Neurology Flashcards
What is the number one neurological disease in primary care other than pain?
Headaches
What is a primary headache? What is a secondary headache? Who experiences mostly secondary headaches?
Primary is not secondary to something else going on. Elderly patients who present with a new onset of headaches —> almost always is secondary to something else. Secondary meaning something else is going on.
What age is considered “elderly” in neurology?
40’s… maybe 50’s
How do you approach a patient who presents with a headache in primary care?
What some red flags?
- Obtain a good history -> if unable to give a history —> send pt out
- Red flags: c/o first or worst headache… worst headache every had (10/10)… refer pt out. Age greater than 40. Neck stiffness especially w/fever (Meningitis).
- Physical exam: most pt’s w/a headache have a normal history & normal physical exam. Pain in the head may not be coming from the head but referring from somewhere else (common place is neck). (Ex. Pt c/o headache feeling like it’s going to pop off and burning — examined pt’s scalp & pt had shingles)
What is the first question to ask a patient that presents to primary care c/o a headache?
Where does it hurt?
When a pt c/o a unilateral headache, what is the most likely headache?
Migraine
What is something that should be documented about headaches?
Characteristics of the headache
What are the characteristics of a migraine headache?
Crescendo headache —> starts at 1 or 2 out of ten pain and then progressively worsens to 8 or 10
How long does a migraine headache lasts?
Between 4-72 hours
With older patients, what is something to look out for?
Temporal arteritis
What changes occur in the cerebral arteries during a migraine headache?
The cerebral arteries dilate
How do “triptan” drugs work?
Constrict cerebral arteries
Do “triptan” drugs just stay in the cerebral arteries?
No. You can get bleed over into the coronary arteries
What diseases would you never want to give “triptans?” What is a drug that interacts with “triptans?”
Uncontrolled hypertension
Angina
Drugs for depression —> SSRIs (drug-drug interaction)
Rationale: called drug disease interactions… Ex. A reaction between triptan and hypertension.
What is the criteria used to diagnose migraines with & without aura?
Look in book… (do not have to memorize)
What is are common triggers for migraines?
Bright lights
Menses
What is the treatment for migraines?
Triptans —> unless contraindicated
What drugs may be used prophylactically to prevent migraines?
Beta blockers
may or may not work ….considered off label drug meaning FDA has not ok-ed drug to be used for specific disease
35 year old female with migraine headaches ask for advice about contraception. What advice should be given?
Putting her on an estrogen-progesterone contraception at her age does increase her risk of a stroke.
*Rationale: migraine + oral contraception does increase (at least a little bit) of having an ischemic stroke. If she has migraine with aura, it doesn’t matter what her age is, the risk of a stroke from oral contraception might be too much. Generally women less than 35 years old, the benefits outweigh the risk provided it’s not a migraine with aura. Women who are older than 35 probably needs some other form of contraception besides an estrogen-progesterone drug because of the risk of stroke.
What is the health promotion regarding migraines?
Prophylactic
How is trigeminal neuralgia described?
Sudden, severe unilateral facial pain coming from the trigeminal nerve.
“Tri” means three — trigeminal nerve has three branches (or divisions).
How is the pain described from trigeminal neuralgia?
Intense, sharp, piercing, stabbing
Pain comes and goes and when it comes, it’s PAINFUL
Trigeminal neuralgia is most common in what age group?
Elderly (older than 40… 50’s.. 60’s).
What drug is used to treat trigeminal neuralgia?
Carbamazepine (Tegretol)
What is an adverse effect of carbamazepine (tegretol)? Patient education regarding adverse effect.
Makes pt’s loopy (cross between sleepy & drunk)
Pt education: take medication when at home
How long does it take for a patient to feel better after taking carbamazepine (tegretol)?
48-72 hours
What are clues that a pt may have temporal arteritis (inflammation of the artery)?
Most important risk factor is aging: mean age is 72 years old
Clue: jaw claudication, pain over temporal artery, headaches… sometimes accompanied by fever & fatigue, and systemic issues
What are the treatments for temporal arteritis?
Refer patient
What cranial nerve is affected by Bell’s palsy?
CN VII (7) (facial nerve)
What is Bell’s palsy caused by?
Herpes virus
What are the symptoms of Bell’s palsy?
Drooping of eyelid
Facial paralysis
Drooping of the lip
Either all three or one of them
What is the most important disease to rule out when a pt presents with symptoms that resemble Bell’s palsy?
Stroke
Once determined that symptoms are due to Bell’s palsy, what is important to do next?
Attention has to be directed towards the patient’s eye on the affected side. The eye on the affected side will end up with permanent change in vision unless the eye is kept lubricated. The first thing to ask the patient to do is to close their affected eye. Important to make sure that eyelid completely covers the eye when they blink or close their eye. If the eyelid does not completely cover the eye, move on to interventions.
What are the interventions for a pt with Bell’s palsy whose eyelid does not completely close on the affected eye?
Ocular lubricant —> rewetting drops that they can use every 1 hour while awake
If cannot close at night —> lacralub gel that is applied to the lower lid and then disperse if over the entire eye to moisten it while they sleep and the manually move the eyelid closed and taped shut for the night.
When does function return for Bell’s palsy patients?
3-4 months
Pt education: can take months before it completely resolves
What medication class is the mainstay of therapy for patient’s with temporal arteritis or Bell’s palsy?
Steroids
How much steroids should be given to a patient with Bell’s palsy?
Days 1-5: Prednisone 60 mg (30 in am, 30 in pm) per day
Day 6: 50 mg
Day 7: 40 mg
Day 8: 30 mg
Day 9: 20 mg
Day 10: 10 mg
