Term
| What type of headache has no identifiable structural cause? |
|
Definition
|
|
Term
| What are the 3 types of Primary headaches? |
|
Definition
|
|
Term
| What type of headaches have an underlying structural or metabolic cause? |
|
Definition
|
|
Term
| What are the characteristics of an acute onset headache? |
|
Definition
sudden onset
rapidly worsen |
|
|
Term
| What are the characteristics of a subacute onset headache? |
|
Definition
| gradual onset and progression |
|
|
Term
| What type of temporal mode classification do the primary headaches have? |
|
Definition
|
|
Term
| What are the Pain sensitive structures of the Head? |
|
Definition
Dura and Meninges at base of brain
Large arteries at base of brain
meningeal arteries
venous sinuses
scalp muscles
upper cervical muscles
periosteum of the skull
facial & head structures/organs |
|
|
Term
| What Brain structure is insensitive to pain? |
|
Definition
Brain parenchyma
(has no sensory receptors) |
|
|
Term
| What will a mechanical or electrical stimulation of the thalamus or trigeminal nucleus caudalis trigger? |
|
Definition
|
|
Term
| What nerves transmit headache pain centrally? |
|
Definition
CNs V, VII, IX, X
nerve roots C2-C3 |
|
|
Term
| What nerve innervates pain in the anterior/middle fossa and scalp? |
|
Definition
CN V1
(Ophthalmic branch of V) |
|
|
Term
| What nerve innervates pain in the posterior fossa? |
|
Definition
|
|
Term
| Where do the pain sensitive fibers first synapse? |
|
Definition
| trigeminal nucleus caudalis and dorsal horn of the upper cervical spinal cord |
|
|
Term
| What is the pathway for pain transmitted centrally? |
|
Definition
| CNs and roots-> synapse in trigeminal nucleuscaudalis and dorsal horn-> synapse in VPL and VPM of thalamus-> sensory cortex |
|
|
Term
| What carries pain from the cervical muscles and posterior scalp? |
|
Definition
|
|
Term
| What are Red Flags that a headache has a secondary origin? |
|
Definition
| Abrupt onset, trauma, fever, immunosuppression, focal neurological symptoms, "Worst headache of my life" |
|
|
Term
| What are unique characteristics of a migraine? |
|
Definition
| Often unilatera, pulsating, nausea, photo/phonophobia, aura |
|
|
Term
| T/F A Migraine is just a headache. |
|
Definition
False
It can have symptoms that start long before the headache |
|
|
Term
| How does a migraine typically progress? |
|
Definition
| Prodrome-> aura-> headache-> postdrome |
|
|
Term
| What is a prodrome and how frequent is it? |
|
Definition
A vague constellation of symptoms seen in 40% of migraine patients
(mood swings, odd food cravings, malaise, fatigue) |
|
|
Term
| What is an aura and how frequent is it? |
|
Definition
More symptoms, like visual disturbance, within 60 minutes of the headache (Scintillations->Scotoma)
May resemble a TIA
Seen in 20% of migraine pts |
|
|
Term
| T/F A migraine is strictly a spontaneous phenomenon. |
|
Definition
False
there can be a trigger, such as menses, no breakfast, late hours, oversleeping, weather, altitude, smoking, emotions.... |
|
|
Term
| What is a frequent dietary trigger of migraines? |
|
Definition
|
|
Term
| How common are migraines? |
|
Definition
10-15% of women
5-10% of men
usually begin <20y/o |
|
|
Term
| What is Familial hemiplegic migraine? |
|
Definition
| Rare form of migraine linked to an AD gene on chromosome 10 |
|
|
Term
| What is "the anatomical substrate for all migraines"? |
|
Definition
| The Trigeminovascular system involving CNV1 innervation of pain receptors in the dura, meninges, and medium/large vessels |
|
|
Term
| What nucleus are parasympathetic fibers & CN VII associated with? |
|
Definition
Superior salivatory nucleus
PS innervation-> vasodilation-> pain |
|
|
Term
| What is the mechanism responsible for the vascular changes associated with migraine? |
|
Definition
| Vessel innervation-> Cell body in the trigeminal ganglion-> synapse at the superior salivatory nucleus-> synapse in the pterygopalatine ganglion-> synapse on the blood vessels |
