Headaches/ Dizziness and Vertigo Flashcards
next diagnostic step for migraine headaches
MRI of brain
migraine with aura
“classic migraine”
- migraine begins with visual, auditory, smell or taste disturbances 5-30 min before pain onset
migraine without aura
“common migraine”
prodrome of migraine
- 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
diff. between aura and prodrome
aura is often associated with frank neurologic dysfunction usually transient in nature
MC type of aura
visual auras - incl. scotomas, teichopias, fortification spectra, photopsias and distortion of images
- sensory auras are 2nd MC
what disorder should you consider in headache pts over age 60?
temporal arteritis
what is temporal arteritis
granulomatous arteritis affecting medium and large sized arteries of upper part of body, esp. temporal vessels of head
when should you consider lumbar puncture in headache pt?
when headache is assoc with fever, stiff neck or altered mental status
what test should always be done before LP?
CT scan of head - to ensure there is no increased ICP
features of postspinal headache
- better when lying down, worse when sitting/standing
- assoc with NV
- improve over time with bedrest and fluids
postcoital cephalgia
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
tx for postcoital cephalgia
pretreatment with analgesics prior to sexual relations
pseudotumor cerebri
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
headache in acute glaucoma
characterized by sudden onset orbital or eye pain in the face of NV; the pain can begin after use of anticholinergic meds
headache in carotid dissection
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
precipitating factors for migraine headaches
fatigue stress hypoglycemia diet - tyramine, alcohol sunlight hormonal changes
side effects of triptan drugs for migraine
nausea, vomiting
numbness/tingling of fingers and toes
C/I to use of triptans
history of CAD or HTN
if pt has hemiplegia or blindness as aura
first line tx of migraine headaches
triptans
when can dihydroergotamine be used
episodic migraine, which can become chronic or intractable
- 0.5 mg IM with 10 mg of metoclopramide for nausea
midrin
- acetaminophen
- dichloralphenazone - muscle relaxant
- isometheptene mucate - vasoconstrictor
- can be used for acute tx and prophylaxis
when should you consider prophylactic tx of migraines
when at least 3 attacks per month or acute attacks are not responsive to meds
first line agents for propylaxis of migraine headache
- anticonvulsants
- gabapentin
- beta blockers
- antidepressants
side effects of anticonvulsants (topiramate) for migraine
- sleepiness
- numbness/tingling in fingers/toes
- blindness in one eye due to increased intraocular pressure
side effects of divalproex
alopecia
tremor
MC prescribed BB for migraine prophylaxis
propranolol
- often difficult to tolerate and used when other options have failed
vascular headache
type of headache, incl. migraine, thought to involve abnormal function of the brain’s blood vessels or vascular system
new daily persistent headache
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
first intervention for tx. of chronic daily headache
removal of any OTC medications, including either acetaminophen or aspirin
preventative med for chronic daily headache
sodium valproate (Depakote ER) - 250 mg at night, increase to 750 as needed
MC form of headache
tension headache
features of a tension headache
band-like constant bilateral pressure and pain from the forehead to the temples and to the neck
pseudotumor cerebri
condition of increased CSF (either overproduction or decreased absorption) asso. with chronic headaches; relieved with lumbar puncture
transformed migraine
migraine disease that transforms into daily less severe headaches punctuated by severe debilitating migraine attacks; overuse of pain relievers is a major factor
syncope
transient LOC and postural tone that results from brain hypoperfusion
neurogenic syncope
acute hypotension results from a sudden reflex change in autonomic cardiovascular control
pathophys of neurogenic syncope
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
autonomic failure as a cause of syncope
inability to activate efferent SNS fibers appropriately, particularily on assumption of upright posture - failure to release NE on standing
what can trigger neurogenic syncope?
micturition, deglutition, carotid sinus compression, sudden underfilling of ventricle, heightened vagal tone
vertigo
sense of motion of self or surroundings (usually rotatory but may be linear) with accompanying N/V and nystagmus
syncope
actual or impending LOC of brief duration usually due to transient reduced cerebral blood flow; MCC are cardiac arrhythmias and orthostatic hypotension
dysequilibrium (sensori-neural mismatching)
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
lightheadedness
feeling faint; usually assoc with anxiety or depression with chronic hyperventilation as the main mechanism
Romberg test
if balance is maintained during Romberg, this implies integrity of both the vestibular apparatus and proprioception
receptors for angular acceleration
semicircular canals
- three pairs, mutually orthogonal
- filled with endolymph
which part of semicircular canal contains hair cells?
ampulla
receptors for linear acceleration
utricle and saccule
- contain hair cells that have calcium carbonate crystals sitting on them
primary sensory cell bodies for vestibular system
vestibular (Scarpa’s ganglion)
what are the five areas that vestibular nuclei project to?
