exam 3 - chronic neurology

primary headaches vs secondary headaches

• primary - no identifiable organic cause

• secondary - caused by underlying organic pathology

headache diagnostic assessment

• diagnostic tests are generally absent in primary

• health history - old carts

• onset, location, duration, characteristics, aggravating/alleviating factors, radiation, timing, severity

tension-type headache

most common type of headache in both men and women

tension-type headache: pain location

• bilateral

• frontal-occipital region

• “hatband” distribution

tension-type headache: pain quality

constant, dull, non-throbbing pressure

tension-type headache: associated symptoms

• photophobia + phonophobia

• you do not feel nausea/vomiting or prodrome

tension-type headache: triggers

• stress

• forward-head posture

• muscle tenderness

tension-type headache: medications

aspirin, acetaminophen, or nsaids

tension-type headache: preventative medications

• tricyclic antidepressants

• anti-seizure medications

migraine headache

• onset typically 25-55 years old

• 20% females and 8% males affected

• linked to estrogen/menstrual cycle

migraine headaches - pathophysiology

trigeminal nerve (V) = causes intracranial vasodilation and neurogenic inflammation → pain nerves

migraine headache: pain location

unilateral, retro-orbital, or temporal

migraine headache: pain quality

severe, throbbing, pulsatile

migraine headache: associated symptoms

• photophobia + phonophobia

• nausea + vomiting

migraine headaches with aura symptoms

• 25% of migraines

• visual: sparkles, flashing lights, scotomata (partial vision loss), halos

• sensory motor: paresthesia, dysphasia

migraine headache: triggers

• stress, seasonal changes, sleep disturbance

• missed meals + menstruation

• food + bright lights

migraine headache: meds

• mild-to-moderate: aspirin, acetaminophen, nsaids, or caffeine

• moderate-to-severe: triptans

  • causes vasoconstriction, therefore, contraindicated for heart diseases

migraine headache: preventative meds

• tricyclic antidepressants

• anti-seizure medications

• ssris + botox

cluster headache

• rare <1% prevalence

• male-to-female ratio is 4:1

• onset between 20s-40s

cluster headache: pain location

unilateral, orbital, retro-orbital, or temporal

cluster headache: pain quality

• excruciating

• stabbing, sharp, “suicide headache”

• can last 15 mins-3 hours

cluster headache: associated symptoms

• related to autonomic nervous system

• includes: miosis (pupil constriction), ptosis, lacrimation, rhinorrhea

cluster headache: triggers

• alcohol + volatile smells

• napping

• weather/seasonal changes

cluster headache: meds

• 100% high-flow oxygen: 12 L/min via non-rebreather for 15 mins sitting upright

• second line: subcutaneous or intranasal triptans

cluster headache: preventative meds

• high-dose verapamil (calcium channel blockers)

• steroid injections

seizure

• uncontrolled electrical discharges in brain neurons

• provoked causes: bg <79, hyponatremia <135, meningitis, drug and alcohol withdrawal

epilepsy

chronic neurological disorder defined by recurrent, unprovoked seizures occurring more than 24 hours apart

seizures: infancy/childhood etiology

• birth injury and acute trauma

• congenital defects

• high fevers

seizures: young adults (20s-30s) etiology

brain lesions, tbi, substance use

seizures: older adults (>50s) etiology

• cerebrovascular disease (stroke)

• brain tumors

• dementia and systemic illness

which antiepileptic drugs should older adults not take and why?

• phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital (Luminal)

• because it can cause cognitive issues, ataxia, nystagmus

which antiepileptic drugs should older adults take?

• levetiracetam (Keppra)

• lamotrigine (Lamictal)

• oxcarbazepine (Trileptal)

• gabapentin (Neurontin)

stages of seizures

1. prodromal: changes in mood hours or days before seizure

2. aural phase: sensory warning occurring immediately before seizure (eyesight change or strange smell)

3. ictal phase: actual seizure

4. postictal phase: recovery period

tonic-clonic seizure: phase 1

• tonic phase (10-20 secs)

• muscle contraction, loss of consciousness, jaw clenching, salivation, cyanosis

tonic-clonic seizure: phase 2

• clonic phase (30-40 secs)

• rapid, rhythmic, symmetric jerking and contraction of extremities

tonic-clonic seizure: phase 3

• postictal phase

• muscle soreness, tired (sleep for hours), confusion and amnesia of event

absence seizures

• typical in children and brief (few seconds)

• staring spells resembling daydreaming

• immediate recovery without postictal phase

atonic seizures

loss of postural muscle tone → pt collapses to ground → high risk for head trauma

myclonic seizures

brief shock-like muscle contraction of extremity or trunk

focal seizures

• localized area of one cerebral hemisphere

• commonly temporal or frontal

focal seizures - focal aware

• simple partial

• pt fully conscious, paresthesia, or sensory hallucinations

focal seizures - focal impaired awareness

• complex partial

• pt experiences altered consciousness, behavioral automatisms (lip smacking or repetitive hand movements), and postictal confusion

focal seizures - focal to bilateral tonic-clonic

starts as focal seizure with aura → goes to both hemispheres → postictally pt may exhibit todd's paralysis (temp weakness or paralysis in one part of the body)

status epilepticus

seizure lasting more than 5 minutes or repeated seizures without the person regaining consciousness between them

status epilepticus - what happens?

