Unit 5 - Quizlet Flashcards
Which of the following statements about ergotamines
is false?
A. are effective for tension-type headaches
B. act as 5-HT1A and 5-HT1D receptor agonists
C. have potential vasoconstrictor effect
D. should be avoided in the presence of coronary artery
disease
a
Causes of insomnia
+ Depression
+ Manic disorders
+ Abuse of ETOH (can be cause of or secondary to a sleep disturbance)
+ Heavy smoking (> pack/day)
+ Other medical conditions (e.g. delirum, pain, respiratory distress, uremia, asthma, thyroid disorders, nocturia r/t BPD)
What medications can be given as “transitional therapy” for 2 weeks or so until prophylactic medications for cluster HA become effective?
+ Prednisone – 60 mg daily for 5 days, followed by gradual withdrawal over 7 - 10 days.
+ Ergotamine tartrate – 0.5 - 1 mg nightly via rectal suppository, 2 mg daily PO, or 0.25 mg TID SQ five days per week.
Fluoxetine
+ Generic name - Fluoxetine
+ Class – SSRI
+ Indications for use
– OCD in adults
– Depression
+ Contraindications
CAUTION IN ETOH use, concurrent CNS depressant use, elderly, pts < 25 years, pregnancy 3rd trimester, hepatic impairment, QT issues, bradycardia, DM
+ Common side effects – Insomnia, nausea, HA, diarrhea, libido ↓, dirrhea, anorexia, somnolence, anxiety, can ↑ serum concentrations of some meds.
+ Dosage
– OCD: Up to 60-80 mg day (start at 20 qd and increase after several weeks. taper to d/c)
– Depression: Starting dose of 10 mg/day for 1 week, before increasing to avg daily dose of 20 mg/day.
Candesartan (not FDA approved for migraine)
+ Generic name – Candesartan
+ Class – Angiotensin receptor blocker
+ Indications for use - Prophylaxis of migraine
+ Contraindications
– CONTRAINDICATED in pregnancy, pts < 1 year old
– CAUTION in renal or hepatic impairment, hyponatremia
+ Common side effects – Dizziness, cough, diarrhea, fatigue
+ Dosage – PO, 8 - 32 mg once daily
Pharmaceutical interventions for anxiety in pediatric patients
Pharmaceutical interventions for anxiety in pediatric patients
+ SSRIs and alpha agonists have shown some benefit, but are not FDA approved for < 8 years old
+ Benzos are not recommended for peds because the developing brain is at increased risk for dependency and iatrogenic substance abuse.
Medication approved for tx of OCD in children and adolescents?
Medication approved for tx of OCD in children and adolescents?
+ Fluoxetine (Prozac)
+ Sertraline (Zoloft)
+ Fluvoxetine (Luvox)
Conversion disorder
Conversion disorder
+ Conversion of psychic conflict into physical symptoms commonly co-occurs wtih panic disorder or depression. (e.g. paralysis for panic disorder)
Treatment of OCD in kids
Treatment of OCD in kids
+ CBT-specific for OCD
+ SSRIs – specifically fluvoxamine and sertraline – have FDA approval for treatment of pediatric OCD
NOTE: Combination of CBT plus medicatio is the most effective tx for patients who do not respond to either treatmetn alone.
Ages in childhood during which sleep-disordered breathing peaks?
Between ages 2 - 6
First line treatment for GAD
First line treatment for GAD
CBT with possible addition of SSRI if response is insufficient
Behavioral states in children
\+ Crying state \+ Quiet alert state \+ Active alert state \+ Transitional state \+ Deep sleep state
– These states are 1) maintained until NECESSARY to shift to another, 2) STABLE over several minutes, 3) SAME STIMULUS elicts a STATE-SPECIFIC response different from other states
– Behavior is more easily influenced during TRANSITIONAL state
What is a “washout time”?
Time between switching from one group of antidepressants to another durig which the previous med clears the system.
++ 2-3 weeks between stopping MAOI and starting TCA
++ at LEAST 2 weeks between stopping SSRI and starting MAOI (ALLOW 4-5 weeks for fluoxetine!)
No washout time is needed for switching WITHIN groups.
Other types of medications often used to treat peripheral symptoms of PTSD
+ Beta blockers - Helps with anxiety (e.g. propranolol)
+ Noradrenergic agents - Help with hyperarousal (e.g. clonadine)
+ α-adrenergic blockers - Decrease nightmares (e.g. prazosin)
+ Antiseizure medications - Mitigate impulsivity and difficulty with anger management (e.g. carbamazepine)
+ Benzodiazepines - Reduce anxiety and panic attacks but CAUTION WITH DEPENDENCE (e.g. clonazepam)
NOTE: 2nd generation antipsychotics have not proven useful.
Differential dx for agoraphobia
+ Other anxiety disorders
+ PTSD
+ Depression
+ Medical conditions (eg inflammatory bowel disease)
Circumcision related to UTI
reduces risk in males
Encopresis
Encopresis
+ Repeated passage of stool into clothes or bed by a child who is chornologically or developmentally older than 4 years.
+ Occurs each month for at least 3 months and is not attributable to meds or medical condition (except for constipation)
Screening tool for pediatric patients and their parents
M-CHAT
Headache associated with pregnancy?
