Final Exam Flashcards
(117 cards)
1
Q
16%
A
Recurrent HA in gen pop
2
Q
57%
A
People report 1+ sig HA / month
3
Q
40%
A
HA sufferers have combo type HA: cervicogenic, migraine, tension
4
Q
Types of HA classified using
A
VINDICATE
5
Q
VINDICATE
A
Vascular Infection/inflammation Neoplasm Degen / dysfxn Intoxicants Congenital Allergy/AI Trauma Endocrine/metabolic
6
Q
99.5%
A
HA are benign
7
Q
Pathologic HA classifications/examples
A
Brain tumor Pseudo tumor cerebra Chiari malformations CNS infection Subarachnoid hemorrhage Subdural hematoma Epidural hematoma Stroke Temporal arteritis Glaucoma
8
Q
Pt presents with HA the progresses over time, signs of increased intracranial pressure, partial seizures, focal neuro deficits incl mental status changes. What kind of HA?
A
Brain tumor
9
Q
Name the signs of intracranial pressure
A
Papilledema HA Nausea Vomiting Visual changes
10
Q
Mets from intracranial tumors MC spread from where?
A
Lung
Breast
Melanoma
11
Q
Intracranial tumors, MC primary neoplasm?
A
Glioma
And then:
Pituitary adenocarcinoma
Schwannoma e.g. acoustic neuroma
Posterior fossa tumors
12
Q
What tumor pushes on the optic chasm and causes bitermoral hemianopsia? This tumor also causes hormonal problems such as amenorrhea, acromegaly, Cushing’s, thyroid problems, and gynomastia. Pt presents with nonspecific signs of brain tumor and increased intracranial pressure signs.
A
Pituitary adenoma
13
Q
Expected lab results for Pituitary adenoma?
A
Elevated TSH, ACTH, GH, other tumors.
14
Q
What condition is idiopathic or 2˚to hormonal/menstrual abnormalities, obesity or hypothyroid? This affects F>M and its a Dx of exclusion (r/o brain tumor). Signs and sx mimic brain tumor including HA that is worse with straining, nausea w/ or w/o vomiting, papilledema, visual disturbances. Morbidity associated with optic atrophy and resulting blindness if left untreated.
A
Pseudotumor Cerebri aka Benign Intracranial Hypertention
15
Q
What is diagnostic for Pseudotumor Cerebri aka Benign Intracranial Hypertention
A
Lumbar puncture
Drain CSF
16
Q
prognosis for Pseudotumor Cerebri
A
Self limiting w/i 6 weeks - 6 months
Meds may be used to lower pressure
Note: if it’s 2˚ to disease, treat the disease
17
Q
Herniation of brainstem and/or cerebellar tonsils through foramen magnum. Usually congenital, may be acquired or worsened d/t trauma. Pt presents with HA that starts in the back of head and signs and sx of cerebellum and brainstem lesion
A
Chiari malformation
18
Q
Pt presents with dull, boring HA w/ superimposed “ice pick jabs.” Rare <50 yo. Tender, rigid, bulging temporal artery, painful chewing, temporal HA, fever, malaise, symmetrical hip or shoulder pain.
Pt with polymyalgia rheumatica are at higher risk for developing this and 40-50% of these patients have polymyalgia rheumatica.
50% develop bilateral blindness if no Tx is rendered. Increased risk of TIA or stroke of ophthalmic arteries lead to sudden blindness.
A
Temporal arteritis (giant cell)
19
Q
Polymyalgia rheumatica complex
A
Malaise, myalgia, weight loss, arthralgia, fever
20
Q
Jaw claudication
A
Giant cell arteritis
21
Q
Increased intraocular pressure accompanied by vision loss. Sx include eye pain, HA, blurred vision “haloes”, pain in trigeminal division, sluggish dilated pupil.
Ophthalmoscopes exam reveals optic nerve atrophy and glaucomatous cupping.
A
Glaucoma
22
Q
Two types of glaucoma
A
Open angle
Closed angle
23
Q
Who gets migraines?
A
F>M
<30 yo
24
Q
Colic and motion sickness as an infant puts you at higher risk of having what kind of HA?
