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N810 > Neurologic Problems > Flashcards

Neurologic Problems Flashcards

1
Q

Primary headache

A
  • More common

- Not symptomatic of another condition

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2
Q

Secondary Headache

A
  • Secondary to another underlying cause

- i.e. sinusitis, tumor, hemorrhage, temporal arteritis, or meningitis

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3
Q

Tension Headache Facts

A
  • Most prevalent type of HA
  • Mild-moderate intensity; bilateral, non-throbbing HA w/o other clinical features
  • 3 subtypes:
  • Infrequent, episodic TTH: HA episodes 15 days/month
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4
Q

Tension HA S/S

A
  • Present most of day
  • May start shortly after awakening (rarely awakens patient
  • N/V NOT present
  • Mild-to-moderate pain
  • From minutes-to-hours in duration
  • Not exacerbated by physical activity
  • Stress is common trigger
  • Pericranial tenderness: muscles around the head, neck or shoulders is exacerbated during TTH
  • MRI, CT, spinal tap usually NL
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5
Q

Tension HA descriptors

A
  • Dull, pressure, head fullness, head feels large, like a tight cap, band-like, heavy weight on my head or shoulders
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6
Q

Tension HA Tx

A
  • Abortive therapy generally more effective
  • Start with maximal dose (goal is to limit repetitive doses
  • Use of triptans or OTC analgesics should be limited to <10 days/month
  • Non-Pharmacologic: stress management, relaxation, biofeedback, aerobic feedback, Castor oil
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7
Q

Tension HA Pharm

A
  • Mild Analgesics:
  • ASA 650mg q4hr
  • APAP 325mg q4hr
  • IBU 400-600mg q4-6hr
  • Excedrin - (APAP 250mg, ASA 250mg, Caffeine 65mg) 2 tab at start of headache
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8
Q

TTH Criteria

A

At least 2 of the following four:
- Pain is bilateral in head or neck
- Pain is steady (pressing, tightness) and non-throbbing
- Mild-to-moderate pain
- No aggravation of the headache by normal physical activity
In addition to these criteria there must be at least 10HA episode fulfilling all other ICHD-2 criteria:
- Duration of pain is b/n 30min-7d
- HA is not attributable to another disorder

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9
Q

Cluster headache facts

A
  • Occur in cyclical patterns or clusters: may last weeks to months
  • VERY painful
  • May awaken patient
  • aka: “Alarm clock headache,” “suicide headache”
  • Not life-threatening
  • M > W (4.3:1)
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10
Q

Cluster Headaches S/S

A
  • Severe orbital, supraorbital, or temporal pain, accompanied by autonomic phenomena
  • Can occur up to 8x/day; usually short-lived
  • UNILATERAL
  • Pt is restless: pace about or rock back and forth
  • Can be so intense that patient is suicidal
  • Risk decreases with increasing age
  • May have autonomic Sx: ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion
  • ** Ipsilateral to side of HA
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11
Q

Cluster headache Risk factors

A
  • Gender: Males more likely
  • Age: 20-49yo
  • Smoking
  • ETOH use
  • Family Hx
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12
Q

Cluster HA: Circadian Periodicity

A
  • Reaches max in about 15min; lasts about 90min-3hrs
  • Described as sharp, penetrating, or burning
  • May have: N/V, photo/phonophobia, aura
  • Attacks often happen at same time of day
  • Majority occur at night, usually 1-2hrs after bedtime
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13
Q

Cluster HA Dx

A
  • requires at least 5 HAs with these criteria:
    1) Severe unilateral orbital, supraorbital, and/or temporal HA attacks, which last 15-180min
    2) HA accompanied by: Ipsilateral conjunctival injection; ipsilateral nasal congestion/rhinorrhea; ipsilateral eyelid edema; ipsilateral forehead/facial sweating; ipsilateral miosis/ptosis; sense of restlessness/agitation
    3) From 1 QOD to 8/day
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14
Q

Cluster Tx

A
  • SQ sumatriptan
  • IN zolmitriptan (Zomig)
  • O2 at 100% via NRB for 15min
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15
Q