Preeclampsia
McPhee p 39
Components of chronic pain syndrome
Components of chronic pain syndrome \+ Anatomic changes \+ Chronic anxiety and depression \+ Anger \+ Changed lifestyle
UTI gold standard for diagnosis
urine culture
Clinical Findings and treatment: Phobic Disorder
FINDINGS:
+ Fear of a specific object or situation
+ Rule out all underlying medication disorders
TREATMENT:
+ SSRIs (e.g. paroxetine, sertraline and fluoxamine) are used.
+ Certain phobias may respond to moderate doses of beta blockers.
+ Behavioral therapies such as systematic desensitaivation have been successful.
“Thunderclap headache” is the classic presentation of what condition?
Subarachnoid hemorrhage! Should precipitate IMMEDIATE workup!
McPhee p 39
Signs of aneurysm prior to rupture
Signs of aneurysm prior to rupture
+ Usually asymptomatic unless they compress adjacent structures.
+ Some pts have headaches with nausea and neck stiffness a few hours or days before massive hemorrhage occurs. (r/t “warning leaks”)
What do younger children with GAD usually worry about?
Competence or performance
Clomipramine
+ Generic name - Clomipramine
+ Class - Tricyclic antidepressants (TCAs)
+ Indications for use - OCD in adults
+ Contraindications
CONTRAINDICATED IN acute MI recovery
CAUTION IN elderly, < 25 years, GI/GU obstruction, urinary retention, seizure disorder, thyrpid disease, DM, asthma, hepatic/renal impairment, bipolar disorder, ETOH abuse, suicide risk.
+ Common side effects - Xerostomia, drowsiness, tremor, dizziness, HA, consiptaion, fatigue, n/v, etc.
+ Dosage
– OCD: 150-250 mg PO qhs (Start at 25 mg po QD and increase gradually over weeks)
NOTE for OCD: Check plasma levels 2-3 weeks after a dose of 50 mg/day is reached to keep plasma levels ↓ 500 ng/mL to avoid toxicity
Tension type headaches
most common type of primary headache disorder
Pt complaints: pericranial tenderness, poor concentration, constant daily headaches with vise like or tight quality but NOT pulsatile
Usually generalized, may be most intense around the neck or back of head and ARE NOT associated with focal neurologic symptoms
May be exacerbated by emotianal stress, fatigue, noise or glare
Biofeedback adn relaxation training may be effective
Treatment similar to migraine but triptans NOT indicated.
Medical management of chronic pain
Medical management of chronic pain
+ SNRIs (e.g. venlafaxine, milnacipran and duloxetine) and TCAs (e.g. nortriptyline) in doses up to those used in depression may be helpful, particularly in neuropathic pain syndromes.
+ Fibromyalgia – Both duloxetine and milnacipram are approved for tx.
+ Duloxetine is approved in chronic pain conditions.
+ SNRIs are safer in overdose than TCAs.
+ Gabapentin and pregabalin anticonvulsants have been shown to be useful in somatic symptom disorders and fibromyalgia.
New, Severe, or acute headaches
more likely to relate to an intracranial disorder
Criteria for dx of separation anxiety disorder
Criteria for dx of separation anxiety disorder
+ Must be distinguished from normal development
+ Must occur for more than 4 weeks for children
+ Must lead to impairment or significant distress
Worsening behavior of a child with autism may be indicative of what?
+ Possible medical issues (e.g. dental abscess or esophagitis)
What medications are approved for maintenance of bipolar disorder, to prevent subsequent cycles of mania and depression?
Olanzapine quetiapine ziprasidone aripiprazole long acting injectable risperidone
Components of good sleep hygiene
\+ Go to bed only when sleepy \+ Use bedroom for sleep and sex \+ Get up if not asleep in 20 minutes \+ Get up at same time every day \+ No caffeine/nicotine in pm \+ Daily exercise \+ Avoid ETOH \+ Limit fluids in PM \+ Use relaxation techniques \+ Bedtime ritual and routine for going to sleep
Attitude of clinician to patient with chronic pain
Attitude of clinician to patient with chronic pain
Honesty, interest and hopefulness – not for a cure but for control of pain and improved function.
Bipolar 1 vs Bipolar 2
+ Bipolar 1 - Individual has manic episodes
+ Bipolar 2 - Individuals who experience hypomanic episodes without frank mania
ESSENTIALS OF DIAGNOSIS: PTSD
+ Exposure to traumatic or life-threatening event
+ Flashacks, intrusive images and nightmares in which pt re-experiences event
+ Avoidance symptoms (e.g. social, numbing) and avoidance of triggers
+ Increased vigilance, such as startle response and difficulty falling asleep
+ Symptoms impair functioning
Lithium
+ Generic name - Lithium
+ Class - Antipsychotic
+ Indications for use
– Tx of mania, bipolar disease
+ Contraindications
– CAUTION - Breastfeeding, elderly, renal issues, thyroid disease, ETOH use
+ Common side effects
- EARLY: Mild GI sx, fine tremors, slight weakness and sedation. Moderate polyuria and polydipsia. Thyroid and kidney issues sometimes (check function at 4 -6 month intervals)
- LONG TERM: Cogwheel rigidity and sometimes EPS.
