Headache and Neurological Disorders

These flashcards cover key terms and concepts from the lecture on headache and neurological disorders, facilitating effective study and review.

Headache

Defined as pain located in the head, neck, or jaw.

Primary headache syndromes

Includes migraine, cluster, and tension headaches.

Secondary causes of headache

Includes intracranial hemorrhage, brain tumor, meningitis, temporal arteritis, and glaucoma.

Migraine

A headache that affects approximately 15% of the general population.

Complete neurological exam

Essential in the evaluation of headache.

First step CT or MRI for abnormal examination

Lumbar puncture (LP) required when meningitis (stiff neck, fever) or subarachnoid hemorrhage (after negative imaging).

Imaging study

A CT or MRI scan indicated if a serious underlying cause is suspected.

Lumbar puncture (LP)

Required when meningitis or subarachnoid hemorrhage is a possibility.

Tension headache

Common headache described as a tight band around the head.

Source of pain in tension headaches

Believed to be chronic contraction of the neck and facial muscles.

Background of stress and worry

Migraine characteristics

Causes episodes of headache lasting between a few hours and a few days.

Typically throbbing, severe, at the front of the head and worse on one side

Familial

Most patients experience their first attack before age 40

2 features: unilateral pain, throbbing pain, aggravated by movement, moderate or severe

1 feature: nausea/vomiting, photophobia, phonophobia

Treatment for migraine attacks

May respond to simple analgesics or dopamine antagonists such as aspirin and metoclopramide

Serotonin such as ergotamine and triptan

If vomiting - medicine can be given sublingually, nasal spray, suppository or injection

Preventive treatment for migraine

Includes the regular administration of beta-adrenergic blockers.

Cluster headache

Characterized by repetitive attacks, occurring at the same time in a cycle.

lasts b/w 30-120minutes

Excruciatingly severe, located around one eye, accompanied by ipsilateral signs of autonomic dysfunction including redness, swelling, nasal congestion, or Horner’s syndrome

Horner’s Syndrome

Combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body, resulting in decreased pupil size, drooping eyelid and decreased sweating on the affected side

Prophylactic treatment for cluster headaches

Starting with steroids and verapamil.

Then methysergide or anticonvulsants (such as topiramate)

Meningismus

Neck stiffness due to meningeal irritation.

Subarachnoid hemorrhage (SAH) - Headache

Severe and sudden onset headache caused by blood in the subarachnoid space.

Intracranial hemorrhage

Epidural - results from lateral skull fracture that lacerates the middle meningeal artery or vain. May or may not lose consciousness. lucid interval lasting several hours to 1-2days followed by rapid evolution of symptoms over hours

headache, progressive obtundation, hemiparesis, and ipsilateral pupillary dilation from brain herniation

Shape: biconvex, lens shaped mass that may cross the midline

Subdural - acute, subacute or chronic after a head injury.

Headache and altered consciousness are principal manifestations. The time b/w trauma and the onset of symptoms is typically longer

Shape: crescent-shaped and may cross the cranial sutures but not the midline

Intracerebral - usually located at the frontal or temporal poles. blood typically enters the CSF, resulting in signs of meningeal irritation and sometimes hydrocephalus

Concussion

A syndrome following head trauma characterized by transient confusion, memory impairment, incoordination

Other symptoms: headache, fatigue, irritability, dizziness, nausea, vomiting, blurred vision, and imbalance

tend to resolve after 1-2 days

Intracerebral contusion

Bruising of the brain tissue related to head injury.

Traumatic brain injury

Range of injury from scalp laceration to loss of consciousness.

Bell’s Palsy

The common disease of the facial nerve causing facial weakness.

Cause - inflammation due to reactivation of herpes simplex virus within nerve ganglion in many cases

Trigeminal neuralgia

Facial pain syndrome characterized by unilateral pain in trigeminal nerve distribution.

develops middle to late life, more common in women than men

unilateral

Pain is unilateral and typically confined to the area supplied by the second (V2) and third (V3) divisions of the trigeminal (V) nerve

>1s to 2s jabs of excruciating pain 

Occurrence during sleep is rare

Diagnosis - CT scan, MRI and arteriography are normal

High-res MRI may show microvascular nerve compression

Treatment -

Carbamazepine 400 - 1200 mg/d orally
Phenytoin 250mg - acute attack
Lamotrigine (400 mg/d) or Baclofen (10mg 3x day) - refractory

Posterior fossa microvascular decompression surgery for patients who fail or cease to respond to drugs.

