Neuro Cases I Flashcards
What is the most frequency headache type?
Tension HA is the most frequent headache in population based studies, but migraine is the most common diagnosis in patients presenting to clinicians with complaint of HA
What are the three primary types of HAs?
tension, migraine, cluster
If a female develops a headache, what is something you would ask her you would not ask a man?
if she has recently changed her birth control (or if she is on her period or something)
*switching from non estrogen emitting to an estrogen emitting birth control can emit headaches
Low risk features of HA compliant
- Age < 50 years
- Features typical of primary HA (see table last slide)
- History of similar HA
- No abnormal neurologic findings
- No concerning change in usual HA pattern
- No high-risk comorbid conditions
- No new or concerning findings on history or examination
What does SNOOP stand for?
- Systemic symptoms, illness, or condition (Fever, wt loss, cancer, pregnancy, immunocompromised state)
- Neuro symptoms or abnormal signs (confusion, papilledema, etc.)
- Onset is new (particularly for age > years or sudden (e.g. “thunderclap”)
- Other associated conditions (head trauma, illicit drug use, worse with Valsalva maneuvers, precipitated by sex, etc.)
- Previous HA history with HA progression or change
Need for Emergency Evaluation
• Sudden “thunderclap” HA
• Acute or subacute neck pain or HA with Horner syndrome and/or
neuro deficit
• HA with suspected meningitis or encephalitis
• HA with global or focal neurologic deficit or papilledema
• HA with orbital or periorbital symptoms
• HA and possible carbon monoxide exposure
Occipital Neuralgia
- Usually unilateral, starts at the area where the neck meets the skull and moves forward to involve the ear and forehead
- Pain caused by trauma to the nerves, including pinching of the nerves by overly tight neck muscles, compression of the nerve as it leaves the spine due to osteoarthritis, or tumors or other types of lesions in the neck.
- A greater occipital nerve block confirms diagnosis
- Tx is massage, NSAIDS and muscle relaxants
What dizziness specific hx should we get?
- History of trauma
- Frequency, intensity, and duration of attack
- Severity (how it affects life, NOT on a 0-10 scale)
- Associated symptoms
- Blurry vision • Syncope
- N/V
- Hearing loss
Dizziness that increases with motion is common to…
both peripheral and central causes.
What is vertigo?
Patients describe a sensation of self-motion when they are not moving or a distorted self-motion during normal head movement.
Vertigo can be:
• Result of asymmetry within the vestibular system
• Disorder of peripheral labyrinth of its central connections
How do we evaluate dizziness?
TiTrATE
- Timing of the symptom (onset, duration and evolution of symptoms)
- Triggers that provoke the symptom ((actions, movements or situations)
- And a Targeted Examination
What three categories does the TiTrATE test place dizziness in?
- Episodic triggered symptoms
- Spontaneous episodic symptoms
- Continuous vestibular symptoms
Episodic Triggered Symtoms
- Brief episodes of intermittent dizziness lasting seconds to hours
- Common triggers are head motion or change in body position
= most likely Benign Paroxysmal Positional Vertigo
Spontaneous Episodic Symptoms
- Dizziness lasting seconds to days
- No triggers, so other elements of the history help determine DDx
- Unilateral hearing loss –> Meniere disease
- Migraine HA –> vestibular migraine
- Psych disorder –> psych dx
Continuous Vestibular Sx
• Dizziness lasting days to weeks
• Classic symptoms = Continuous dizziness or vertigo with N/V, nystagmus,
gait instability, and head motion intolerance
• Often related to exposure to trauma or toxin
• In 23% of older adults with dizziness, medications are the cause
• Use of 5 or more meds is associated with increased risk for dizziness
• If no toxin or trauma exposure, consider vestibular neuritis or central etiologies
