Neuro Cases 1 & 2

Question 1

For tension-type HA,
Location?
Characteristics?
Duration?
Pt appearance?
Associated sx?

Answer 1

Location: bilateral

Characteristics:pressure or tightness, wanes

Duration: 30 minutes-7 days

Pt appearance: pt may remain active or need rest

Associated sx: none

Question 2

What specific hx should be taken for HA?

Answer 2

–presence of aura and prodrome
–frequency, intensity and duration of attack
–# of HA per month
–time and mode of onset
–quality, site and radiation of pain
–associated sx and abnormalities
–family hx of migraines
–precipitating and relieving factors
–age of onset
–exacerbation or relief with position change
–effect of activity on pain
–relationship w/ for alcohol
–response to previous tx
–review current meds
–recent vision changes
–recent trauma
–changes in sleep, exercise, weight or diet
–state of general health
–change in work or lifestyle
–change in method of birth control
–environmental factors
–menstrual cycle

Question 3

Discuss vestibular migraines

Answer 3

–central cause
–episodic vertigo in pt with hx of migraine
–most common cause of vertigo in kids
–3x more common in women than men
–most common in 20-50YO
–family hx
–tx: stress relief, sleep, exercise, medications

Question 4

What type of dizziness if common to both peripheral and central causes?

Answer 4

Dizziness that increases with motion

Question 5

What specific hx should be taken for dizziness?

Answer 5

–hx of trauma
–frequency, intensity, duration of attack
–severity (how it affects life)
–associated sx (blurry vision, syncope, N/V, hearing loss)
–personal and family hx of similar problems
–review of meds

Question 6

For cluster HA,
Location?
Characteristics?
Duration?
Pt appearance?
Associated sx?

Answer 6

Location: unilateral, around eye or temple

Characteristics: begins quickly reaching a crescendo within minutes, deep pain, continuous, excruciating and explosive

Duration: 15 minutes-3 hours

Pt appearance: pt remains active

Associated sx: ipsilateral lacrimation and redness of eye, stuff nose, rhinorrhea, pallor, sweating, Horner’s, facial neuro sx, restlessness or agitation, sensitivity to alcohol

Question 7

For migraine HA,
Location?
Characteristics?
Duration?
Pt appearance?
Associated sx?

Answer 7

Location: unilateral in most adults, bilateral in most teenagers and kids

Characteristics: gradual onset, crescendo pattern, pulsating, moderate or severe intensity, aggravated by routine PA

Duration: 4-72 hours

Pt appearance: prefers to rest in a dark, quiet room

Associated sx: nausea, vomiting, photophobia, photophobia, aura

Question 8

Differentiate between Parkinson’s tremor and essential tremor: body parts

Answer 8

Parkinson’s: hands and legs

Essential: hands, head, voice

Question 9

Discuss continuous vestibular sx and possible dx

Answer 9

=dizziness lasting days to weeks
–classic sx: continuos dizziness or vertigo with N/V, nystagmus, gait instability and head motion intolerance
–often related to trauma or toxin
–if not trauma or toxin exposure, consider vestibular neuritis or central etiologies

Question 10

What does TiTrATE stand for?

Answer 10

Timing of the sx
Triggers of the sx
And a Targeted Examination

Question 11

Discuss resting tremors

Answer 11

–occurs in body part that is relaxed and supported against gravity
–enhanced by central stress or movement of another body part
–diminished voluntary movement of that body part

Question 12

Discuss essential tremors

Answer 12

–most common pathological tremor
–kinetic is most common
–common in hands and wrists but can also effect head, LE and voice
–usually bilateral
–can be inherited
–progresses with age
–can cause social embarrassment and early retirement
–exacerbated by caffeine and fatigue
–lessened by alcohol

Question 13

What would you include in a targeted exam for CC of dizziness?

Answer 13

–HEENT
–CV
–Neuro including Romberg
–Dix-Hallpike maneuver to dx BPPV

Question 14

What is a tremor?

Answer 14

=involuntary, rhythmic, oscillatory movement of a body part; most common movement disorder seen in primary care practices

Question 15

Discuss vestibular neuritis,
Presentation and sx?
Tx?

Answer 15

–Peripheral cause
–2nd most common cause of vertigo
–May be cause by virus
–Most commonly affects 30-50YO
–Sx: rotatory vertigo with movement of objects in the visual field
–Horizontal nystagmus to non affected side
–Abnormal gait with tendency to fall to affected side
–Lasts a few days, less severe sx can linger
–Tx: anti-emetic, anti-histamine, benzos

Question 16

Discuss enhance physiologic tremors

Answer 16

–everyone has an asymptomatic physiological tremor
–low ampliytude, high frequency at rest and during activity
–enhanced by anxiety, stress, certain medications and metabolic conditions
–if pts have tremors that come and go with anxiety, med use, caffeine intake or fatigue, they don’t need further testing

Question 17

Differentiate between Parkinson’s tremor and essential tremor: distribution

Answer 17

Parkinson’s: asymmetrical

Essential: symmetrical

Question 18

Discuss psychogenic tremors

Answer 18

–can be difficult to differentiate from organic tremor
–some features are consistent incl. abrupt onset, spontaneous remission, changing tremor characteristics, ↑with attention and extinction with distraction
–more frequently seen in patients in allied health progressions

Question 19

What sx of a headache would require an emergency evaluation?

