NEURO

OBJECTIVES

  • Understand the etiology, incidence, and pathophysiology of commonly occurring acute neurological symptoms and disorders in adults.

  • Identify differential diagnosis of commonly occurring acute symptoms and disorders of the neurological system.

  • Know relevant subjective and objective data necessary to make an accurate diagnosis.

  • Identify appropriate diagnostic studies needed to establish an accurate diagnosis.

ACUTE NEUROLOGICAL DISORDERS

  • Common disorders include:

    • Headaches

    • Vertigo

    • Delirium

    • Seizures (Primary care management and workup)

    • Bell’s Palsy

    • DANGER SIGNALS:

      • Acute bacterial Meningitis

      • Acute Stroke

      • Chronic Subdural hematoma

      • Giant Cell Arteritis

      • Multiple Sclerosis

      • Subarachnoid Hemorrhage

MOST COMMON ACUTE NEUROLOGICAL PRESENTATION: HEADACHE

  • Goals of Evaluation of Headache:

    • Identify and rule out life-threatening causes (secondary headache).

    • Example: Sinus headache vs. Meningitis - DANGER SIGNALS!

    • Correctly diagnose the etiology of the headache and identify any underlying disease or problem.

    • Provide symptom relief and help with prevention of future headaches.

TYPES OF HEADACHES

NON-EMERGENT

  • Common Types:

    • Migraine

    • Tension

    • Cluster

    • Mixed (combination headache)

    • Can be familial (migraine, hypertension)

EMERGENT - Red Flag HA

  • Serious Types include:

    • Giant Cell Arteritis

    • Subarachnoid Hemorrhage

    • Stroke

    • Infection

  • Primary: Migraine, Tension, Cluster

  • Secondary: Underlying pathology, “red flag” headaches

HEADACHE ASSESSMENT

  • Key Components to Evaluate:

    • Chronology (most important historical item).

    • Location, duration, and quality of headache.

    • Associated activity: exertion, sleep, tension, relaxation.

    • Timing of menstrual cycle.

    • Presence of associated symptoms.

    • Presence of triggers.

OFFICE VISIT ASSESSMENT - RED FLAGS IN PT HX

  • Sudden Onset in Seconds or Minutes:

    • Thunderclap headache: SAH.

  • “First or Worst” Headache:

    • Hemorrhage or infection.

  • Focal Neuro Symptoms:

    • Indicators of mass, arteriovenous malformation (AVM).

    • Focal changes include: movement changes (paralysis, weakness), sensation changes (paresthesia, numbness), change in personality or mental status, loss of consciousness (LOC).

TENSION HEADACHE

  • Most Common Type of Headache (90% of all headaches):

    • Causes: Emotional/physical stress, mental tension, head and neck movements.

    • At-Risk Patients: Adults.

SIGNS/SYMPTOMS OF TENSION HEADACHES

  1. Vise-like or tight quality.

  2. Usually generalized pain.

  3. May be most intense at the neck or back of the head.

  4. No associated focal neurological symptoms.

  5. Usually lasts for several hours.

Three Main Subtypes of Tension Headaches:

  • 1. Infrequent Episodic: Episodes last less than 1 day a month.

  • 2. Frequent Episodic: Occurs 1-14 days per month.

  • 3. Chronic: Occurs 15 or more days per month.

  • Influencing Factors: Environmental, genetic factors, heightened sensitivity of pain pathways in CNS and likely PNS, and muscular factors.

DIAGNOSTIC TESTING FOR TENSION HEADACHES

  • Most of the diagnosis is from history, often supported by physical findings.

  • Clinical Diagnosis: No specific labs for tension headaches.

MANAGEMENT OF TENSION HEADACHES

  • Medications:

    • OTC analgesics:

    • NSAIDs: Naproxen (BID), ibuprofen (QID), or Aspirin (Q4-6h).

    • Combination drugs (like Excedrin) are alternative options for patients not achieving relief from a single agent.

    • Limit Butalbital (Fioricet, Fiorinal) to 3 times or less per month (current guidelines do not support these or opioids as first-line management).

