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HA, Migraine, Encephalitis Flashcards

1
Q

Primary vs Secondary HA

A

primary is benign

secondary is sign of organic disease

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2
Q

What do you need to obtain in a headache history?

A

general health (head trauma, prev LOC, seizures, allergies, meds, sleep or mood sidorders)

family/social hx (smoker, job with constant change in sleep schedule, fam hx ha)

how many types of ha

frequency (previous vs current, gradual or sudden increase)

pain (intensity/quality, location, duration, impact of exertion on pain)

prodrome (change in energy or mood or appetite, fatigue, muscle aches, aura)

behavior (dark room, paces, rocks)

triggers (hormones, diet, stress, environmetn, sensory)

current and past meds

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3
Q

What does a sign of worsening ha with exertion lead you to think?

A

malicious or migraine

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4
Q

What are common sx of ha?

A

N/V/anorexia
photophobia
phonophobia

less common:
diarrhea
--stuffy/runny nose
--watery eyes
--ptosis-miosis
dizziness

– common in migraines and cluster HA

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5
Q

Describe HA exam

A

Vitals (BP/pulse, look for HTN or hyperthyroid cause)

cardiac status

extracranial structures (neck)

ROM of C-spine

neuro exam

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6
Q

What are worrisome signs in HA evaluation that lead you to think secondary HA?

A

WORST ha of life

onset after 50

atypical HA for patient

HA with fever

abrupt onset in second to minutes

subacute HA that is progressively worsening over time (slow growing lesion)

drowsiness, confusion, memory impairment

weakness, ataxia, loss of coordination

paresthesias, sensory loss paralysis

abnormal PE or neuro exam

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7
Q

Describe meningitis

A

inflammation of meninges surrounding brain and spinal cord

can have associated encephalitis (inflammation of brain tissue)–> meningoencephalitis

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8
Q

What is the most common cause of bacterial meningitis

A

Strep pneumoniae

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9
Q

What is the most common cause of bacterial meningitis in young adults and teenagers/military?

A

Nisseria meningitidis

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10
Q

What is a consideration for the etiology of bacterial meningitis in elderly?

A

Listeria monocytogenes

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11
Q

What is a common cause of meningitis in diabetic patients of immunocompromised?

A

FUNAL meningitis

cryptococcal

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12
Q

Is viral or bacterial meningitis more serious?

A

bacterial–> quickly progress

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13
Q

What used to be the cause of meningitis in kids but is essentially eradicated d/t vaccine?

A

Hemophilus influenza

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14
Q

What are common causes of viral meningitis?

A

enterovirus
HSV
HIV
West Nile

–> all usually self-limiting

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15
Q

What are signs of meningitis in people over 2?

A

sudden high fever

stiff neck (meningismus)

severe HA (diff than nml)

HA w N/V

confusion, diff concentrating

seizures

sleepiness/diff waking

photophobia

no appetite or thirst

skin rash (meningococcal meningitis)

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16
Q

What are signs of meningitis in newborns?

A

high fever

constant crying/unconsolable

excessive sleepiness or irritability

inactivity or sluggishness

poor feeding

bulge in fontanel

stiffness in body and neck

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17
Q

What is the general medication regimen for those with suspicion of meningitis?

A

Vancomycin + 3rd generation cephalosporin (rocephin, cefitraxone) + steroid (dexamethasone)

may add acyclovir

GIVE steroid before abx

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18
Q

What is the difference in evaluation for immunocompromised or focal neuro deficit in suspected meningitis?

A

Patient without immuno, hx CNS disease, papilledema or focal neuro def:

blood culture and LP immediately–> steroid and abx therapy–> if CSF has bac men then continue therapy

If immuno or focal def:

blood culture STAT–> steroid and abx therapy–> CT scan of head (if negative, do LP)

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19
Q

CSF of bacterial meningitis

A

elevated opening pressure

markedly elevated WBC

PMN predominance (neu, bas, eos)

mild-marked elevation of protein

normal-marked decrease of glucose

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20
Q

CSF of viral meningitis

A

normal opening pressure

mild WBC elevation (less than 100)

lymphocyte predominance

normal-elevated protein

normal glucose

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21
Q

CSF of fungal meningitis

A

variable opening pressure and WBC

lymphocyte predominance

elevated protein

low glucose

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22
Q

CSF of tubercular meningitis

A

variable opening pressure and WBC

lymphocyte predominance

elevated protein

low glucose

same CSF as fungal meningitis

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23
Q

What is thought to be the main cause of encephalitis?

