CNS Flashcards
Migraine without Aura
Consider migraine without aura if the person has had at least five attacks fulfilling the following criteria:
Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated).
The headache has at least two of the following four characteristics:
Unilateral location.
Pulsating quality.
Moderate or severe pain intensity.
Aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs).
During the headache at least one of the following; nausea and/or vomiting; photophobia and phonophobia.
Migraine with Aura
Consider migraine with aura if the person has had at least two attacks with at least one or more of:
Visual symptoms such as zigzag lines and/or scotoma— visual aura is the most common type of aura.
Sensory symptoms such as pins and needles.
Speech and/or language symptoms such as aphasia.
Motor weakness.
Brainstem symptoms such as vertigo or diplopia.
Retinal symptoms such as monocular scintillations or scotoma.
At least two of the following four characteristics:
At least one aura symptom spreads gradually over at least 5 minutes, and/or two or more symptoms occur in succession.
Each individual aura symptom lasts 5-60 minutes.
At least one aura symptom is unilateral.
The aura is accompanied, or followed within 60 minutes, by headache.
Tension-type headache
Consider tension-type headache if:
The person has recurrent episodes of headache lasting from 30 minutes to 7 days which is not associated with nausea or vomiting (the headache may also be associated with no more than one of photophobia or phonophobia) and
The headache has at least two of:
Bilateral location.
Pressing or tightening (non-pulsating) quality.
Mild or moderate intensity.
Not aggravated by routine physical activity such as walking or climbing stairs.
Cluster headache
Consider cluster headache if:
The person has had at least five attacks of severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes and
The headache is associated with at least one of: ipsilateral conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid oedema; forehead and facial sweating; forehead and facial flushing; sensation of fullness in the ear; or miosis and/or a sense of restlessness or agitation.
Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active.
Medication overuse headache
Consider medication overuse headache if:
The person has headache occurring on at least 15 days per month and a pre-existing headache disorder.
The person has regularly overused, for more than 3 months, one or more drugs that can be taken for acute and/or symptomatic treatment of headache such as ergotamines, triptans, simple analgesics or opioids.
Headache RED FLAG
new or unexpected headache (sudden severe or over 50)
headache that has changed dramatically
Associated features:
fever/seizure/neck pain/photophobia (?infection)
papilloedema
Neurological deficit
atypical aura (> 1 hr or inc motor symptoms) or new aura when on combined oral contraceptives
Dizziness
Visual disturbances
Vomiting
Treatment Cluster headache
refer as need diagnosis. over 18 years old: Sumatriptan SC (all adults, max 12 mg OD) OR intranasal (18-65 only, max 40mg OD) OR Zolmitriptan intranasal (unlicensed) DO NOT OFFER: Paracetamol NSAIDs opioids ergots oral triptans
Treatment tension-type headache
for > 16:
Paracetamol
aspirin
NSAIDs
Offer person to take a therapeutic dose as soon as
DO NOT offer opioids
Prophylaxis - low dose amitriptyline 10-75mg OD (off-label) or acupuncture.
Treatment medication overuse
refer if overuse involves opioids
Triptans and NSAIDs/paracetamol can be abruptly stop - try for 1/12 (pt will feel worst for weeks after discontinuation)
medication could be reintroduced within 2/12 of stopping.
Diamorphine is painkiller of choice in palliative care - TRUE/FALSE
TRUE - greater solubilty allows greater doses to be administered in lower volumes, esp important for patient presenting with severely frail (very little muscle mass) - emaciated patients
Less nausea and hypotension than morphine
Post-op nausea and vomiting drugs
5HT3-rec antagonist: 1. Cyclizine (antihistamines) droperidol Dexamethasone Prochlorperazine (Phenothiazines) For high risk - give 2 or more with different mechanisms of action.
Risk factors for N+V post-op
female sex
non-smoker
hx postoperative N+V/motion sickness
use of opioids
Anti-emetics C/I in Parkinson’s
metoclopramide Prochlorperazine Chlorpromazine Droperidol Promethazine ALL CARRY EPSE Ondansetron is C/I with apomoprhine
Dispersible anti-parkison med
Co-Beneldopa (Madopar) is the only one available in dispersible form
used for NG/PEG
When switching from M/R levodopa to dispersible form - reduce dose by 30%
When switching the prev preparation of levodopa should be discontinued 12 hrs prior
Anti-emetics in Chemotherapy
5HT3 - Ondesantron, Granisetron ,Palonosetron
Dexamethasone (with metoclopramide, prochlorperazine, lorazepam or 5HT3 antagonist)
Lorazepam
High risk emesis: Aprepitant, fosaprepitant, rolapitant (in addition to dexamethasone + 5HT3 antagonist)
PreTreatment N+V in chemo
Dexamethasone
Lorazepam
Treatment delayed symptoms of N+V in chemo
moderate risk emesis: Dexamethasone + 5HT3
High risk: Aprepitant, Dexamethasone, 5HT3
Rolapitant and metoclopramide also effective
Prevention anticipatory N+V in chemo
Lorazepam due to its anxioloitic, sedative and amnesic effects.
S+S of Reye’s syndrome
Initially: persistent effortless vomiting
tiredness + listlessness (lack interest)
Drowsiness
rapid breathing
Seizures
As the condition progresses:
irritability, irrational or aggressive behaviour
Delirium (severe anxiety, hallucinations)
Coma
Blood test: LFT’s and WCC.
DOACS and spinal epidurals
ALL DOACS are not recommended to be given when pt is on spinal epidural as there is a risk of lumbar haemorrhage which could lead to paralysis.
Risk is increased with indwelling epidural catheter.
No evidence of risk with LWMH.
NSAIDs associated with less GI S/E
COX-2 inhibitors have less S/E
1. Ibuprofen
NSAIDs associated with less CV S/E
Naproxen is considered one with least CV S/E
low dose ibuprofen (1.2g daily or less)
NSAIDs associated with high CV S/E
Diclofenac
High dose Ibuprofen (2.4 g daily or more than 1.2 g)
aceclofenac
etoricoxib
NSAIDs associated with high GI S/E
Piroxicam
Ketoprofen
ketorolac trometamol