Cluster HA: Tx with Sumatriptan (Imitrex, Alsuma)

A
  • Sumatriptan and zolmitriptan (Zomig) are used to treat
  • SQ sumatriptan 6mg found typically effective (pain-free wthin 20min) in 75% of patients
  • Imitrex may also be effective, but slower, when given IN
  • IN Zomig 5-10mg has similar results
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16
Q

Triptan Notes

A
  • Side effects: non-iscemic chest pain; distal paresthesia
  • AVOID in people w/Prinzmetal’s angina, CVD, CVA, uncontrolled HTN, or pregnancy
  • SQ sumatriptan 6mg limited to no more than 2 doses in 24hrs
  • IN triptans limited to no more than 3 doses in 24hrs
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17
Q

Cluster HA: Other Tx

A
  • Octreotide (Sandostatin LAR) 100mcg SQ
  • Lidocaine 1mL given ipsilateral to the pain
  • Ergots - More effective if given early
  • ** 2mg SL: q 30 min with daily max at 6mg and weekly max at 10mg
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18
Q

Cluster HA: Prevention

A
  • Verapamil: TOC; 240mg PO qd

- Other choices: glucocorticoids, lithium, topiramate, & methysergide

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19
Q

Migraine Facts

A
  • 2 types: with aura, without aura
  • General Hx: ipsilateral, pounding/throbbing
  • Moderate-to-severe
  • Aggravated y activity
  • Episodic: 4-72hrs
  • cause uncertain: possible connection to serotonin and dopamine
  • In childhood: M>W
  • In adulthood: W>M
  • Rare after 50yo
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20
Q

Migraine Risks

A
  • Genetics
  • Overweight
  • Certain foods/substances
  • behaviors
  • Environmental factors
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21
Q

Migraine S/S

A
  • Aura <20%
  • Usually in front of head or on one or both sides of the temples
  • N/V, Diarrhea, yawning, irritability, hypotension, feelings of anxiety or hyperactivity, photophobia, phonophobia, dark circles under eyes
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22
Q

Phases of Migraine

A
  • Onset of migraine can occur over the course of several hours to days
  • Typical migraine with aura has 4 phases: prodrome, the aura, the headache, and the postdrome
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23
Q

Migraine prodrome

A
  • Occurs in up to 60% of patients
  • Affective or vegetative symptoms that appears 24-48hrs before onset of HA
  • Prodromal s/s: euphoria, depression, irritability, food cravings, constipation, neck stiffness, increased yawning
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24
Q

Migraine aura: visual

A
  • most often vsual, but may be sensory, verbal, or motor
  • Classic aura begins as small area of visual loss or bright spot
  • During the following 5min to one hr, thee visual disturbance expands to involve a quadrant of the visual field
  • Following the margin are geometric shapes or zigzagging lines often appear (fortification spectrum)
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25
Q

Migraine aura: sensory

A
  • another visual aura is a sickle or C-shape over visual field (scotoma)
  • Sensory aura typically follow the visual aura within minutes (usually begins as a tingling in one limb or on one side of face; migrates across one side of face or down the limb; face and/or limb is numb and it may last up to an hour
  • Slow spread of positive symptoms (scintillations or tingling) followed by negative symptoms (scotoma or numbness) is a classic migraine
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26
Q

Migraine aura: Language/motor

A
  • May have language or dysphasic aura: from mild wording difficulties to frank dysphasia with paraphasic errors
  • Motor aura is rare: Limbs and and face on one side of body become weak; classified as hemiplegic migraine
  • Some patients experience migraines during HA
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27
Q

3rd Phase: Migraine headache

A
  • Usually unilateral, throbbing, or pulsing
  • Increases in severity over the course of one to several hours
  • Often accompanied by n/v, photo/phonophobia
  • relief sought in dark/quiet room
  • Untreated, may last from hours to days
  • Often resolves during sleep
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28
Q

Migraine Postdrome

A
  • During this phase a sudden head movement transiently causes pain in the location of the antecedent headache
  • Often feel drained, exhausted, or mild elation or euphoria
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29
Q