Brain blood supply

Aorta - major arty carrying recently oxygenated blood away from the heart

Common carotid arteries

• Internal carotid artery

  • enters cranium through carotid canal in temporal bone

• external carotid artery

  • supply blood to the tissues on surface of cranium

Vertebral arteries - Second set of vessels that supply the CNS

pass through transverse foramina of the cervical vertebrae

Two vertebral arteries → the basilar artery

The left and right internal carotid arteries and branches of basilar artery wall → the circle of Willis, a confluence of arteries that can maintain perfusion of the brain even if narrowing or a blockage limits flow through one part

Blood supply to the brain

Anterior brain

2 carotid arteries → internal carotid arteries → in the head the anterior (ACA) and middle 9<CA) cerebral arteries

Posterior brain

2 vertebral arteries → the basilar artery → the posterior cerebral arteries (PCA)

Circle of Willis - Internal carotid and basilar arteries connect at the base of the brain

Stroke

Causes of stroke -

1. Occlusion (blockage) of arteries → cerebral ischemia or infarction

   1. Ischemia - reversible

      1. Common cause - thrombus formation at site of atheromatous plaque. Thrombus can block vessels or throw off emboli which block more distal arteries

      2. less common cause - embolism from the heart

   2. Infarction - irreversible cell death

2. Rupture of arteries → intracranial hemorrhage

Hemorrhage more destructive and dangerous than ischemic stroke with higher mortality rates

Ischemic stroke is more common with wider range of outcome

Cerebral ischemia and infarction and the effects 

Anterior cerebral artery -

1. loss of use/or feeling in contralateral leg

Middle cerebral artery -

1. Loss of use on the contralateral face and arm

2. loss of feeling in the contralateral face and arm

3. dysphasia

4. dyslexia, dysgraphia, dyscalculia

Posterior cerebral artery

1. partial vision loss

Management of ischemia

Brain CT scan for hemorrhage

Thrombolytic therapy

Systematic assessment of swallowing

Early mobilization to prevent the secondary problems of pneumonia, deep vein thromboses, pulmonary embolism, pressure sores, frozen shoulder and contracture.

BP management, socialization to help depression

Lacunar stroke

patients with hypertension or diabetes may occlude smaller arteries within the brain through pathological process

“Small vessel disease” may cause infarcts a few millimeters in diameter

Transient Ischemic attack

mini-heart attack that takes place within minutes to hours.

Recovery that takes longer than 24 hours is diagnosed as stroke

Intracranial Hemorrhage

Sudden release of arterial blood, either into the subarachnoid space around the brain or directly into substance of the brain

Bleeding usually come from berry aneurysm arising from one of the arteries at the base of the brain, around the circle of Willis

Peripheral nerve leision

Peripheral nerves in the limbs may be damaged by any of the following:

1. Trauma -Sharp objects/knives/glass

   1. Trauma of bone fractures

2. Iatrogenic ally 

   1. Following prolonged tourniquet application (e.g radial nerve in arm)

   2. ill-fitting plaster cast

   3. inaccurate localization of intramuscular projections, acupuncture needle

3. Acute compression

   1. pressure from hard object on nerve

4. Chronic Compression

   1. Entrapment neuropathy

5. Multifocal neuropathy

   1. produce discrete local lesion in nerves

Peripheral nerve lesion - recovery

Severed nerve → no recovery

Axonal destruction → requires regrowth of axons distally from the site of injury, slow and incompletely efficient process

Injured myelin sheaths → recovers well. Axon is intact, schwann cells reconstitute myelin quickly around intact axons

Nerve root lesion

1. Radiculopathy - suggests lesion involving dorsal and ventral nerve roots and/or spinal nerve 

2. Presence of neck or back pain that radiates to the extremities in radicular distribution also suggests a root lesion

3. Common syndromes associated with pathology

   1. prolapse intervertebral disc

   2. herpes zoster

   3. Metastatic disease in the spine

Prolapsed intervertebral disk

When the central, softer material, nucleus puposus of an intervertebral disc protrudes through a tear in the outer skin, annulus fibrosus

most common pathology to affect nerve roots and spinal nerves

most common b/w C4 and T1, L3 and S1

Prolapsed intervertebral disk - clinical features

Skeletal -

• Pain, tenderness and limitation in the ROM in the affected area of the spine

• Reduced straight leg raising on the side of the lesion, in the case of lumbar disc prolapse

