Neurological Disorders Flashcards
Diagnosing an Acute Headache
- Fever, Vision changes, neck stiffness
- HIV infection
- Current or past hx of HTN
- Neuro findings: mental status changes, motor/sensory deficits, +LOC
Careful assessment of 5 areas crucial when acute HA comes in
- Visual acuity
- Ocular gaze
- Visual fields
- Pupillary Defects
- Optic Discs
Medications to treat Migraines
- NSAIDS (PO, nasal, IM Toradol)
- Metoclopramide
- Dihydroergotamine
- Triptans (PO, nasal, SubQ)
Avoid using Morphine/Hydromorphone as 1st line therapy
- Subanesthetic ketamine infusions used for Chronic Migraines/New Daily HA when unresponsive to other therapy
All HA types should receive what in the ED
High-flow O2
Treatment for SAH, Intracranial mass, Meningitis
Admit to hospital and emergent treatment
OTTAWA SAH Clinical Decision Rule (predicting)
100% Sensitivity in predicting SAH
OTTAWA SAH Clinical Decision Rule (clinical finding/symptoms)
- 40+ years of age
- Neck pain/stiffness
- Witnessed LOC
- Onset during exertion
- “Thunderclap” headache
- Limited Neck flexion
“Thunderclap” HA
Rapid onset of severe pain
Tension-type HA
- Dull, band-like or vise-like generalized HA, worse in neck/back of head
- Not pulsatile or worse with physical activity/position
- No N/V
- EITHER photophobia or phonophobia (not both)
- May occur daily
Treating tension-type HA
- OTC analgesics
- Avoid narcotics (rebound HA)
- Stress management
- muscle relaxation
- Exercise
- Diet changes
- Counseling
Cluster HA
- SEVERE, UNILATERAL episode of periorbital pain
- Lasts 15 min - 3 hours
- Ipsilateral nasal congestion
- Rhinorrhea
- Lacrimation
- Eye redness
- Horner’s Syndrome
- Cyclic (may occur daily for several weeks and then remit for weeks or months)
Cluster HA Triggers
- Stress
- Glare
- ETOH
- Certain Foods
Cluster HA Treatment
- “Z’s” (Zolmitriptan, Sumatriptan, etc) + 100% O2 via non-rebreather for 15 mins
Preventative: lithium, topiramate, prednisone, volproate, verapamil
Drugs responsible for Medication Overuse HA
- Acetaminophen
- Ergots
- Opioids
- Butalbital (Fioricet, Esgic)
- NSAIDs
- Midrin
Treatment for Medication Overuse HA
- Avoid daily use of analgesics
- Early initiation of migraine preventative tx
Essentials of diagnosing Migraines
- UNILATERAL pain
- N/V
- Photophobia/Phonophobia
- Aura (commonly visual)
- Can occur without aura
Symptomatic therapy of Migraines
- Rest in quiet, dark room
- ASA, Tylenol, Naproxen may help
- Other prescription meds may be necessary including
- Ergotamines - 1-2 tabs taken at onset then 1 tab q30 mins, 6 tabs max per episode
- Triptans - given to patients with prolonged attacks
- Chlorpromazine
- Butalbital-containing combo meds (last resort only)
Other causes of HA
- Cerebrovascular disease
- Internal carotid artery occlusion or Carotid dissection after endarterectomy
- SAH
- Meningeal infections
- Pseudomotor Cerebri (IIH - Idiopathic Intracranial HTN)
- Lumbar puncture
Essentials to diagnose trigeminal neuralgia (TN)
- Brief episode of stabbing facial pain
- Pain is in area of 2nd and 3rd division of trigeminal nerve
- Pain exacerbated by touch
- Most common in middle and later life
- Affects women > men
- Neuro exam shows no abnormality
- Bilateral symptoms = further investigation needed
TN under the age of 40
Suspect possible multiple sclerosis
S/S of trigeminal neuralgia
- Momentary episodes of sudden, lacinating facial pain (commonly near one side of mouth) that shoots toward the ear, eye, or nostril on same side
- Symptoms remain confined to distribution of trigeminal nerve on ONE SIDE ONLY
TN triggers
- Touch
- Movement
- Drafts
- Eating
Atypical facial pain
- Common in middle-aged women (many are depressed)
- Facial pain without typical features of TN
- Constant pain (often described as burning)
- Pain spreads to entire side of face and can include neck and back of head as well
Treatment: - Trial of simple analgesics - Trial of tricyclic antidepressants - Carbamazepine - Oxcarbazepine - Phenytoin (response is often disappointing)
Diagnosing Postherpetic Neuralgia
- Develops in 15% of patients with shingles (herpes zoster)
- Most common in elderly or immunocompromised
- Rash
Primary Prevention:
- Recombinant Zoster vaccine to patients over 50 years old
Treatment of Postherpetic Neuralgia
- Acyclovir (5x/day) or Valacyclovir (3x/day) when given w/in 72 hours of rash onset these can reduce incidence of postherpetic neuralgia by 50%
- Simple analgesics –> tricyclics (amitriptyline or nortriptyline)
- SYSTEMIC CORTICOSTERIOIDS DO NOT HELP
Glossopharyngeal Neuralgia
- Uncommon disorder with no structural abnormalities
- Similar pain to TN, but occurs in throat and sometimes in deep ear/back of tongue
Triggers and treatment of Glossopharyngeal Neuralgia
Triggers:
- swallowing, chewing, talking, yawning, syncope
Treatment:
- Oxcarbazepine
- Carbamazepine
- Surgery considered if medications fail
- Surgical intervention is microvascular decompression
Other causes of facial pain
- TMJ
- Sinusitis/Ear infections
- Glaucoma
- Pain in jaw (could be angina pectoris)
Risk factors for Subarachnoid Hemorrhage (SAH)
- Older age
- Female
- Non-white ethnicity
- HTN
- Smoking
- High ETOH consumption
S/S of Subarachnoid Hemorrhage (SAH)
- “Thunderclap” HA leading to N/V
- Signs of meningeal irritation usually present
- Obtundation common
- Focal deficits frequently absent
Diagnosing of Subarachnoid Hemorrhage (SAH)
- CT scan (performed immediately to confirm hemorrhage has occurred)
- CT arteriography determines source of bleeding
- Transcranial doppler - only screens for vasospasms
Lab studies of Subarachnoid Hemorrhage (SAH)
- CSF shows elevated RBC count
- Absolute RBC count (<2,000 RBC is very unlikely due to SAH)
- WBC (peripheral leukocytosis)
- UA (transient glycosuria)
- ECG (arrhythmias or MI)
Characteristics of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)
- HA that worsens with straining
- Visual obscuration or diplopia
- Papilledema
- Abducens palsy commonly present
- CSF fluid is normal
Causes of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)
- Can be caused by stopping long-term oral steroids
- Using tetracycline or oral contraceptives can contribute to cause
Diagnosing of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)
- MUST SCREEN FOR SPACE-OCCUPYING LESION OF BRAIN!
- CT or MRI of brain
- MR Venography - important to screen for thrombosis of IC venous sinuses
Treatment of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)
- Acetazolamide (3x/day) - slowly increase dose
- Topiramate
- Furosemide
- Repeated LP (lowers ICP)
- Surgical placement of VP shunt or optic nerve fenestration if medications fail
ALL PATIENTS SHOULD BE REFERRED!
