Neurological Disorders Flashcards
(3) most common types of primary headaches
tension, cluster, migraine
Cause of primary headaches
idiopathic, likely r/t interaction of genetic and environmental factors
Cranial/Vascular causes of secondary headaches (5)
intracranial hemorrhage, thrombosis, arteriovenous malformation, carotid dissection, temporal arteritis
Secondary headache causes, generally (9)
cranial/vascular, posttraumatic, substance abuse, medication use, infection, tumor, TMJ, narrow angle glaucoma, psychiatric
DIAGNOSE: Pt presents with CC of headache. On physical exam, note a red hot steamy eye. Describes headache as deep-seated pain behind the eye
headache s/t narrow angle glaucoma
Most important step in diagnosing a headache
thorough history
Headache red flags (10)
sudden onset, worst headache of life, worsening pattern, focal neuro deficits, fever, change in mental status or LOC, radiation to lower neck and shoulders, meningismus, severe headache after strenuous exercise, papilledema on exam, new headache in certain populations*
Certain populations to be concerned about new headache (6)
<5yo, >40yo, cancer, lyme disease, HIV, pregnant or recent postpartum
Higher _____ in birth control can be responsible for headaches
estrogen
Physical exam and diagnostic workup for CC headache
BP; HR; auscultate heart, lungs, and for carotid/temporal bruits; palpate head and neck for muscle tension; neuro exam. Consider CBC, ESR, TSH, and imaging (CT vs MRI)
CC headache, see elevated ESR on lab results. Suspect….
temporal arteritis
Most common headache by prevalence (not primary care visits)
tension headache
DIAGNOSE: Pt presents with CC of headache. Pain described as bilateral, non-throbbing pressure or tightness that waxes and wanes
tension headache
Recommendations for tension headache (3)
OTC analgesia (tylenol, NSAIDs), avoid triggers, stress management
Cluster headaches are also known as…..
trigeminal autonomic cephalgia
True or False: Cluster headaches require imaging to work up
False - strictly a clinical diagnosis
DIAGNOSE: Pt presents with CC of headache. Upon entering exam room, pt is visibly agitated, restless, and pacing. Describes a unilateral, deep, continuous, excruciating headache with pain localized to temporal and orbital region of one side of the face. Abrupt in onset and attack lasts 15 minutes - 1.5 hours, 1-8x per day for past 6-12 weeks
Cluster headache (trigeminal autonomic cephalgia)
Trigeminal autonomic cephalgia, aka…..
cluster headache
Common accompanying ipsilateral symptoms in cluster headaches
lacrimation, conjunctival injection, nasal congestion, ptosis, miosis, eyelid swelling, rhinorrhea, sweating
Treatments for acute cluster headache attack
O2 & sumatriptan
Prophylactic treatment for cluster headaches
refer to neurologist First line is Verapamil (HTN med).. Other options include Prednisone or topiramate
Most common presenting headache in primary care
migraine
DIAGNOSE: Pt presents with cc of headache. Unilateral and pulsating in quality, moderate-severe intensity. Gradual onset preceded by visual disturbances (since resolved). +Photophobia, phonophobia.
Migraine
(3) types of migraines
with aura, without aura (most common), menstrual
Diagnostic criteria for migraine without aura
at least 5 attacks of a headache lasting 4-72 hours, with 2 of the following [unilateral, pulsating, moderate-severe pain, aggravated by routine activities] and 1 of the following [photophobia, phonophobia, nausea, vomiting]
Diagnostic criteria for migraine with aura
at least 2 attacks with one or more of the following fully reversible auras [visual, sensory, speech, motor, brainstem, or retinal] and 2 of the following [aura symptom spreads gradually over >5 min, each aura symptom lasts 5-60 min, one aura symptom is unilateral, aura is followed by headache within 60 min]
Priority diagnosis to r/o in migraine headache
TIA
(4) preventative therapies for folks with migraine headaches that are frequent, long-lasting, or impacting QOL
antihypertensives, antidepressants, anticonvulsants, NSAIDs
Type 1 menstrual migraine headache
more common; onset during peri-menstrual time (2 days before to 3 days after) in 2/3 of menstrual cycles and/or with other attacks occurring at other times
Type 2 menstrual migraine headache
less common; onset strictly limited to peri-menstrual period and do not occur at other times of the month
True or false: menstrual migraines do not have aura
true
Abortive therapy for menstrual migraine headache
triptans or aspirin/acetaminophen/caffeine combo
Priority concern with severe sudden thunderclap headache
subarachnoid hemorrhage
Diagnostic testing for thunderclap headache
CT WITHOUT contrast, lumbar puncture if normal CT but highly suspicious for subarachnoid headache
Temporal arteritis, aka….
giant cell arteritis
What is temporal arteritis?