Neurological

• Pain, sensory symptoms and sensory loss inthe dermatome of the affected nerve root

• Lower motor neuron signs (weakness and wasting) in the myotome of the affected nerve root

• Loss of tendon reflexes of the appropriate segmental value

Prolapsed intervertebral disk - disease syndromes

1. Single acute disc prolapse

   1. Sudden, often related to usually heavy lifting or exertion, painful and very incapacitating

2. Gradually evolving

   1. multiple-level disc herniation in association with osteoarthritis of the spine. Disc degeneration is associated with osteophyte formation, not just in the main intervertebral joint between body and body, but also in the intervertebral facet joints.

3. Cervical myelophathy

   1. when spinal cord compression is in the cerivcal reguin. More likely in patients w/ constitutionally narrow spinal cord

4. Cauda equina compression at several levels due to lumbar disc disease and spondylosis. 

   1. May develop sensory loss in the legs or weakness on exercise. Urinary retention, urinary and/or fecal incontinence

Diagnosis

• MR scanning of the spine at appropriate level

Treatment

• Acute

  • settle with analgesics

• Nerve roote compression/persistent symptoms

  • microsurgical removal of the prolapsed material

Peripheral neuropathy

in pateints with perpheral neuropathy

• malfunction in peripheral nerves of body

2 types of pathology

• Distal axonal degeneration

  • distal distribution of symptoms and signs in the limbs

• Segments of nerve fibers become demyelinated

Normal passage of nerve impulse along the nerve fiber becomes impaired

Impulse either fails to be conducted accross the demyelinated section, or travels very slowly

Diabetes Mellitus

• Most common cause of peripheral neuropathy

• Occurs in both type I and II

• Most common form of neuropathy in diabetes is a predominatly sensory one

• Combination of neuropathy and atherosclerosis affecting thenerves and arteries in the lower limbs very strongly predisposes the feet of diabetic patients to trophic lesions, which are slow to heal

Multiple Sclerosis - other facts

• affects 350K Americans

• Onset mostly often in early to middle adulthood

• Women 3x more than men

• Cause unknown

• Potentially severe, MS ddoes not inevitably lead to disability, wheelchair life or worse

Multiple Sclerosis - definition

Plaque of demyelination in the CNS

• lesion in CNS, not peripheral nervous system

• Main insult is to the myelin sheaths with relative sparing of the axon

• Nature of neurological deficit depends on the site of the plaque of demyelination

Multiple sclerosis - clinical features

Relapsing-remitting - 85% of case, progression does nto occur b/w attacks

Secondary progressive - 80% of case, gradually progressive course after initial relapsing-remitting pattern

Primary progressive - 10% of cases, with gradual progression of disability from clinical onset

Progressive-relapsing - rare, acute relapses being superimposed on a primary progressive course

Occurence of lesion in different parts of CNS, occur at different times

Preventricular white matter

• Lesions are very common in this part fo the brain. They are seen early in disease in apteients studied by MR brain scanning and are always found post mortem. They do not give rise to definite symptoms

Obtic nerve

• Optic neuritis - typical manifestation of MS, effect on vision in the affected eye is to reduce acuity and cause blurring

• Color vision - fades, even to a pint fo fairly uniform grayness

Midbrain, pons an dmedulla

• Double vision

• facial numbness/weakness

• vertigo, nausea, vominting, ataxia

• dysarthria and dysphagia

• motor/sensory deficit in any of the 4 limbs

Spinal cord

• heaviness, dragging or weakness of the arms, trunk or legs

• loss of pain and termperature sensation in the arms, trunk or legs

• tingling, numbness, senses include - coldness, skin weatness, skin tightness or a sensatoin like that which follows a local anesthetic, in the arms, trunk or legs

• Clumsiness of a hand due to the loss of position in stereognosis

• Bladder, bower or sexual malfucnction

Diagnosis

• MRI

• can be diagnosed right away if pateients with at least 2 typical attacks and 2 MRI lesions

Multiple sclerosis management

Immunomodulatory drugs

• azathioprine, beta-interferon, copaxone, mitoxandtrone to reduce incidence of relapse

Torticosteroids

• high-dose intravenous methyl-prednisolone over 3 days

  • reduce duration and severity of episodes of demyelination, w/o influencing the final outcome.

