Test 5 Flashcards
What is the presentation of a Tension headache? “muscle contraction” h/a
- may be frequent, infrequent, or chronic episodes
- typically bilateral, nonpulsating
- pressing or tightening, squeezing, “band-like” pain; mild to moderate intensity
- lasts minutes to days
- not associated w/ routine physical activity, n/v not common, no photophobia
- gradual onset, duration 1/2 hr to 1 wk
- may effect sleep pattern*
Other:
* may be related to serotonin, norepinephrine, and dopamine pathway (connection with depression)
* more prevalent in women, peaks b/w 30-38 years
* common in White, educated
* anxious/depressed patients
What are the physical findings of cluster headaches? “vascular” h/a
- severe, uniLateral orbitaL, supraorbital, temporal, or combination
- nonpulsatile, constant, may radiate to forehead, neck, shoulder
- nasaL/eye symptoms (watery or red eyes) r/t ophthalmic nerve pain/tenderness, facial sweating
- no nausea, not related to physical activity
- lasts 15min-3 hrs; can occur every other day to 8x/day
Other:
* middle age men most common
* often occurs at night
* alcohol, histamine, or nitroglycerin can trigger
What is an effective treatment for cluster headaches?
- follow migraine guidelines, avoidance education, triggers
- SQ imitrex is 1st line
- 100% oxygen therapy nonrebreather mask
- Preventative-**Propranolol **(first-line BB) and Verapamil (first-line CCB)
What are the demographics of migraine sufferers?
- more prevalent in women
- 25% of women during reproductive years
- present at 1st menstrual period or age of menarche
- connected to hormonal shifts “menstrual migraines”
- more prevalent in AA and nonwhites of Hispanic origin
- more common in younger adults-risk decreases with age
- 5% of school age headaches
- often hereditary, onset usually before age 20
What are the red flags of a headache that would require further evaluation?
- S-systemic illness
-
N-neurological -focal neuro findings: nuchal rigidity, altered mental status
seizures, falls, drooling - O-onset is new or sudden, w/exertion, cough, sexual activity
- O-other associated features (drugs, toxins)
- P-previous h/a hx with progression or change in characteristics
- c/o worst h/a ever
- presence of orbital bruit
- personality changes, depression, or suspected temporal lobe mass
- older adult with late onset h/a (40+)
- children w/severe/changing h/a or neuro dysfunction, seizures
What is the workup for a headache with unspecified origin/etiology?
- CT or MRI-atypical presentation
- CBC, Chem profile, UA to r/o systemic illness
- TSH, ESR, UDS (r/o substance use)
- consider CT/MRI in children w/severe/changing h/a or neuro dysfunction
- older adult with late onset migraine-order CT
- physical exam
Know migraine triggers. “vascular” h/a
- food
- odors
- light, sound
- sleep
- weather changes
- hormonal changes, menstruation, falling estrogen levels
- stress, physical activity
- substance that cause vasodilation (sodium nitrate-preservative in processed meat and food coloring, alcohol); vasoconstriction (caffeine most common)
What is the prophylactic treatment for migraines?
EXERCISE-30 min 3-7 days/wk, relaxation techniques (yoga, deep breathing)
SLEEP-adequate sleep
EAT-eat regularly, scheduled meals; do not skip meals; avoid food triggers (diary)
DRINK-no more than 2 caffeinated drinks/day, stay hydrated
* Biofeedback, CBT
* avoid overuse of medication
* cold compresses to area
* Preventative-Propranolol (beta-blocker) is first-line
Other:
* Abortive therapy-lessen degree of migraines (NSAIDs, ASA)
* Rescue therapy-oral triptans and NSAID not helping
What are the presenting symptoms of premenstrual migraines?
- head pain-dull to severe
- sensitivity-light, sounds, smells
- scalp tenderness
- loss of appetite
- dizziness, blurred vision
- tiredness
- n/v, abd pain
- s/s similar to migraine, onset around menstrual cycle
Other:
* birth control-tri-cycling (skip 7 days of placebo for consistent level of hormone in the body)
* decrease the level of progesterone in body which causes ovulation-depo shot/implant
* Perimenstrual period: Naproxen 550mg, 6 days before period and 7 days after period
What are the presenting symptoms of temporal arteritis (TA)?
- throbbing, continuous deep, burns
- unilateral or bilateral in temporal artery area or back of head; continuous
- temporal artery swelling, constriction, tenderness
- Hallmark: scalp tenderness, jaw pain (head hurts w/ chewing), sudden eyesight problems (can lead to blindness)
- systemic: sweating, low-grade fever, malaise, muscle aches (s/s of bad flu)
- face pain
- hearing loss
Other:
* equal in men and women
* age 60+ (risk increases with age)
* r/t faulty immune response (i.e. overuse of antibiotics)
What are the presenting symptoms of petit mal seizures (absence)?
- absence seizures; brief arrest of activity, may stare into space or in a daze/blank stare, daydreaming, may go unnoticed
- not preceded by aura/warning
- flickering of eyelids, lip-smacking
- may have numerous episodes during day
- episodes usually less than 10 sec, no postictal stage
What is the most informative test in diagnosing epilepsy?
EEG
What is the relationship between antiseizure medication and contraception?
- oral contraceptives less effective in pts on AEDs
- women taking enzyme-inducing AEDs should use backup or alternative birth control method
Management of patients who want to conceive who are taking seizure medication. (Hint: Lamictal)
- Lamictal among safest med for developing fetus; may have to increase dose while pregnant as it is excreted from body faster during pregnancy
- pts may have a harder time conceiving due to irregular periods and hormonal d/o associated with seizure d/o and meds
Other:
* teratogenic effects associated with AEDs
* 1st trim use of one AED associated w/2-5 fold increase in major fetal anomalies (neural tube defects, cleft lip and palate, cardiac anomalies)
* attempt to decrease to monotherapy or taper to lowest dose
* if no seizures in 2-5 yrs consider withdrawal of meds
S/S of Parkinson’s
4 prominent features:
1. Bradykinesia (slow movement/speech, difficulty swallowing, pooling saliva)
2. Muscular rigidity (cogwheel type)
3. resting tremor
4. postural instability (failure of postural “righting” reflexes leading to poor balance/falls
Treatment for Parkinson’s disease
- Levodopa w/ Carbidopa (Sinemet)-first line (most effective for s/s); Levodopa has shown to reduce morbidity/mortality, take 1 hr before meals
- Dopamine agonist-second-line, often given w/ lower doses of Levodopa (Mirapex and Requip)
- Anticholinergic-tremors and drooling (Artane)
- Ergot derivatives, neuroprotective agents
- TCAs, benzos, diphenhydramine, low dose chloral hydrate for sleep d/o
- No single DMT can slow/stop progression. Polypharmacy is hallmark
- Neuro referral for comanagement; immediate treatment
- regular exercise, high fiber/calcium diet, adequate hydration
- monitor protein intake d/t levodopa interation
Which cranial nerve would you assess for visual acuity?
CN II
Know the difference between central vs peripheral vertigo?
- peripheral (inner ear)-change in hearing or ear pain, more common
- central (CNS)-h/a, neck pain, visual changes, ataxia, speech problems, CNS complaint
What are the causes of syncope?
- acute global reduction in cerebral blood flow
- Vasovagal episodes
- Situational-coughing, urination, defecation
- Medications
- decrease in cardiac output caused by blood-flow obstruction (seizures, mitral/aortic stenosis); focal or generalized decrease in cerebral perfusion
- metabolic abnormalities (hypoglycemia, hypoxia)
- Psychiatric illnesses (panic attacks, anxiety, depression)
- unknown cause