+ Interactions
– ↑ lithium levels! AVOID thiazide diuretics (loop ok), ACEI, fluoxetine, ibuprofen, K-sparing diuretics
+ Dosage
– Bipolar/Manic disorder: start at 300 mg po bid or tid, measure trough after 5 days, 12 hours after last dose. Peak serum levels in 1 - 3 hours.
Primary treatment for anxiety disorder in children
Cognitive behavioral therapy (CBT)
Acute HA - RED FLAGS in adults
Acute HA - RED FLAGS in adults \+ New onset HA in pt > 50 yrs \+ Thunderclap HA \+ HA + fever \+ Hx head trauma \+ Vision changes \+ Hx of/current HTN \+ Immunosupprssion \+ Positive neuro exam (e.g. dilated eyes, slowed responses, etc.) \+ Changes in personality
TRIGEMINAL NEURALGIA: Phenytoin
+ Generic name - phenytoin
+ Class – Antiseizure
+ Indications for use - Tx of trigeminal neuralgia
+ Contraindications
CONTRAINDICATED in sinus bradycardia, SA block, AV block
CAUTION in CV disease, hypotension, ETOH use, elderly, renal/hepatic impairment, DM, thyroid disease, depression
+ Common side effects - Nystagmus, ataxia, sedatino, confusion, blood dyscrasias, SLE, peripheral neuropathy
+ Dosage – PO, 200 - 400 mg daily
McPHee p 990
Males have an earlier age of onset of OCD, usually occuring before ____ years of age
10
Depression medication – If no background information is available, what two medications are good STARTING places?
Depression medication – If no background information is available, what two medications are good STARTING places?
FULL TRIALS can be started with either:
+ Sertraline (Zoloft) - 25 mg PO, increase gradually to 200 mg
+ Venlafaxine (Effexor) - 37.5 mg/day PO and titrated graually to maximum dose of 225 mg/day.
+++Monitor for worsening mood or suicidal ideatio ecry 1-2 weeks until week 6.
When does GAD usually present?
RARELY does it present before adolescence
Commonly used antidepressants:
SSRIs (from $ to $$$, sedation from 1 - 4)
Commonly used antidepressants:
SSRIs (from $ to $$$, sedation from 1 - 4)
+ Citalopram (Celexa): 20 mg qd (max 40 mg qd) S0
+ Escitalopram (Lexapro): 10 mg qd (max 20 mg qd) S0
+ Paroxetine (Paxil): 20-30 mg qd (max 50 mg qd) S1
+ Sertraline (Zoloft): 50-100 mg qd (max 200 mg qd) S0
+ Fluvoxamine (Luvox): 100-300 mg qd (max 300 qd) S1
+ Fluoxetine (Proxac): 5-40 mg qd (max 80 mg qd) S0
What are some predictors of persistent social anxiety disorder over time?
1) Early age of onset
2) More severe avoidance
3) Presence of panic symptoms
Obsessions and compulsions of OCD consume more than _________ (time) per day
1 hr
Autism severity score per DSM-5
Autism severity score per DSM-5
Level I - Requiring support
Level II - Requiring substantial support
Level III - Requiring very substantial support
Typical presentation of colic
Typical presentation of colic
+ Severe, paroxysmal crying that occurs mainly in late afternoon.
+ Knees are drawn up and fists clenched, flatus expelled, facies has pained appearance, soothing is difficult
+ Crying occurs for more than 3 hours a day, for more than 3 days per week, for more than 3 weeks (“rule of threes”)
+ INFANT IS HEALTHY AND WELL FED
A patient is at HIGH RISK if he thinks about suicide > _____________ hours per day
ONE
Kernig and Brudzinski signs are indicative of what?
Meningeal irritation
McPhee p 40
Cystitis treatment
Uncomplicated - amoxil, bactrim, or first gen cephalosporin for 7-10 days
Frequently occurring UTIs can be treated prophalactically with bactrim and macrobid
Age of normal colic presentation
+ Begins in first few weeks of life, and peaks at age 2 - 3 months.
