Headache, Dizziness, and Syncope Flashcards
What are basic primary headaches?
Tension-Type HA, Migraine, and Cluster
What are headache specific questions to consider during pt interview?
Alleviating/exacerbating movements/positions, effect of activity on pain, food/alcohol consumption, current medications, changes in vision, any recent trauma
For females: change in both control method? Recent period?
Important physical exam aspects for headache
BP and Pulse (assess orthostatics- also high BP with major correlation with HA), listen for carotid bruit (indicates stenosis), look for signs of AVM, palpate head, neck and shoulder, examine spine and neck muscles (for tension HA) and Finally ALWAYS neuro test- even if neuro symptoms are not obviously or immediately present
What does SNOOP stand for?
Why is it important?
Systemic symptoms- fever, weight loss, pregnancy, immunocompromised
Neuro symptoms or abnormal signs (alertness, confusion, papilledema)
Onset is new or sudden (thunderclap HA associated with subarachnoid hemorrhage)
Other associated conditions (trauma, drug use, precipitated by sex, worse with valsalva maneuvers)
Previous history of HA with progression or change from usual sx
Used to identify possible dangerous eitiologies, like mass, vascular lesion, infection, metabolic disturbance, or other systemic problems
Headache associated symptoms that indicate a need for Emergent evaluation/ imaging
Sudden thunderclap onset, acute or subacute neck pain with Horner Syndrome or neuro deficit, Suspicion for meningitis or encephalitis, global or focal neuro deficit, papilledema, orbital or periorbital symptoms, possible CO exposure
Tension-Type HA
Most Common, 10 episodes fewer than 1day/mo, usually last 30min to 7days, generally bilateral, pressure-like pain with mild to moderate intensity (possibly can be more frequent than noted)
NOT aggravated by physical activity, No N/V, No photo/phonophobia
Migraine HA
POUND diagnostic criteria
Usually diagnosed when pt has had 5 episodes lasting 4-72hrs, usually unilateral pulsating, moderate to severe pain aggravated by physical activity, N/V, photo/phonophobia May also have an aura= reversible visual, sensory symptoms, numbness, dysphasic speech disturbance that either preceed the HA or occur within 5 minutes of HA onset POUND Pulsatile nature Onging 4-72hrs Unilateral Nausea or vomiting Disabling intensity (severe)
Cluster HA
5 episodes of sever unilateral orbital, supraorbital, or temporal pain lasting 15-180min once every other day or as frequent as 8/day.
Accompanied by ipsilateral autonomic sx, conjunctival injection or lacrimation (tearing), nasal congestion, rhinorrhea, and eyelid edema
Commonly misdiagnosed as chronic sinus infections
Episodic vs Chronic Cluster HA
Episodic: HA occur once eevry other day to 8/day for a short period of time for 2 periods a year
Chronic: no clear periods of remission for at least 1 year
Criteria for Low-risk HA
Age <30yr, Features of typical primary HA, Hx of similar HA, No concerning change in HA pattern, No neuro signs, No high-risk co-morbid conditions (like HIV or morbid obesity), No new concerning Hx or findings (recent trauma etc)
Concerning Diagnoses for the following groups associated w/HA
a) rapid onset with exercise
b) thunderclap
c) over 50yr old
d) Papilledema
a) Carotid A. Dissection, Intracranial Bleed
b) Subarachnoid hemorrhage, AVM, Mass
c) Temporal Arteritis, Mass lesion
d) Encephalitis, Meningitis, Pseudotumor, Mass
TiTrATE approach to dizziness
Timing of sx- constant? intermittent? episodic?
Triggers that provoke the sx- head movement? turning over in bed? spontaneous?
And
Targeted neuro
Exam- Dix-Hallpike? Hearing?