A
Migraine HA
25
Describe migraine
```
Unilateral
N/V
Diarrhea
Scalp tenderness
Photophobia
Photophobia
Light headedness
```
26
Migraine triggers
```
Tyramine
Phenylethelamine
Catecholamines
Stress
Pregnancy
Oral contraceptives
Menstruation
Lack of sleep
Food/additives
Allergies
Eye strain
Fluorescent lights
Perfumes
Smoke
Cervical problems
Drugs
```
27
How long does migraine w/o aura (“common” migraine) last for?
4-72 hours
28
Dx criteria for “common” migraine?
At least 2 of
- unilateral
- pulsating quality
- mod-severe
- aggravation by physical activity
Accompanied by at least 1 of:
- N/V or both
- photophobia or phonophobia
29
10% of migraine patients have
Aura that accompany or precedes migraine
30
Visual types of auras
scotomas, flashing lights
31
Sensory types of auras
Paresthesia
32
Motor types of auras
less common - aphasias, weakness
33
A variate of migraine with stroke-like sx including numbness and visual defects
Basilar migraine
34
Migraine w/o HA
Patient has aura, but HA never arrives.
MC in elderly with hx of migraines in remission.
35
Tx during migraine?
Ice
Darkness
CMT to upper Cx spine
STM
Elim sugar, refined carbs, alcohol, food allergies
Supplement Mg, Riboflavin, vit E, fish oil, antioxidants, feverfew
36
Dx criteria for cluster HA
1 -severe pain lasting 15 -180 minutes
2 -at least 1 of:
- conjunctival injection
- lacrimation
- rhinorrhea
- nasal congestion
- meiosis
- ptosis
- eyelid edema
- forehead and facial sweating
3 -frequency of attack from 1 every other day up to 8/day
37
2 patterns of cluster HA
Episodic (bouts with remission)
| Chronic (continuous)
38
Sx of cluster HA
Unilateral periorbital P
Less common: temporal, frontal, maxillary, zygomatic P
39
Cluster HA tx
During: CMT, STM, ice to neck, heat to hands
Capsaicin cream intranasal spray to ipsi nostril 2-4x/day for 7 days
Melatonin 10mg/day in the evening for 15 days (episodic)
Oxygen therapy
Lidocaine: intranasal infusion
Meds: ergotamine
40
International Headache Society Cervicogenic Headache Diagnostic Criteria
1. Pain referred from a source in the neck and perceived in 1 or more regions of the head and/or face, fulfilling criteria 3 and 4.
2. Clinical, laboratory, and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as a valid cause of HA.
3. Evidence that the pain can be attributed to the neck disorder or lesion based on one or more of the following:
- Demonstration of clinical signs that implicate a source of pain in the neck.
- Abolition of HA following diagnostic blockade of the cervical structure or its nerve supply using placebo or other adequate controls.
4. Pain resolves within 3 months after successful treatment of the causative disorder or lesion.
41
Where is P in cervicogenic HA?
Localized to neck and occiput region
| May project to forehead, orbital region, temples, vertex, ears
42
Signs and Sx of cervicogenic HA
Unilateral P on dysfunctional side
P triggered by neck movements or sustained head postures
P elicited by external pressure over ipsi neck area
Neck, shoulder, arm P of vague, non-radicular nature
Reduced ROM in cervical spine
43
Cervicogenic HA PE:
Resistance to /limitation of passive neck movements
Changes in neck mm contour, texture, tone, response to stretching and contraction
Abnormal tenderness of neck muscles
44
Tx for cervicogenic HA
Manipulation CO-3
STM trigger points
Rehab cervical muscles
Address nutritional/habitual issues
45
What underlying conditions may cause HA (5)
- Upper cross syndrome
- Myofascial pain syndrome
- Temporomandibular joint dysfxn
- Tension-type HA
- Posttraumatic HA and post-concussive syndrome
46
What muscles are tight in Upper cross syndrome?
```
Upper trap
Elevator scap
Pec major and minor
SCM
Suboccipital mm
```
47
What mm are weak in Upper cross syndrome?
Deep neck flexors
| Lower/middle trap
48
International Headache Society Classification of Tension-Type Headaches
1. 10 or more episodes of headache
2. HA lasting from 30 minutes to 7 days
3. At least 2 of the following pain characteristics:
- Pressure/tightening (non-pulsating quality)
- Mild or moderate intensity (may inhibit, not prohibit activities)
- Bilateral location
- No aggravation by walking stairs or similar routine physical activity
4. Both of the following:
- No nausea or vomiting
- Photophobia and/or photophobia are absent
5. History physical, and neurological examinations do not suggest another type of HA
49
Prognosis for posttraumatic HA?