+ In about 30-40% of cases, colic continues into the 4th and 5th months
ESSENTIALS OF DIAGNOSIS + TYPICAL FEATURES:
Anxiety Disorder in children
+ Fear or anxiety that is excessive or persists beyond developmetnally appropriate period
+ Fear or anxiety is accompanied by behevioral disturbances or physical manifestations
+ Symptoms cause functional impairment or significant distress
ESSENTIALS OF DX + TYPICAL FEATURES:
Sleep disorders in children < 12 years
+ Difficulty initiating or maintaining sleep that is viewed as problem by child or caregiver
+ May be characterized by its severity, chronicity, frequency AND associated impairment in daytime function in child or family
+ May be due to primary sleep disorder OR occur in association with other sleep, medical or psychiatric disorders
Lorazepam
+ Generic name - Lorazepam (valium)
+ Class - Benzodiazepine
+ Indications for use
– INSOMNIA
+ Contraindications
+ Common side effects
+ Dosage
– INSOMNIA: 0.5 mg PO nightly
Most common cause of subarachnoid hemorrage
Most common cause of subarachnoid hemorrage
Trauma. Prognosis depends on severity of head injury
MIGRAINE or CLUSTER HA: Sumatriptan
+ Generic name – Sumpatriptan
+ Class – Triptan
+ Indications for use – Used to abort migraine attacks or as treatment for cluster HA
+ Contraindications
–AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity)
– CAUTION in pts with controlled HTN
– CONTRAINDICATED in pts with coronary or peripheral vascular disease
+ Common side effects – Nausea and vomiting
+ Dosage for migraine
– SQ, 4-6 mg once, repeat after 2 hours if needed; max dose 12 mg/24 hours
–Nasal and PO avajilable, but less effective r/t slower absorption
Dosage for cluster HA
–SQ 6mg or IN 20 mg/spray
Commonly used antidepressants:
TCAs and similar (from $ to $$$, sedation from 1 - 4)
+ Amitriptyline (Elavil): 150-250 mg qd (max 300 mg qd) S4
+ Doxepin (Sinequan): 150-200 mg qd (max 300 mg qd) S4
+ Imipramine: 150-200 mg qd (max 300 mg qd) S3
+ Amoxapine: 150-200 mg qd (max 400 mg qd) S2
+ Nortriptyline: 100-150 mg qd (max 150 qd) S2
+ Maprotiline: 100-200 mg qd (max 300 qd) S4
+ Desipramine: 100-250 mg qd (max 300 qd) S1
+ Trimipramine: 75-200 mg qd (max 200 qd) S4
+ Protriptyline: 15-40 mg qd (max 60 qd) S1
+ Clomipramine: 100 mg qd (max 250 qd) S3
NOTES: Effective in panic disorder, pain syndromes and anxiety states. Also OCD, enuresis, psychotic depression and craving reduction in cocaine withdrawal. Full trial is daily for 6 weeks. ↑ anticholinergic effects
Physical exam for UTI
Physical exam for UTI
BP assessment
Abdominal exam - check for masses, one of most common abd. mass in children is renal in origin.
GU exam
Secondary causes of headache?
Some examples: \+ Intracranial lesions \+ Head injury \+ Cervical spondylosis \+ Dental/ocular disease \+ TMJ dysfunction \+ Sinusitis \+ Hypertension \+ Depression
Education of adolescent patient and family on a dx of depression
Education of adolescent patient and family on a dx of depression
1) It’s an illness, not a weakness. Very common. Genetic + environment
2) Functional impairment in various domains can be manifestations of illness
3) Can be recurrent. Recovery may take awhile
4) Stay with tx plan long term is KEY
5) Parent/child stress may be part of problem
6) Ask adolescent about future goals (if none, be wary of suicidal ideation)
Critical components of physical exam for complaint of HA?
+ Vital signs
+ Complete neuro exam
+ Vision testing (with funduscopic exam)
McPhee p 40
Components of visual exam for pt presenting with HA?
\+ Visual acuity (Snellen) \+ Ocular gaze (Motor test - 9 positions) \+ Visual fields (Cover test - central/periph vision) \+ Pupillary defects (Size, dilation) \+ Optic disks \+ Retinal vein pulsations
McPhee p 40
Prophylactic treatment for migraine headaches includes the use of: A. amitriptyline. B. ergot derivative. C. naproxen sodium. D. clonidine.
a
Glossopharyngeal neuralgia - Symptoms and tx
+ Symptoms: Trigeminal neuralgia-like pain occurs in throat, near tonsillar fossa and sometimes deep in ear and at back of tongue
+ Pain may be precipiated by yawning, swallowing, chewing, talking and is cometimes accompanied by syncope
+ No underlying structural issue, often. MS is sometimes responsible
+ Oxcarbasepine and carbamazepine are tx of choice
ESSENTIALS OF DIAGNOSIS: Some severe depressions
+ Psychomotor retardation or agitation
+ Deulsions of a somatic or persecutory nature.
+ Withdrawal from activties
+ Physical symptoms of major severity, e.g. anorexia, insomnia, reduced sexual drive weight loss and various somatic complaints
+ Suicidal ideation
ESSENTIALS OF DX + TYPICAL FEATURES:
Obsessive compulsive disorder
+ Recurrent obsessive thoughts, impules or images that are experienced as instrusive at times
+ Repetitive compulsive behaviors or mental acts are performed to prevent or reduce distress stemming from obsessive thoughts
+ Obsessions and compulsions cause marked distress, are time-consuming and interfere with normal activities
What types of headaches should be referred?
+ Frequent migraines not responsive to std tx
+ Migraines with atypical features
+ Chronic daily ha r/t medication overuse
Confirming dx of PTSD lies in the ability to do WHAT?
Identify the hx of exposure to actual or perceived life-threatening event, serious injury or sexual violence
Deepest NREM sleep occurs when?
During the first 1-3 hours after going to sleep
More than _____________% of cases of encopresis result from constipation
90%
Diagnosis of UTI is made upon the basis of these three factors (choose 3):
a) presence of pyuria
b) b/l flank pain
c) frank hematuria
d) 50,000 colonies per mL or more of a single uropathogenic organism
e) urine specimen must be appropriately collected
A D E
CLINICAL FINDINGS: Adjustment disorder with depressed mood
CLINICAL FINDINGS: Adjustment disorder with depressed mood
+ Depression occuring in reaction to some identifiable stressor or adverse life situation.
