Neuro

Question 1

Prevalence of recurrent, severe headaches

Answer 1

25%

Question 2

Migraine economic burden

Answer 2

due to missed work days, costs US economy 31 billion dollars annually

Question 3

Primary headache

Answer 3

90% of all headaches. Idiopathic with NO underlying disease. Recurrent. Most commonly a migraine. Can be tension or cluster

Question 4

Secondary headache

Answer 4

10% of all headaches. FROM an underlying disease. Can be brain tumor, subarachnoid hemorrhage, meningitis, temporal arteritis, close angle glaucoma. Symptoms can be acute onset of unilateral headache and eye pain, n/v, impaired vision or seeing halos with a mid dilated pupil from close angle glaucoma

Question 5

Brain tumor s/s

Answer 5

Chronic nausea. Significant change in prior headache pattern, worsening overtime. Worse with changing position especially bending over, sneezing, coughing, exertion. Early morning headache. Abnormal neuro exam with papilledema, unilateral weakness, sensory loss, aphasia

Question 6

Most common type of brain tumor

Answer 6

Intracranial tumor- gliomas and meningiomas from brain mets. Mets from lung cancer, breast cancer, melanoma, renal cell carcinoma

Question 7

Dx brain tumor

Answer 7

MRI with and with out contrast. Most accurate is biopsy

Question 8

Subarachnoid hemorrhage mortality rate

Answer 8

50%. 25% die within first 24 hours

Question 9

SAH s/s

Answer 9

severe headache, worst headache I have ever had in my life, thunderclap maximum intensity in 1 minute, may have LOC, focal deficits, seizures, nausea or vomiting, meningeal signs

Question 10

SAH bleeding

Answer 10

caused by a ruptured brain aneurysm, looks like bright white areas on ct scan

Question 11

Test for SAH

Answer 11

CT scan with out contrast. Sensitivity highest within 24 hours. If CT negative, need LP follow up

Question 12

Meningitis

Answer 12

headache, fever, nuchal rigidity, photophobia, change in mental status, ill appearance, brudzinski, kernig

Question 13

Meningitis caused by

Answer 13

Strep pneumonae, N meningitis.

Question 14

Dx Meningitis

Answer 14

LP showing increased WBCs and neutrophils, CT may be done first to exclude a mass lesion

Question 15

Temporal arteritis

Answer 15

Giant cell arteritis a vasculitis of cranial branches of the arteries that originate from the aortic arch. Cause is unknown. Mean age is 72, never younger than 50

Question 16

s/s Temporal arteritis

Answer 16

over 50. New onset temple headache. Temple scalp tenderness. Jaw claudication. Visual disturbances. Systemic s/s of fatigue, fever, anorexia, elevated erthrocyte sedimentation rate, c-reactive protein

Question 17

Diagnose temporal arteritis

Answer 17

biopsy

Question 18

Treatment of temporal arteritis

Answer 18

high dose systemic steroids, do not wait for bx to initiate treatment

Question 19

Danger signs

Answer 19

SNOOP. Systemic illness. Neuro symptoms abnormal. Onset is new after age 40 or sudden. Other associated features. Previous headache history with a headache progression or change in severity and frequency. No SNOOP then No imaging.

Question 20

Less dangerous secondary headaches

Answer 20

dental pain - sensitivity to cold, sweets, dental caries is 50% of all orofacial pains. TMJ disorder - localized, dull, exaccerbated by chewing. Sinusitis - purulent nasal discharge, congestion, possible fever, periorbital and frontal pressure and tenderness, pain worse when bending over

Question 21

Migraine = Pound

Answer 21

Pulsatile. One day duration. Unilateral. Nausea. Disability

Question 22

Migraine aura

Answer 22

20-30% have auras, bright lights, shapes, halos, scotomas

Question 23

Migraine w aura stroke risk

Answer 23

doubled. If also smoking, taking oral contraceptives = stroke risk x 7

Question 24

Migraine triggers

Answer 24

stress, menstruation, weather changes, sleep disturbances, fasting, wine, chocolate, odors, lights

Question 25

Migraine etiology

Answer 25

largely unknown. Vascular theory: local vasodilation as a rebound of vasocontriction. Neuro-vascular possibly from neurotransmitters like dopamine and inflammatory markers cause brain irritability, this inflammation causes the pain.=

Question 26

Dx migraine

Answer 26

clinically, no imaging unless changes in the pattern or focal symptoms

Question 27

Abortive treatment of migraines mild-moderate

Answer 27

As soon as the headache starts this is most effective. For mild to moderate do NSAIDs, tylenol and or an antiemetic, Excedrin, or Fioricet

Question 28

Moderate-severe migraine treatment

Answer 28

As soon as the headache starts. First line is Triptans. these are selective agonist for seratonin on the intracranial blood vessels causing vasoconstriction. Ergots are similar to dopamine and serotonin they are a weak vasocontrictor but last longer. Oral steroids also work.