Migraine Treatment Goals

A
  • Reduce the frequency of attacks
  • Improve the response to therapy
  • Restore the patient to normal functioning
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30
Q

International Headache Society (IHS) diagnostic criteria for migraine w/out aura

A
  • HA last 4-72hr
  • HA has at least 2 of the following: unilateral location; pulsating quality; moderate or severe intensity; aggravation by routine physical activity
  • During HA at least 1 of the following: N and/or V; photo/phonophobia
  • At least 5 HA filling the above criteria
  • H&P and neuro exam do not suggest underlying organic disease
31
Q

IHS diagnostic criteria for migraine w/ aura

A
  • The migraine aura fulfills crteria for one of the subforms of aura with migraine HA
  • The s/s are not attributed to another disorder
  • 6 subforms of aura: Typical aura with migraine HA; typical aura with non-migraine HA; typical aura without HA; familial hemiplegic migraine; sporadic hemiplegic migraine; basilar-type migraine
32
Q

Triptans: Basics

A
  • Effective for relief of pain, nausea, & sensitivity to light/sound 2/t migraine
  • Includes: sumatriptan (Imitrex); rizatriptan (Maxalt); almotriptan (Axert); naratriptan (Amerge); zolmitriptan (Zomig); frovetriptan (Frova); eletriptan (Relpax)
  • Side effects: Nausea, dizziness, & muscle weakness
  • Combo tab of sumatriptan/naproxen (Treximet) has proven more effective than either alone
33
Q

Triptans: MOA

A
  • Sumatriptan and 2nd-gen triptans are cerebral and coronary vacoconstrictors
  • Act by vasoconstriction and inhibition of neurogenic inflammation
  • 2nd-gen triptans have better
34
Q

Migraine: Abortive therapy OTC

A
  • ASA: 650-1000mg PO x 1 dose
  • IBU: 400-1200mg PO x 1 dose
  • Indomethacin: PR 50mg x 1 dose
  • APAP 1000mg PO x 1 dose
  • ** Found to be highly effective for treating pain, functional disability, photophobia, phonophobia
  • Excedrin: Combo of ASA+APAP+caffeine; found to relieve migraine pain
35
Q

Migraine: Other drugs

A
  • Ergot: ergotamine + caffeine combos (Migergot, Cafergot); less expesive, but also less effective than triptans
  • Anti-emetics: Metoclopramide (Reglan); prochlorperazine (Compazine)
  • Opiates: Usually only used as last resort
  • Dexamethsone: Used in conjunction with other meds to improve pain relief; should not be used frequently due to risk of steroid toxicity
36
Q

Migraine: Prophylaxis BB

A
  • General rule: If HAs are interfering with work or other activities more than once/wk, it is reasonable to consider prophylactic medications (>3-4 days/month)
  • Most prophylactic drugs require several weeks to several months to establish efficacy; give 2mo trial for each meds
  • First line for prophylaxis: Beta-blockers - capable of reducing the frequency and severity of attacks by 50%
  • For patients who cannot tolerate beta-blockers: CCBs (AVOID in pts with CHF or heart block)
37
Q

Migraine: Prophylaxis Others

A
  • ACE/ARB: Reduction of HA in ~30%
  • TCA: Nortriptyline/amitriptyline
  • Consider relationship b/n migraine and depression
  • NSAIDS: ASA, IBU, Naproxen
  • Antiepileptics: Valproate, toprimate
  • Vitamins: Possible prophylactic role for high-dose riboflavin (VB12) in doses of 400mg/day
38
Q

Migraine: Beta-blockers

A
  • Propanolol (Inderal): 20mg PO q12hr; 40-160mg/day
  • Metoprolol (Lopressor): 50mg PO q12hr; 100-200mg/day
  • Timolol (Blocadren): 10mg PO q12hr; dose range 20-30mg/day
  • Nadolol (Corgard): 80mg PO qd; 80-240mg
  • Atenolol (Tenormin): 100mg PO qd
  • Improvement can take several weeks
    • Doses should be titrated and maintained for 3mo before considering med a failure
39
Q

