NEURO 1 Flashcards
TRIGEMINAL NEURALGIA
- Treat with anticonvulsant/anti-seizure meds:
o _____ with serial CBC and LFTs FIRST LINE
o Oxcarbazepine/Trileptal (does not have FDA indication yet) - Baclofen, Topiramate, or Lamotrigine (Lamictal) may be tried alone or in combo with above
- _____ may relieve pain especially in those nonresponsive to conventional drugs or with MS
FOR THOSE WITH VASCULAR COMPROMISE LEADING TO SYMPTOMS
- Microvascular surgical decompression and separation of the anomalous vessel from the nerve root produce lasting relief of symptoms
- Elderly patients – _____ (cutting out that nerve) is sometimes preferred because it is easy, has few complications, and provides symptomatic relief for a period of time
- _____ to the trigeminal nerve root is another noninvasive approach that appears successful in patients
Carbamazepine
Gabapentin
rhizotomy
Gamma radiosurgery
POST HERPETIC NEURALGIA
PREVENTION OF POST-HERPETIC NEURALGIA
- TREAT THE HERPES ZOSTER OUTBREAK TO REDUCE THE RISK OF POST-HERPETIC NEURALGIA _____ or Valacyclovir when given within 72 hours of rash onset reduces the incidence of post-herpetic neuralgia by half
- Systemic corticosteroids do not help
TREATMENT
- Management of the complication is essentially medical:
o Simple _____ (Tylenol, NSAIDs)
o _____ (amitriptyline or nortriptyline is often effective)
o Other patients respond to carbamazepine, phenytoin, gabapentin or pregabalin
o A combo of gabapentin and morphine orally may be better than each agent taken alone
o Topical capsaicin cream (zostrix) may be helpful
o Topical lidocaine is worth a trial
PREVENTION OF HERPES ZOSTER ITSELF
- Administration of attenuated _____ to patients over the age of 60 is important in reducing the likelihood of herpes zoster and reducing the severity of post herpetic neuralgia should reactivation occur
Acyclovir
analgesics
TCAs
zoster vaccine
ATYPICAL FACIAL PAIN
- Simple _____, TCAs, carbamazepine, oxcarbazepine, phenytoin – response is disappointing
- Opioids pose danger of addiction
- No surgical attempts should be made
analgesics
GLOSSOPHARYNGEAL NEURALGIA
- _____ and _____ are treatments of choice prior to surgical procedures
- Microvascular _____ often effective and is generally preferred over rhizotomy
Oxcarbazepine
carbamazepine
decompression
BELLS PALSY
- Approximately 60% of cases recover completely without treatment
- _____ (60mg qd x 5d then a taper) increase the chances of complete recovery at 9-12 months by 12-15%
- Valacyclovir or acyclovir (antivirals) indicated when there are _____ (post-herpetic symptoms)
- Protect eye with lubricating drops and _____ and patching if eye closure is not possible
- PT if facial function needs to improve
- No role for surgical decompression
Steroids
vesicles
ointment
MIGRAINE HEADACHES
- DRUG THERAPY (2 pathways: Prophylaxis or Acute Episodes) **chart on slide 42 **acute vs. chronic tx of migraines
o PROPHYLAXIS = take every day to prevent future headaches or if you get very often (ex: 2 migraines a week)
1) BETA-BLOCKERS: _____ for vasculature vasodilate
2) CCB: _____ for vasculature vasodilate
3) ___: Amitriptyline or venlafaxine regulate serotonin & help neuropathic pain
4) _____: Topiramate (TOPAMAX) or Valproic acid clean drugs, don’t cause weight gain
OTHER CARDIOVASC DRUGS: Candesartan (ARB) or Guanfacine (↓ HR)
MONOCLONAL ANTIBODIES against ____: ErenUMAB, fremanezUMAB, GalcanezUMAB newer, injectable or infused (for most severe pts, tried all other prophylaxis)
Adjunctive: Botox, Riboflavin, Butterbur
o ACUTE EPISODES = nonspecific or specific
NONSPECIFIC
1) _____ (single or in combo with each other)
o ASA
o NSAIDS – good for pain relief but hard on GIT
o Acetaminophen
o Narcotics ***avoid because habit forming
o _____ (good for potentiating pain esp in combo with NSAIDS or ASA)
2) ANTI-EMETICS as needed for n/v: Prochloperazine, Metoclopramide, _____
SPECIFIC **side effects or contraindications of Triptans and Erogtamines
1) _____ = vasoconstrictor older drug, effective, may cause rebound _____
**avoid in pregnant pts & pts with significant __ disease
2) _____ = vasoconstrictor enhances serotonin and/or dopamine blockade (available in many forms/preps, may cause n/v)
o Names end in “triptan” – don’t need to memorize them all: sumatriptan, almotriptan, eletriptan, etc.
