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Neuro > HA, Migraine, Encephalitis > Flashcards

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
Q

What is the definition of encephalitis?

A

inflammatory process of brain in association with clinical evidence of neuro dysfunction

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26
Q

What are the common causes of infectious encephalitis in neonates?

A

HSV2

CMV

Rubella

Listeria monocytogenes

Treponema pallidum (syphilis)

Toxoplasma gondii

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27
Q

What are the common causes of infectious encephalitis in infants and children?

A

Eastern equine encephalitis

Japanese encephalitis

Murray Valley encephalitis

Influenza

La Crosse

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28
Q

What are the common causes of infectious encephalitis in elderly?

A

Eastern equine encephalitis

St Louis encephalitis

West Nile

CJD

Listeria monocytogenes

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29
Q

Describe HSV 1 encephalitis

A

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

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30
Q

Describe autoimmune encephalitis

A

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

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31
Q

What are general treatments for autoimmune encephalitis?

A

high-dose steroids

IVIg

plasma exchange

immunosuppressives (rituximab, cyclophosphamide)

32
Q

Is NMDA encephalitis more common in men or women?

A

young-middle aged WOMEN

33
Q

Describe presentation of NMDA encephalitis

A

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
Q

What would be the lab/diagnostic findings in NMDA encephalitis?

A

Abnormal EEG with extreme delta brush

CSF with pleocytosis (increased WBC), oligoclonal bands and/or NMDA receptor antibodies

35
Q

What are NMDA encephalitis associated with?

A

teratomas (ovarian)

36
Q

How long does NMDA encephalitis take to improve with aggressive treatment?

A

over 1 year, long time

37
Q

Is LGI1 encephalitis more common in men or women?

A

Men

38
Q

Describe LGI1 encephalitis presentation

A

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
Q

Should imaging be done on patient with ha?

A

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
Q

What is the difference between classic and common migraine?

A

classic–> aura

common–> no aura

41
Q

What is a theory to the etiology of migraines?

A

neurogenic inflammation
–> activated trigeminal nerve–> neuropeptide release–> painful neurogenic inflammation in meninges and dural vasculature–> vasodilation, extravasation of protein, mast cell degranulation

42
Q

Describe chronic migraine and who gets them

A

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
Q

Describe aura in classic migraine

A

usually last 15-30 minutes (can be longer)

common visual sx but can be anything neurological

44
Q

Common sx of migraine

A

N, V, photophobia, phonophobia

least common: diarrhea, conjunctival injection, stuffy nose, lacrimation, miosis, ptosis

45
Q

Prodrome of migraines

A 
mood changes
myalgias
food cravings
sluggishness
excessive yawning
46
Q

Postdrome of migraines

A

fatigue
irritability
fog

47
Q

Describe behavior during migraines

A

retreat to dark, quiet room

48
Q

What is the frequency/duration/location of migraines?

A

1-4 attacks per month

4-72 hours (12-24 most common)

unilateral or BL

throbbing/sharp/pressure

49
Q

Are migraines more common in men or women?

A

women

moderate-severe

50
Q

Do migraines inhibit ADLs?

A

yes, also aggravated by exertion/activity

51
Q

Onset of migraines

A

late teens-20s, peak between 35-40

52
Q

What is the frequency/duration/location of tension HA?

A

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
Q

Do tension HA inhibit ADLs?

A

may inhibit but doesn’t prohibit

54
Q

Are tension HA more common in men or women?

A

women

55
Q

Are cluster HA more common in men or women?

A

men

56
Q

Do cluster HA inhibit ADLs?

A

yes (prohibit)

57
Q

What is the frequency/duration/location of cluster HA?

A

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
Q

What are cluster HA commonly associated with?

A

obstructive sleep apnea

59
Q

Prodrome of cluster HA

A

brief to mild burning in ipsilateral inner canthus or eye or internal nares

60
Q

Sx of cluster HA

A

ipsilateral ptosis

miosis

conjunctival injection

lacrimation

stuffy/runny nose

61
Q

What are common HA triggers?

A

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
Q

TMT of migraines

A

TRIPTANS

OTC analgesics

isometheptene

butalbital

opioids

DHE nasal spray

63
Q

Contraindicaitons to triptans

A

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
Q

What can be used to break the cycle of prolonged migraines?

A

prednisone taper

65
Q

What are preventive treatments for migraines?

A 
antidepressants
beta blockers
calcium channel blockers
anticonvulsants
NSAIDS
ergot alkaloids
muscle relaxants
methysergide
BOTOX
66
Q

What is the only FDA approved treatment for chronic migraines?

A

BOTOX q 3 months for 1 year

67
Q

Non-prescription treatment for migraines

A 
exercise
stop smoking
HA education
riboflavin
magnesium
stress management
68
Q

Tmt for acute tension HA

A

OTC analgesics
NSAIDS
opioids
midrin

69
Q

Acute tmt for cluster HA

A 
DHE
lidocaine
narcotics
OXYGEN 100% 8L mask
SUMATRIPTAN
--> subq or nasal spray to 
     work quickly
70
Q

Describe trigeminal neuralgia

A

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
Q

Describe trigeminal autonomic cephalgias (TACs)

A

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
Q

Describe SUNCT syndrome

A

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
Q

Describe paroxysmal hemicrania

A

similar to cluster HA
(unilateral, periorbital, severe and excruciating)

shorter duration (minutes) and increased frequency (more than 5 times per day)

74
Q

What is exquisitely responsive to indomethacin?

A

paroxysmal hemicrania

75
Q

DHE protocol for migraines has the same contraindicaitons as…

A

triptans

Neuro (18 decks)

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