More often seen in older folks (mean age 72yo), temporal arteritis (aka giant cell arteritis) is a symptomatic blood vessel inflammation (chronic vasculitis) in cranial branches of arteries that originate from the aortic arch
Temporal arteritis commonly co-occurs with…
polymyalgia rheumatica
Priority risk of untreated temporal arteritis
vision loss
DIAGNOSE: 72yo pt presents with CC of headache. They describe as different than any other type of headache they have had before. Abrupt in onset, first symptom was visual disturbance. Describe aching stiffness in shoulders, jaw pain with chewing, and unexplained fever. On lab workup, you note elevated ESR.
Temporal arteritis
Management of temporal arteritis
refer to rheumatologist Steroids and aspirin therapy (daily aspirin to reduce risk of stroke)
DIAGNOSE: Pt presents with CC of headache. Describes as unilateral, non-throbbing pain that starts in the neck and radiates to occipital area of head. On physical exam, note reduced range of motion of the neck with pain on movement.
Cervicogenic headache (diagnostic nerve block is required to r/o from other causes — refer!)
Medical term for brain freeze
sphenopalatine gangioneuralgia
DIAGNOSE: Pt presents with CC of facial and tooth pain. Describes as sudden, unilateral, superficial,severe pain that is stabbing and electric in quality and radiates up the face. Lasts only seconds to a minute at most. Recurrent episodes triggered by light touch, chewing, and cold air. Feels like their face is spasming. Pain abates with sleep but resumes upon awakening
Trigeminal neuralgia (most commonly caused by compression of the trigeminal nerve)
Gold standard for diagnosis of trigeminal neuralgia
MRI
Trigeminal neuralgia may be a sign of this underlying condition, depending on the constellation of other symptoms
multiple sclerosis
First line therapy for trigeminal neuralgia (chronic)
carbamazepine or oxycarbazepine (monitor CBCs r/t risk for anemia, leukopenia)
Treatment for trigeminal neuralgia (acute)
IV phenytoin or lidocaine (inpatient setting)
What is Bell’s Palsy?
The most common acute mononeuropathy. This condition is paralysis of cranial nerve 7 (facial nerve).
Population at 3x higher risk for Bell’s Palsy
pregnancy (3rd trimester and 1st week postpartum)
DIAGNOSE: 32yo F presents 1 week postpartum with CC of sudden paralysis of one side of her face, preceded by ear pain. On physical exam, you note unilateral eyebrow sagging, inability to close eye, and mouth drawn to the non-affected side. Lacrimal secretions to the affected side. Focal deficits to cranial nerves 5 and 7. Physical exam otherwise normal.
Bells palsy (r/o stroke)
What causes Bell’s palsy
viral inflammatory/immune etiology – most commonly herpes simplex
You suspect Bells Palsy in your pt, but when might you recommend imaging?
atypical symptoms, slow progression (>3 weeks), no improvement in 6 months, facial spasm followed by weakness (concerned about tumor)
Treatment for Bells Palsy
most of the time will resolve without treatment. Educate patient to protect the open eye. For mild to severe facial palsy, oral glucocorticoids with or without valacyclovir. Preferable that therapy start within 3 days of symptom onset
Ageusia
loss of taste
Crocodile tears syndrome
lacrimation while eating
Possible complications of Bells Palsy (4)
ageusia, chronic facial spasm, corneal infection, crocodile tears syndrome
Most common sensorineural cause of tinnitis
ototoxic medications (aspirin)
Hearing loss at cochlea or cochlear nerve level
sensorineural
Ototoxic medication classes (4)
anti-inflammatories (NSAIDs, ASA), antibiotics, loop diuretics, chemotherapy
Tinnitus described as pulsatile, rushing, flowing, or humming quality…. suspect _______ cause
vascular
Tinnitus described as continuous and high pitched….. suspect ______ cause
sensorineural hearing loss or cochlear injury
Tinnitus described as continuous and low pitched…. suspect ______ cause
meniere’s disease
Workup of tinnitus must include referral to….
audiology
Workup of tinnitus should include CBC to r/o….