85% recover in 3 years
80% in 2 years
70% in 1 year
50
An idiopathic neuralgia or 2˚ to disease e.g. MS, cerebellopontine angle tumor. Sx unilateral face pain that last seconds and may recur in “trains” or “electric shocks.” May be dull or achy between attacks. Patient may also complain of jaw pain. Triggers include chewing, talking, brushing teeth, wind. Trigger zones are located medically on face or mouth. Neuro exam is WNL except for hyperalgesia and hyperesthesia.
Trigeminal neuralgia
51
Sx include itching, tingling, burning, aching 4-5 days before appearance of rash. Then macules for 1-3 days. Unilateral, resolves within weeks.
Herpes zoster
52
What is a common sequellae of herpes zoster?
Post herpetic neuralgia
53
Capsaicin cream may be effective for
- post herpetic neuralgia
- cluster HA
- diabetic peripheral neuropathy
54
Pain radiating up to the ear, down to the throat, to the base of the tongue, occasionally associated with cough or hoarseness. Pain may come in 1 minute square wave paroxysms/clusters. Nocturnal attacks are common. Triggers: certain tastes, cold temp, swallowing. Clusters may last 5-30 days
Glossopharyngeal neuralgia
55
Unilateral submandibular pain. Some have constant pain with paroxysms/clusters. Pain provoked by swallowing, strain of voice, head turn, coughing, sneezing, yawning, blowing the nose. trigger zone is lateral neck above larynx. Patients voice may become weak or hoarse if there is nerve damage.
Superior laryngeal neuralgia
56
What is the difference between glossopharyngeal neuralgia and superior laryngeal neuralgia?
Glossopharyngeal
• younger aged women
• reproduce CC through stim of peritonsillar trigger zones
Superior Laryngeal
• middle aged men
57
Patient presents with lancinating “ice pick” P in the low, posterior area of the scalp. Unilateral pain. They point to occiput. Paresthesia/dysesthesia along C2 dermatomal. Tinel’s at supperior unchallenged line is positive.
Occipital neuralgia
58
Tx for Occipital neuralgia?
Injection or surgical decompression
59
The ability to maint orientation of the body and its parts in relation to external space
Equilibrium
60
2 Disorders of equilibrium
Vertigo
| Ataxia
63
Describe peripheral vertigo
```
Peripheral vestibular lesions affect labyrinth of inner ear or vestibular division of vestibulocochlear (VIII) nerve.
• intermittent
• brief periods
• more distress than CNS vertical
• NYSTAGMUS is always present
• hearing loss, tinnitus
```
64
Describe central vertigo
Vertigo of CNS origin usually results from lesions that affect the brainstem vestibular nuclei or their connections; rarely, vertigo is produced by cerebral cortical lesion e.g. sx of complex partial seizures
• with or w/o nystagmus
• intrinsic brainstem or cerebellar signs e.g. motor or sensory deficits, hyperreflexia, extensor plantar responses, dysarthria, limb ataxia
65
Which type of vertigo (CNS or PNS) is induced or worsened by head position?
PNS
66
Describe how PNS vertigo is induced or worsened by head position
Latency - up to 30 sec before vertigo starts in provoking head position
Fatigability - gets better when position is maint 30-45 sec
Habituation - repeating provoking action reduces response
67
Positional nystagmus and vertigo are usually associated with [peripheral / central] lesion and are a feature of ___.
Peripheral vestibular lesion
| Benign positional vertigo (BPV)
68
Describe Benign positional vertigo (BPV)
Otolith in the inner ear “comes loose”
• nighttime
• 30-45 seconds
69
Tx for Benign positional vertigo (BPV)
Epley’s maneuver
Cervical manip
Meds for sx relief
70
What is an upper cervical proprioception disorder that causes vertigo and nystagmus with movement of the neck?
Cervicogenic vertigo
Associated with cervical trauma, degen, other mechanical problems
71
Rapid onset of severe vertigo and nystagmus. Often post-viral, pt no longer sick. It’s continuous, worse with head movement. After it peaks it subsides over 2-6 weeks.