|
|
Term
| What is the current theory concerning migraine pathogenesis? |
|
Definition
1. Peripheral stimulation intiates a signal that releases glutamate & peptides in CNS
2. Antidromic activation (retrograde signalling) down the same sensory nerve intitiates release of sensitizing neuropeptides back in the periphery (peripheral sensitization)
3. This causes more central stimuli, which decreases inhibition at the nucleus caudalis and dorsal horn (central sensitization) |
|
|
Term
| How is the aura thought to arise? |
|
Definition
| A wave of depolarization spreads across the brain at a speed of 2-5 mm/min and renders the neurons in the area nonfunctional while leading to vasodilation (hyperemia) |
|
|
Term
| What does the existance of an aura depend on? |
|
Definition
| the cortical site of depolarization |
|
|
Term
| In the majority of migraineurs who do not experience an aura, what activates neurogenic inflammation? |
|
Definition
| Central Generator or Triggers |
|
|
Term
| What region of the brain is stimulated in auras? |
|
Definition
|
|
Term
| What accounts for an auras bright multicolored scintillations changing to scotoma? |
|
Definition
Cortical Spreading Depression
Wave of excitation briefely increases blood flow, as wave pass a point of cortex excitation changes to prolonge depolarization and decreased blood flow. Depolarized tissue is non-functional-> transient loss of vision (scotoma) until neurons recover |
|
|
Term
| What are the 2 main neurotransmitters involved in the cerebral vasodilation during migraines/headaches? |
|
Definition
Calcitonin Gene Related Peptide (CGRP)
Substance P |
|
|
Term
| What are the 3 functions of CGRP? |
|
Definition
1. Vasodilation
2. Mast cell degranulation
3. Direct stimulation of the central brain stem neuron |
|
|
Term
| What evidence is there to confirm CGRP's role in migraines? |
|
Definition
IV CGRP-> headache
Triptans Tx (Block CGRP) |
|
|
Term
|
Definition
| Agonize 5HT1 receptors, which are found throughout cerebral vasculature and nerve fibers that release CGRP |
|
|
Term
|
Definition
Direct CGRP antagonists
(block the CRL receptors on blood vessels, mast cells, and pain transmitting nerves) |
|
|
Term
| What are unique characteristics of a cluster headache? |
|
Definition
Pain always unilateral, frontal, retro-orbital
Constant, severe, nonpulsating pain for wks/months
remission for yrs |
|
|
Term
| How are cluster headaches treated? |
|
Definition
Acute: Nasal oxygen, triptans
Prevention: CCB (verapamil), lithium, valproic acid, prednisone |
|
|
Term
| What is the male to female ratio for cluster headaches? |
|
Definition
|
|
Term
| What are unique characteristics of a tension headache? |
|
Definition
Usually bilateral and bandlike
typical headache everyone gets |
|
|
Term
| How do episodic tension headaches differ from the chronic persuasion? |
|
Definition
Episodic - Daily attacks <15 days/month
Chronic - Daily attacks >15 days/month |
|
|
Term
|
Definition
Episodic - Pts self-medicate with analgesics
Chronic - Refer pt to neurologist and let them figure it out |
|
|
Term
| What type of headache can cause tears, stuffy or runny nose? |
|
Definition
|
|
Term
| What is idiopathic intracranial hypertension (IIH)? |
|
Definition
| CSF pressure >250 mm H2O in the presence of a normal MRI |
|
|
Term
| What are the Clinical Features of IIH? |
|
Definition
| Headache of varying character Papilledema Transient visual obscurations Diplopia secondary to CN VI paresis Tinnitus Constriction of visual fields |
|
|
Term
| What is another name for IIH? |
|
Definition
|
|
Term
| What should IIH be considered and why? |
|
Definition
| Neurologic emergency, since failure to diagnose and treat in a timely manner my lead to loss of vision |
|
|
Term
| What are the Risk Factors for IIH? |
|
Definition
9:1, Female:Male
Ages 20-45
Obesity by 20% overweight |
|
|
Term
|
Definition
Most idiopathic
CSF production > CSF reabsorption