infection
Vascular origin tinnitus qualities
pulsatile, rhythmic, increases with exertion, alters with movement of the head or neck
(4) types of dizziness
vertigo, syncope/orthostasis, disequilibrium, NOS
Symptom of illusory movement
vertigo
DIAGNOSE: Pt presents with CC of dizziness. Describes episodic dizziness such that “the room is spinning” worsened with head movements, and associated nausea. VS normal, BP stable. On physical exam, you note vertical nystagmus with + Dix-Hallpike Maneuver
benign paroxysmal positional vertigo
(3) most common peripheral etiologies for vertigo
benign paroxysmal positional vertigo, vestibular neuritis, meniere’s disease
Most common etiology of benign paroxysmal positional vertigo
calcium stone in semicircular canal (canalithiasis)
BPPV maneuvers
Diagnose - Dix Hallpike
Treat - Epley
DIAGNOSE: Pt presents with CC of dizziness. Describes rapid onset dizziness such that “the room is spinning”, persistent for the past 2 days. Worsened with head movements, +n/v. VS normal, BP stable. On physical exam, you note gait instability without loss of ability to ambulate
Vertigo s/t vestibular neuritis
DIAGNOSE: Pt presents with CC of dizziness. Describes rapid onset dizziness such that “the room is spinning”, persistent for the past 2 days. Preceded by recent cold, since resolved. +n/v. VS normal, BP stable. On physical exam, you note gait instability and unilateral hearing loss.
Vertigo s/t labyrinthitis
Medication treatment for vertigo s/t vestibular neuritis or labyrinthitis
methylprednisone, antiemetics, antihistamines, antivirals in herpes suspected, antibiotics if ear infection suspected
When might you recommend neuroimaging for vertigo?
acute sustained vertigo lasting >48 hours, pt who is >60yo, accompanying headache with focal neuro deficits or vascular risk factors
DIAGNOSE: DIAGNOSE: Pt presents with CC of dizziness. Describes dizziness such that “the room is spinning” lasting 2-4 hours, with +hearing loss, “fullness” in ear, and unilateral tinnitus, +n/v. Attacks started a year ago, and have recurred multiple times since but they never came in because they always remitted. VS normal. On physical exam, you note postural imbalance and nystagmus during attack.
Meniere’s disease
Working up meniere’s disease
diagnosis of exclusion, refer to otologist/otolaryngologist
Pt presents with vertigo, first (5) things to r/o
orthostatic hypotension, cardiac arrhythmia, stroke/CVA, multiple sclerosis, CNS drug effect
Anyone with syncope and cardiac risk factors needs….
an ECG
Sense of imbalance that occurs primarily when walking
Disequilibrium
(5) causes of disequilibrium
peripheral neuropathy, MSK disorder interfering with gait, vestibular disorder, cervical spondlyosis, parkinson’s disease
Spondylosis
Spondylosis refers to degenerative changes in the spine such as bone spurs and degenerating intervertebral discs between the vertebrae. Spondylosis changes in the spine are frequently referred to as osteoarthritis.
(4) causes of dizziness NOS
psychiatric, hyperventilation, head trauma, hypogylcemia
Seizures are characterized by excessive electrical neuronal activity resulting in (4)
altered consciousness, abnormal motor activity, abnormal sensory perception, loss of bowel and bladder control
(3) most common causes of seizures
infection with high fever, head injury, epilepsy
Withdrawal from this medication can commonly cause seizures
benzos
Priority interventions if patient is having a seizure in the office
do not put anything in mouth, lower to reclining position and turn on side, remove sharp objects from vicinity, place pillow under head if possible, call 911
Seizures lasting longer than ____ are considered status epilepticus
5 minutes
1 cause of disability in the US
CVA (cerebral vascular accident)
80% of CVAs are _____ in nature
ischemic (vs. hemorrhagic)
(3) types of ischemic cerebral vascular accidents
thrombotic, embolic, systemic hypoperfusion
(2) types of hemorrhagic cerebral vascular accidents
intracerebral, subarachnoid
CVA thrombosis vs. embolism
thrombosis = local obstruction of an artery by debris that originates in diseased arterial wall of the brain Embolism = particles of debris originate outside the brain structure and travel to obstruct
Priority cause of CVA ischemic attack thrombosis
arteriosclerosis
Epidural hematoma occurs between….
dura mater and skull
Subdural hematoma occurs between….
subdural space
Subarachnoid hemorrhage occurs between….
arachnoid mater and pia mater
1 risk factor for hemorrhagic aneurysm
hypertension
