1
Q
- Most prevalent headache type, women affected more than men
- Constant daily bilateral headaches
- Vise-like pressure of tightness that waxes and wanes but does not throb
- Exacerbated by emotional stress, fatigue, noise, glare, but not normal physical activity
- Complaints of poor concentration and other vague non-specific symptoms
- Generalized and often most intense about the neck or back of the head, muscles may be sore
- No focal neurological symptoms
A
Tension HA
2
Q
- Middle aged men affected more than women
- Unilateral pain beginning around the eye or temple
- During attacks, patients are often restless and agitated
- Episodes often occur at night and last between 15 min to 3 hours
- May be associated with; ipsilateral nasal congestion or rhinorrhea, lacrimation and redness of the eye
- Horner Syndrome; Ptosis/Miosis/Anhidrosis
- Usually no family history of headache or migraine
- Occur in ““clusters””, that is daily on the same side of the face for several weeks
- Spontaneous remission
- During a bout, PT may report that alcohol, stress, glare, or indigestion of specific foods triggers and attack
A
Cluster HA
3
Q
- Gradual buildup of a throbbing headache, often unilateral
- Duration of several hours or longer
- Aura may or may not be present
- Focal disturbances of neurologic function that precedes or accompanies the headache
- Visual disturbances; field deficits or luminous visual hallucinations such as seeing stars, light flashes, zigzags of light or geometric patterns
- Other focal disturbances such as aphasia or numbness, tingling, clumsiness, or weakness in a circumscribed distribution
- Family history is positive for headaches
- Triggers may or may not be known
A
Migraine
4
Q
- After head injury, it is common to have headaches
- Symptoms occur within 1-2 days of injury and subside within 7-10 days
- Often accompanied by impaired memory, poor concentration, emotional instability, and increased irritability
A
Post-traumatic HA
5
Q
- Present in about 50% of patients with chronic daily headaches
- Typically present with chronic pain or with complaints of headache unresponsive to medication
- History will reveal heavy use of analgesics
A
Medication Overuse HA
6
Q
- MOTOR SEIZURES - have motor signs; convulsive jerking, involuntary movements of contralateral side
- SENSORY SEIZURES - have sensory signs; paresthesia, tingling, flashing lights, unusual sounds or odors, indicate involvement of visual/auditory/olfactory/gustatory regions of brain
- AUTONOMIC SEIZURES - have autonomic signs; abnormal epigastric sensations, sweating, flushing, pupillary dilation
- HIGHER CORTICAL SEIZURES - have higher cortical signs; dysphasia, deja vu, affective disturbances, illusions, hallucinations, etc
A
Partial Seizures
7
Q
•Arise from both cerebral hemispheres simultaneously
•Have loss of conciousness as hallmark
ABSENCE(PETIT MAL)
•Sudden, brief impairment of conciousness without loss of postural control
•Lasts for only seconds, consciousness returns as suddenly as it was lost and no post-ictal confusion
•Usually accompanied by automatisms
•Can occur hundreds of times per day, but PT may be unaware
•First clue is unexplained ““daydreaming”” and a decline in school performance
A
Generalized Seizure Absence (Petit mal)
8
Q
TONIC-CLONIC(GRAND MAL)
•Usually begins abruptly without warning; PT becomes rigid, falls to ground, and respiration is arrested
•Initial phase is TONIC; contractions of muscles throughout the body, after 10-20 seconds, evolves into the CLONIC phase; periods of muscle relaxation and contraction(jerking) lasting about 2-3 minutes, POST-ICTAL phase; unresponsiveness, muscular flaccidity, excessive salivation, stridorous breathing, and bladder/bowel incontinence
•Gradually retain conciousness over minutes to hours and typically have post-ictal confusion, headache, fatigue, and muscle aches
A
Generalized Seizure Absence (Grand mal)
9
Q
- Sudden and brief muscle contraction that may involve one part of the body or the entire body
- Sudden jerking movement observed while falling asleep
- Associated with metabolic disorders, degenerative CNS diseases, or anoxic brain injury
- Usually coexist with other forms of generalized seizure disorders; may generalize to tonic-clonic
- If only myoclonic, no LOC typically
A
Generalized seizure myoclonic
10
Q
- Often part of a conversion reaction to outside stress
- Difficult to make determination clinically
- Usually females more than males and usually in front of witnesses
A
Generalized Seizure NON-ELECTRIC (Psychogenic, Non-epileptic, pseudo)
11
Q
- Continuous seizures >5 min
- After 30-45 minutes, signs become increasingly subtle
- Patients may only have mild clonic movements of fingers or fine, rapid movements of the eyes.