**avoid in pregnant pts; hemiplegic or _____ migraines; pts with _____ risk factors (uncontrolled HTN, prior stroke or TIA, DM, dyslipidemia, obesity)
**contraindicated in coronary or peripheral _____ disease
o Can be used with caution in controlled HTN
o Best benefit = combined with naproxen (combo pill)
Propranolol Verapamil TCA ANTICONVULSANTS CGRP ANAGLESICS caffeine Zofran ERGOTAMINE headaches CV TRIPTANS basilar stroke vascular
MENSTRUAL MIGRAINE
_____, Ergotamine derivatives, hormone manipulation (Birth control)
o Don’t use BC in older pts or stroke risk pts
NSAIDS
MENOPAUSAL MIGRAINE
- TX = _____ replacement (pure estradiol may be useful w/ continuous dosing)
estrogen
CLUSTER HEADACHES
- Avoid triggers
- Abortive therapy
o FIRST LINE if they agree/comply = 100% __ therapy (usually works immediately)
Can be used adjunctively
o Oral medications are generally not effective
Can use _____ (injectable pens or sublingual) or ergotamines
High dose prednisone (60-80 mg daily until headache frequency diminishes) LIMIT to 5-7 days, only used if nothing else works
o Intranasal lidocaine
- Prophylaxis choose based on comorbid conditions o Antidepressants: SSRIs o Anticonvulsants: Lithium, Topamax o \_\_\_\_\_ o CCB: Verapamil
O2
SumaTRIPTAN
Ergotamine
CHRONIC PAROXYSMAL HEMICRANIA
- TX = Oral _____, indomethacin are effective (CPH is treated as cluster headache)
NSAIDs
TENSION TYPE HEADACHE
- Nonpharmacologic therapies as in migraines:
o Elimination of triggers
o Biofeedback (done more in neuro offices)
o Relaxation
o Moderate exercise
o Cognitive-behavioral therapy
o Quit smoking
o Acupuncture
o Maintain regular sleep and eating patterns - PREVENTITIVE: TCA or _____
- ABORTIVE: _____
SSRIs
NSAIDS
POST TRAUMATIC HEADACHES
- TX = may respond to simple analgesics
o Severe headaches may need preventive treatment as outlined for migraine (avoid triggers, try drugs, log headaches, etc.)
o _____ and if that doesn’t work NSAIDS
Tylenol
PRIMARY COUGH HEADACHES
- TX = _____ 75-150 mg orally may provide relief
Indomethacin
NEUROPATHIES ASSOCIATED WITH CRITICAL ILLNESS
- Treatment is _____
- Prognosis is good provided patients recover from the underlying critical illness
TOXIC NEUROPATHIES
- Treatment is by preventing further _____ to the causal agent
- Isoniazid neuropathy is prevented by pyridoxine supplementation
supportive
exposure
OVERALL NEUROPATHY TREATMENT
- Treatment is of the underlying cause
- When feasible, __ is done to prevent contractures
- _____ can maintain a weak extremity in a position of useful function
PROTECT AREAS OF POOR SENSATION
- Anesthetic extremities must be PROTECTED from injury
- To guard against _____, patients should check water temperatures and hot surfaces with a portion of the skin having normal sensation
- Cold water for washing or reduce setting on the hot water heater
- Shoes should be examined during the day for grit or foreign objects to prevent pressure lesions
- Patients with polyneuropathies or mononeuritis multiplex are subject to additional nerve injury at pressure points and should avoid such behaviors as leaning on elbows or sitting with crossed legs for lengthy periods
- The use of frame or cradle to reduce contact with bedclothes may be helpful
MEDS *FR: MEDS USED TO TREAT PERIPHERAL NEUROPATHY
- Neuropathic, burning pain – may respond to simple analgesics such as _____ or NSAIDs and to gabapentin
- Painful diabetic neuropathy – duloxetine/_____ or venlafaxine/effexor may be helpful (antidepressants)
- Episodic stabbing pains – may respond to _____, pregabalin, carbamazepine, or TCAs
- Opioids may be necessary for severe hyperpathia or pain induced by minimal stimuli but use should be avoided as much as possible
AUTONOMIC DYSFUNCTION
- Postural hypotension helped by wearing waist-high elastic stockings and sleeping in a semi-erect position at night
o _____ reduces postural hypotension but doses as high as 1 mg/day are sometimes necessary for patients with diabetes and may lead to recumbent hypertension
- Midodrine (alpha-agonist) is sometimes helpful
- ED and diarrhea are difficult to treat
PT splints burns aspirin cymbalta gabapentin Fludrocortisone