+ Anger is often associated with the loss, and this in term often produces a feeling of guilt
+ Occurs within 3 months of the stressor and causes significant impairment in social or occupational functioning
+ The presence of a stressor is NOT the determining diagnostic! It is the resultant syndromal complex.
Highest prevalence of encopresis is between __________ and ________ years of age
5 and 6
Depression can be secondary to what illnesses and medications?
ILLNESSES
+ Chronic illnesses like RA, MS, stroke and chronic heart disease
+ Common in cancer, and especially high in pancreatic cancer.
+ ETOH dependency frequently coiexists with serious depression.
MEDICATIONS
+ Reserpine
+ Corticosteroids and oral contraceptives are associated with depression and hypomania
+ Anti-HTN meds likemthyldopa, guanethidine and clonidine have been associated with development of depressive episodes, as have dititalis and antiparkinsonism medications.
+ Interferon is strongly associatd with depressed mood and fatigue as a side effect
At what age does night waking often start?
at 9 months, as separation anxiety is beginning
+ At this time, parents should receive guidance to know to reassure theri child without making the interaction prolonged or pleasurable.
Dosage of triptans in tx of migraine
+ Take at onset of HA
+ Most can be repeated q2h for a total of 2 doses in 24 hours.
Propranolol (and other ß-adrenergic antagonists)
+ Generic name – propranolol
+ Class – Beta blocker
+ Indications for use - Prophylaxis of migraine
+ Contraindications
– CONTRAINDICATIONS – Bradycardia or heart block w/o pacemaker, bronchial asthma
– CAUTION in elderly, 2nd/3rd trimester of pregnancy, rena/hepatic impairment, PVD, DM, thyroid disorder
+ Common side effects – Fatigue, dizziness, hypotension, bradycardia, depression, insomnia, n/v, constipation
+ Dosage – PO, 80 - 240 mg, divided 2 to 4 times daily
Carbamazepine
+ Generic name - Carbamazepine
+ Class - Antiseizure
+ Indications for use
- Tx of trigeminal neuralgia
- Tx of bipolar in pts who cannot take lithium (doesn’t work or ↑ side effects)
+ Contraindications
CONTRAINDICATED in pts using MAOIs, bone marrow depression, sensitivity to TCAs
CAUTION in CNS depressant use, ETOH use, elderly, asian, hepatic/renal impairment, CV disease, arrhythmia risk (MONITOR WITH serial blood counts and LFTs)
+ Common side effects – Nystragmus, dysarthria, diplopia, ataxia, drasiness, nausea, hepatoxicity, hyponatremia
+ Interactions
– Will ↑ carbamazepine levels! – NSAIDs (except aspirin), erythromycin, isoniazid, some CCBs (verapamil and diltiazem, but not nifedipine), fluoxetine, cimetidine (Tagamet).
+ Dosage
- Trigeminal neuralgia: 400 - 1600 mg (immediate or extended release) divided in 2 daily doses
- Bipolar: Start at 400-600 PO daily and increase to 800 - 1600 PO daily.
Commonly used antidepressants:
Atypicals and other (from $ to $$$, sedation from 1 - 4)
Commonly used antidepressants:
Atypicals and other (from $ to $$$, sedation from 1 - 4)
+ Mirtazipine (Remeron): 15-45 mg qd (max 45 mg qd) S4
+ Trazodone: 100-300 mg qd (max 400 mg qd) S4
+ Buproprion SR: 300 mg qd (max 400 mg qd) S0
+ Vilazodone: 10-40 mg qd (max 40 mg qd) S1
+ Buproprion XL: 300 mg qd (max 450 mg qd) S0
+ Nefazodone: 150-600 mg qd (max 600 qd) S3
+ Vortioxetine: 10 mg qd (max 20 qd) S0
Symptoms for diagnosis or ruling out migraine in the absence of “classic” presentation (e.g. scintillating scotomoa, unilateral ha, photophobia and n/v)?
Symtoms: Nausea, photophobia, phonophobia and exacerbation with physical activtiy
THREE OR MORE = MIGRAINE
< THREE = r/o MIGRAINE
McPhee p 39
Treatment for OCD in adults
Treatment for OCD in adults
+BEHAVIORAL/PSYCHOLOGICAL
++ Behavior modificatyion with systematic desensitization which involves gradually exposing patient to his fears to help manage anxiety.
— Do research to help educate patient and family and help with desensitization
++ “Thought-stopping”
+ PHARMACOLOGY
++SSRIs and TCAs are recommended, but may take up to 12 weeks to take effect.
– Clomipramine (TCA) - Primary med. Same dose as with depression. OR can be used as low dose adjunct to SSRI, but caution with seratonin syndrome.
– Fluoxetine (SSRI) - Primary med. higher dose than with depression
++ Antipsychotics and topiramate may be used as adjuncts to SSRIs in treatment-resistant cases.
+ OTHER
++ Work with employer to facilitate leave for recovery
What are the Kleinmann questions?
What are the Kleinmann questions?