3 Categories of Dizziness?
Episodic Triggered Symptoms
Spontaneous Episodic Symptoms
Continuous Vestibular Symptoms
Episodic Triggered Symptoms of Dizziness
Brief episodes of intermittent dizziness lasting seconds to hours with usual triggers of head motion and change in body position Think BPPV (Benign Paroxysmal Positional Vertigo)
Spontaneous Episodic Symptoms of Dizziness
Episodes of dizziness lasting seconds to days that occur without triggers
Think Meniere’s Disease, Vestibular Migraine, and Anxiety
Continuous Vestibular Symptoms of Dizziness
Persistent dizziness lasting days to weeks with vertigo, nausea, vomiting, nystagmus, gait instability, and head-motion intolerance
In the absence of trauma think vestibular neuritis, or central etiologies
BPPV
Benign Paroxysmal Positional Vertigo cause by dislodged canaliths in the semicircular canals
Diagnosed via Dix-Hallpike maneuver if transient upbeat-torsional nystagmus is noted with triggering of vertigo within a minute of maneuver
MOST COMMON cause of vertigo
Dix-Hallpike Maneuver
Patient sitting up on table. Physician turns head to right at a 45 degree angle and then hold the head as the patient lies back quickly with their head hanging off the edge of the table for 30 seconds. The the patient is returned to sitting and watched for nystagmus
Repeat turning head to the left.
Vestibular Neuritis
Spontaneous episodes of vertigo caused by inflammation of the vestibular nerve or labyrinthine organs- usually viral
The SECOND most common cause of vertigo
Meniere Disease
Spontaneous episodes of vertigo associated with unilateral hearing loss caused by excess endolymphatic fluid in the inner ear
Epley Maneuver
Used to treat BPPV. An attempt to move the dislodged canalith into proper place.
Pt sitting with eyes open and head turned 45 degrees to more affected side, Pt lies back quickly with head hanging 20degrees off table and physician rotates the head 90 degrees to opposite side and holds position for 30 seconds. The physician again rotates the head another 90 degrees further as patient turns onto that side (basically maintains position). Patient chills another 30 secs then sits up and is assessed for relief.
How to treat Meniere Disease?
Limit sodium intake, reduce caffeine intake, and limit alcohol to 1 drink/day if it was more previously
If not controlled with lifestyle changes, thiazide diuretic may help improve sx
Episodic vertigo in a patient with a history of migraine HA suggests…?
Vestibular Migraine
Must have 5 episodes of vestibular sx lasting 5min to 72hours, history of migraine HA with one or more migraine features, and no other identifiable cause of vestibular sx
HINTS exam?
What does this most effectively rule out?
Head-Impulse (thrust head 10degrees to right- if sx reproduced and saccade noticed, it is likely peripheral etiology)
Nystagmus
Test of Skew (as pt to look straight ahead and cover then uncover one eye. Vertical deviation of the eye is abnormal and suggests a central etiology)
This exam is key for ruling out potential stroke
3 Classifications of Syncope
Cardiac (most dangerous), Neurally Mediated (reflexive), and Orthostatic Hypotension
Neurally Mediated Syncope
Most common cause of syncope
Can be vasovagal, situational, or secondary to carotid sinus hypersensitivity
Cardiac Syncope
Accounts for about 20% of syncope presentations
Usually due to arrhythmia but can be structural cardiac abnormality (obstructive cardiomyopathy, MI, valvular disease, aortic dissection, cardiac masses, cardiac tamponade, saddle PE)
Orthostatic Hypotension Syncope
Usually syncope from sitting to standing due to issues in autonomic regulation as well as drug-induced, postural tachycardia, and volume depletion
Important HPI questions for Syncope
History of cardiac disease/abnormality? Other reason for LOC? Situation surrounding syncope?
PE and workup of Syncope
EKG, orthostatics, look for trauma associated with syncopal event (ex hitting head when falling), H/L, assess for anemic signs, potentially carotid massage to see if it is Carotid sinus hypersensitivity (right side first), Head tilting upwards can reproduce pre-syncopal symptoms and indicated Neurally mediated syncope
If cardiac syncope is suspected or highly suspicious, ECHO and Holter monitoring should be considered