    • Muscle relaxants are not recommended due to lack of efficacy.

  • Lifestyle Modifications:

    • Relaxation techniques (yoga, tai chi).

    • Gradually reduce caffeine, ensure sleep hygiene, and consider therapy counseling.

MIGRAINE HEADACHES

EPIDEMIOLOGY

  • Prevalence: 45% of headache visits are for migraine headaches.

  • Etiology: Primary neuronal dysfunction.

  • Significant Racial Differences:

    • African Americans and nonwhite Hispanics are 2 times as likely as whites or Asians to be migraine sufferers.

  • Age Relationship: Inverse relationship; prevalence highest in adults younger than 40 and lowest over 60.

  • Impact: Migraines account for the loss of more than 157 million workdays annually.

  • Often hereditary in women; traced to hormonal shifts; associated with mutations in calcium-channel genes.

CAUSES/TRIGGERS

  • Common Onset: Typically begins in adolescence or early adulthood.

  • More frequently occurs in females.

  • Triggers Include:

    • Emotional or physical stress, lack of sleep, missed meals, specific foods, alcohol, menstruation, use of oral contraceptives, nitrate-containing foods, changes in weather.

  • Statistics on Trigger Factors:

    • Emotional stress (80%), Hormonal changes in women (65%), Not eating (57%), Weather changes (53%), Sleep disturbances (50%), Alcohol consumption (38%), Smoking (36%), Late sleeping (32%), Heat (30%), Food (27%), Odors (44%), and Neck pain (38%).

PATHOPHYSIOLOGY OF MIGRAINE

  • Mechanism:

    • Neuropeptide release and trigeminal nerve (CN V) activation lead to vasodilation, increased plasma protein extravasation, and mast cell degranulation resulting in activation of nociceptors.

CLASSIFICATION OF MIGRAINES

  • Categories:

    • Classic migraine (with aura) and common migraine (without aura).

  • Historically attributed to dilation and excessive pulsation of branches of the external carotid artery; migraines typically last 2-72 hours, following the trigeminal nerve pathway (CN V).

SYMPTOMS OF MIGRAINES

  • Characteristics:

    • Unilateral, lateralized throbbing headache occurring episodically.

    • May vary between dull and throbbing, building gradually, and lasting for hours or longer.

    • Focal neurological disturbances or visual disturbances may precede migraines (i.e., field defects, luminous visual hallucinations).

    • Accompanied by symptoms such as nausea, vomiting, and photophobia/phonophobia.

PHASES OF A MIGRAINE

  1. Prodrome: Affective or vegetative symptoms 24-48 hours prior to headache (77% of patients).

  2. Aura: Focal neurological symptoms, occurring in 25% of patients, lasting 5-60 minutes.

  3. The Headache: Often unilateral with photophobia/phonophobia lasting 4-72 hours.

  4. Postdrome: Fatigue and exhaustion following the headache (migraine hangover), lasting 24-48 hours.

DIAGNOSIS OF MIGRAINE HEADACHES

  • Necessary Characteristics:

    • Headache lasting 4-72 hours with at least 2 of the following: unilateral quality, pulsating nature, moderate to severe intensity, aggravated by routine activity.

  • During the headache, nausea and/or photophobia/phonophobia (at least 1) should be present.

  • Minimum of 5 episodes with these characteristics.

  • No other explanation for the headache occurrence.

  • Involves attacks of aura (visual, sensory, motor, brainstem, retinal, or speech changes) that must be fully reversible, developing over 5-60 minutes, with headache onset within 60 minutes.

PATIENT ASSESSMENT FOR MIGRAINES

  • Commonly shows normal findings, although may reveal neurological deficits.

  • Physical Examination: Careful neurological assessment for focal deficits or findings suggestive of tumors.

  • Baseline Studies: Necessary for new migraine patients to exclude organic causes of symptoms.

