Neurology Flashcards
Acute management of cluster headaches
100% O2 @ 6-12 L/min x 15min
+
Sumatriptan 6mg s/c* or 20mg i/n
Zolmitriptan 5mg i/n* or 10mg PO
or Lido 4-10% i/n
or Octreotide
Bridging Treatment of cluster headaches
- Unnilateral greater occipital nerve block w/ Methylpred 80mg + 2mL 2% Lido
- Pred 60mg PO x 5d then ↓10mg q2d or Methylpred 100mg PO then taper
- Ergotamine
Prophylaxis for cluster headaches
- Verapamil 80mg TID **ECG @ baseline
- Ergotamine
- Topiramate 100mg/d (CI : nephrolithiasis)
- Lithium 300mg OD then ↑300mg qwk
- Valproic Acid 5-20mg/kg, Melatonin 10mg HS, Baclofen 15-30mg, Neuromodulators
Diagnostic Criteria of Cluster Headaches
5xHA w/ :
1. severe UNIlateral orpital/temporal pain lasting 15-180minutes
- ≥1 autonomic sx (UNI+IPSI) : conjunctival injection, lacrimation, congestion/rhino, eye/forehead edema, miosis/ptosis, agitation
**Think parasympathetic
**Think Horner Syndrome
Frequency : 8/d ad q2d
Circadian : episodic or chronic
50% have migraine sx
Investigations for Cluster Headaches
Usually clinical, no imaging unless red flags
Can do TSH, prolactin, pituitary function
Name the red flags of headaches
SNOOP4
Systemic sx
Neuro sx
Onset (sudden/thunderclap)
Older pts (>50)
Papilledema (optic disc swelling)
Postural aggravation (incr standing/DD)
Preciptiated by valsalva
Pattern change
DDx : Cluster Headaches
MM…IT ACHES!
Migraine
Meningitis
Increased intracranial pressure
Tension HA, Temporal/Giant Cell Arteritis
AV malformation
Cluster migraine
HTN
Eye disorder (glaucoma, refractory error)
Sinusitis, SAH, systemic illness
For suspected subarachnoid hemorrhage (SAH), what is the initial investigation?
Non-contrast CT scan of the head; if negative and suspicion remains high, follow with lumbar puncture (LP) to check for xanthochromia 12 hours after symptom onset.
**CT scans may miss small or early bleeds, especially if done more than 6 hours after symptom onset
If you suspect temporal arteritis (Giant Cell Arteritis), what tests should you order?
Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) as initial screens, followed by temporal artery biopsy if ESR/CRP are elevated and clinical suspicion remains high.
For a patient with suspected temporal arteritis, what treatment should be initiated promptly, even before confirmation?
Start high-dose corticosteroids (e.g., prednisone 40-60 mg daily) to prevent vision loss, especially if there are symptoms like jaw claudication or vision changes.
Consider Aspirin: Low-dose aspirin (81 mg daily) may be given to reduce ischemic complications, such as stroke.
In a patient with suspected SAH and a negative CT, what is the next diagnostic step?
Perform a lumbar puncture (LP) to look for xanthochromia, which indicates the presence of blood breakdown products in the cerebrospinal fluid.
**12 hours after symptom onset for + LP
What does an elevated ESR in a patient over 50 with a new headache indicate?
It raises suspicion for temporal arteritis (Giant Cell Arteritis); initiate corticosteroids promptly and consider biopsy.
What are potential contraindications for lumbar puncture in the workup of a headache?
Increased intracranial pressure due to mass lesion (risk of herniation), coagulopathy, and localized infection at the puncture site.
What are the initial steps in managing a patient with suspected meningitis?
- Begin empirical antibiotics immediately (e.g., ceftriaxone + vancomycin ± ampicillin if Listeria is a concern).
Perform a lumbar puncture for CSF analysis.
Do not delay antibiotics for imaging or LP if meningitis is strongly suspected.
Clinical presentation of giant cell arthritis or temporal arthritis
HEAD PAIN
Headache : new, unilateral, temporal region
Elevated ESR/CRP
Age > 50
Double vision, vision loss or other visual disturbances
Pain in jaw (jaw claudication)***
Atemporal artery tenderness
Inflammatory symptoms (systemic sx, PMR sx)
Needs steroids immediately
