Neuro Cases 1 Flashcards by Colin Hemond

Where do migraines exhibit pain?

Adults: Unilateral in 60 to 70%; bifrontal or global in 30%

Children/Adolescents: Bilateral in majority

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What are the characteristics of a migraine?

Gradual onset
Crescendo pattern

Pulsating

Moderate to severe intensity

Aggrevated by routine exercise

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What is the patient appearance with migraine?

Patient prefers rest in a dark quiet room

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What is the duration of a migraine?

4 to 72 hours

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Associated symptoms with migraine?

Nausea

Vomiting

Photophobia

Phonophobia

May have visual aura

but can involve other senses

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What is the location of pain in a tension type (TT) headache?

Bilateral

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What is the charactersitic of a TT headache?

Pressure or tightness whcih waxes and wanes

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What is the patient appearance of a TT headache?

Patient may remain active or may need rest

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What is the duration of a TT headache?

30 min to 7 days

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What are the associated symtpoms with TT headache?

NONE

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What is the location of pain of a Cluster (C) headache?

Always Unilateral

Usually begins around the eye or temple

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What is characteristic of a C headache?

Pain begins quickly

Reaches crescendo within minutes

Pain is deep

Continuous pain

Excruciating and explosive in quality

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What is the patient appearance with a C headache?

Patient remains active

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What is the duration of a C headache?

15 min to 3 hours

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What are the associated symtpoms with a C headache?

Ipsilateral lacrimation and redness of the eye

Stuffy nose

Rhinorrhea

Pallow

Sweating

Horner Syndrome

Restlessness or agitation

Focal neurologic symptoms rare

Senstivity to ALCOHOL

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What are the low risk features for a Headache Complaint?

Age <= 50 years

Features typical of primary HA

History of similar HA

No abnormal neurologic findings

No high-risk comorbid conditions

No new or concerning findings on history or examination

What are the Danger Factors of a headache?

SNOOP

Systemic symptoms, illness, or condition (fever, weight loss, cancer, pregnancy, immunocompromised state)

Neuro symptoms or abnormal signs (confusion, papilledema)

Onset is new (particularly for age >= 50 years or sudden (e.g., thunderclap)

Other associated conditions (head trauma, illicit drug use, worse with valsalva maneuvers, precipitated by sex, etc)

Previous headache history BUT WITH HEADACHE PROGRESSION OR CHANGE

When is there a need for an emergency evaluation for a headache?

Sudden thunderclap headache

Acute or subacute neck pain or headache with Horner Syndrome and or neuro deficit

HA with suspected meningitis

HA with global or focal neurologic deficit or papilledema

HA with orbital or periorbital symptoms

HA and possible carbon monoxide exposure

What is VERTIGO?

Sesnation fo self motion when they are not moving or a distorted self motion during normal head movement

Can result from asymmetry within the vestibular system

Disorder of the peripheral labyrinth of its central connections

Distinction between vertigo and dizziness has limited clinical usefulness

How do you evaluate dizziness?

TiTrATE

3 distinct components:

TIMING of the symptom (onset, duration, and evolution of symptoms)

TRIGGERS that provoke the symptom (Actions, movements, or situations)

AND a TARGETED EXAMINATION

What are the three clinical scenarios for dizziness?

Responses place dizziness in one of three clinical scenarios:

Episodic Triggered symptoms

Spontaneous Episodic Symptoms

Continuous Vestibular Symptoms

What are Episodic Triggered Symptoms?

Brief Episodes of intermittent dizziness lasting seconds to hours

Common triggers are head motion or change in body position

MOST LIKELY: Benign Paroxysmal Vertigo (BPPV)

What are Spontaneous Episodic Symptoms?

Dizziness lasting seconds to days

No triggers, so other elements of the history help determine DDx

If dizziness is associated with symptoms of unlateral hearing loss - Meniere Disease (my ear!)

If dizziness is associated with symptoms of migraine headache - Vestibular Migraine (MOST COMMON IN CHILDREN)

If dizziness progresses from episodic to continuous - Psych Diagnosis

What are Continuous Vestibular Symptoms?

Dizziness lasting Days to weeks

Classic symptoms = continuous dizziness or vertigo with N/V, nystagmus, gait instability, and head motion intolerance

Often related to exposure to trauma or toxin

In 23% of older adults with dizziness, medications are the cause
Use of 5 or more meds is associated with increased risk for dizziness

If no toxin or trauma exposure, consider vestibular neuritis or central etiologies

What is the Dix-Hallpike Maneuver?

Test for Benign Paroxysmal Vertigo (BPPV) Pt sits on exam table facing forward, eyes open Physician turns the patients head 45 degress to the RIGHT Physician supports the patients head as the patient lies back quickly from a sitting to supine position ending with the head hanging 20 degrees off the end of the exam table Pateint remains in this position for 30 seconds Patient returns to upright position and is observed for 30 seconds Maneuver is repeted with patients head turned LEFT Positive test is indicated if any of these maneuvers trigger vertigo with or without nystagmus

What causes BPPV?

Occurs when loose canaliths get stuck in semicircular canals

Who is affected by BPPV?

Any people at any age Most common between ages 50-70 years No obvious cuase found in most older people Head trauma is a consideration in younger people

How do you treat it?

Treatment consists of Epley Maneuvers in the office Home treatment with Brandt-Daroff exercises can also help No role for pharmacological treatment

What is vestibular Neuritis?

Second most common cause of vertigo Most commonly affected ages 30-50 m=F Symptoms include rotatory vertigo with apparent movement of objects in visual field Horizontal nystagmus to nonaffected side Abnormal gait with tendence to fall to affected side Dix-Hallpike not useful, symptoms NOT POSITIONAL Lasts a few days generally Less severe symtpoms can linger a couple months Combo of anti-emetic, anti-histamine, or benzodiazepines can help

What is Meinere Disease?

Vertigo with hearing loss (+/- tenitus) Any age, most common at 20-60 Vertigo so severe often requires bedrest Any accompanying HA and hearing loss can be worsened during an attack Exact cause unknown Can have BPPV and Meneire disease - Dix-Hallpike test can be positive

What is Vestibular Migraine?

Episodic Vertigo in patient with history of migraine suggests this etiology Kids: most common form of vertigo Adults: 3x more common women - ages 20-50, fam history + Treat with stress relief adequate sleep/exercise, consider medications to block migraine or suppress vestibular functions