A

viruses

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24
Q

What are the common causes of infectious encephalitis in adults?

A

HSV (1 or 2)

HIV

West Nile

Varicella Zoster

Treponema pallidum (syphilis)

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25
What is the definition of encephalitis?
inflammatory process of brain in association with clinical evidence of neuro dysfunction
26
What are the common causes of infectious encephalitis in neonates?
HSV2 CMV Rubella Listeria monocytogenes Treponema pallidum (syphilis) Toxoplasma gondii
27
What are the common causes of infectious encephalitis in infants and children?
Eastern equine encephalitis Japanese encephalitis Murray Valley encephalitis Influenza La Crosse
28
What are the common causes of infectious encephalitis in elderly?
Eastern equine encephalitis St Louis encephalitis West Nile CJD Listeria monocytogenes
29
Describe HSV 1 encephalitis
Herpes Simplex 1 encephalitis: rapidly progressive neuro illness --> F, HA, impaired consciousness, seizures, focal neuro sx MRI and EEG abn in TEMPORAL lobes IV acyclovir 1/4 can develop NMDA encephalitis or recurrent neuropsych sx
30
Describe autoimmune encephalitis
mimic infectious encephalitis a/w seizures (intractable epilepsy) autoantibodies in CSF rapidly progressive (less than 6 weeks) encephalopathy or psych disturbance +/- F prompt identification and initiation of tmt important
31
What are general treatments for autoimmune encephalitis?
high-dose steroids IVIg plasma exchange immunosuppressives (rituximab, cyclophosphamide)
32
Is NMDA encephalitis more common in men or women?
young-middle aged WOMEN
33
Describe presentation of NMDA encephalitis
rapid onset (less than 3 monhts) of at least 4: - abnormal psych behavior or cognitive dysfunction - speech dysfunction (pressured, reduced, mutism) - seizures - movement disorder, dyskinesia, rigid/abnormal postures - decreased LOC - autonomic dysfunction or central hypoventilation
34
What would be the lab/diagnostic findings in NMDA encephalitis?
Abnormal EEG with extreme delta brush CSF with pleocytosis (increased WBC), oligoclonal bands and/or NMDA receptor antibodies
35
What are NMDA encephalitis associated with?
teratomas (ovarian)
36
How long does NMDA encephalitis take to improve with aggressive treatment?
over 1 year, long time
37
Is LGI1 encephalitis more common in men or women?
Men
38
Describe LGI1 encephalitis presentation
faciobrachial dystonic seizures (brief seizures involving one side of face and arm 100x/day) sleep disturbance in half 1/3 relapse after tmt temporal lobe abn
39
Should imaging be done on patient with ha?
some say at least once AAN-1996: person with HA (migraine with aura), no recent change, no hx seizures, no focal neuro sx--> not warranted
40
What is the difference between classic and common migraine?
classic--> aura common--> no aura
41
What is a theory to the etiology of migraines?
neurogenic inflammation --> activated trigeminal nerve--> neuropeptide release--> painful neurogenic inflammation in meninges and dural vasculature--> vasodilation, extravasation of protein, mast cell degranulation
42
Describe chronic migraine and who gets them
Many patients with episodic migraine ultimately develop chronic consistent HA with migraine 15+ days per month, last 4+ hours for period of 3 months (not attributable to another disorder)
43
Describe aura in classic migraine
usually last 15-30 minutes (can be longer) common visual sx but can be anything neurological
44
Common sx of migraine
N, V, photophobia, phonophobia least common: diarrhea, conjunctival injection, stuffy nose, lacrimation, miosis, ptosis
45
Prodrome of migraines
``` mood changes myalgias food cravings sluggishness excessive yawning ```
46
Postdrome of migraines
fatigue irritability fog
47
Describe behavior during migraines
retreat to dark, quiet room
48
What is the frequency/duration/location of migraines?
1-4 attacks per month 4-72 hours (12-24 most common) unilateral or BL throbbing/sharp/pressure