A set of questions used to elicit the patient’s thoughts about the cause of their depression:
1) What do you think caused your problem?
2) Why do you think it started when it did?
3) What do you think your sickness does to you?
4) How severe is illness? Short or long course?
5) What kind of tx should you receive?
6) What are the most important results for you?
7) What are the chief problems your illness has caused in YOU?
8) What do you fear most about your sickness?
Components of the neurodevelopmental examination of pediatric patient
Components of the neurodevelopmental examination of pediatric patient
1) Defining child’s level of developmental abilities in a variety of domains, including:
- - language
- - motor
- - visual-spatial
- - attention
- - social abilities
2) Determine etiology of any developmental delays
3) Planning a treatment program
ANY abnormality on neuro exam (esp mental status) of pt with HA warrants….
EMERGENT neuroimaging
Mainstay of treatment for specific phobia
Mainstay of treatment for specific phobia
CBT aimed at reducing anxiety or fear of the phobic stimulus
Ottawa criteria for evaluation of pts presenting with acute non-traumatic headache for signs of subarachnoid hemorrhage
\+ ≥ 40 years of age \+ Neck pain/stiffness \+ Witnessed loss of consciousness \+ Onset during exertion \+ Thunderclap headache \+ Limited neck flexion on examination
Symptoms of seratonin syndrome
Symptoms of seratonin syndrome \+ Rigidity \+ Hyperthermia \+ Autonomic instability \+ Myoclonus \+ Confusion \+ Delirium \+ Coma
Characteristics of sleepwalking and age when it starts
Characteristics of sleepwalking and age when it starts
+ Occurs during slow wave/deep sleep
+ Common between 4 - 8 years of age
Parents should take steps to ensure that child doesn’t injure himself walking around at night – maybe a bell on the door to alert parents if child gets up.
Causes of pseudotumor cerebri
1) Thrombosis of transverse venous sinus as a complication of otitis media or chronic mastoiditis
2) Sagittal sinus thrombosis
3) Chronic pulmonary disease
4) Lupus
5) Uremia
6) Endocrine disturbances such as hypoparathyroidism, hypthyroidism or Addison disease
7) Vitamin A toxicity
8) Use of tetracycline or oral contraceptives
9) Occasionally withdrawal of long term corticosteroids
Symptoms of migrainous headaches
+ Usually lateral, can be generalized
+ Usually throbbing, can be dull
+ Can be associated with anorexia, n/v, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision
+ Build up gradually and last ≥ 7 hours
+ Visual disturbances may precede or accompany HA
+ Triggered by emotional/physical stress, lack of/excess sleep, missed meals, specific foods, ETOH, bright lights, loud noise, menstruation, use of oral contraceptives
Most common type of primary headache disorder?
Tension-type headache
Pt with HA and hypertension, “cotton wool spots”, flame hemorrhages and disk swelling suggests….
Acute severe hypertensive retinopathy
Uses of lithium
Uses of lithium
+ Works best in patients with Bipolar 1 disorder
+ Works bets in patients with low frequency of episodes.
+ Sometimes useful in prophylaxis of recurrent unipolar depressions.
+ Can be used alone long-term for dx of bipolar disease in MOST patients.
What is the STAR*D trial and what does it suggest with regard to medication for depression?
If response to 1st medication is inadequate, best alternatives are:
1) Switch to a second agent from the same or different class of antidepressant
2) Try augmenting the 1st agent with buproprion (150-450 mg/day), lithium (300-900 mg/day PO), thyroid medication (liothyronine 25-50 mcg/day PO) or a 2nd generation antipsychotic (aripiprazole 5-15 mg/day or olanzapine 5 - 15 mg/day).
Treatment of insomnia
Treatment of insomnia
+ Psychological
– Start here for primary insomnia
– Good sleep hygiene
+ Medical: Short 2 week course
- BENZOS: Lorazepam (0.5 mg) or temazepam 7.5 - 15 mg)
- NON-BENZOS: Zolpidem (5 mg ♀, 5-10 mg ♂), zaleplon (5-10 mg).
Cyclothymic disorders
Cyclothymic disorders
Chronic mood distrubances with episodes of subsyndromal depression and hypomania. Symptoms must have at least a 2 year duration and are milder than those that occur in depressive or manic episodes.
+ If symptoms escalate into a full blown manic or depressive episode, reclassification as bipolar 1 or 2 would be warranted
Pt with HA and ipsilateral ptosis and miosis suggests….
Horner syndrome AND/OR carotid artery dissection
Symtoms of cluster headaches
+ Episodes of severe, unilateral periorbital pain occurring daily for several weeks
+ Frequently accompanied by one or more of following: Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of eye, Horner syndrome (ptosis, pupillary meiosis, facial anhidrosis/hypohydrosis)
+ Restlessness/agitation during attacks
+ Often occur at night, waking patient
+ Last between 15 minutes to 3 hours
+ Remission can last for weeks or months, but will recur.
+ Bouts may last for 4 - 8 weeks and recur several times a year.
+ Triggers can be ETOH, stress, glare, ingestion of specific foods
Adolescents need _______ hours per night but often only get ____.
