Neurology Flashcards
Name two unique pain conditions associated with MS
Trigeminal neuralgia
Migraine headache
What kind of pain disorder can patients with SCI have?
Syringomyelia
Central Dysesthetic Pain Syndrome
Name the 4 main headaches?
Migraine
TTH
Trigeminal Autonomic Cephalalgias - Cluster
Other primary headache disorders
Name 5 medications that can cause medication overuse headache
acetaminophen, NSAIDs, ergotamine, triptans, opioids
Name two secondary headaches
reversible cerebral vasoconstrictive syndrome vertebral artery dissection SAH Venous thrombosis Spontaneous intracranial hypotension Low CSF pressure headache Idiopathic intracranial hypertension
QST is useful for what purposes?
- identification of subgroups of patients with different underlying pain mechanisms
- prediction of therapeutic outcomes
- quantification of therapeutic interventions
Name the sensory fibers associated with the components of the QST:
Cold Detection Threshold:
Warm Detection Threshold:
Vibration Detection threshold:
Cold Detection Threshold: A-delta
Warm Detection Threshold: C-fiber
Vibration Detection threshold: A-beta
The 2008 IASP definition of neuropathic pain has a grading system for neuropathic pain. What are the criterion of this grading system?
- pain distribution
- link between the distribution and the patient’s symptoms
- confirmatory neurological tests that match he sensory signs linked with the innervation territory of the lesioned nervous structure
- further confirmatory diagnostic tests to identify the lesion of disease underlying the neuropathic pain.
What are the grades of the neuropathic pain in the IASP definition?
Possible neuropathic pain
Probable neuropathic pain
Definite neuropathic pain
Increased sensitization to heat points to ______ sensitization while increased sensitization to mechanical stimuli points to _______ sensitization.
peripheral; central
In what patients is QST not appropriate?
- very young children
- mentally disabled individuals
- acutely psychotic individuals
- people with hearing impairments
- language difficulties (aphasia)
- excessively sedated
Thermoreception, nociception, and viscerorecption decussate immediately and travel up the spinal cord in the ______ and mechanorecptors and proprioceptors travel up the _____
ventrolateral STT; dorsal columns and cross over in the lower brainstem (cuneate and gracile nucleus)
QST summary:
- Cool - ____ fibers
- Warm - ____ fibers
- Cold pain - ____ fibers
- Heat pain (at threshold) - ____ fibers
- Heat pain (supramaximal) - ____ fibers
- Mechanical pain (single) - ____ fibers
- Mechanical pain (repetitive) - ____ fibers
- Mechanical non-pain (vibratory) - ____ fibers
- Mechanical (von Frey) - ____ fibers
- Current 5 Hz - ____ fibers
- Current 250 Hz - ____ fibers
- Current 2000 Hz - ____ fibers
- A-delta
- C
- A-delta+C
- C
- A-delta
- A-delta+C
- C
- A-beta
- A-beta
- C
- A-delta
- A-beta
Compare & Contrast PHN vs TN
Distribution: PHN (V1 80%) vs TN (V2/3 predom)
PHN (Herpetic lesions of face - not confined to trigeminal system, can also involve geniculate ganglion, eruption near ear) vs. TN (confined to V1-3 distribution)
Etiol: PHN (HZV preceding) vs. TN (Idiopathic)
Pathophys: TN (compression of trigeminal root of posterior fossa by superior cerebellar artery vs PHN (VZV infection into DRG + peripheral sensory nerve, w/ eventual necrosis of DRG & atrophy of dorsal horn (DH))
Assoc Symp: PHN (facial lesions) vs. TN (facial muscle spasm - tic douloureux)
Compare/contrast TN vs GN
Pain pattern: TN (V2/3 > V1) vs GN (ear, base of tongue, tonsillar fossa, beneath angle of jaw)
Pathophys: TN (compression of trigeminal root of posterior fossa by superior cerebellar artery) vs. GN (vasc impingement by the posterior cerebellar artery)
Affected nerves: TN (V) vs. GN (auricular/pharyngeal branches of IX, X)
Precipitation: TN (innocuous trivial stimuli -LT/stim to face, mouth; wash/shave/smoke/talk) vs GN (chewing, talking, swallowing, yawning, coughing)
SAME: U/L, recurrent, paroxysms, electrical shock like, shooting pain, severe intensity, duration: fraction of a sec-2 min,
EMG testing can identify injury to which anatomic sites?
