48
Q

If migraines become more frequent or prolonged = what can we give?

A

Prednisone taper

49
Q

In general, if the patient is experiencing one or more HA’s per week, consider what?

A

Preventive medication to ⬇︎ the frequency/ severity

  1. Antidepressants: TCAs, SSRIS, SNRIs, MAOIs

2. BBlockers

3. Ca2+ channel blockers

50
Q

What is the only FDA approved treatment for chronic migraines?

A

BOTOX injections

51
Q

Acute Tx. Of Cluster HA

A

Avoid oral drugs!

  1. DHE 1 mg. IM or Ergotamine 2mg SL
  2. Sumatriptan 6 mg SQ
  3. Zolmitriptan Nasal spray
  4. Lidocaine 4% - 1 ml intranasal
  5. Narcotics (e.g.meperdine, morphine)
  6. Oxygen 100% 8L/min. by mask
52
Q

What’s Trigeminal Neuralgia?

Treatment?

A
  1. Excruciating sharp, shooting, electric pain occuring in paroxysms in one or more distributions of the trigeminal nerve, often freqent through the day
  2. Treatment is usually carbamazepine or oxcarbamazepine
53
Q

A group of headache disorders characterized by unilateral trigeminal distribution pain that occurs with prominent ipsilateral cranial autonomic features

A

TAC’s (Trigeminal Autonomic Cephalgias)

54
Q

What 5 types of headache disorders are classified as Trigeminal Autonomic Cephalgias (TAC’s)?

A
    1. Cluster HA
    1. Paroxysmal hemicrania
    1. Hemicrania continua
    1. SUNCT syndrome
    1. SUNA syndrome (similar to SUNCT, but with autonomic sx’s
55
Q
  • Symptoms of SUNCT syndrome are the same as Cluster. What is the difference?
A

SUNCT = shortlasting, unilateral neuralgiform HA with conjunctival injection and tearing

  1. Lasts seconds => few mins, occuring frequently throughout the day
  2. Onset typically over 50 in men
56
Q

Symptoms of Paraxysmal Hemicrania are the same as Cluster. What is the difference?

A
  • Shorter duration (often only minutes) and ⬆︎ frequency (usually > 5 times per day).
57
Q

Paroxysmal Hemicrania (HA) is exquisitely reponsive to which drug?

A

Indomethacin

58
Q

What’s a good oral preventative tx for someone experiencing multiple cluster HA’s in a year?

A

Verapamil (Ca2+ channel blocker)

59
Q

What is the treatment for SUNCT syndrome?

A
  • Usually anticonvulsants = particularly lamotrigine

NMSK Exam 2: Neuro (15 decks)

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