Neurology

Question 1

What are the 3 main categories of primary headaches? ~90% of headaches are one of these

Answer 1

• migraine
• tension type headache
• trigeminal autonomic cephalgias

Question 2

What is the most common headache in clinical practice?

Answer 2

Migraine headache

Question 3

Pneumonic to diagnose Migraine?

Answer 3

POUND
Pulsatile quality
One-day duration (4-72 hrs)
Unilateral in location 
Nausea or vomiting 
Disabling intensity (patient goes to bed)

Question 4

Migraine with aura description

Answer 4

Aura during or within 1 hour of migraine

Visual loss, hallucinations, flashing lights, numbness, tingling, aphasia, confusion

Question 5

Migraine with brainstem aura

Answer 5

Presence of vertigo, ataxia, dysarthria, diplopia, tinnitus, hyperacusis, or alteration in consciousness

Question 6

Hemiplegic migraine

Answer 6

any aura complex that involves some degree of motor weakness

Question 7

DBT - Primary Headaches

• 90% of patients with “sinus headache” have ___ headache that will respond to ___ medications
• ____ is indicated only for atypical headache features or for headaches that do no meet strict definition of migraine

Answer 7

• migraine; triptan

- neuroimaging

Question 8

Name the differential diagnosis for migraine:

• 30 min to 7 days
• typically bilaterally
• pressure or tight quality
• does no prohibit activity
• not associated with nausea
• treat acute headache with NSAIDS
• a TCA may be needed for prophylaxis

Answer 8

tension type headache

TCAs: amitriptyline, clomipramine, mirtazapine, nortriptyline

Question 9

Name the differential diagnosis for migraine:

• brief paroxysms of unilateral lancinating pain in the V2/V3 area of trigeminal nerve, often triggered by light touch
• what is the imaging to obtain and drug to use for treatment?

Answer 9

Trigeminal neuralgia

• MRI to exclude intracranial lesions and MS
• carbamazepine for treatment

Question 10

DDx for migraine:
- chronic headache that occurs >15 days per month in patients using combination analgesics, ergotamine products or triptans >10 days per month

Answer 10

Medication overuse headache

Withdraw all meds

Question 11

DDx for migraine:

• headache occurring >15 days per month for >3 months
• headache possesses the features of migraine >8 days per month
• RFs include migraine headache frequency or acute medication use >10 days per month

Answer 11

chronic migraine headache

Question 12

DBT - Primary headaches

What categories of meds have no role in acute or preventative treatment of tension type headache?

Answer 12

muscle relaxants, benzos, botulinum toxin A

Question 13

____ or ____ are 1st line treatment for acute mild to moderate migraine

Answer 13

NSAIDs or aspirin

Question 14

____ or ____ may be used for severe acute migraine or poor response to 1st line treatment

Answer 14

triptan or dihydroergotamine

Question 15

Migraines present on awakening, associated with vomiting or escalates rapidly, best treated with nasal ____ or subQ _____

Answer 15

triptans; sumatriptan

Question 16

_____ is effective for migraine associated nausea and enhances efficacy of abortive meds

Answer 16

metoclopramide

Question 17

Migraine prophylaxis indications:

Answer 17

• migraines not responding to therapy
• HA occurs >8 days per month
• disabling HA occurs >4 days per month
• use of acute migraine meds >8 days per month

Question 18

migraine prophylaxis meds:

Answer 18

topiramate, valproic acid, metoprolol, propranolol, timolol

Question 19

DBT - primary headaches

• Don’t choose oral meds for patients with ___ & ___
• ___ are contraindicated in presence of CAD, cerebrovascular disease, brainstem aura and hemiplegic migraine
• don’t use acute therapies more than _____ days per week to avoid medication overuse headaches
• _______ containing contraceptive must be avoided in women experiencing aura with migraine b/c of increased risk of stroke

Answer 19

• nausea; vomiting
• triptans
• 2-3 days
• estrogen

Question 20

Name the Trigeminal Autonomic Cephalgia diagnosis:
Pain usually periorbital, duration 20-60 minutes, several times per day, repeating over weeks then disappearing for months or years, unilateral tearing and nasal congestion or rhinorrhea, ptosis, miosis; treat with ____ or ____ and ____ for long term prevention

Answer 20

Cluster headache

triptan; oxygen; verapamil

Question 21

Name the Trigeminal Autonomic Cephalgia diagnosis:

occurs at least 5x daily lasting 3-20 minutes; responds completely to _____

Answer 21

chronic paroxysmal hemicrania

indomethacin

Question 22

Name the Trigeminal Autonomic Cephalgia diagnosis:

Dozens to hundreds of headaches a day with duration 1 - 600 seconds; typically resistant to treatment