- There may also be paroxysmal episodes of tachycardia, hypertension, and pupillary dilation
A
Status Epilepticus
12
Q
- Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction that resolved within 24 hours
- Sudden onset focal neurological deficit
A
Transient Ischemic Attack (TIA)
13
Q
- Symptoms depend on the site of bleed
- Intracerebral hemorrhage usually has gradual onset as blood builds
- SAH has maximal impact right away usually with intense ““worse headache of my life”
A
Hemorrhagic Stroke (ICH and SAH)
14
Q
- "”creeping, crawling”” sensation or ““pins and needles feeling”” in the limbs, especially in the legs
- Tends to occur during waking and at sleep onset
- Being recumbent increases leg discomfort and leads to difficulty sleeping
A
Restless Leg Syndrome
15
Q
- Episodic neurologic symptoms
- PT usually under 55 years old at onset
- Single pathologic lesion cannot explain clinical findings
- Multiple foci best visualized by MRI
- Weakness, numbness, tingling, or unsteadiness in a limb
- Spastic paraparesis
- Retrobulbar optic neuritis
- Diplopia
- Dysequilibrium or a sphincter disturbance such as urinary urgency or hesitancy
- May appear after a few days or weeks, although exam often reveals a residual deficit
A
Multiple Sclerosis
16
Q
- Level of conciousness is depressed
- Stuporous PTs only respond to repeated vigorous stimuli
- Comatose PTs are unarousable and unresponsive
A
Altered Mental Status
17
Q
- Hallmarks are confusion and amnesia
- May occur with or without loss of consciousness
- May be immediately apparent or delayed by several minutes
- Amnesia almost always includes the traumatic event itself, but may also extend to events before and after trauma
- Clues such as lack of recall or repetitious questioning should be red flags
- Early symptoms - headache, dizziness, vertigo, imbalance, nausea, vomiting
- Delayed Symptoms - mood/cognitive disturbance, light/noise sensitivity, sleep disturbance
- COMMON SIGNS - vacant stare, delayed verbal expression, inability to focus attention, disorientation, slurred or incoherent speech, gross observable incoordination, emotionality out of proportion to circumstances, memory deficits, any period of LOC
- LESS COMMON SIGNS - Seizures, complicated concussion
A
Closed Head Injury
18
Q
•Skull may be depressed, or open
•Thin in several area; temporal region, nasal sinuses
•Scalp will bleed profusely
BASILAR SKULL FRACTURES
•Battle signs, Raccoon eyes, hemotympanum, CSF/rhinorrhea/otorrhea, cranial nerve deficits
A
Cranial Trauma
19
Q
- Usually caused by traffic accidents, falls, and assaults
- 75-95% have associated skull fracture
- Immediate LOC after significant head trauma
- "”Lucid interval”” with recovery of consciousness
- After a period of hours, increasing headache with deteriorating neurologic function
- May also see seizure, coma, anisocoria, respiratory collapse
A
Epidural Hemorrhage
20
Q
- Elderly, ETOH abusers, and anticoagulated at risk
- May occur without impact
- Severe head trauma with subdural hematoma(SDH) and coma
- Minor head trauma with SDH and LOC
- Minimal head trauma with SDH and mental status exam changes
- Acute SDH presents 1-2 days after onset
- Symptoms of elevated ICP; headache, vomiting, anisocoria, dysphagia, cranial nerve changes
A
Subdural Hemorrhage
21
Q
- Sudden, severe headache
- Classically described as the ““worst headache of my life””
- May be accompanied by AMS, LOC, seizure, nausea, meningeal signs
- Up to 43% may have a ““warning leak”” preceding major bleed by 6-20 days
- May be associated with exercise
A
Subarachnoid Hemorrhage
22
Q
- Hx of MVA, falls, violence, or sports
- Young, drunk males
- Direct damage to spinal structures
A
Spinal Cord Injury
23
Q
- Pain, numbness, or tingling in the lower back and spreading down 1 or both legs
- Leg weakness or ““foot drop””; which is when you cannot seem to hold your foot up
- Problems with bowel or bladder control
- Problems with sex
A
Cauda Equina Syndrome
24
Q
- Acute or subacute progressive polyradiculoneuropathy
- Weakness is more severe than sensory disturbances
