Headache, Meningitis & Encephalitis (Hon) Flashcards
Things to inquire about in a patient with a headache complaint?
Headache hx - onset and frequency
Pain - intensity, location, duration
Prodrome - do they know when it’s coming? aura?
Associ symptoms - n/v, photophobia/phonophobia
Behavior -paces/rocks/dark quiet room
Triggers -hormone, diet, stress, environmental or sensory stimuli
Meds - used to prevent/treat and others
Physical examination for a patient with a headache complaint?
Vitals (**BP/Pulse)
cardiac
Neuro (include ROM of C-spine)
What are some worrisome signs associated with a headache complaint?
“Worst HA” - subarachnoid hemorrhage
Onset of HA after age of 50 yrs
Atypical HA for patient
HA with fever - infection (meningitis/encephalitis)
Abrupt onset
HA worsening over time
Neurological symptoms w HA - confusion, weakness, paresthesias
What is the most common cause of bacterial meningitis in adults, infants and young children?
Streptococcus pneumoniae
What is the most common cause of bacterial meningitis in teenagers and young adults?
Nisseria meningitidis; highly contagious
What is the most common cause of bacterial meningitis in the elderly?
Listeria monoctyogenes
Potential complications of bacterial meningitis?
hearing loss, memory difficulty, learning disabilities, brain damage, hair problems, seizures, shock and death
What is the most common cause of viral meningitis?
enteroviruses, HSV, HIV, West Nile
What is the most common cause of fungal meningitis?
cryptococcal; particularly in diabetics and the immunocompromised
Signs and symptoms of meningitis?
Sudden high fever
Stiff neck
Severe headache (seems different than the normal HA)
HA w/ n/v
Confusion and seizures
Immediate treatment of bacterial meningitis?
Steroids (dexamethasone) and antibiotics; don’t delay treatment and wait for imaging and LP results!
CSF of bacterial meningitis?
Elevated pressure
Elevated WBCs (PMNs)
Elevated proteins
Decreased glucose
CSF of viral meningitis?
Normal pressure
Low WBCs (lymphocytes)
Normal to elevated proteins
Normal glucose
CSF of fungal meningitis?
Variable pressure
Variable WBCs (lymphocytes)
Elevated proteins
Low glucose
**similar to TB
CSF in TB meningitis?
Variable pressure
Variable WBCs (lymphocytes)
Elevated proteins
Low glucose
**similar to fungal
Common causes of infectious encephalitis?
majority are viruses - HSV1 or 2, HIV, West Nile, Varicella Zoster or Treponema pallidum
Herpes Simplex 1 encephalitis
HSV1 infection causing inflammation of the brain; rapidly progressive neurological illness; MRI and EEG abnormalities in the TEMPORAL lobes; treatment is acyclovir; up tp 1/4 of the patients can develop recurrent neuropsychiatric symptoms
Typical MRI or EEG of an HSV1 encephalitis patient?
focal abnormalities in the TEMPORAL lobes
Treatment of HSV1 encephalitis?
acyclovir
Concerning later complicated of treated and untreated HSV1 encephalitis patients
later development of neuropsychiatric symptoms; sometime associated with autoantibodies (NMDA) with secondary autoimmune encephalitis
What are two common known etiologies of autoimmune encephalitis?
NMDA encephalitis
LGI 1 encephalitis
NMDA encephalitis
common in women; presents with 4 out of the 6 symptoms: abnormal psychiatric behavior, speech dysfunction, seizures, movement disorder, decreased level of consciousness, and autonomic dysfunction/hypoventilation; EEG will show extreme delta brush; commonly associated with presence of a teratoma; will improve with treatment (takes a long time - 1 yr)
Typical EEG of someone with NMDA encephalitis?
extreme delta brush; normal finding in neonates - pathological in adults
What is a common associated with NMDA encephalitis?
teratoma
Treatment of NMDA encephalitis?