- anterior horn cell
- spinal root
- plexus
- peripheral nerve
- NMJ
- muscle
EMG testing can identify injury to which types of neurons?
- sensory
- motor
- autonomic
EMG testing can determine which types of pathological injury?
- demyelination
- axonal degeneration
EMG testing can determine the time course of injury into what main categories?
- acute
- subacute
- chronic
What are the main neurophysiological entities recorded in EMG studies?
- compound muscle action potential (CMAP); motor (mV)
- sensory nerve AP (SNAP)
- amplitude
- latency (msec)
- conduction velocity (m/s)
- H reflex (soleus and flexor carpi radialis); helpful for polyneuropathies, S1 radiculopathy, UMN lesions
- F waves
EMG - what is an F wave?
- a response from a stimulus that travels first to and then from the cord vis motor pathways
- a long latency muscle AP seen after supramaximal stimulation to the nerve
- useful for studying the proximal portion of motor nerves
- Helpful in the evaluation of radiculopathy, GBS, motor neuron disease, peripheral neuropathies, entrapment neuropathies, demyelinating neuropathies
EMG - what MUAPs?
motor unit action potentials:
- the summation of the muscle fiber APs of a given motor unit
- onset frequency is the firing rate of a single MUAP maintained at the lowest frequency (<10Hz)
- recruitment freq is when the 2nd MUAP is recuited
What is seen on EMG in demyelinating disease?
- no spontaneous activity
- reduced recruitment with conduction block
- normal MUAP
- prolonged latency
- temporal dispersion
- slow NCV
What is seen on EMG in axonal injury?
- increased insertional activity and spontaneous activity
- reduced recruitment
- large amplitude, long duration polyphasics
- satellite potentials
- normal NCV latency
- slow NCV
- small CMAP/SNAP amplitude
What are the findings/changes on EMG in axonal injury (using the following neurophys entities)?
- insertional activity
- Spont activity
- MUAP amplitude
- Duration
- Phase
- Stability
- Recruitment
- amplitude
- Insertional activity - increased
- Spont activity - present
- MUAP amplitude - increased
- Duration - increased
- Phase - increased
- Stability - Normal
- Recruitment - decreased
- Amplitude - decreased
What are the findings/changes on EMG in NMJ defect (using the following neurophys entities)?
- insertional activity
- Spont activity
- MUAP amplitude
- Duration
- Phase
- Stability
- Recruitment
- Insertional activity - increased
- Spont activity - present
- MUAP amplitude - decreased
- Duration - decreased
- Phase - increased
- Stability - variable
- Recruitment - normal
What are the findings/changes on EMG in myopathic disease (using the following neurophys entities)?
- insertional activity
- Spont activity
- MUAP amplitude
- Duration
- Phase
- Stability
- Recruitment
- Insertional activity - increased
- Spont activity - present
- MUAP amplitude - decreased
- Duration - decreased
- Phase - increased
- Stability - normal
- Recruitment - increased
What changes do you see on EMG as time goes on following axonal injury (in the following categories)? 0-1 week 1-2 weeks 2-3 weeks 1-3 months 3-6 months
0-1 week - decreased recruitment 1-2 weeks - decreased recruitment - increased insertional activity 2-3 weeks - decreased recruitment - increased fibrillation potentials 1-3 months - decreased fibrillation potentials - decreased amplitude - increased duration - increased phase 3-6 months - increased recruitment - increased amplitude - increased duration - increased phase
What changes do you see on NCV as time goes on following axonal injury (in the following categories)? 0-1 week 1-2 weeks 2-3 weeks 1-3 months 3-6 months
0-1 week - decreased amplitude, proximal 1-2 weeks - decreased amplitude, proximal and distal 2-3 weeks - decreased amplitude, proximal and distal 1-3 months - increased amplitude 3-6 months - increased amplitude
What do you see on EMG in CTS?
- distal sensory conduction slowing, reduced latency
- if severe, secondary axonal damage/loss in thenar muscles
- if severe, prolonged distal latency (normal proximal) in motor studies with reduced CMAP
What is the most common neuropathy from HIV ?
DSPN - Distal symmetric polyneuropathy
HIV – what are the risk factors for developing neuropathy?
