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Neurology > Headaches/ Dizziness and Vertigo > Flashcards

Headaches/ Dizziness and Vertigo Flashcards

1
Q

next diagnostic step for migraine headaches

A

MRI of brain

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2
Q

migraine with aura

A

“classic migraine”

- migraine begins with visual, auditory, smell or taste disturbances 5-30 min before pain onset

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3
Q

migraine without aura

A

“common migraine”

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4
Q

prodrome of migraine

A
  • nonspecific phenomenon that occur days-hours before onset of pain and include:
  • mental sx: depression, euphoria, irritability
  • constitutional sx: increased urination, defecation, anorexia, fluid retention
  • photophobia, phonophobia and hyperosmia
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5
Q

diff. between aura and prodrome

A

aura is often associated with frank neurologic dysfunction usually transient in nature

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6
Q

MC type of aura

A

visual auras - incl. scotomas, teichopias, fortification spectra, photopsias and distortion of images
- sensory auras are 2nd MC

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7
Q

what disorder should you consider in headache pts over age 60?

A

temporal arteritis

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8
Q

what is temporal arteritis

A

granulomatous arteritis affecting medium and large sized arteries of upper part of body, esp. temporal vessels of head

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9
Q

when should you consider lumbar puncture in headache pt?

A

when headache is assoc with fever, stiff neck or altered mental status

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10
Q

what test should always be done before LP?

A

CT scan of head - to ensure there is no increased ICP

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11
Q

features of postspinal headache

A
  • better when lying down, worse when sitting/standing
  • assoc with NV
  • improve over time with bedrest and fluids
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12
Q

postcoital cephalgia

A

occurs both before and after orgasm and is seen equally in men and women; head pain is usually sudden, pulsatile and involves the entire head

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13
Q

tx for postcoital cephalgia

A

pretreatment with analgesics prior to sexual relations

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14
Q

pseudotumor cerebri

A

benign intracranial HTN

  • increased ICP w/o evidence of CNS malignancy; pts complain of headaches with visual disturbances
  • pts are usually obese females with menstrual irregularities
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15
Q

headache in acute glaucoma

A

characterized by sudden onset orbital or eye pain in the face of NV; the pain can begin after use of anticholinergic meds

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16
Q

headache in carotid dissection

A

orbital or neck pain assoc. with neurologic findings, usually Horner syndrome with ipsilateral ptosis and miosis; usually precipitated by trauma or vigorous movements of the neck

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17
Q

precipitating factors for migraine headaches

A 
fatigue
stress
hypoglycemia
diet - tyramine, alcohol
sunlight
hormonal changes
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18
Q

side effects of triptan drugs for migraine

A

nausea, vomiting

numbness/tingling of fingers and toes

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19
Q

C/I to use of triptans

A

history of CAD or HTN

if pt has hemiplegia or blindness as aura

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20
Q

first line tx of migraine headaches

A

triptans

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21
Q

when can dihydroergotamine be used

A

episodic migraine, which can become chronic or intractable

- 0.5 mg IM with 10 mg of metoclopramide for nausea

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22
Q

midrin

A
  1. acetaminophen
  2. dichloralphenazone - muscle relaxant
  3. isometheptene mucate - vasoconstrictor
    - can be used for acute tx and prophylaxis
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23
Q

when should you consider prophylactic tx of migraines

A

when at least 3 attacks per month or acute attacks are not responsive to meds

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24
Q

first line agents for propylaxis of migraine headache

A
  • anticonvulsants
  • gabapentin
  • beta blockers
  • antidepressants
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25
Q

side effects of anticonvulsants (topiramate) for migraine

A
  • sleepiness
  • numbness/tingling in fingers/toes
  • blindness in one eye due to increased intraocular pressure
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26
Q

side effects of divalproex

A

alopecia

tremor

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27
Q

MC prescribed BB for migraine prophylaxis

A

propranolol

- often difficult to tolerate and used when other options have failed

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28
Q

vascular headache

A

type of headache, incl. migraine, thought to involve abnormal function of the brain’s blood vessels or vascular system

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29
Q

new daily persistent headache

A

acute development of a daily headache, over a short period of time, usually less than 3 days; pts are usually younger and may have history of a precipitating event i.e. viral illness

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30
Q

first intervention for tx. of chronic daily headache

A

removal of any OTC medications, including either acetaminophen or aspirin

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31
Q

preventative med for chronic daily headache

A

sodium valproate (Depakote ER) - 250 mg at night, increase to 750 as needed

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32
Q

MC form of headache

A

tension headache

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33
Q

features of a tension headache

A

band-like constant bilateral pressure and pain from the forehead to the temples and to the neck

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34
Q

pseudotumor cerebri

A

condition of increased CSF (either overproduction or decreased absorption) asso. with chronic headaches; relieved with lumbar puncture

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35
Q

transformed migraine

A

migraine disease that transforms into daily less severe headaches punctuated by severe debilitating migraine attacks; overuse of pain relievers is a major factor

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36
Q

syncope

A

transient LOC and postural tone that results from brain hypoperfusion

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37
Q

neurogenic syncope

A

acute hypotension results from a sudden reflex change in autonomic cardiovascular control

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38
Q

pathophys of neurogenic syncope

A

reflex triggered by excessive afferent discharges from arterial or visceral mechanoreceptors; afferent impulses via vagus nerve lead to cardioinhibition and vasodepression, resulting in hypotension and bradycardia

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39
Q

autonomic failure as a cause of syncope

A

inability to activate efferent SNS fibers appropriately, particularily on assumption of upright posture - failure to release NE on standing

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40
Q

what can trigger neurogenic syncope?