NEED 9 - 9.5 hours
GET 7 - 7.25 hours
+ This is complicated by the 1 - 3 hours sleep phase delay due to physiologic changes in hormonal regulation of adolescent circadian rhythms.
Meds for symptomatic relief of migraine
+ Cafergot: 1/100 mg (ergot/caff), start with 1-2 tabs, repeat q 30 min to max dose of 6 mg per 24 hours
+ Triptans
- CONTRAINDICATED in CV disease
- CAUTION in pregnancy, hemiplegic or basilar migraines, hx of stroke or TIA, hx of DM, hyperlipidemia or obesity
May be combined with naproxen
Guanfacine
+ Generic name – Guanfacine
+ Class – Cardiovascular, alpha-2 adrenergic receptor agonist
+ Indications for use – Prophylaxis of migraine
+ Contraindications
– CAUTION in elderly, hepatic/renal impairment, CV disease or hx, CAD, recent MI
+ Common side effects – Dry mouth, somnolence, dizziness, constipation, erectile dysfunction
+ Dosage – PO, 1 mg once daily
You are examining a 65-year-old man who has a history
of acute coronary syndrome and migraine. Which
of the following agents represents the best choice of
acute headache (abortive) therapy for this patient?
A. verapamil
B. ergotamine
C. timolol
D. sumatriptan
c
Pt with HA and ophthalmoplegia or visual field defects suggests….
+ Venous sinus thrombosis
+ Tumor
+ Aneurysm
McPhee p 40
When to refer pt with sx of HA?
+ Thunderclap onset
+ Increasing HA unresponsive to simple measures
+ Hx of trauma, HTN, fever, visual changes
+ Presence of neuro signs or scalp tenderness
Migraine medication precautions and contraindications
Max dosages in 24 hours and limitations of number of days per month
Ergotamine meds should be avoided during pregnancy, CVD, patients taking potent CYP 3A4 inhibitors
Triptans should be avoided during pregnancy, hemiplegia or basilar migraine, risk factors for stroke or TIA (uncontrolled HTN), DM, hypercholesterolemia, obesity. Contraindicated in pts with coronary or peripherial vascular disease.
Avoid opioid analgesics due to high rates of rebound headaches and risk of overuse
What types of headaches may respond well to high-flow O2 therapy?
ALL types
MIGRAINE or CLUSTER HA or TRIGEMINAL NEURALGIA: Topiramate
+ Generic name – Topiramate
+ Class – Anticonvulsant
+ Indications for use – Prophylaxis for migraine and cluster HA
+ Contraindications
–CAUTION if use of CNS depressant, use of ETOH, depression, suicidal ideation, hepatic impairment
+ Common side effects – Somnolence, nausea, dyspepsia, irreiability, dizziness, ataxia, nystagmuse, diplopia, glaucoma, renal calculi, weight loss, hypohidrosis, hyperthermia
+ Dosage for MIGRAINE
– PO, 100 mg divided twice daily
Dosage for CLUSTER HA
– PO, 100-400 mg daily
Dosage for TRIGEMINAL NEURALGIA
– PO, 50 mg BID
True/false: Depression is a normal response to loss
True/false: Depression is a normal response to loss
FALSE. Sadness and grief are normal, but depression is not.
Grief is usually accompanied by intact self-esteem, whereas depression is marked by a sense of guilt and worthlessness.
Signs/symptoms of pseudotumor cerebri
+ HA
+ Diplopia and other visual disturbances due to papilledema and abducens nerve dysfunction
+ Some pts have pulse-synchronous tinnitus
NOTE: Exam reveals papilledema and some enlargement of blind spots, but patients otherwise look well.
Valproic acid (not FDA approved for migraine)
+ Generic name – Valproic acid
+ Class – Anticonvulsant
+ Indications for use
- Prophylaxis for migraine
- Tx of mania
+ Contraindications
- CONTRAINDICATED in hepatic disease or impairment, pregnancy
- CAUTION in peds, elderly, renal impairment, head injury, hx of hepatic disease
+ Common side effects – N/V, diarrhea, drowsiness, alopecia, weight gain, hepatotoxicity, thrombocytopenia, tremor, pancreatitis. Blood/liver/glucose tests at 2, 4, 12 weeks initially.
+ Interactions
- Aspirin will ↑ valproate levels
- Carbamezepine or phenytoin will ↓ valproate levels
- Valproate will ↑ warfarin levels!
+ Dosage – PO, 500 - 1000 mg divided twice daily
When is preventive tx of migraines indicated?
+ Migraines occur > 2-3 times per month, OR
+ Significant disability is associated with attacks
Acute Postinfectious Glomerulonephritis
May follow recent group A B-hemolytic strep infection (pharyngitis or impetigo)
Cornerstone to a unified approach to chronic pain syndromes is __.
A comprehensive behavioral program.
Management of night terrors
Management of night terrors
+ Reassurance of parents
+ Measures to avoid stress, irregual sleep schedule or sleep deprivation (which prolongs deep sleep when night terror occur).
Prevention of medication overuse headaches
1) Limit simple analgesics to ≤ 15 days per month
2) Limit combination analgesics to ≤ 10 days per month
Horner Syndrome mnemonic
Horner Syndrome mnemonic
P - Ptosis
A - Anhydrosis
M - Miosis
Relationship of creativity and mood disorders
Relationship of creativity and mood disorders
Best work is done BETWEEN episodes of mania and depression.