• Age • Rx w/ anti-retroviral therapy • Stavudine exposure • Lower CD4 count • Co-morbidities: o DM II • Statin Use • Substance use
Define neuropathic pain.
Pain caused by a lesion or disease of the somatosensory nervous system
Most common sites for disc herniation leading to radiculopathy?
- L4/5
- L5/S1
What are the mechanisms of CRPS?
- CeS
- PeS
- Altered Sympatho-afferent coupling
- Genetic Susceptibility
- Brain changes
- Psychological maladaptive changes/factors
- Inflammatory/immune related factors
- Impaired descending inhibition
- Adrenergic Changes
- Nerve injury
- Ischemic reperfusion injury or oxidative stress
What are the 1st line treatments for central post-stroke pain?
- Pregabalin
- Gabapentin
What are the 2nd line treatments for central post-stroke pain?
- Amitriptyline
- Duloxetine
What are the 3rd line treatments for central post-stroke pain?
- Opioids
- Tramadol
What are the 1st line treatments for SCI pain?
- Pregabalin
- Gabapentin
- Amitriptyline
What are the 2nd line treatments for SCI pain?
- Tramadol
- Lamotrigine
What are the 3rd line treatments for SCI pain?
- tDCS
- combined visual illusion and tDCS
What are the 4th line treatments for SCI pain?
- TENS
- oxycodone
- DREZ procedure
What are the treatments to be advised against in SCI pain?
- levetiracetam
- mexiletine
What are the diagnostic criteria for MS?
- damage of 2 separate areas of the CNS (includes brain, SC and optic nerve; demyelinating lesions) AND
- the damage occurred at 2 different time points
- R/O other diagnoses
What is the most common type of neuropathic pain in MS
- dysaesthetic extremity pain (lifetime prev 12-28%)
- also have thermal sensory abnormalities (cold or tactile allodynia)
- ## more common in primary progressive or progressive-relapsing vs relapsing remitting
Central pain syndromes are a results of damage to what brain structure or spinal tract?
Thalamus or spinothalamic tract
What is the most common type of neuropathic pain in SCI?
Central Dysesthetic pain syndrome:
- pain caudad to the site of injury (extremities and post trunk)
- lasting > 4 weeks
- starts within 12 months of injury
- prevalence greatest in incomplete quadriplegia
Syringomelia
A complication of SCI
- continuous escalation of pain
- may take months or years to develop
- aching and burning at level fo lesion (+/- above and below the lesion)
What are the medications used to treat MS-related pain?
- Gabapentin
- Pregabalin
- TCAs
- SNRIs
- Lamotrigine
- Topiramate
- nabilone (2nd line)
What lab investigations do you do to investigate NeP?
Standard: - electrolytes - Cr, Urea - Rheum screens - TFTs - CXR Advanced: - SPEP - HIV - Lyme titres - Vit B1, B6, B12 - LP - Toxins - Nerve biospy - EMG/NCS - QST
What investigations do you do to investigate NeP?
Standard: - electrolytes - Cr, Urea - Rheum screens - LFTs - CXR Advanced: - SPEP - HIV - Lyme titres - Vit B1, B6, B12 - LP - Toxins - Nerve biospy - EMG/NCS - QST
Name two tools/scales used in NeP?
- LANSS (greater or equal to 12 - likely NeP)
- DN4 (greater or equal to 19 - likely NeP 90% probability)
Migraine criteria?
A. 5 episodes B. Lasts 4-72 hours C. 2 of: - moderate to severe - aggravated by physical activity - unilateral - pulsating/throbbing D. 1 of: - nausea or vomiting - photophobia and photophobia E. Not better explained by other ICHD Dx
Aura criteria?
A. 2 attacks B. One or more of fully reversible symptoms in the following categories: - sensory - motor - visual - brainstem - speech and/or language - retinal C. At least 3 of: - one positive symptom - one unilateral symptom - gradually spreads over 5 or greater minutes - headache occurs within 60min after initiation of aura symptoms - 2 or more occur in succession - each individual symptoms lasts 5-60min D. Not accounted by another ICHD Dx
Migraine with brainstem aura?
A. meets criteria for migraine with aura B. Aura has both of (1 AND 2): 1. at least 2 of following reversible symptoms - dysarthria - vertigo - tinnitus - hypacusis - diplopia - ataxia not due to sensory deficits - decreased LOC (<13) 2. no motor or retinal symptoms
Hemiplegic migraine?