A

micturition, deglutition, carotid sinus compression, sudden underfilling of ventricle, heightened vagal tone

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41
Q

vertigo

A

sense of motion of self or surroundings (usually rotatory but may be linear) with accompanying N/V and nystagmus

42
Q

syncope

A

actual or impending LOC of brief duration usually due to transient reduced cerebral blood flow; MCC are cardiac arrhythmias and orthostatic hypotension

43
Q

dysequilibrium (sensori-neural mismatching)

A

sense of imbalance due to dysfunction in either vision, proprioception or vestibular apparatus; pt feels dizzy in their feet, i.e. only when standing and walking

44
Q

lightheadedness

A

feeling faint; usually assoc with anxiety or depression with chronic hyperventilation as the main mechanism

45
Q

Romberg test

A

if balance is maintained during Romberg, this implies integrity of both the vestibular apparatus and proprioception

46
Q

receptors for angular acceleration

A

semicircular canals

  • three pairs, mutually orthogonal
  • filled with endolymph
47
Q

which part of semicircular canal contains hair cells?

A

ampulla

48
Q

receptors for linear acceleration

A

utricle and saccule

- contain hair cells that have calcium carbonate crystals sitting on them

49
Q

primary sensory cell bodies for vestibular system

A

vestibular (Scarpa’s ganglion)

50
Q

what are the five areas that vestibular nuclei project to?

A
  1. spinal cord (lateral and medial vestibulospinal tracts)
  2. cerebellum (vermis)
  3. reticular formation (vomiting centre in medulla)
  4. EOM via MLF
  5. medial geniculate body and cortex (conscious proprioception)
51
Q

clinical features of peripheral vertigo

A 
severe
position-dependant
fatigable
short duration with lag time of several sec
accompanying N/V, tinnitus, hearing loss
52
Q

acute vestibulitis (vestibular neuronitis or labryinthitis)

A

acute onset, severe positional vertigo with nausea and vomiting that can persist for days but usually resolves spontaneously; due to viral infection –> patient looks acutely ill, anxious and diaphoretic

53
Q

feature of nystagmus in acute vestibulitis

A

strictly unilateral and may be suppressed by visual fixation; fast phase of nystagmus beats toward unaffected ear

54
Q

pathophys of acute vestibulitis

A

viral infection results in decreased rate of firing of semicircular canals on one side resulting in net imbalance between two ears with a false sense of motion

55
Q

tx of acute vestibulitis

A

symptomatic - usually resolves within several weeks; mild bouts of positional vertigo may persist for months to years after an attack

56
Q

CF of benign positional vertigo

A

brief attacks of vertigo that last several seconds and are brought on by changes in head or body position; usually older individuals
- vertigo occurs several seconds after change in body position and is fatigable

57
Q

how can you bring on an attack of BPV?

A

turning in bed or rising from supine position

- in office: Nylen-Barany maneuver (Dix Hallpike)

58
Q

pathophys of BPV

A

calcium otoliths dislodge from utricle/saccule and migrate into ampulla (posterior) –> semicircular canal then senses angular AND linear motion

59
Q

most effective tx for BPV

A

Epley liberatory maneuver

  • series of rapid head/trunk tilts that forces dislodged calcium debris into utricular cavity
  • 50% of pts may have recurrence of attacks
60
Q

how can you dx BPV

A

see vertical and torsional nystagmus with the Dix-Hallpike maneuver (offending ear is facing ground when vertigo occurs during the test)

61
Q

what do you see with infarction of inner ear?

A

internal auditory aa (branch of anteroinferior cerebellar aa) – sudden onset deafness, vertigo or both

62
Q

clinical triad of Meniere’s disease

A

tinnitus
recurrent vertigo
hearing loss (low frequency)

63
Q

CF of Meniere’s

A

unilateral, progressive hearing loss
onset in 3rd or 4th decade
nystagmus - fast beat towards unaffected ear
episodes lasts from 30 min to several hours

64
Q

cause of Meniere’s dz

A

increase in endolymph (endolymphatic hydrops)

65
Q

Tx of Meniere’s dz

A

symptomatic w/ anti-vertigo meds
diuretics: acetazolamide, furosemide
surgical shunting of endolymph
destructive labryinthectomy

66
Q

acute post-traumatic vertigo

A

vertigo, NV and nystagmus that begin acutely after a head injury, due to unilateral labryinthine concussion causing vestibular paresis