Question 29

Prophylactic migraine treatment required if

Answer 29

Frequent 3-4month with longer episodes, refractory to abortive treatment, significant disability

Question 30

Prophylactic treatment for migraines

Answer 30

BB: Propranolol, metoprolol, CCB: verapamil, antidepressants like: amitriptyline (elavil) and effexor, and anticonvulsants: like valproate (valproic acid) and topirmate (topamax)

Question 31

Prophylactic treatment for migraines leads to this reduction of headaches

Answer 31

50 percent reduction. If hx of HTN use BB or CCB. If arrythmias use BB or CCB. Depression - anti. Insomnia - amitriptyline (elavil), obesity - topamax. Women child bearing age no anticonvulsant especially valproic acid - they can take verapamil

Question 32

Lifestyle modifications for migraines

Answer 32

sleep, routine meal schedules, regular exercise, managing of triggers

Question 33

Tension headache

Answer 33

mild to moderate. BILATERAL. NOT throbbing, band like, no other features like aura, n/v, not aggravated by daily activities, does have muscle tenderness in head neck and shoulders. women higher prevalence. precipitated by stress, mental tension. clinically dx

Question 34

Treatment for tension headaches

Answer 34

nsaids, acetaminophen

Question 35

Cluster headaches

Answer 35

rare. severe UNILATERAL. pain behind eye. May have conjunctival injection. Nasal congestion. Can last minutes to hours. More prevalent in men. Can feel restless. Can be precipitated by alcohol. Clinically diagnosed.

Question 36

Abortive treatment for cluster headache

Answer 36

high flow oxygen for 15 minutes. triptans to cause vasoconstriction

Question 37

Medication overuse headache

Answer 37

consequence of regular overuse of acute headache medications for more than 2 times a week. highest potential is opiods. intermediate is triptans. lowest is NSAIDs. s/s daily headache, vary in intensity or location. behavior factors: fear of headache, obsessional drug taking behavior, psychological drug dependence

Question 38

dx MOH and tx

Answer 38

drug taking hx, including OTC. treatment: stop the overuse of medications, educate on detrimental side effects of these meds, screen for psych conditions

Question 39

Trigeminal neuralgia s/s, triggers

Answer 39

unlateral electric shock like facial pain, distribution of the trigeminal nerve, abrupt onset and termination, lasts several seconds, triggered by chewing, talking, brushing teeth, cold air, smiling. Caused by idiopathic compression of of TN root, acoustic neuroma, or meningioma

Question 40

Dx Trigeminal neuralgia

Answer 40

clinically. use MRI to rule out a structural lesion

Question 41

Medical tx of TN

Answer 41

carbamazepine Tegretol - side effects of dizziness, drowsiness, rare aplastic anemia CYP34 inducer

Question 42

Surgical treatment of TN

Answer 42

if medication is ineffective. Microvascular decompression. Botox.

Question 43

Insomnia

Answer 43

impaired daytime functioning due to difficulty initiating sleep, difficulting maintaining sleep, 10% population. increases w age.

Question 44

Why treat insomnia

Answer 44

low quality of life, poor daily performance, irritable, self medication with alcohol = risk for abuse, insomnia leads to increased mortality and cardiovascular disease, depression, anxiety

Question 45

Types of insomnia

Answer 45

short: less than 3 months, a/w stressors. self limited. chronic: 1 - primary: w out comorbidities, existing w out other disorders. 2 - secondary: caused by a comorbid disorder like depression

Question 46

Insomnia underlying conditions

Answer 46

depression, anxiety, pulmonary diseases, chronic pain, cancer, HF, substances like stimulants or substance withdrawals, frequently with BPH, GERD, hyperthyroidism, diuretics

Question 47

dx Insomnia

Answer 47

sleep study. daily sleep log for 1-2 weeks. like number of awakenings, duration of awakenings, duration of the problem, bedtime, awakening time, sleep environment

Question 48

Treat primary insomnia

Answer 48

behavioral counseling regarding good sleep hygiene and stimulus control, cognitive counseling establishing realistic expectations

Question 49

Smells like poop

Answer 49

Avery Gardner