- Dull, band-like or vise-like generalized HA, worse in neck/back of head - Not pulsatile or worse with physical activity/position - No N/V - EITHER photophobia or phonophobia (not both) - May occur daily

- SEVERE, UNILATERAL episode of periorbital pain - Lasts 15 min - 3 hours - Ipsilateral nasal congestion - Rhinorrhea - Lacrimation - Eye redness - Horner's Syndrome - Cyclic (may occur daily for several weeks and then remit for weeks or months)

- Stress - Glare - ETOH - Certain Foods

- "Z's" (Zolmitriptan, Sumatriptan, etc) + 100% O2 via non-rebreather for 15 mins Preventative: lithium, topiramate, prednisone, volproate, verapamil

Neurological Disorders Flashcards by Mike Hickman

Diagnosing an Acute Headache

Fever, Vision changes, neck stiffness
HIV infection
Current or past hx of HTN
Neuro findings: mental status changes, motor/sensory deficits, +LOC

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Careful assessment of 5 areas crucial when acute HA comes in

Visual acuity
Ocular gaze
Visual fields
Pupillary Defects
Optic Discs

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Medications to treat Migraines

NSAIDS (PO, nasal, IM Toradol)
Metoclopramide
Dihydroergotamine
Triptans (PO, nasal, SubQ)

Avoid using Morphine/Hydromorphone as 1st line therapy

Subanesthetic ketamine infusions used for Chronic Migraines/New Daily HA when unresponsive to other therapy

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All HA types should receive what in the ED

High-flow O2

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Treatment for SAH, Intracranial mass, Meningitis

Admit to hospital and emergent treatment

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OTTAWA SAH Clinical Decision Rule (predicting)

100% Sensitivity in predicting SAH

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OTTAWA SAH Clinical Decision Rule (clinical finding/symptoms)

40+ years of age
Neck pain/stiffness
Witnessed LOC
Onset during exertion
“Thunderclap” headache
Limited Neck flexion

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“Thunderclap” HA

Rapid onset of severe pain

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Tension-type HA

Dull, band-like or vise-like generalized HA, worse in neck/back of head
Not pulsatile or worse with physical activity/position
No N/V
EITHER photophobia or phonophobia (not both)
May occur daily

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Treating tension-type HA

OTC analgesics
Avoid narcotics (rebound HA)
Stress management
muscle relaxation
Exercise
Diet changes
Counseling

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Cluster HA

SEVERE, UNILATERAL episode of periorbital pain
Lasts 15 min - 3 hours
Ipsilateral nasal congestion
Rhinorrhea
Lacrimation
Eye redness
Horner’s Syndrome
Cyclic (may occur daily for several weeks and then remit for weeks or months)

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Cluster HA Triggers

Stress
Glare
ETOH
Certain Foods

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Cluster HA Treatment

“Z’s” (Zolmitriptan, Sumatriptan, etc) + 100% O2 via non-rebreather for 15 mins

Preventative: lithium, topiramate, prednisone, volproate, verapamil

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Drugs responsible for Medication Overuse HA

Acetaminophen
Ergots
Opioids
Butalbital (Fioricet, Esgic)
NSAIDs
Midrin

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Treatment for Medication Overuse HA

Avoid daily use of analgesics

- Early initiation of migraine preventative tx

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Essentials of diagnosing Migraines

UNILATERAL pain
N/V
Photophobia/Phonophobia
Aura (commonly visual)
Can occur without aura

Symptomatic therapy of Migraines

Rest in quiet, dark room
ASA, Tylenol, Naproxen may help
Other prescription meds may be necessary including
- Ergotamines - 1-2 tabs taken at onset then 1 tab q30 mins, 6 tabs max per episode
- Triptans - given to patients with prolonged attacks
- Chlorpromazine
- Butalbital-containing combo meds (last resort only)

Other causes of HA

Cerebrovascular disease
Internal carotid artery occlusion or Carotid dissection after endarterectomy
SAH
Meningeal infections
Pseudomotor Cerebri (IIH - Idiopathic Intracranial HTN)
Lumbar puncture