A. Attacks fulfilling criteria for 1.2 Migraine with aura and criterion B below
B. Aura consisting of both of the following:
1. fully reversible motor weakness
2. fully reversible visual, sensory and/or speech/language symptoms.
Genes involved in Familial hemiplegic migraine?
FHM1 - CACNA1A
FHM2 - ATP1A2
FHM3 - SCN1A
Tension type headache Dx?
A. 10 episodes occuring < 1 day/month B. 30min to 7 days C. at least 2 of: - bilateral - mild to moderate - no aggravation by physical activity - pressing or tightening (not pulsatile) D. both of: - no N/V - no more than one of photophobia or phonophobia E. No other ICHD Dx to account for symptoms
Chronic TTH?
A. headaches occurring 15 days or more per month for more than 3 months
B. Lasts hours to days or unremitting
C,D,E - same at Episodic TTH
Chronic migraine?
A. headaches occurring 15 days or more per month for more than 3 months
B. At least 5 attacks
C. On 8 or more days per month, can have any of the following:
- Migraine attack
- aura
- believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
Cluster Headache Dx?
A. 5 attacks
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 min
C. One or more of:
1. at least one ipsilateral autonomic symptom
2. restlessness or agitation
D. occurs from every other day to 8 times per day
E. not better accounted by other ICHD Dx
Hemicrania continua?
A. Unilateral headache
B. Present for > 3 months with exacerbations if moderate or greater intensity
C. One or more of:
1. at least one ipsilateral autonomic symptom
2. restlessness or agitation
D. Responds absolutely to indomethacin
E. not better accounted by other ICHD Dx
Paroxysmal hemicrania?
A. 20 attacks B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 2-30 min C. One or more of: 1. at least one ipsilateral autonomic symptom 2. restlessness or agitation D. Occurs more than 5 times per day E. Prevented absolutely by indomethacin F. not better accounted by other ICHD Dx
Short-lasting unilateral neuralgiform headache attacks Dx?
A. 20 attacks
B. Moderate to severe unilateral orbital, supraorbital, temporal and/or other trigeminal distribution pain lasting 1-600sec, occuring as single stabs or series of stabs in saw-tooth pattern
C. One or more of:
1. at least one ipsilateral autonomic symptom
2. restlessness or agitation
D. Occurs at least once per day
E. not better accounted by other ICHD Dx
SUNCT Dx?
A. Short-lasting unilateral neuralgiform headache Dx
B. Both ipsilateral conjunctival injection and lacrimation
SUNA Dx?
A. Short-lasting unilateral neuralgiform headache Dx
B. Not more than one of conjunctival injection or lacrimation
Occipital neuralgia Dx?
A. Uni or bilateral pain in distribution of GON, LON or TON
B. at least 2 of:
- recurring paroxysmal attacks (3 seconds to minutes)
- severe intensity
- shooting, stabbing or sharp
C. pain is associated with both of:
1. dysesthesia and/or allodynia during innocuous stim of scalp or hair
2. either or both of:
- tenderness over affected nerves
- trigger points at emergence of GON or distribution of C2
D. Pain eased by LA block of affected nerve(s)
E. Not better accounted by other ICHD Dx
Cervicogenic Headache Dx?
A. Any headache that fulfills C.
B. Clinical or imaging evidence of a disorder or lesion within the C-spine or soft tissues of the neck, known to be able to cause headache
C. evidence of causation by at least 2 of:
- HA developed in temporal relation to the C-spine disorder or lesion
- HA has improved or resolved in parallel with improvement or resolution of C-spine disorder
- ROM is reduced or HA made worse by provocative maneuvers
- HA abolished by block of C-spine or its nerve supply
D. Not better accounted by other ICHD Dx
TN Dx?
A. Recurrent paroxysms of unilateral facial pain in the distribution(s) of one or more divisions of the trigeminal nerve, with no radiation beyond
B. Pain has all of the following characteristics:
- lasting from a fraction of a second to 2 minutes
- severe intensity
- electric shock-like, shooting, stabbing or sharp in quality
C. Precipitated by innocuous stimuli within the affected trigeminal distribution
D. Not better accounted for by another ICHD-3 diagnosis.
Glossopharyngeal Dx?