Migraine: CCBs

A
  • Verapamil (Calan, Verelan, Isoptin): 40mg PO q8hr; 120-240mg/day
  • Often 1st choice due to low side effects
  • TID can cause non-compliance
  • Tolerance can develop with CCBs
  • 42% treated with nifedipine (Procardia), 49% treated with verapamil developed tolerance
  • Tolerance can be overcome by increasing dose or changing to different CCB
40
Q

Migraine: ACE/ARB

A
  • Lisinopril (Prinivil) 10mg PO qd x 1wk then 20mg PO qd made significant difference in duration & severity
  • Candesartan (Atacand) 16mg PO qd gives similar results
  • Not used often
  • BB show better results
41
Q

Migraines: Antidepressants

A
  • TCA –> Amitriptyline (Elavil): 10mg qhs; 20-50mg/day
  • Other TCAs: nortriptyline, doxepin, protriptyline
  • Side effects: sedation, dry mouth, constipation, tachycardia, palpitations, orthostatic hypotension, weight gain, blurred vision, urinary retention, confusion
  • SNRI –> Venlafaxine (Effexor) 37.5mg PO qd; 75-150mg qd
42
Q

Migraines: Anticonvulsants

A
  • Valproate (Depakote): May cause nausea, somnolence, tremor, dizziness, weight gain, alopecia; Contraindicated in pregnancy
  • Topiramate (Topamax): 25mg PO qd; Max 100mg PO q12hr; may have residual benefit for up to 6mo after discontinuation
43
Q

Migraines: Others

A
  • Botulinum toxin: Ineffective for EPISODIC migraines; effective for CHRONIC migraines
  • Butterbur: Effective and well tolerated; Forewarn patients that butterbur contains pyrolizidine alkaloids (potential carcinogens)
  • Coenzyme Q10: 100mg TID; 50% reduction; well tolerated
  • Feverfew: Mixed evidence; unknown safety
44
Q

Migraines: Magnesium

A
  • Many patients w/migraines found to have low Mg
  • Current popular drug
  • Mixed results in RCTs
  • Most common side effects: diarrhea, GI discomfort
45
Q

Migraines: NSAIDs

A
  • Naproxen: Found to be more effective in prevention than placebo; strongest evidence of NSAIDs
  • Fenoprofen (Nalfon), IBU, ketoprofen (Orudis): May also be effective
  • Indomethacin: may help prevent; available in suppository
46
Q

Migraines: Non-pharmacological

A
  • Wellness programs: avoid triggers (cheese, chocolate, citrus fruit, nuts, red wine); supportive psychotherapy
  • HA diary: Document the number of HA, triggers, and treatment successes/failures
  • Behavior mod.: relaxation, stress mgmt.; biofeedback; acupressure; wellness
47
Q

Secondary HA: Brain tumor

A
  • Can mimic TTH
  • IC tumors are associated with HA at initial presentation 20% of time but present in course of DZ 60% of time
  • Worse unilaterally, worse when bending over, associated with significant N/V
  • Be vigilant about possibility when patient presents with new, subacute, or progressive HA suggestive of TTH
48
Q

Secondary HA: Medication overuse HA (MOH)

A
  • Should be suspected in pt with c/o frequent or daily HA depite, or b/c of, regular HA meds
  • MOH diagnostic criteria: HA >14d/mo; regular overuse for >3mo of 1+: ergotamine, triptans, opioids, or combo analgesics >9d/mo on a regular basis for >3mo; HA has developed or markedly worsened during med overuse
  • Must wean pt off of meds (Detox)
  • Patients suffer high withdrawal symptoms
49
Q

Secondary HA: sinus HA

A
  • Many pts presenting with sinus HA turn out to have Migraine, MOH, or TTH
  • Occurrence of nasal symptoms with HA should neither trigger Dx of siuns HA nor exclude Dx of other primary HA
50
Q

Secondary HA: Cervicogenic HA

A
  • Consider if HA is STRICTLY unilateral
  • Caused by referred pain from upper cervical joints
  • Characterize by: unilateral, nonthrobbing, nonlancinating head pain of mod-to-sev intenity; variable duration; increased by movement of the head; radiates from occipital to frontal regions
  • Muscle tenderness in posterior head and upper neck in a primary diagnostic criterion of cervicogenic HA; is common in TTH as well
  • Dx established using controlled anesthetic blocks of cervical structures or their nerve supply
51
Q

What is Dementia?

