Neurological problems Flashcards
Tension or muscle contraction headaches
in general population, probably more prevalent than migraine
- -> produce little disability & generally effectively managed with OTC products
- ->rarely seen in primary care
- ->episodic can last 30 minutes to several hours
Tension headache features
2/4 of these should describe pain :
- bilaterality
- steady and nonpulsatile
- mild to moderate intensity (may prohibit but not inhibit activity)
- not aggravated by routine activity
- *NO nausea or vomiting
- there can be photophobia or phonophobia but not both
- should be no evidence of underlying disease that accounts for the headache
Migraine without aura (common migraine )
last 4-72 hours characterized by at least 2 of the following features: **unilateral head pain **throbbing **moderate to severe intensity **pain aggravated by routine activity **in addition, 1 of the following feature shoud also be present: NAUSEA &/or VOMITING PHOTOPHOBIA & PHONOPHOBIA
Migraine with aura (classic migraine)
Aura’s occur in approximately 15% of migraine attacks
generally precede headache by less than 1 hour but may occur during headache
most aura’s are VISUAL, ie flashes of light, alternating geometric patterns, alterations in perception–> the “Alice in Wonderland” syndrome
Somatosensory auras
primarily numbness and tingling in the lips & fingers although they can occur anywhere
phases of migraines:
***Preheadache or premonitory
- prodrome is far more common than aura
- prodromes involve changes in mood or energy level (depression, euphoria, fatigue), alteration in sensory processing, changes in muscle tone, food cravings, fluid retention, yawning and a variety of other nondescript symptoms
- probably reflect the chemical milieu of the CNS
prodromes
research has shown that he need to eat chocolate reflect carbohydrates craving and was a prodrome & not a trigger
Prodromes become important markers for the timing of treatment
Auras can also be part of the pre-headache phase
phase of migraines:
***headache phase
begins mild and progresses from mild to severe over 30 minutes to several hours.
unilateral but can be bilateral
lasts 4-72 hours menstrual migraine may last longer
in children and adolescents duration is usually less than 4 hours
phase of migraines:
***post headache or postdrome
after the headache has resolved, other symptoms associated with migraine may linger 1-2 days
fatigue irritability inability to concentrate muscle pain and or food intolerance are common
diagnostic questions for migraine headache
how do your headaches interfere with your life ?
has there been any change in your headache pattern ?
How do you experience headaches of any types?
How often do you use medication to treat headaches?
- -> rate pain 0-10
- ->keep diary to identify/avoid triggers
diagnostic : migraine headache
testing should not be done unless it will change management
if dx is uncertain based on H & P may need testing to differentiate primary & secondary headaches
cluster headache
extremely severe, most often seen in men –> suicide risk
tx: oxygen
other headache causes
cerebral aneurysm
subarachnoid hemorrhage
increased intercranial pressure
analgesic rebound
suspect with C/O daily headache
inquire about frequency of analgesia use
traction/inflammation (secondary)
diseases of the bones of the cranium
referred pain from eyes sinuses teeth TMJ ears & back
meningeal irritation
Temporal arteritis
migraine management: non-pharm
avoid triggers
relaxation techniques
accupressure
regular exercise, adequate sleep & good nutrition
migraine management: abortive therapy
important to use at first indication of headache
- TRIPTANS (separate all doses by at least 2 hours, may augment with REGLAN if n/v severe, pregnancy cat. C- contraindicated)
- NSAIDs
- Narcotics (last choice !!)
- combination analgesics: ie, EXCEDRIN, FIORINAL
- Corticosteroids
- generally pregnant pts should be counseled to avoid triggers, use non-pharm measures, except accupressure & may take tylenol or midrin
migraine management: preventive therapy
if more than 4 episode of headache in a month very severe do not respond well to medication **consider comorbid conditions such as htn epilepsy class of preventive therapy: (1) Beta blockers (2)Ca channel blockers (3) anti-convulsants (4) tricyclic antidepressants (5) SSRIs
follow up for migraines
RTC every 2-4 weeks x 3 months until responding well to medication
Red flags & indications for referral:
–> not controlled by routine medications
–>rebound HA or habituation limits outpatients therapy
–> HA is new & progressive worsening
–>describes as “worse of my life”
–>affecting patient’s quality of life
–>accompnaied by neurologic symptoms that last longer than 30 minutes or is accompanied by numbness or hemiparesis
Dizziness/Vertigo
dizziness is a symptom
Vertigo is a condition that causes dizziness
–>important to differentiate dizziness : the sensation of the person spinning or the environment spinning around the person
–> from disequalibrium : loss of balance & lack of coordination
vestibular
imbalance in vestibular system
- ->peripheral: problems of inner ear or cranial nerve VIII most common type of vertigo
- ->central include brainstem ischemia & infarction & demylenating disease such as MS (uncommon)