Acute labyrinth it is/vestibular neuronitis
Ddx: stroke, BPV, cervicogenic vertigo, Meniere’s
72
Repeated episodes of severe vertigo lasting minutes to hours accompanied by tinnitus and progressive stepwise sensorineural hearing loss. M>F and 20-50 yo.
Sx vertigo, sensorineural hearing loss, tinnitus, feeling of pressure in the ear.
Ménière’s disease
73
Pathogenesis for Meniere’s?
Increased volumes of endolymph fluid in inner ear
74
How do you dx Ménière’s disease
Audiometry test which demonstrates sensorineural hearing loss
75
Tx for Meniere’s
Medications
Dietary suggestions
Vestibular habituation exercises
Surgical Tx
76
What is caused by immobility of the stapes?
Otosclerosis
77
Tx for Otosclerosis?
Sodium fluoride
Vitamin D
Intratympanic dexamethasone
Surgical stapedectomy
78
Coughing, sneezing, straining, increase in intracranial pressure causes Sx. Self-limiting in 3-8 weeks with avoidance of coughing, sneezing, nose blowing, etc.
Endolymph fistulas
79
What is the pathogenesis of endolymph (perilymph) fistulas?
Vertigo d/t tiny crack in the round window caused by head trauma.
80
Stroke causing occlusion of PICA or brackens, or vertebral artery.
Wallenberg syndrome
81
What is the MC artery affected in wallenburg syndrome?
Vertebral artery accounts for 2.5% of cerebral infarction
82
Sx in upper medullary lesions vs lower medullary lesions vs lateral medulla and cerebellum
Upper medullary lesions
• dysphagia
• hoarseness
• weakness of face
Lower medullary lesions
• dizziness
• uncoordinated gait
• oscillopsia
Lateral medulla and cerebellum
• tissue ischemia
• necrosis
83
Sx of wallenburg syndrome
```
Vertigo
Nystagmus
N/V
**Neck pain
Hoarseness
**Hiccups
Difficulty swallowing
Gagging
Ipsi ataxia
Crossed pattern numbness
Loss of pain and temp
```
84
How to Dx wallenburg syndrome?
MRI
85
Tx for wallenburg syndrome
Anti platelet drug therapy
• Aspirin
• Aspirin + dipyridamole
• Clopidogrel
86
What is the mnemonic thingy to remember the clinical features of vertebrobasilar artery insufficiency/dissection?
5Ds And 3Ns
87
5Ds And 3Ns for the clinical features of Vertebrobasilar Artery Insufficiency/Dissection
```
Dizzy
Diplopia
Drop attacks
Dysarthria
Dysphagia
```
Ataxia
Nausea
Nystagmus
Numbness
88
What is MC: Vertebral Artery Dissection or Carotid Artery Dissection?
CAD
89
What to do if someone has VAD in your office
1. Call 911
2. Keep patient supine and still
3. Maint gentle support to neck - no movement
4. Monitor vitals: check pupils for equality, light reflex/accommodation, diplopia, nystagmus
5. Test CN and cerebellar fxn
6. Test mm strength, sensory, pathologic reflexes
90
MC cerebellopontine angle tumor?
Benign acoustic neuroma, 30-60 yo pt, slow progressive
Less common:
• meningitis’s
• cholesteatoma
• mets
91
MC initial sx of acoustic neuroma
* Insidious unilateral sensorineural hearing loss
* Tinnitus w/ dizziness “unsteady” or vertigo
* HA
* facial weakness
* facial pain
* numbness/tingling
* fullness in the ear
* ataxia
92
What is a congenital abnormality that cause herniation of cerebellar tonsils and brainstem through foramen magnum?
Arnold Chiari Malformation
93
Central vertigo, down beat nystagmus, cerebellar signs, bilateral lower brainstem/CN signs. NECK PAIN AND HA
Arnold Chiari Malformation
94
A sensation of fairness or light-headedness usually in an upright posture that is caused by global cerebral ischemia
Pre-syncope
95
Causes of global cerebral ischemia?