Answer 19

–thunderclap HA
–acute or subacute neck pain with Horner syndrome and/or neuro deficit
–suspected meningitis or encephalitis
–neuro deficit or papilledema
–orbital or periorbital sx
–possible CO exposure

Question 20

Discuss cerebellar tremors

Answer 20

–low frequency
–slow-intension or postural tremor
–d/t MS with cerebellar plaques, stroke or brainstem tumors

Question 21

Differentiate between Parkinson’s tremor and essential tremor: course

Answer 21

Parkinson’s: progressive

Essential: stable or slowly progressive

Question 22

Differentiate between Parkinson’s tremor and essential tremor: writing

Answer 22

Parkinson’s: micrographia

Essential: tremulous

Question 23

Discuss resting tremors

Answer 23

–most common type of tremor
–occur with voluntary muscle contraction
–postural: maintaining position against gravity (i.e. arm elevation)
–isometric: muscle contraction against right stationary object (i.e. making a fist)
–kinetic: associated with voluntary movements, includes intention tremors (i.e. reaching for a pen)

Question 24

What are some low risk features for HA complaint?

Answer 24

–≤50YO
–primary HA
–hx of similar hx
–no abnormal neuro findings
–no concerning changes
–no high-risk comorbid conditions

Question 25

What are the danger signs of a HA?

Answer 25

SNOOP
–systemic sx (i.e. fever, weight loss, cancer, pregnancy)
–neuro sx
–onset is new
–other associated conditions
–previous HA hx with progression or change

Question 26

How does occipital neuralgia present? Dx? Tx?

Answer 26

Presentation: unilaterally, starts where neck meets skull and moves forward to involve ear and forehead; pain caused by trauma to nerves including pinching of the nerve by overly high neck muscles and compression of the nerve as it leaves the spine

Dx: via occipital nerve block

Tx: massage, NSAIDS, muscle relaxants

Question 27

Differentiate between Parkinson’s tremor and essential tremor: other neuro sx

Answer 27

Parkinson’s: bradykinesia, rigidity, loss of postural reflexes

Essential: none

Question 28

Discuss spontaneous episodic sx for dizziness and possible dx

Answer 28

=dizziness lasting seconds to days; no triggers

–unilateral hearing loss→Meziere dz
–sx of migration HA→vestibular migraine
–continulus, associated with psych disorder→psych dx

Question 29

What is the most frequent headache? What is the most common dx for pts who present to clinicians with HA complaints?

Answer 29

Most frequent: tension HA

Most common dx: migraine

Question 30

Differentiate between Parkinson’s tremor and essential tremor: frequency

Answer 30

Parkinson’s: 3-6 Hz

Essential: 5-12 Hz

Question 31

Differentiate between Parkinson’s tremor and essential tremor: family hx

Answer 31

Parkinson’s: less common

Essential: often

Question 32

What are the three clinical scenarios for dizziness?

Answer 32

–episodic triggered sx
–spontaneous episodic sx
–continuous vestibular sx

Question 33

Differentiate between Parkinson’s tremor and essential tremor: tremor type

Answer 33

Parkinson’s: at rest, ↑with walking, ↓with posture holding or action

Essential: posture holding or action

Question 34

Discuss BPPV,
Cause?
Presentation?
Tx?

Answer 34

Cause: peripheral cause; loose canaliths get stuck in semicircular canals; no obvious cause in older individuals, head trauma in younger individuals

Presentation: most commonly in individuals 50-70YO

Tx: EPley maneuvers, Brandt-Daroff exercises, no pharm tx

Question 35

Discuss Parkinsonism tremors

Answer 35

–various meds cause Parkinsonism by blocking or depleting DA
–most common form is idiopathic PD
–classic tremor starts as a pill-rolling motion of the fingers
–bradykinesia includes difficulty rising from a seated position, ↓arm swing while walking, micrographia
–70% of PD pts have a resting tremor which can get better with action

Question 36

Discuss Meneire dz

Answer 36

–peripheral cause
–vertigo with hearing loss
–most common from 20-60YO but can affect any age
–severe vertigo, requires bedrest
–unknown cause
–can have BPPV too so Dix-Hallpike test may be positive

Question 37

What should you do during a PE for a HA CC?

Answer 37

–BP and P
–listen for bruit at neck, eyes and head
–palpate head, neck and shoulder regions
–check temporal and neck arteries
–examine spine and neck muscles
–neuro exam (mental status, CN, funduscopy and otoscope, symmetry on motor reflex cerebellar sensory etc., gait, station)

Question 38

Discuss episodic triggered sx for dizziness and possible dx

Answer 38

=brief episodes of intermittent dizziness lasting seconds to hours; common triggers include head motion or change in body position

Most likely BPPV

Question 39

What hx should be taken for tremor CC?

Answer 39

–family hx of neurologic dz (genetic component especially for essential tremors)
–tremor in older pts with gradual onset is more likely PD or essential tremor
–sudden onset more likely to be psychogenic, related to medications or toxins or in rare cases, a brain tumor