***central need to be referral !!!
central vestibular of vertigo
need to be referral
- -> typically present with vertigo in association with other brainstem deficits
- -> may be associated with other signs and symptoms including diplopia & focal, sensory or motor deficits
non-vestibular causes of vertigo
systemic viral or bacterial infection causing postural hypotension (severe case of FLU)
metabolic problems such as hypo/hyperglycemia
electrolyte disturbances, anemia (severe)
drugs: hypnotic, antihypertensives, alcohol, analgesic, tranquilizers
peripheral vestibular –> Benign positional paroxysmal vertigo (BPPV)
most common type of vertigo : caused by free floating particular matter which moves within the semicircular canal with certain head movements
- ->position changes cause an abrupt onse
- ->NO tinnitus or hearing loss but may have associated n &v with episodes
- -> a common problem with the elderly
Meniere’s disease
dx criteria:
- *2 episodes (vertigo)
- *last at least 20 minutes each
- *accompanied by hearing loss, tinnitus, or aural fullness
- -> vertigo unrelated to position change
- -> hearing loss which is initially reversible may become permanent in 75% of cases
- ->symptoms are usually unilateral
vestibular neuronitis (acute labyrinthitis)
also involves the cochlea and may cause hearing loss
- -> caused by viral infection of the labyrinth
- *frequently occurs after URI followed by vertigo
- *symptoms resolves in 3-6 weeks with no sequelae
Weber test
lateralization to unaffected with sensorineural hearing loss- Meniere’s , labyrinthitis
Rinne (AC: BC)
with sensorineural loss, BC and AC are both reduced but ratio remains the same
conductive loss
seen with serous otitis & otitis media
Hallpike maneuver
produces intense vertigo in patients with vestibular problems
May cause mild vertigo in pts with central problems
Nystagmus with peripheral causes produces a 3-10 second dely in onset, lessens with repetition, and is in a fixed direction
Nystagmus with central causes begins immediately, does not fatigue with repetition and may be in any changing positions
diagnostic of vertigo
- lab tests identify the cause of vertigo in less than 1% of pt. with vertigo (history & physical more important !!!)
- audiometry- quantify hearing loss
- elecronystagmography (ENG) can be useful in dx chronic pheripheral disorders such as Meniere’s and persistant BPPV
- MRI if vertigo is of sudden onset and accompanied by severe HA, direction changing nystagmus or if risk factors for stroke
- CBC/ electrolytes if suspect anemia, diabetes or electrolyte imbalances
management for Benign positional paroxysmal vertigo (BPPV)
- may resolve in a few days or weeks w/o any treatment
- referral for vestibular PT may shorten recovery tiem
- Epley’s maneuver-can be taught to do at home, especially if recurrence (50% of pts)
- MECLIZINE (antivert) can be used but is not as effective as exercise and do not suppress acute attack –> pregnacy cat. B
management of Meniere’s
-refer to otolaryngologist for testing and management
bed rest during attack
may recommend decreasing NA. caffeine, alcohol, and tobacco but benefit unclear
Antivert and antiemetics with severe symptoms may help
Diuretics may reduce severity of attacks
management of vestibular neuronitis
- lie down in darkened room
- antibiotics if associated bacterial infection
- methylprednisone
- antivert & antiemetics may be helpful during an attack but should be stopped after 3 days since continuing may slow recovery
- symptoms resolve spontaneously in 3-6 weeks with no sequelea
Bell’s Palsy
- presents with unilateral paralysis of face
- often preceded by viral infection
- CN VII affected
- Acute onset with maximum paralysis in 48-72 hours
- May have altered state and increased sensitivity to sound
Bell’s Palsy
acute onset
viral infections
insect bites: Bell’s Palsy is a common neuropathy with Lyme’s disease
occur often in pregnancy
-corneal light reflex may be decreased
-Eyeball may roll upward when close eyelid
diagnostics : Bell’s Palsy
usually not indicated
may be useful to exclude other conditions such as Lyme disease (titre) or other infection (CBC w/diff)
management : Bell’s Palsy
- -> prevention of eye injury is the most important goal
- *prevent exposure keratitis by protecting cornea with eye drops (methylcellulose bid and lubricant at HS)
- *protective eyewear
- *patching at bedtime
- –> massage of facial muscles.
Pharmacological therapy: Bell’s Palsy
PREDNISONE recommended in all patients
antiviral (Valacyclovir) preg. cat B –>recommended for pts with severe facial paralysis
NSAIDS can be used for associated pain
majority of patients recover full function 4-6 months, 12 at most
trigeminal neuralgia
- -> affects 5th (trigeminal) cranial nerve
- -> most cases are idiopathic
- ->presents with recurrent episodes of intense sharp, penetrating electric like pain on one side of the face
- ->frequency and duration varies
triggers of trigeminal neuralgia
cold, chewing, touch, talking or facial movements within trigger zone
–> this information should be elicited in the hx
physical exam should include examination of all cranial nerves
the neuro exam should be normal
management : trigeminal neuralgia
TEGRETAL 100mg BID may increase to max 1200/d
- **need serial blood counts & liver function tests
- *abrupt withdrawal should be avoided
follow up : trigeminal neuralgia
following evaluation: patient should be referred to neurologist for more comprehensive evaluation & initiation of treatment
Care can then be managed by the PCP
SSRI may be indicated if associated with depression
If limited pain relief, referral to neurosurgeon may be indicated
Meningitis
an infection that results in inflammation of the brain’s meningeal membranes
most often caused by a bacterial agent
typically it presents with HIGH FEVER, headache, photophobia, and NECK PAIN and STIFFNESS (nuchal rigidity)
meningitis hx should included…
exposures to travels out of the country, food consumption sexual practices drug use hx of infectious disease immunocompromise any systemic disorder
Brudinski’s sign
signs of meningeal irritation
–> hip & knee flexion with the neck flexed
Kernig’s sign
meningeal irritation
–>inability to fully extend the legs
meningitis assessments include ….
LOC: confusion lethargy stupor coma
cranial nerves: diplopia deafness facial weakness pupillary abnormalities
meningitis initial dx
CBC- marked elevation of WBC’s
Blood cultures
Serum glucose
Lumbar Puncture is indicated but will be done after referral
management: meningitis
if s/sx indicate possibility of meningitis immediate referral to neurologist or ED is warranted
how to prevent meningitis
unexposed
- -> pneumococcal & H. influenza vaccines-all ages
- ->meningococcal vaccine–young adolescents, college freshmen and military also high risk pt. and travelers to endemic areas
exposed
- -> meningococcal or H. influenza–> RIFAMPIN or CIPRO
- -> Pneumococcal - non recommended