Answer 22

SUNCT = Short lasting unilateral Neuralgiform headaches with conjunctival injection and tearing

Question 23

Name the Trigeminal Autonomic Cephalgia diagnosis:

Persistent strictly unilateral headache that responds to indomethacin

Answer 23

Hemicrania continua

Question 24

Red flag signs, typically sign of secondary headache disorders

Answer 24

• first or worst headache
• abrupt onset or thunderclap
• progression or change in pattern
• abnormal exam findings
• neurologic symptoms > 1 hour
• new headache in persons <5 or >50
• new headache in patient with cancer, immunosuppression or pregnancy
• alteration or LOC
• triggered by exertion, sexual activity or Valsalva

Question 25

Name the thunderclap headache: | Sudden onset of worst headache of my life; warning sentinel headaches beforehand

Answer 25

SAH | Neurosurgery

Question 26

Name the thunderclap headache: | Neck pain and ipsilateral headache, neurologic findings in territory of involved vessel; pulsatile tinnitus

Answer 26

Carotid or vertebral dissection | Aspirin, heparin or OAC

Question 27

Name the thunderclap headache: | Exertional headache, papilledema, neurological findings; consider in hypercoagulable states, pregnancy, use of OCPs

Answer 27

Thrombosis of cerebral vein or dural sinus | LMWH followed by warfarin

Question 28

Name the thunderclap headache: Premenopausal women with recurrent thunderclap headaches, imaging with strokes, hemorrhages or cerebral edema, often triggered by exposure to adrenergic or serotonergic drugs

Answer 28

Reversible cerebral vasoconstriction syndrome | Normalization of BP and elimination of triggering drugs

Question 29

Increased intracranial HTN without identifiable structural pathology; patient usually female, obese, child bearing age; +papilledema CSF > 250 MRI with normal or small ventricles Name the diagnosis and treatment

Answer 29

Idiopathic intracranial HTN or pseudotumor cerebri | Tx: acetazolamide

Question 30

Headache and mental status abnormality

Answer 30

Epidural or subdural hematoma

Question 31

brief "lucid interval" before subsequent precipitous decline

Answer 31

epidural hematoma

Question 32

Protocol for athlete who suffers TBI

Answer 32

Immediate removal from play. Sideline evaluation. Prohibition from sports until patient returns to cognitive baseline and asymptomatic without taking meds

Question 33

Persistence of symptoms of mild TBI beyond a typical recovery period of several weeks

Answer 33

post concussion syndrome Repeat imaging for worsening headache, repeated vomiting, drowsiness, persistent confusion, dysarthria or focal neurologic findings

Question 34

Treatment for postconcussion syndrome

Answer 34

supportive with rehabilitation

Question 35

Posttraumatic headache treatment

Answer 35

NSAIDs and triptans | TCAs, SSRI, SNRIs

Question 36

Clues to identify a partial seizure that progressed to a generalized seizure

Answer 36

- unilateral shaking - head turning to one side - aura - postictal weakness

Question 37

Name the seizure type: Normal consciousness and awareness with single neurologic modality (sensory, motor, olfactory, visual gustatory) involving single area of the body

Answer 37

simple partial seizure

Question 38

Name the seizure type: Conscious but unresponsive or staring. Automatism (lip smacking, swallowing or manipulating objects). Postictal confusion

Answer 38

Complex partial seizure

Question 39

Name the seizure type: | loss of consciousness at onset, no prodromal or localizing symptoms, whole body stiffening and or jerking seizures

Answer 39

primary generalized seizure

Question 40

Name the common epilepsy syndrome: | Complex partial seizure preceded by an aura. Medical temporal sclerosis is a characteristic finding on MRI

Answer 40

Temporal lobe epilepsy

Question 41

Name the common epilepsy syndrome: | Nocturnal complex seizures that awaken patients from sleep. Often associated with underlying structural pathology

Answer 41

Frontal lobe epilepsy

Question 42

Name the common epilepsy syndrome: any combination of tonic-clonic seizures, absence seizures and myoclonic seizures. MRI typically normal. EEG may show generalized spike-wave abnormality

Answer 42

Idiopathic generalized epilepsy

Question 43

Name the common epilepsy syndrome: | a generalized seizure associated with morning onset of brief, lightning like jerks of the arms not associated with LOC

Answer 43

Myoclonic seizure

Question 44

DBT - Epilepsy - Consider drugs (alcohol & cocaine) as cause of 1st time seizure - Diagnostic eval may not be needed for a provoked seizure if ____ - Seizures that occur within a week of head trauma or ICH may benefit from short course of ____ but do not necessarily require long-term treatment

Answer 44

- normal findings on neurologic exam | - AED