67
Q

post-traumatic positional vertigo

A

begins usually several days –> weeks after injury; CF and tx is identical to BPV

68
Q

CF perilymphatic fistula

A

pt reports a “pop” during sneezing, coughing, nose blowing or straining followed by abrupt onset of vertigo; may be accompanied by fluctuating conductive hearing loss

69
Q

where does the fistula develop in perilymphatic fistula

A

in region of oval or round windows

70
Q

what kind of nystagmus is seen with central vertigo

A

vertical or direction-changing gaze evoked nystagmus

71
Q

clinical triad of acoustic schwannoma

A

hearing loss
tinnitus (high pitched)
ill-defined dizziness

72
Q

what area does an acoustic schwannoma involve?

A

vestibular portion of CN VIII

73
Q

if an acoustic schwannoma gets large enough, what other structures can it involve?

A

CN V and VII (facial numbness and weakness)

middle cerebellar peduncle (ataxia)

74
Q

how can you confirm acoustic schwannoma? (3)

A

CT/MRI
audiograms - sensorineural hearing loss
BAER tests - prolongation in latency bw waves I and II on involved side

75
Q

tx of acoustic schwannoma

A

surgical

- observation only if small

76
Q

vertebrobasilar insufficiency as a cause of vertigo

A

episodes of dizziness, diplopia, dysarthria, ataxia and facial/limb numbness or weakness

77
Q

who is at risk of vertebrobasilar insufficiency

A

elderly individuals with diffuse atherosclerosis

78
Q

tx of vertebrobasilar insufficiency vertigo

A

risk factor mods

aspirin

79
Q

in young pts with MS, new-onset dizziness implies..

A

brain stem demyelinating lesion (until proven otherwise) - MC vestibular nuclei

80
Q

basilar migraine

A

acute vertigo, nausea, vomiting and dizziness followed by severe, unilateral headache

81
Q

which drugs have strictly vestibular toxicity

A

anticonvulsants

ethanol

82
Q

drug classes that are ototoxic

A 
anticonvulsants
ethanl
aminoglycosides
salicylates
quinine
cisplatinum
83
Q

head shake test

A

have patient shake his head rapidly for several seconds – this can precipitate attack of vertigo and nystagmus

84
Q

Dix-Hallpike test

A

pt quickly moved from sitting position to supine position with head positioned 45 degrees below plane of bed and to one side; maintain position for one minute and observe for nystagmus

85
Q

electronystagmogram

A

spontaneous nystagmus or an imbalance in nystagmus evoked by maneuvers for right and left ears suggest vestibular pathology

86
Q

what is speech discrimination a test of?

A

retro-cochlear auditory processing

87
Q

what lesions have preserved speech discrimination

A

cochlear lesions

- retrocochlear processes have impaired speech discrimination

88
Q

sum of speech discrimination score plus speech reception threshold

  • < 100 (1)
  • > 100 (2)
A

< 100 = 8th nerve lesion

> 100 = cochlear lesion

89
Q

what drug classes can be used in tx of vertigo

A 
antihistamines
anticholinergics
phenothiazines
benzodiazepines
TCAs
90
Q

CF of occiptal neuralgia

A

usually in elderly

  • head pain in intermittent, often brought on by neck motion
  • radiates up posterior neck
  • compression of C2 and C3 cervical nerve roots by bony spurs
91
Q

CF in low pressure headaches

A

sx worse in upright position, better in recumbent position; may be throbbing and usually bilateral

92
Q

MCC of low pressure headache

A

LP (iatrogenic)

- descent of brain due to low CSF volume causes traction of pain sensitive fibers

93
Q

Tx. of low pressure headaches

A

recumbency
hydration and caffeine
epidural blood patch

94
Q

young obese women presents with headache worse in recumbent position and in morning; assoc. with pulsatile tinnitus, transient visual obscurations that are precipitated by Valsalva; on P/E she has papilledema and CN VI palsy

A

idiopathic intracranial HTN (pseudotumor cerebri)

95
Q

potential causes of IIH

A
  • previous meningeal inflammatory disorders
  • thrombosis of superior sagittal sinus
  • hypervitaminosis A
  • tetracycline ingestion
  • corticosteroid withdrawl
96
Q

pathophys of IIH

A

defect in CSF absorption by arachnoid granulations (communicating hydrocephalus) with excessive CSF accumulation by brain tissue

97
Q

CF in IIH

A

global headache in young, obese women
diplopia (CN VI palsy)
visual loss - late finding

98
Q

physical exam findings in IIH

A

papilledema
bilateral CN VI paresis
enlargement of blind spot (earliest finding)
constricted peripheral vision with loss of visual acuity

99
Q

neuroimaging in IIH

A

usually normal, no identifiable mass

slit-like ventricles

100
Q

how do you diagnose IIH?

A

LP –> increased opening pressure (250-500 mm H20), total protein decreased

Neurology (15 decks)

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