- Acute dysautonomia may be life-threatening
- Main complaint of weakness that varies widely in severity in different patients and often has a proximal emphasis and symmetric distribution
- Usually begins in the legs, spreading to a variable extent but frequently involving the arms and often one or both ides of the face
- The muscles of respiration and deglutition may also be affected
- Sensory symptoms; distal paresthesia, dysesthesia, neuropathic or radicular pain
- Autonomic disturbances; tachycardia, cardiac irregularities, hypo/hypertension, facial flushing, sweating abnormalities, pulmonary dysfunction, and impaired sphincter control
A
Guillain-Barre Syndrome
25
* Focal motor or sensory deficit
* Compression of the median nerve between the carpal ligament an other structures within the carpal tunnel
* Pain, burning, and tingling in the distribution of the median nerve
* Most bothersome during sleep
* Late weakness or atrophy of the thenar eminence
* Can be caused by repetitive wrist activities
* Commonly seen during pregnancy and patients with diabetes mellitus or rheumatoid arthritis
* Likely positive Tinel or Phalen's sign
Carpal Tunnel Syndrome
26
* Pain with back flexion or prolonged sitting
* Radicular pain into the leg due to compression of neural structures
* Lower extremity numbness and weakness
* L5-S1 disk is affected in 90% of cases
* Can cause cauda equina syndrome
* Discogenic pain of the lower back, sciatica, pain worsened with back flexion such as bending or sitting, numbness, weakness, including weakness with plantar flexion of the foot
Lumbar Disc Herniation
27
* Acute facial palsy (paralysis) of a specific pattern
* Pain about the ear precedes or accompanies the weaknes in many cases but usually lasts only a few days
* Face feels stiff and pulled on one side
* May be ipsilateral restriction of eye closure and difficulty with eating and fine facial movements
* Disturbance of taste, tearing or dryness of the eye, and less frequent blinking on the affected side
* Bell's phenomenon (upward rolling of eye on attempted lid closure)
* Subjective numbness of the affected side
* Drooling, hyperacusis, viral prodrome
Bell's Palsy
28
* CLASSIC TRIAD - Fever, nuchal rigidity, and change in mental status
* Headache usually severe and generalized, not easily confused with normal headache
* Photophobia, seizures, focal signs, papilledema
* Petechia and palpable purpura
* Arthritis
* Nuchal rigidity
* Evaluate for Kernig/Brudzinski sign
Mennigitis
29
* Can be Viral or Post-infectious
* May look like meningitis, but brain function is impaired
* Seizures and post-ictal states can be seen with meningitis or encephalitis
* Symptoms can mimic meningitis
* Typical presentation; nonspecific fevers, headache, nausea, nuchal rigidity
Encephalitis
30
* Chronic complaints of pain
* Symptoms frequently exceed signs
* Minimal relief with standard treatment
* History of having seen many clinicians
Chronic Pain Syndrome
31
* Difficulty getting to sleep or staying asleep, intermittent wakefulness during the night, early morning awakening, or any combinations
* Stress, caffeine, physical discomfort, daytime napping, and early bedtimes are common factors
* Psychiatric disorders are often associated with persistent insomnia
* Tendency to use alcohol as a means of getting to sleep without realizing it disrupts the normal sleep cycle
* Heavy smoking (more than a pack a day) causes difficulty falling asleep
Insomnia
32
•Either a sensation of motion when there is no motion or an exaggerated sense of motion in response to movement
•Duration and association with hearing loss are the key to diagnosis
•PERIPHERAL; onset is sudden, often associated with tinnitus and hearing loss; horizontal nystagmus may be present
CENTRAL; onset is gradual, no associated auditory symptoms
•Cardinal symptom of vestibular disease
•Typically experienced as a distinct ""spinning"" sensation or a sense of tumbling or of falling forward or backward
Vertigo
FEP MDT S/Sx's
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