A. Recurrent paroxysms of unilateral facial pain in the distribution(s) of one or more divisions of the glossopharyngeal nerve, with no radiation beyond
B. Pain has all of the following characteristics:
- lasting from a few seconds to 2 minutes
- severe intensity
- electric shock-like, shooting, stabbing or sharp in quality
C. Precipitated by innocuous stimuli within the affected glossopharyngeal distribution (tonsillar fossa, post part of the tongue, pharynx or angle of the jaw, +/- in the ear)
D. Not better accounted for by another ICHD-3 diagnosis.
Name the TN subtypes
Idiopathic - no known cause
primary - Vascular compression (SCA or AICA)
secondary - tumor, AVM, AVF, aneurysm, skull base deformity, CTD, genetic
painful trigeminal neuropathy - continuous, neural damage, sensory deficits, and burning, squeezing quality to it
Medication overuse headache Dx?
A. Headache 15 or more days per month
B. Using acute treatment medications regularly for more than 3 months
- NSAIDs, Acetaminophen (15 or more days per month)
- opioids, triptans, ergotamines (10 or more days per month)
C. Not better accounted for by another ICHD-3 diagnosis.
Interventional treatments for TN?
Gasserian ganglion RF MVD Balloon compression Gamme knife chemical ablation (glycerol)
Poor prognostic factors for TN?
- young age
- bilateral symptoms
- sensory symptoms
- lingering pain
What are the opening pressure cutoffs for:
- headache attributable to low CSF pressure
- headache attributable to elevated CSF pressure
- < 60mm
2. > 250mm (280m in obese children)
What are the treatments for daytime TMD symptoms?
Relaxation/Stress Management:
- breaking daytime muscle tensing habits
- learning to relax masticatory muscles
- learning stress management techniques
- biofeedback
Orthotic
- occlusive orthotic device during the day
Rx:
- TCA BID
Clinical features of Headache attributed to TMD?
- most prominent in temporal, preauricular or masseter muscles
- mainly bilateral
- TMD is second most common cause of facial pain (after tooth pain)
Pain generators:
- disc displacement
- joint OA
- degenerative disease
- hypermobility
- regional myofascial pain
Prophylactic Rx for Migraines
1st line - Propranolol, Metoprolol, Amitriptyline
2nd line - Topiramate, Candesartan
3rd line - Mg2+Citrate, Riblofalvin, Coenzyme Q10
4th line - Venlafaxine, Gabapentin, Valproic Acid, Flunarizine, Lisinopril
Acute Rx for Migraines
1st line - NSAIDs/Acetaminophen 2nd line - Triptans PO 3rd line - Triptans SC/IN 4th line - Combo - NSAID + Triptans 5th line - DHEA or NSAIDs IM Recommend against opioid & Fiorinal
Acute Rx for Cluster HA
1st line - Sumitriptan SC or Zolimtriptan IN or 100% O2 7-12L/min +/- Prednisone
2nd line: DHEA injections
3rd line: non-invasive vagal nerve stimulation
GON block or steroids - transition
Prophylactic for Cluster HA
1st line - Verapamil
2nd line - Lithium
3rd line - Topiramate or melatonin or non-invasive vagal nerve stimulation
TOP
Acute and Prophylactic Rx for TTH
Acute: Ibuprofen, Acetaminophen, ASA, Naproxen
Preventative:
1st line - TCA’s (amitriptyline, nortriptyline)
2nd line - Mirtazapine or Venlafaxine
TOP
5 main Categories for non-pharm Rx of migraine HA
- Diet - frequent, small meals, hydration
- Avoid caffeine
- Minimize possible triggers
- Regular Exercise - min 30 min daily
- Sleep
- Mood/Stress reduction
Rx any underlying psychiatric or mood disorders
Other: CBT, MBSR, Relaxation Therapy
Rx for awaking + daytime TMD
- Medication: NSAIDs &/or steroids
- Passive: PT modalities (heat, ice, US, iontophoresis); jaw stretching ex’s
- Active: H+N posture improvement
- Indirect: Cervical therapies, manual tehcniques, NM re-education
- Interventionl: Arthroscopy or arthroplasty
- Psychological: CBT, Biofeedback, Education, stress reduction/relaxation therapy