• Dietary exclusions and most supplements are of no proven advantage. Fish oil supplements may be of benefit. Main dietary requirement is the avoidance of obesity in the enforced sedentary state.

Parkinson disease

Move slow, resting tremor, taking small steps

Dopamine deficient

Characteristics

• tremor

• hypokinesia

• rigidity

• abnormal gait and posture

Drugs that can cause Parkinson

• Neuroleptic agents (Haloperidol, chloropromazine)

• antiemetics (metoclopramide)

• Poisoning from carbon monoxide, cyanide and manganese

• lesion aroun dhte basal ganglia

Patients who have survived an episode of encephalitis can develop post-encephalitic Parkinsonism

Treatments

• Levodopa - turned into dopamine within the remaining neurons in the substantia nigra

• Dopamine agonist - mimic effect of dopamine in striatum

• Drugs which inhibit the metabolism of dopamine, and from drugs that modify other neurotransmitters in the striatum such as amantadine and anticholinergics.

Seizures

Characterized by recurrent unprovoked electrical disruptions in the brain.

Causes

• Genetic

• Structural/metabolic

  • trauma, tumor, vascular disease, infectious disease, degenerative disorders, metabolic disorders

• Unknown

Epilepsy

Recurrent unprovoked seizures

Focal seizures

Seizures affecting only part of the brain.

Generalized seizures

Seizures that affect both hemispheres of the brain.

Absence seizure (petit mal)

A type of generalized seizure marked by brief loss of consciousness.

may miss a few words during conversation

ends by age 20

Tonic-clonic seizure (grand mal)

Characterized by loss of consciousness, body rigidity, and convulsions.

1. Tonic Phase (<1min)- patient becomes rigid and falls, respiration is arrested

2. Clonic phase (2-3 min) - jerking of body masculature

3. Flaccid coma

Evaluation for seizures

Includes medical history, physical exam, and potentially EEG.

Lumbar puncture is indicated if suspicion of CNS infection such as meningitis or encephalitis

Management of acute seizures

Includes positioning the patient semi-prone to avoid aspiration

Give oxygen face mask

Reversible metabolic disorders

• hypoglycemia, hyponatremia, hypocalcemia, drugs or alcohol should be prompty corrected

Dementia

Progressive decline in intellectual function

start after age 60

Neuropsychological assessment - Folstein Mini Mental State Exam (MMSE)

Treatment -

• mental stimulation

• cholinesterase inhibitors

• Donepezil, rivastigmine, galantamine

Mood and behavioral disturbances

• Selective serotonin reuptake inhibitors (SSRIs)

Insomnia

• Trazode, OTC antihistamine hypnotics must be avoided along with benzodiazepines. Worsens cognition

Major depressive disorder (MDD)

Mood disorder presenting with at least two weeks of symptoms that alter function.

Risk factors for MDD

Include family history, stress exposure, and hormonal differences.

Many studies have reported abormalities in serotonin, norepinephrine and dopamine. 

Treatment for MDD

Includes antidepressants and psychotherapy as therapeutic approaches.

Bipolar disorder

A mood disorder characterized by the occurrence of both major depression and mania.

• Bipolar I - major depressive and manic episodes

  • elevated mood (mania) for at least 1 week

  • greatest genetic linkage

  • Mood stabilizers - lithium

  • benzodiazepines

  • antipsychotic (clozapine)

• Bipolar II - major depressive and hypomanic (milder manic)

Schizophrenia

Thought disorder impacting perceptions of reality and behavior.

associated with high levels of dopamine and abnormalities in serotonin

treatment

• antipsychotic medication

Anxiety

psychologic

• worry that is difficult to control

• hypervigilance and restlessness

• difficulty concentrating

• sleep disturbance

Panice attack

Panic disorder → recurrent unexpected panic attack

last a few minutes, impending fear of death

treatment

• ssri

• alprazolam