A
  • An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient
  • Progressive and disabling
  • Not an inherent aspect of aging
  • Different from normal cognitive lapses
52
Q

Dementia: Facts

A
  • General term to describe various disesaes that damage brain cells
  • Alzheimer’s (Most Common): progressive disorder that damages and eventually destroys brain cells, leading to memory loss and changes in thinking and other brain functions; develops slowly; gradually worsens; ultimately fatal
  • Other types: vascular dementia, mixed dementia, Lewy body dementia, fronto-temporal dementia
53
Q

Dementia: RIsk factors

A
  • Age, Family Hx, Head injury, female gender
  • Head-Heart connection: Growing evidence links brain health to heart health
  • Risk of ALZ or Vasc dementia increased by cond. that damage the heart or blood vessels
  • African-Americans and Hispanics have higher rates of CVD, thus increased rates of ALZ or Vasc. Dementia
54
Q

Dementia: Warning signs (Memory, planning)

A
  • Memory loss that affects daily life: esp. in early stages -> forgetting recently learned info.; forgetting important dates or events; asking the same questions over
  • Challenges in planning or solving problems: changes in their ability to develop and follow or work with numbers; trouble following familiar recipes or keeping track of monthly bills; difficulty concentrating and take much longer to do things than previously
  • Difficulty completing tasks at home, work, or leisure: Often find it hard to complete daily tasks; trouble driving to familiar locations, managing a budget at work or remembering the rules of games
55
Q

Dementia: Warning signs (time, space)

A
  • Confusion with time or place: People with ALZ can lose track of dates, seasons, and the passage of time, trouble understanding something if it is not happening immediately
  • Trouble understanding visual images and spatial relationships: may have difficulty reading, judging long distance, determining color/contrast
  • May not recognize own reflection
56
Q

Dementia: Warning signs (Language, remembering locations)

A
  • New problems with words in speaking or writing: trouble starting/joining conversation, may stop in middle of conversation, struggle with vocabulary, have problem finding the right word
  • Misplace things and lose the ability to retrace steps: put things in unusual places, accuse others of stealing
57
Q

Dementia: Warning signs (Judgment, withdrawal, mood)

A
  • Decreased or poor judgment: May experience changes in judgment or decision making (i.e. dealing with money, grooming
  • Withdrawal from work or social activities
  • Changes in mood/personality: may become easily upset, confused, suspicious, fearful, depressed, or anxious
58
Q

Normal Aging

A
  • No consistent, progressive deviations on testing of memory
  • Some decline in progressing and recall of new information: slower, harder
  • reminders at work: visual tips, notes
  • Absence of significant effects on ADLs or IADLs due to cognition
59
Q

Distinguishing signs of delirium

A
  • Acute onset
  • Cognitive fluctuations over hours or days
  • Impaired consciousness and attention
  • Altered sleep cycles
60
Q

Depression vs. Dementia

A
  • In depression:
    1) demonstrate decreased motivation during cognitive testing
    2) express cognitive complaints that exceed measured deficits
    3) Maintain language and motor skills
  • Treatment of depressive symptoms may improve cognitive function
61
Q

ALZ: S/S

A
  • Onset: Gradual
  • Cognitive symptoms: primarily memory
  • Motor symptoms: rare early, apraxia later
  • Progression: gradual, 8-10yr on average
  • Labs: NL
  • Imaging: Possible global atrophy, small hippocampal volumes
62
Q

Apraxia

A
  • Adisorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked, even though:
  • The request or command is understood
  • They are willing to perform the task
  • The muscles needed to perform the task work properly
  • The task may have already been learned
63
Q