Migraine symptom management
Migraine symptom management
Consists of symptomatic and preventative therapy
rest in quiet darkened room
simple anagesics (tylenol, ibuprofen, asa, naproxen)
Limit simple anagesic use to <15 days/mo and combo anagesic to <10 days/mo to prevent medication overuse
ESSENTIALS OF DX + TYPICAL FEATURES:
Tantrums and breath-holding spells
+ Behavioral responses to stress, frstration and loss of control
+ Tantrum - Child may throw him or herself on the grown, kick, scream or strike out at others
+ Breath-holding spell - Child engages in a prolonged expiration that is reflexive and may become pale or cyanotic
+ R/o underlying organic disease in children with breath-holding spells (e.g. CNS abnormalities, Rett syndrome, seizures, etc.)
Causes of headache that require IMMEDIATE TREATMENT
\+ Vascular events \+ Infections \+ Intracranial masses \+ Preeclampsia \+ Carbon monoxide poisioning
McPhee p 39
Prophylaxis of cluster headaches
+ PO meds
- Lithium carbonate (start at 300 mg daily, titrate up to total daily dose of 900-1200 mg as tolerated)
- Verapamil (start at 240 mg daily, increase by 80 mg q2weeks to 960 mg daily – MONITOR WITH ECG for changes in PR interval)
- Topirimate (100-400 mg daily)
Treatment of psuedotumor cerebri
+ Medications to reduce production of CSF to ↓ ICP. Some examples
- Acetazolamide (250-500 mg PO TID, increasing slowly to maintenance dose of up to 4000 mg daily divided 2 to 4 times per day)
- Topiramate (also causes weight loss)
- Furosemide (can be used as adjunct tx)
+ Sometimes CSF is drawn off to ↓ ICP. Shunts are sometimes inserted.
Factitious disorders
+ Symptoms are produced CONSCIOUSLY
+ Self-induced or described symptoms or false physical or lab findings for purpose of deceiving clinicians or other health care personnel. Also known as “Munchausen’s”
– Examples: Self-mutilation, fever, hemorrhage, hypoglycemia, seizures, etc.
+ Disorders can be imposed on another person (previously known as “Munchausen’s by proxy”) for perceived psychological benefit of the first person.
+ “Doctor shopping” is common in these pts
Components of treatment for NE
Components of treatment for NE
+ Education and not shaming child
+ Waking child at night so that he can go urinate
– Requires CONSISTENCY from parents
– Bedwetting alarms are useful
– Therapy needs to continue for 3 months and be used EVERY NIGHT
– Most common cause of tx faiure is that the child doesn’t awaken OR that the parents do not wake the child.
Diagnostic criteria for GAD
+ At least ONE of these symptoms:
- Fatigue
- Restlessness or poor concentration
- Irritability
- Feeling on edge
- Sleep disturbance
+ Symptoms must cause significant distress or disturbance of function AND be present for ≥ 6 (SIX) months
Which triptan is good for pts with prolonged attacks or attacks provoked by menstrual periods?
Eletriptan
+ Contraindications
–AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity)
– CAUTION in pts with controlled HTN
– CONTRAINDICATED in pts with coronary or peripheral vascular disease
+ Common side effects – Nausea and vomiting
+ Dosage – PO, 20-40 mg at onset, may repeat ONCE after 2 hours (MAXIMUM DOSE = 80 mg/24 hours)
New headache in a patient > ________________ years or with ___________________ (condition) should warrant IMMEDIATE neuroimaging.
+ > 50years
+ HIV infection
McPhee p 39
ESSENTIALS OF DIAGNOSIS: Pseudotumor cerebri
ESSENTIALS OF DIAGNOSIS: Pseudotumor cerebri
+ HA, worse on straining
+ Viscual obscurations or diplopia may occur
+ Examination reveals papilledema
+ Abducens palsy is commonly present (6th nerve palsy causes eye to turn out)
Treatment for agoraphobia
Treatment for agoraphobia
+ Challenging because often pt won’t leave home
+ CBT with exposure is 1st line tx
+ Addition of SSRI for pts who do not respond to treatment or who are severely impacted
Dysthymia
+ Chronic depressive disturbance.
+ DIAGNOSIS: Sadness, loss of interest and withdrawal from activites over a period of ≥ 2 years with a relatively persistent course.
+ Milder symptoms but longer lasting than a major depressive episode
To meet criteria for a panic attack, what must occur
Pt must experience fear or or related to future attacks that leads to maladaptive behavior
Must ≥ 4 (FOUR) of the following symptoms \+ Palpitatations \+ Sweating \+ Shortness of breath \+ Choking \+ Chest pain or tightness \+ GI distress \+ Dizziness or associated feelings \+ Chills or heat \+ Numbness or tingling
Headaches that worsen with standing and improve with lying down are suggestive of _________ caused by ________.
a. increased intracranial hypertension, hydrocephalus
b. low pressure headaches, tear in dura from an LP, trauma, or surgery
c. CNS infection, bacterial infection.
b
What medications are recommended for management of sleep disorders in children?
none