• medical emergency!!

• brain consumes energy → neuronal exhaustion → permanent brain hypoxia → systemic lactic acidosis → hyperthermia → cardiac dysrhythmias → death

status epilepticus - first-line emergency drug

• IV benzodiazepines

• ex. lorazepam (Ativan) or diazepam (Valium)

• if IV is not available = rectal diazepam (DiaStat)

status epilepticus - second emergency drug

• first drug is followed by IV long-acting anti-seizure

• levetiracetam (Keppra), phenytoin (Dilantin), or phenobarbital

status epilepticus - diagnostic eeg

• pinpoints epileptogenic focus and helps classify seizure type

• pt prep: wash hair thoroughly so electrodes can stick to scalp, avoid coffee 12-24 hrs, does not need to be npo

status epilepticus - diagnostic ct/mri

performed to rule out structural lesions, tumors, or hemorrhage

status epilepticus - laboratory studies

• serum sodium and calcium

• bg + urinalysis

• liver/renal function + tox screens

pre-seizure set-up

• suction equipment and oxygen ready

• maintain patent IV - saline lock

• bed positioned to lowest height

• padded side rails

active seizure interventions

• turn pt to lateral (side-lying) side + do this postictal

• cushion pt head + loosen clothing around neck

• note exact start time and duration of seizure

active seizure interventions: what not to do?

• never insert any object into pt’s mouth

• never attempt to force open a clenched jaw

• never restraint pt’s extremities

ketogenic diet

• high fat and low-carb diet

• decreases seizures in drug resistant epilepsy:

  • ketone bodies cross blood-brain → replace glucose as energy source for neurons → reduces hyperexcitability → stabilizes neurons firing

parkinson’s disease

• chronic, progressive, neurodegenerative disorder

• onset >50 years of age + males>females

parkinson’s disease - pathophysiology

• progressive and degenerative loss of dopamine neurons in substantia nigra of basal ganglia

• dopamine levels decline = unchecked overactive acetylcholine activity bc dopamine inhibits ACh

parkinson’s disease - cardinal motor manifestations

• t - tremor

  • rest tremor, described as “pill-rolling” motion of hand

• r - rigidity

  • higher muscle tone → jerky, ratchet-like “cogwheel” motion

• a - ankiesnia/bradykinesia

• p - postural instability

parkinson’s disease - ankiesnia/bradykinesia

• akinesia - loss of voluntary movement + bradykinesia - slowness of movement

• freezing spells + mask-like facial expression bc low blinking

• hypokinetic dysarthria (soft, slurred, monotone speech)

parkinson’s disease - postural instability

shuffling, gait imbalances with flexed arms and loss of arm swings

parkinson’s disease - non-motor manifestations

• autonomic dysfunction - excessive sweating, orthostatic hypotension, constipation, urinary retention

• sensory dysfunction - depression, anxiety, dementia

parkinson’s disease - diagnosis

• based strictly on patient history and physical motor assessment (presence of cardinal trap symptoms)

• no specific lab or imaging unless to rule out secondary causes

parkinson’s disease - diagnostic confirmation

drastic clinical improvement in motor symptoms in response to initial trial of levodopa

parkinson’s disease - gold standard med

• levodopa: crosses the bbb and converts into dopamine

• carbidopa: does not cross bbb and prevents levodopa from breaking in bloodstream → allowing more to brain + prevents peripheral side effects (nausea + hypotension)

parkinson’s disease - complications of chronic therapy

• “wearing off” phenomenon: medication wears off sooner, so symptoms return before the next dose

• “on-off” fluctuations: periods of good mobility and sudden severe ankinesia

• drug toxicity/dyskinesia: can cause involuntary movements, hence, provider may adjust the dose

which antiviral drug helps with parkinson’s as an adjunctive medications?

• amantadine (Symmetrel) - stimulates dopamine release from surviving presynaptic terminals

• blocks dopamine reuptake + helpful in managing levodopa-induced dyskinesias

which mao-B inhibitor helps with parkinson’s as an adjunctive medications?

• selegiline

• inhibits breakdown of dopamine in brain

• prolonging half-life + effectiveness of levodopa

which anticholinergic helps with parkinson’s as an adjunctive medications?

• benztropine

• blocks overactive cholinergic receptors to balance neurotransmission and decrease tremors

parkinson’s disease - deep brain stimulation surgery

• electrodes are surgically implanted into thalamus and connected to pulse generator in chest

• electrical impulses disrupt abnormal firing patterns

• reserved for severe cases + drug-resistant pt

parkinson’s disease - ablative surgery

destruction of specific thalamic or globus pallidus tissue to reduce severe tremors or dyskinesis

parkinson’s disease - aspiration + nutrition

• position pt upright at 90 degrees during all meals and 30 mins post-meal

• provide soft, pureed, or bite-sized meals

• avoid high-protein meals during levodopa + consume small high-carb meals

parkinson’s disease - vitamin b6

needs to be managed according to provider instructions to prevent altered drug metabolism

parkinson’s disease - safe mobility

• teach conscious gait technique: step over imaginary lines with heel-toe walking, lift feet high, actively force arm swings

• encourage yoga and dance therapy

parkinson’s disease - bowel management

need to manage constipation due to anticholinergic meds