FOLLOW-UP AND DIAGNOSTIC STUDIES

  • Diagnostic Tests: Often include blood chemistries, BMP, CBC, ESR (GCA), CT scan of head (for hemorrhage/hematoma), and urinalysis. EEG is not typically useful in routine evaluation and recommended only when indicated by history and physical exam.

  • Management Approaches:

    • Nonpharmacologic: Avoid triggers, stress management.

    • During Acute Attack: Rest in quiet, darkened space, and icepack on the forehead; ginger ale for nausea.

PHARMACOLOGIC TREATMENT FOR MIGRAINES

  • Acute migraine management options include:

    • Mild to moderate attacks may benefit from simple analgesics such as ASA, acetaminophen, or ibuprofen taken immediately.

    • Antiemetics may be added if nausea/vomiting is present.

    • For moderate-severe attacks, Triptans (first-line therapy) such as Imitrex (Sumatriptan) can be administered SQ at onset and repeated once in an hour (up to three times a day) or taken orally.

  • Patient Precautions: Patients with specific contraindications to triptans should be identified.

OTHER MEDICATIONS

  • Ergots:

    • Acute migraine treatment; do not combine with triptans.

    • Examples include dihydroergotamine and ergotamine.

  • Prophylactic Management: For patients with attacks occurring 2-3 times a month, consider anticonvulsants (Valproate, Topiramate, Gabapentin), antidepressants (Amitriptyline, Nortriptyline), beta-blockers (Propranolol, Metoprolol), and potentially, Onabotulinum for chronic migraines (31 injections every 12 weeks).

CLUSTER HEADACHES

EPIDEMIOLOGY AND CAUSES

  • Typically occur in middle-aged men; first onset between 20 and 30 years; characterized by clusters of headaches.

  • The occurrence may involve extreme pain and is classified under trigeminal cephalalgias, characterized by unilateral head pain with ipsilateral autonomic symptoms.

CLINICAL PRESENTATION

  • Symptoms Include:

    • Stabbing pain behind one eye, may be precipitated by alcohol, occurring nightly and often waking the patient from sleep.

    • Lasts less than 2 hours with pain-free intervals of months or years.

  • Physical Examination Findings: May reveal eye redness, lacrimation, nasal congestion, or ptosis on the affected side.

MANAGEMENT/TREATMENT OF CLUSTER HEADACHES

  • Treatment of individual attacks often requires inhalation of 100% oxygen or administration of Sumatriptan SQ.

  • Prophylaxis options include Verapamil (CCB) for chronic cluster headaches (240 mg daily as initial dose).

IMAGING IN HEADACHES

  • When to Consider Imaging:

    • “Red Flag” headache.

    • Change in headache pattern, frequency, or severity.

    • Worsening of headache despite therapy.

    • New or unexplained neurological symptoms.

    • New onset headache over age 50, headaches associated with fever, stiff neck, cognitive impairment.

DIZZINESS AND VERTIGO

  • Definitions:

    • Dizziness: Sensation of unsteadiness with a feeling of movement within the head.

    • Vertigo: False sensation of rotation or movement of self or surroundings, usually linked to inner ear disease or CNS disturbances.

  • Common Accompanying Symptoms: Nausea, vomiting, nystagmus, unsteady gait.

VERTIGO CATEGORIES AND DIFFERENTIAL DIAGNOSES

  • Acute, prolonged, severe nonpositional: Vestibular neuronitis, Meniere’s disease.

  • Recurrent spontaneous attacks: Meniere disease, vestibular migraine.

  • Recurrent positionally triggered attacks: BPPV.

  • Chronic persistent dizziness: Stroke, tumor.

TREATMENT/MANAGEMENT OF VERTIGO

  • BPV Medications:

    • Meclizine (Antivert), Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl).

  • Consultation referral for cases other than BPV is often necessary.

DELIRIUM

DELIRIUM VS DEMENTIA

  • Delirium: Abrupt decline in cognitive function that fluctuates over time; disturbed attention and awareness.

  • Dementia: Progressive decline in functioning typically characterized by preserved attention (early stages).