Essentials to diagnose trigeminal neuralgia (TN)

Brief episode of stabbing facial pain
Pain is in area of 2nd and 3rd division of trigeminal nerve
Pain exacerbated by touch
Most common in middle and later life
Affects women > men
Neuro exam shows no abnormality
Bilateral symptoms = further investigation needed

TN under the age of 40

Suspect possible multiple sclerosis

S/S of trigeminal neuralgia

Momentary episodes of sudden, lacinating facial pain (commonly near one side of mouth) that shoots toward the ear, eye, or nostril on same side
Symptoms remain confined to distribution of trigeminal nerve on ONE SIDE ONLY

TN triggers

Touch
Movement
Drafts
Eating

Atypical facial pain

Common in middle-aged women (many are depressed)
Facial pain without typical features of TN
Constant pain (often described as burning)
Pain spreads to entire side of face and can include neck and back of head as well

Treatment:
- Trial of simple analgesics
- Trial of tricyclic antidepressants
- Carbamazepine
- Oxcarbazepine
- Phenytoin 
(response is often disappointing)

Diagnosing Postherpetic Neuralgia

Develops in 15% of patients with shingles (herpes zoster)
Most common in elderly or immunocompromised
Rash

Primary Prevention:
- Recombinant Zoster vaccine to patients over 50 years old

Treatment of Postherpetic Neuralgia

- Acyclovir (5x/day) or Valacyclovir (3x/day) when given w/in 72 hours of rash onset these can reduce incidence of postherpetic neuralgia by 50% - Simple analgesics --> tricyclics (amitriptyline or nortriptyline) - SYSTEMIC CORTICOSTERIOIDS DO NOT HELP

Glossopharyngeal Neuralgia

- Uncommon disorder with no structural abnormalities | - Similar pain to TN, but occurs in throat and sometimes in deep ear/back of tongue

Triggers and treatment of Glossopharyngeal Neuralgia

Triggers: - swallowing, chewing, talking, yawning, syncope Treatment: - Oxcarbazepine - Carbamazepine - Surgery considered if medications fail - Surgical intervention is microvascular decompression

Other causes of facial pain

- TMJ - Sinusitis/Ear infections - Glaucoma - Pain in jaw (could be angina pectoris)

Risk factors for Subarachnoid Hemorrhage (SAH)

- Older age - Female - Non-white ethnicity - HTN - Smoking - High ETOH consumption

S/S of Subarachnoid Hemorrhage (SAH)

- "Thunderclap" HA leading to N/V - Signs of meningeal irritation usually present - Obtundation common - Focal deficits frequently absent

Diagnosing of Subarachnoid Hemorrhage (SAH)

- CT scan (performed immediately to confirm hemorrhage has occurred) - CT arteriography determines source of bleeding - Transcranial doppler - only screens for vasospasms

Lab studies of Subarachnoid Hemorrhage (SAH)

- CSF shows elevated RBC count - Absolute RBC count (<2,000 RBC is very unlikely due to SAH) - WBC (peripheral leukocytosis) - UA (transient glycosuria) - ECG (arrhythmias or MI)

Characteristics of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)

- HA that worsens with straining - Visual obscuration or diplopia - Papilledema - Abducens palsy commonly present - CSF fluid is normal

Causes of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)

- Can be caused by stopping long-term oral steroids | - Using tetracycline or oral contraceptives can contribute to cause

Diagnosing of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)

- MUST SCREEN FOR SPACE-OCCUPYING LESION OF BRAIN! - CT or MRI of brain - MR Venography - important to screen for thrombosis of IC venous sinuses

Treatment of Pseudomotor Cerebri - Idiopathic Intracranial HTN (IIH)

- Acetazolamide (3x/day) - slowly increase dose - Topiramate - Furosemide - Repeated LP (lowers ICP) - Surgical placement of VP shunt or optic nerve fenestration if medications fail ALL PATIENTS SHOULD BE REFERRED!