AD: Diagnosis

A
  • Development of cognitive deficits manifested by: Impaired memory AND aphasia, apraxia, agnosia, disturbed executive function
  • Significantly impaired social, occupational function
  • Gradual onset, continuing decline
  • Not due to CNS or other physical conditions (i.e. PD, delirium)
  • Not due to Axis I disorder (i.e. schizophrenia)
64
Q

Agnosia

A
  • A rare disorder characterized by an inability to recognize and identify objects or persons
  • May have difficulty recognizing the geometric features of an object or face
  • May be able to perceive the geometric features but not know what the object is used for
  • May not know whether a face is familiar or not
  • May be limited to 1 sensory function such as vision or hearing
  • May retain cognitive abilities in other areas
65
Q

Vascular Dementia: S/S

A
  • Onset: May be sudden/stepwise
  • Cognitive symptoms: depend on anatomy of ischemia
  • Motor symptoms: correlates with ischemia
  • Progression: stepwise with further ischemia
  • Labs: NL
  • Imaging: cortical or subcortical changes on MRI
66
Q

DSM-IV criteria for vascular dementia

A
  • Develpment of cognitive deficits manifested by: Impaired memory AND aphasia, apraxia, agnosia, disturbed executive function
  • Significantly impaired social, occupational function
  • Focal neurologic symptoms and signs or evidence of cerebrovascular disease
  • Deficits occur in the absence of delirium
67
Q

Lewy Body Dementia: S/S

A
  • Onset: gradual
  • Cognitive Symptoms: Memory, visuospatial, hallucinations, fluctuations
  • Motor symptoms: Parkinsonism
  • Progression: Gradual but faster than AD
  • Labs: NL
  • Imaging: Possible global atrophy
68
Q

Fronto-Temporal Dementia

A
  • Onset: Gradual, usually >60yo
  • Cognitive symptoms: executive; disinhibition; apathy; behavior changes
  • Motor symptoms: none; may be associated with ALD in rare cases
  • Progression: gradual but faster than AD
  • Labs: NL
  • Imaging: Atrophy in frontal and temporal lobes
69
Q

Dementia Tx: Acetylchilnesterase Inhibitors

A
  • Cholinesterase inhibitors:
  • Donepezil (Aricept): approved for ALL stages
  • Galantamine (Razadyne): approved for mild-to-moderate AD
  • Rivastigmine (Exelon): Approved for mild-to-moderate AD
  • Tacrine (Cognex) - 1st of the class; high side effects; no longer used
  • Prevent the breakdown of acetylcholine -> supports communication among nerve cells
  • Delay worsening of symptoms for 6-12mo for about 1/2 people who take them
  • Are generally well tolerated
  • Side effects: N/V; loss of appetite; increased bowel movements
70
Q

Dementia Tx: N-Methyl-D-Aspartate Receptor Antagonist

A
  • Memantine (Namenda): Prescribed to improve memory, attention, language, and the ability to perform simple tasks
  • regulates activity of glutamate (messenger chemical involved in learning and memory)
  • Delays worsening of symptoms for some people
  • May be used alone or with other AD Tx
  • ** some evidence shows benefit of memantine + cholinesterase inhibitor for severe AD
  • Side effects: HA, constipation, confusion, dizziness
71
Q

Dementia Tx: Vitamin E

A
  • Antioxidant
  • Delays loss of ability to carry out daily activities and placement in residential care
  • May slightly increase risk of death from CAD
72
Q

Dementia: Accompanying S/S

A
  • Sundowning
  • Psychoses (delusions, hallucinations)
  • Sleep disturbances
  • Aggression, agitation
  • Hypersexuality
73
Q

Dementia: Other meds

A
  • Antidepressants for mood and irritability: SSRI, SNRI
  • Anxiolytics for anxiety, restlessness, disruptive behavior: Lorazepam, oxazepam
  • Antipsychotics for hallucinations, delusions, aggression, agitation, hostility, uncooperative

N810 (18 decks)

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