- spinal cord (lateral and medial vestibulospinal tracts)
- cerebellum (vermis)
- reticular formation (vomiting centre in medulla)
- EOM via MLF
- medial geniculate body and cortex (conscious proprioception)
clinical features of peripheral vertigo
severe position-dependant fatigable short duration with lag time of several sec accompanying N/V, tinnitus, hearing loss
acute vestibulitis (vestibular neuronitis or labryinthitis)
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
feature of nystagmus in acute vestibulitis
strictly unilateral and may be suppressed by visual fixation; fast phase of nystagmus beats toward unaffected ear
pathophys of acute vestibulitis
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
tx of acute vestibulitis
symptomatic - usually resolves within several weeks; mild bouts of positional vertigo may persist for months to years after an attack
CF of benign positional vertigo
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
how can you bring on an attack of BPV?
turning in bed or rising from supine position
- in office: Nylen-Barany maneuver (Dix Hallpike)
pathophys of BPV
calcium otoliths dislodge from utricle/saccule and migrate into ampulla (posterior) –> semicircular canal then senses angular AND linear motion
most effective tx for BPV
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
how can you dx BPV
see vertical and torsional nystagmus with the Dix-Hallpike maneuver (offending ear is facing ground when vertigo occurs during the test)
what do you see with infarction of inner ear?
internal auditory aa (branch of anteroinferior cerebellar aa) – sudden onset deafness, vertigo or both
clinical triad of Meniere’s disease
tinnitus
recurrent vertigo
hearing loss (low frequency)
CF of Meniere’s
unilateral, progressive hearing loss
onset in 3rd or 4th decade
nystagmus - fast beat towards unaffected ear
episodes lasts from 30 min to several hours
cause of Meniere’s dz
increase in endolymph (endolymphatic hydrops)
Tx of Meniere’s dz
symptomatic w/ anti-vertigo meds
diuretics: acetazolamide, furosemide
surgical shunting of endolymph
destructive labryinthectomy
acute post-traumatic vertigo
vertigo, NV and nystagmus that begin acutely after a head injury, due to unilateral labryinthine concussion causing vestibular paresis
post-traumatic positional vertigo
begins usually several days –> weeks after injury; CF and tx is identical to BPV
CF perilymphatic fistula
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
where does the fistula develop in perilymphatic fistula
in region of oval or round windows
what kind of nystagmus is seen with central vertigo
vertical or direction-changing gaze evoked nystagmus
clinical triad of acoustic schwannoma
hearing loss
tinnitus (high pitched)
ill-defined dizziness
what area does an acoustic schwannoma involve?
vestibular portion of CN VIII
if an acoustic schwannoma gets large enough, what other structures can it involve?
CN V and VII (facial numbness and weakness)
middle cerebellar peduncle (ataxia)
how can you confirm acoustic schwannoma? (3)
CT/MRI
audiograms - sensorineural hearing loss
BAER tests - prolongation in latency bw waves I and II on involved side
tx of acoustic schwannoma
surgical
- observation only if small
vertebrobasilar insufficiency as a cause of vertigo
episodes of dizziness, diplopia, dysarthria, ataxia and facial/limb numbness or weakness
who is at risk of vertebrobasilar insufficiency
elderly individuals with diffuse atherosclerosis
tx of vertebrobasilar insufficiency vertigo
risk factor mods
aspirin
in young pts with MS, new-onset dizziness implies..
brain stem demyelinating lesion (until proven otherwise) - MC vestibular nuclei
basilar migraine
acute vertigo, nausea, vomiting and dizziness followed by severe, unilateral headache
which drugs have strictly vestibular toxicity
anticonvulsants
ethanol
drug classes that are ototoxic
anticonvulsants ethanl aminoglycosides salicylates quinine cisplatinum
head shake test
have patient shake his head rapidly for several seconds – this can precipitate attack of vertigo and nystagmus
Dix-Hallpike test
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
electronystagmogram
spontaneous nystagmus or an imbalance in nystagmus evoked by maneuvers for right and left ears suggest vestibular pathology
what is speech discrimination a test of?
retro-cochlear auditory processing
what lesions have preserved speech discrimination
cochlear lesions
- retrocochlear processes have impaired speech discrimination
sum of speech discrimination score plus speech reception threshold
- < 100 (1)
- > 100 (2)
< 100 = 8th nerve lesion
> 100 = cochlear lesion
what drug classes can be used in tx of vertigo
antihistamines anticholinergics phenothiazines benzodiazepines TCAs
CF of occiptal neuralgia
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
CF in low pressure headaches
sx worse in upright position, better in recumbent position; may be throbbing and usually bilateral
MCC of low pressure headache
LP (iatrogenic)
- descent of brain due to low CSF volume causes traction of pain sensitive fibers
Tx. of low pressure headaches
recumbency
hydration and caffeine
epidural blood patch
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
idiopathic intracranial HTN (pseudotumor cerebri)
potential causes of IIH
- previous meningeal inflammatory disorders
- thrombosis of superior sagittal sinus
- hypervitaminosis A
- tetracycline ingestion
- corticosteroid withdrawl
pathophys of IIH
defect in CSF absorption by arachnoid granulations (communicating hydrocephalus) with excessive CSF accumulation by brain tissue
CF in IIH
global headache in young, obese women
diplopia (CN VI palsy)
visual loss - late finding
physical exam findings in IIH
papilledema
bilateral CN VI paresis
enlargement of blind spot (earliest finding)
constricted peripheral vision with loss of visual acuity
neuroimaging in IIH
usually normal, no identifiable mass
slit-like ventricles
how do you diagnose IIH?
LP –> increased opening pressure (250-500 mm H20), total protein decreased