49
Are migraines more common in men or women?
women moderate-severe
50
Do migraines inhibit ADLs?
yes, also aggravated by exertion/activity
51
Onset of migraines
late teens-20s, peak between 35-40
52
What is the frequency/duration/location of tension HA?
mid-moderate variable age of onset, usually 20-40 episodic (<15 days/month) -->several hours chronic (more than 15, consider analgesic rebound HA and chronic migraine in ddx) --> wax and wane all day bifrontal/ occipital, neck, shoulders, BAND-LIKE dull, aching, squeezing, pressure NO PRODROME OR AURA no change in behavior typically
53
Do tension HA inhibit ADLs?
may inhibit but doesn't prohibit
54
Are tension HA more common in men or women?
women
55
Are cluster HA more common in men or women?
men
56
Do cluster HA inhibit ADLs?
yes (prohibit)
57
What is the frequency/duration/location of cluster HA?
severe/excruciating 20-50 episodic: 1+a day for 6-8 weeks - ->same time every year chronic: several/week without remission 30min-2hr 100% UNILATERAL (orbitotemporal) nonthrobbing, excruciating, sharp, boring, penetratin frenetic, pacing, rocking behavior no aura
58
What are cluster HA commonly associated with?
obstructive sleep apnea
59
Prodrome of cluster HA
brief to mild burning in ipsilateral inner canthus or eye or internal nares
60
Sx of cluster HA
ipsilateral ptosis miosis conjunctival injection lacrimation stuffy/runny nose
61
What are common HA triggers?
hormones (menses, ovulation, HRT, OC) alcohol, chocolate, aged cheese, MSG, aspartame, caffeine, nuts, etc weather, altitude, sleep changes let down periods of stress, major life chages bright or flickering lights, odors
62
TMT of migraines
TRIPTANS OTC analgesics isometheptene butalbital opioids DHE nasal spray
63
Contraindicaitons to triptans
ischemic herat disease CVD cerebrovascular or peripheral vascular disease raynaud's syndrome uncontrolled HTN hemiplegic or basilar migraine severe renal or hepatic impairment use w/ 5-HT1 agonists
64
What can be used to break the cycle of prolonged migraines?
prednisone taper
65
What are preventive treatments for migraines?
``` antidepressants beta blockers calcium channel blockers anticonvulsants NSAIDS ergot alkaloids muscle relaxants methysergide BOTOX ```
66
What is the only FDA approved treatment for chronic migraines?
BOTOX q 3 months for 1 year
67
Non-prescription treatment for migraines
``` exercise stop smoking HA education riboflavin magnesium stress management ```
68
Tmt for acute tension HA
OTC analgesics NSAIDS opioids midrin
69
Acute tmt for cluster HA
``` DHE lidocaine narcotics OXYGEN 100% 8L mask SUMATRIPTAN --> subq or nasal spray to work quickly ```
70
Describe trigeminal neuralgia
excruciating sharp, shooting, ELECTRICAL pain - -> brought on by eating, talking, drinking hot liquids - -> over trigeminal nerve distribution spasm-like throughout the day carbamazepine or oxcarbazepine
71
Describe trigeminal autonomic cephalgias (TACs)
group of HA disorders: unilateral trigeminal distribution of pain, occurs with prominent ipsilateral cranial autonomic features - -> cluster HA - -> paroxysmal hemicrania - -> hemicrania continua - -> SUNA syndrome (autonomic sx) - -> short lasting unilateral neuralgiform HA attacks with conjunctival injection and tearing (SUNCT)
72
Describe SUNCT syndrome
short lasting unilateral neuralgiform HA attacks with conjunctival injection and tearing excruciating, burning, stabbing, electrical HA in periorbital area second to minutes frequently throughout day >50 men anticonvulsant tmt
73
Describe paroxysmal hemicrania
similar to cluster HA (unilateral, periorbital, severe and excruciating) shorter duration (minutes) and increased frequency (more than 5 times per day)
74
What is exquisitely responsive to indomethacin?
paroxysmal hemicrania
75
DHE protocol for migraines has the same contraindicaitons as...
triptans

Neuro (18 decks)

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