```
Orthostatic hypotension
Vasovagal response to stress
Hyperventilation syndrome
Autonomic failure seen in diabetes
Medications
Cardiovascular disease
```
96
Patients with UMN and/or LMN signs with spinal and/or bulbar involvement.
Amyotrophic lateral sclerosis AKA Lou gehring disease
97
Pathogenesis for Amyotrophic lateral sclerosis AKA Lou gehring disease?
Tropic factors (proteins) cause early programmed cell death of motor neuron cells which leads to oxidative injury d/t defective superoxide dis tase function which becomes a CNS detox problem. Glutamate excitotoxicity increases motor neuron cell death. Degen of ant horn cells in the spinal cord, motor nuclei of lower CN in the brainstem, corticospinal and corticobulbar pathways.
98
Clinical presentation of Amyotrophic lateral sclerosis AKA Lou gehring disease
* weakness of UE and/or LE with easy fatiguability, twitching, wasting, mm cramps, stiffness
* bulbar involvement = dysarthria, dysphagia, difficulty chewing, coughing, breathing, tongue fasciculations
* UMN and LMN signs and Sx present
99
Tx for Amyotrophic lateral sclerosis AKA Lou gehring disease?
Riluzole reduce mortality and slows progression; prolongs life 2-3 months
SE fatigue, dizziness, GI disorders, reduced pulmonary fxn, liver damage
100
Patient presents with viral sx w/ acute disease. LMN issues.
Poliomyelitis AKA polio
101
Fluctuating weakness and fatiguability that affects smaller muscles. Especially ocular muscles or CN muscles.
Myasthenia gravis
102
Infectious NM junction disease caused by toxin that prevents release of ACh at neuromuscular junction that causes paralysis.
Botulism
103
Onset of Botulism?
12-72 hours after ingestion
104
Sx of Botulism
N/V
| Paralysis of ocular mm and other structures inner gated by CN incl respiratory and limb mm.
105
Tx for Botulism?
Anti-toxin and guanidine
106
Uncommon inflammatory disease that causes mm weakness affecting both sides of body. Difficult to climb stairs, rise from seated, lift objects or reach overhead
Polymyositis
Adults 30,40,50s
African American > Caucasian
F > M
Develop gradually over weeks or months
107
Polymyositis signs and Sx PLUS erythematous rash over eyelids and extensor surfaces.
What is it and how to Dx?
Dermatomyositis
* CPK and aldolase confirms
* Mm biopsy is also diagnostic
108
Tx for polymyositis and dermatomyositis?
Corticosteroids
Anti-inflammatories
Plasma exchange
109
Mm pain w/o weakness, AI sx, HA
Polymyalgia rheumatica
110
20% of polymyalgia rheumatica patients will have __
Temporal arteritis
111
Labs for polymyalgia rheumatica?
Elevated SED rate
EMG, CK/aldolast, mm biopsy are negative
112
Tx for polymyalgia rheumatica?
Low dose corticosteroids
113
What is the dizziness stimulation battery?
```
Halpike maneuver
Swivel chair test
Neck rotation w/ extension
Orthostatic hypotension test
Caloric test
```
114
The illusion of movement of the body or environment.
Vertigo
115
Acute or subacute poly radiculopathy that sometimes follows infective illness, inoculations, surgical procedures. Associated w/ campylobacter jejuni enteritis.
Guillan-Barre syndrome
116
CMDT Dx for Guillan-Barre syndrome
1. Acute or subacute progressive polyradiculo-neuropathy.
2. Weaknesses more severe than sensory distribution.
3. Acute dysautonomia may be life-threatening (CMDT 2013).
117
2 types of Diagnosis: 1. Acute or subacute progressive polyradiculo-neuropathy. 2. Weaknesses more severe than sensory distribution. 3. Acute dysautonomia may be life-threatening (CMDT 2013).
1. Demyelination - MC
| 2. Axonal
118
* Symmetrical ascending weakness/paralysis (LMN only) that usually begins in the legs.
* Loss of DTRs — Achilles is often first.
* Mild sensory complaints
* Possible autonomic dysfunction including tachycardia, labile BP, disturbed sweating, etc.
* Bowel and bladder are generally not affected.
Clinical features of Gilliane-Barre Syndrome
119
Dx of Gilliane-Barre Syndrome
Lumbar puncture showing high protein w/ normal cell counts
EMG/NCV testing
