Neurological Disorders Flashcards by Emily Friedman

(3) most common types of primary headaches

tension, cluster, migraine

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Cause of primary headaches

idiopathic, likely r/t interaction of genetic and environmental factors

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Cranial/Vascular causes of secondary headaches (5)

intracranial hemorrhage, thrombosis, arteriovenous malformation, carotid dissection, temporal arteritis

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Secondary headache causes, generally (9)

cranial/vascular, posttraumatic, substance abuse, medication use, infection, tumor, TMJ, narrow angle glaucoma, psychiatric

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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

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Most important step in diagnosing a headache

thorough history

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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*

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Certain populations to be concerned about new headache (6)

<5yo, >40yo, cancer, lyme disease, HIV, pregnant or recent postpartum

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Higher _____ in birth control can be responsible for headaches

estrogen

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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)

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CC headache, see elevated ESR on lab results. Suspect….

temporal arteritis

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Most common headache by prevalence (not primary care visits)

tension headache

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DIAGNOSE: Pt presents with CC of headache. Pain described as bilateral, non-throbbing pressure or tightness that waxes and wanes

tension headache

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Recommendations for tension headache (3)

OTC analgesia (tylenol, NSAIDs), avoid triggers, stress management

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Cluster headaches are also known as…..

trigeminal autonomic cephalgia

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True or False: Cluster headaches require imaging to work up

False - strictly a clinical diagnosis

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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)

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Trigeminal autonomic cephalgia, aka…..

cluster headache

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Common accompanying ipsilateral symptoms in cluster headaches

lacrimation, conjunctival injection, nasal congestion, ptosis, miosis, eyelid swelling, rhinorrhea, sweating

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Treatments for acute cluster headache attack

O2 & sumatriptan

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Prophylactic treatment for cluster headaches

refer to neurologist First line is Verapamil (HTN med).. Other options include Prednisone or topiramate

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Most common presenting headache in primary care

migraine

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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

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(3) types of migraines

with aura, without aura (most common), menstrual

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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