HA, Migraine, Encephalitis Flashcards
Primary vs Secondary HA
primary is benign
secondary is sign of organic disease
What do you need to obtain in a headache history?
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
What does a sign of worsening ha with exertion lead you to think?
malicious or migraine
What are common sx of ha?
N/V/anorexia
photophobia
phonophobia
less common: diarrhea --stuffy/runny nose --watery eyes --ptosis-miosis dizziness
– common in migraines and cluster HA
Describe HA exam
Vitals (BP/pulse, look for HTN or hyperthyroid cause)
cardiac status
extracranial structures (neck)
ROM of C-spine
neuro exam
What are worrisome signs in HA evaluation that lead you to think secondary HA?
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
Describe meningitis
inflammation of meninges surrounding brain and spinal cord
can have associated encephalitis (inflammation of brain tissue)–> meningoencephalitis
What is the most common cause of bacterial meningitis
Strep pneumoniae
What is the most common cause of bacterial meningitis in young adults and teenagers/military?
Nisseria meningitidis
What is a consideration for the etiology of bacterial meningitis in elderly?
Listeria monocytogenes
What is a common cause of meningitis in diabetic patients of immunocompromised?
FUNAL meningitis
cryptococcal
Is viral or bacterial meningitis more serious?
bacterial–> quickly progress
What used to be the cause of meningitis in kids but is essentially eradicated d/t vaccine?
Hemophilus influenza
What are common causes of viral meningitis?
enterovirus
HSV
HIV
West Nile
–> all usually self-limiting
What are signs of meningitis in people over 2?
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)
What are signs of meningitis in newborns?
high fever
constant crying/unconsolable
excessive sleepiness or irritability
inactivity or sluggishness
poor feeding
bulge in fontanel
stiffness in body and neck
What is the general medication regimen for those with suspicion of meningitis?
Vancomycin + 3rd generation cephalosporin (rocephin, cefitraxone) + steroid (dexamethasone)
may add acyclovir
GIVE steroid before abx
What is the difference in evaluation for immunocompromised or focal neuro deficit in suspected meningitis?
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)
CSF of bacterial meningitis
elevated opening pressure
markedly elevated WBC
PMN predominance (neu, bas, eos)
mild-marked elevation of protein
normal-marked decrease of glucose
CSF of viral meningitis
normal opening pressure
mild WBC elevation (less than 100)
lymphocyte predominance
normal-elevated protein
normal glucose
CSF of fungal meningitis
variable opening pressure and WBC
lymphocyte predominance
elevated protein
low glucose
CSF of tubercular meningitis
variable opening pressure and WBC
lymphocyte predominance
elevated protein
low glucose
same CSF as fungal meningitis
What is thought to be the main cause of encephalitis?
viruses
What are the common causes of infectious encephalitis in adults?
HSV (1 or 2)
HIV
West Nile
Varicella Zoster
Treponema pallidum (syphilis)
What is the definition of encephalitis?
inflammatory process of brain in association with clinical evidence of neuro dysfunction
What are the common causes of infectious encephalitis in neonates?
HSV2
CMV
Rubella
Listeria monocytogenes
Treponema pallidum (syphilis)
Toxoplasma gondii
What are the common causes of infectious encephalitis in infants and children?
Eastern equine encephalitis
Japanese encephalitis
Murray Valley encephalitis
Influenza
La Crosse
What are the common causes of infectious encephalitis in elderly?
Eastern equine encephalitis
St Louis encephalitis
West Nile
CJD
Listeria monocytogenes
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
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
What are general treatments for autoimmune encephalitis?
high-dose steroids
IVIg
plasma exchange
immunosuppressives (rituximab, cyclophosphamide)
Is NMDA encephalitis more common in men or women?
young-middle aged WOMEN
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
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
What are NMDA encephalitis associated with?
teratomas (ovarian)
How long does NMDA encephalitis take to improve with aggressive treatment?
over 1 year, long time
Is LGI1 encephalitis more common in men or women?
Men
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
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
What is the difference between classic and common migraine?
classic–> aura
common–> no aura
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
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)
Describe aura in classic migraine
usually last 15-30 minutes (can be longer)
common visual sx but can be anything neurological
Common sx of migraine
N, V, photophobia, phonophobia
least common: diarrhea, conjunctival injection, stuffy nose, lacrimation, miosis, ptosis
Prodrome of migraines
mood changes myalgias food cravings sluggishness excessive yawning
Postdrome of migraines
fatigue
irritability
fog
Describe behavior during migraines
retreat to dark, quiet room
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
Are migraines more common in men or women?
women
moderate-severe
Do migraines inhibit ADLs?
yes, also aggravated by exertion/activity
Onset of migraines
late teens-20s, peak between 35-40
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
Do tension HA inhibit ADLs?
may inhibit but doesn’t prohibit
Are tension HA more common in men or women?
women
Are cluster HA more common in men or women?
men
Do cluster HA inhibit ADLs?
yes (prohibit)
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
What are cluster HA commonly associated with?
obstructive sleep apnea
Prodrome of cluster HA
brief to mild burning in ipsilateral inner canthus or eye or internal nares
Sx of cluster HA
ipsilateral ptosis
miosis
conjunctival injection
lacrimation
stuffy/runny nose
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
TMT of migraines
TRIPTANS
OTC analgesics
isometheptene
butalbital
opioids
DHE nasal spray
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
What can be used to break the cycle of prolonged migraines?
prednisone taper
What are preventive treatments for migraines?
antidepressants beta blockers calcium channel blockers anticonvulsants NSAIDS ergot alkaloids muscle relaxants methysergide BOTOX
What is the only FDA approved treatment for chronic migraines?
BOTOX q 3 months for 1 year
Non-prescription treatment for migraines
exercise stop smoking HA education riboflavin magnesium stress management
Tmt for acute tension HA
OTC analgesics
NSAIDS
opioids
midrin
Acute tmt for cluster HA
DHE
lidocaine
narcotics
OXYGEN 100% 8L mask
SUMATRIPTAN
--> subq or nasal spray to
work quicklyDescribe 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
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)
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
Describe paroxysmal hemicrania
similar to cluster HA
(unilateral, periorbital, severe and excruciating)
shorter duration (minutes) and increased frequency (more than 5 times per day)
What is exquisitely responsive to indomethacin?
paroxysmal hemicrania
DHE protocol for migraines has the same contraindicaitons as…
triptans