DSM-5 DIAGNOSTIC CRITERIA FOR DELIRIUM

  1. Disturbance in attention and awareness.

  2. Disturbance develops over a short period and fluctuates in severity.

  3. Additional disturbances in cognition.

  4. Evidence of physiological changes leading to disturbance.

RISK FACTORS FOR DELIRIUM

  • Common Risks:

    • Geriatric syndromes (e.g., dementia, depression).

    • Age > 65 years, male gender.

    • Medications, infections, and underlying medical conditions.

CLINICAL ASSESSMENT

  • Assessment Approaches:

    • Review of medications, cognitive screenings (Minicog, MOCA), cardiac assessments, abdominal considerations that can provoke delirium following acute events like surgery or infections.

  • Mnemonic for Assessment: D - Drugs, E - Electrolyte imbalance, L - Lack of drugs, I - Intracranial processes, R - Reduced sensory input, I - Infection, U - Urinary retention, M - Myocardial infarction.

LABS/IMAGING FOR DELIRIUM

  • Common tests include urinalysis, CBC, BMP, and other targeted tests based on suspected causes, including EKGs or imaging for acute changes.

PREVENTION AND TREATMENT OF DELIRIUM

  • Management: Focus on removal of offending agents and addressing underlying causes. Encourage hydration, orientation, mobility, and other supportive measures.

PHARMACOLOGY TREATMENT

  • Consideration for treatments should only occur once the etiology is established. Medications may include Haloperidol or Olanzapine for agitation with proper monitoring for side effects.

SEIZURES

SEIZURES AND THEIR TYPES

  • Overview: Abnormal electrical activity in the brain affecting 8-10% of the population with various implications.

  • Types Include: Acute symptomatic (related to systemic insult) and unprovoked (linked to preexisting conditions).

HISTORY AND PHYSICAL EXAMINATION

  • Assessment Includes: Detailed history of seizure events, including circumstances, risk factors, duration, and any postictal behavior or neurological changes observed.

DIAGNOSTIC LABS

  • Essential tests include EEGs, CT, MRI, and various lab screens to identify possible triggers or underlying conditions related to seizure events.

TREATMENT AND MANAGEMENT

  • Treatment of seizures often begins with antiseizure medications if multiple unprovoked seizures occur. Referral to a neurologist is crucial for developing management strategies.

BELL'S PALSY

RISK FACTORS AND LOCATION

  • Common Risk Factors: Diabetes, hypertension, infections (like herpes simplex), and underlying vascular issues.

  • Physiological Changes: Involves dysfunction of CN VII manifesting symptoms of facial weakness or paralysis on one side of the face.

DIAGNOSIS OF BELL'S PALSY

  • Typical Symptoms: Sudden onset of facial weakness, inability to close the eye, and drooping of mouth corners. Diagnostic exclusion from other conditions is critical, supported by physical examinations and history.

MANAGEMENT FOR BELL'S PALSY

  • Treatment: A 10-day course of corticosteroids is recommended for symptom mitigation in some patients. Acyclovir may be suggested based on recent evidence indicating a herpetic etiology.

ACUTE BACTERIAL MENINGITIS AND OTHER DISORDERS

  • Symptoms of Acute Bacterial Meningitis: Acute onset of high fever, severe headache, stiff neck, altered mental status.

  • Acute Stroke Symptoms: Ischemic stroke manifests as one-sided paralysis or speech impairments; hemorrhagic stroke presents with severe sudden headaches.

  • Chronic Subdural Hematoma: Often occurs after trauma with gradual cognitive impairments over time.

  • Giant Cell Arteritis (GCA): Consider with new headaches in patients older than 50 with associated symptoms like jaw claudication or visual changes; elevated ESR/CRP may support diagnosis.

QUESTIONS?

  • Engage in discussions by posing hypothetical clinical scenarios or examining signs and symptoms to reinforce understanding and applications of knowledge regarding acute neurological disorders.

TEST YOUR KNOWLEDGE

  • Assess understanding of concepts by evaluating responses to clinical scenarios, drug classifications, and management approaches in patients with neurological disorders (examples provided throughout).