these patients can be treated, improvement takes a long time - typically 1 yr; high dose steroids
LGI1 encephalitis
common in men; faciobrachial dystonic seizures; involves one side of the face and the arm on the same side spasms occur frequently (100s of times a day); sleep disturbance in 50% of patients; temporal lobe (hippocampal) area commonly affected; may result in permanent brain damage - memory problems; 1/3rd of patients relapse after treatment
Common area of the brain affected in LGI1 encephalitis patients?
temporal lobe - hippocampal region - memory problems
Treatment of LGI1 encephalitis patients?
can be treated; 1/3rd of patients relapse after treatment; high dose steroids
If you suspect a patient to have a subarachnoid hemorrhage and the CT comes back negative, what is the next step?
Get a lumbar puncture (for blood); CT’s can miss 5-10% of subarachnoid hemorrhages
Common Migraine
migraine w/o aura; moderate to severe; unilateral or bilateral throbbing/sharp/pressure pain aggravated by activity (interrupts daily activity); peaks between 35-40 yrs; more common in females; lasts 4 - 72 hours and typically followed by a migraine “fog”; typically seen with excessive yawning; patients typically retreat to a dark quiet room
Classic Migraine
migraine w/ aura - commonly visual (can be sensory or dizziness); lasts 15-30 mins
Chronic Migraine
patient with a history of consistent migraines; headache 15 or more days per month lasting 4 hours or more; lasting a period of at least 3 months
Tension-Type Headache
most common type of headache; bifrontal, bioccipital, neck, shoulders, band-like; dull/achy pain; can be episodic or chronic; no aura or prodrome
Cluster Headache
severe, excruciating headache UNILATERAL (typically the worst type of HA); orbitotemporal region; stops daily activity; lasts 30 mins to 2 hours; typically seen with frenetic pacing and rocking; common in men; associated with obstructive sleep apnea
Typical prodrome and behavior of someone with a common migraine complaint?
excessive yawning and sluggish; patients typically retreat to a dark quiet room
Common associated symptoms of a patient with a common migraine?
Nausea (90%)
Vomiting, Photophobia/Phonotobia
What is thought to be the cause of migraines?
neurogenic inflammation; trigeminal activation - release of neuropeptides causing painful neurogenic inflammation effecting the dural vasculature
What is a common association with cluster headaches?
obstructive sleep apnea
When treating acute migraines with triptans, if one doesn’t work, what is the next step?
try another one; also consider nasal sprays and injectables
Treatment of n/v with migraines?
consider an antiemetic agent
When treating insomnia with migraines?
consider a sedative/hypnotic or major tranquilizer to help “sleep off” the migraine
When do you consider preventative treatment of a migraine?
if patient is experiencing one or more headache per week
BOTOX injections of preventive treatment of chronic migraines
the only FDA-approved treatment for chronic migraines; improvements seen after 1st treatment; multiple treatments are needed (9-12 months); have shown to be life changing in some patients; not approved for HAs so insurance won’t pay for it
Preferred treatment for trigeminal neuralgia
carbamazepine or oxcarbazepine
Trigeminal neuralgia
excruciating sharp, shooting, electrical quality pain along the trigeminal nerve distribution (commonly V2) that is frequent through the day
Paroxysmal hemicrania
one of the Trigeminal Autonomic Cephalgias (TAC’s) characterized by unilateral trigeminal distribution pain; very similar to a cluster headache but is much shorter (lasts mins compared to 30 mins); treated with indomethacin
Treatment of Paroxysmal hemicrania?
very responsive to indomethacin
Shortlisting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT syndrome)
one of the Trigeminal Autonomic Cephalgias (TAC’s) characterized by unilateral trigeminal distribution pain; very similar to a cluster headache but is much shorter (few seconds compared to 30 mins); typically seen in men over 50 yrs; treated with lamotrigine
Treatment of SUNCT syndrome?
very responsive to lamotrigine
If Babinski is present, what is the plantar response?
extension
If Babinski is absent, what is the plantar response?
flexion