Primary - Metobolic abnormality
Secondary - physical block |
|
|
Term
| What is the pathogenesis of primary IIH? |
|
Definition
Hypervitaminosis A
Antibiotics
Steroid withdrawal |
|
|
Term
| What is the pathogenesis of Secondary IIH? |
|
Definition
Venous Sinus thrombosis
Chronic meningitis
Chiari Malformation |
|
|
Term
| How is IIH (pseudotumor cerebri) Diagnosed? |
|
Definition
Clinical Presentation
MRI and MRV - Normal
LP - opening pressure > 250 mmH2O
Visual Fields |
|
|
Term
| How do you assess whether IIH treatment is success or disease progression? |
|
Definition
| Visual fields over time for imporvement/decay |
|
|
Term
|
Definition
WEIGHT LOSS
Lower CSF production (Rx or LP)
Surgery |
|
|
Term
| What is Giant Cell Arteritis (GCA)? |
|
Definition
| Autoimmune, systemic vasculitis causing granulomatous infiltration and occlusion of medium/small elastic arteries |
|
|
Term
| What are the symptoms of GCA? |
|
Definition
Headache (usually unilatera and the CC in 70% of cases)
scalp tenderness over temporal artery
visual symptoms
Stroke |
|
|
Term
|
Definition
No single test
ESR is usually High
C-reactive protein elevated
Biopsy may be negative
Should be considered in pts >55 with new unilateral headache |
|
|
Term
|
Definition
|
|
Term
| What are the complications of GCA? |
|
Definition
| can progress to acute onset monocular blindness |
|
|
Term
| What does a depressed level of consciousness indicate? |
|
Definition
| Disruption of ascending arousal system in the upper brainstem |
|
|
Term
| What does a stiff neck indicate? |
|
Definition
|
|
Term
| What does hypotension with a fever indicate? |
|
Definition
|
|
Term
| Is Meningococcus a clinical concern? |
|
Definition
| A little bit... Can kill patients in 6-12 hrs. Yikes |
|
|
Term
| How can death from Meningococcus be prevented? |
|
Definition
| Treating empirically even before the bacteria has been isolated |
|
|
Term
| How do bacteria get into the CSF? |
|
Definition
Bacteremia
Nearby infection (otitis, sinusitis)
Direct CSF communication with the outside (trauma, surgery) |
|
|
Term
| How do bacteria cause damage once in the CSF? |
|
Definition
Immune Response-> Damage
TNF and IL-1 released-> meningeal inflammation, vasculitis, thrombophlebitis |
|
|
Term
| What allows bacteria to flourish in CSF? |
|
Definition
| Few immune cells (initially), lots of glucose |
|
|
Term
| What is the result of IL-1 and TNF release in CSF? |
|
Definition
Vigorous inflammatory response-> small vessel vasculitis and thrombophlebitis -> ischemia
Decreased BBB |
|
|
Term
| What happens if the infection leads to SIADH? |
|
Definition
| Decreased [Na]-> hypo-osmolar blood-> worsened edema-> septic shock |
|
|
Term
| What should be given before antibiotics to Tx bacterial meningitis and why? |
|
Definition
Corticosteroids to mildly suppress immunity
Antibiotics tear bacterial cell walls apart-> Increases host immune response |
|
|
Term
| Name 2 most common causes of bacterial meningitis in adults. |
|
Definition
| Pneumococcus and Menigococcus |
|
|
Term
| Name 3 most common causes of bacterial meningitis in neonates. |
|
Definition
| Group B strep, E. coli, Listeria |
|
|
Term
| What are immunosuppressed, elderly, and pregos at risk for? |
|
Definition
|
|
Term
| What's the leading cause of community-acquired meningitis? |
|
Definition
| Pneumococcus (S. pneumoniae) |
|
|
Term
| Why has Meningococcus been less of a threat lately? |
|
Definition
|
|
Term
| What had Meningococcus outbreaks been associated with? |
|
Definition
Outbreaks in Military Barracks, Schools
(Found in nares of 5% of the population and require less than 3 ft to transmit) |
|
|
Term
| What is Waterhouse-Friderichsen Syndrome? |
|
Definition
| Depletion of corticosteroids following hemorrhagic necrosis of adrenal glands from a Meningococcus infection - causes Addison's crisis (Give Steroids) |
|
|
Term
| What are the risk factors for Pheumococcus? |
|
Definition
EtOH
Chronic Otitis/sinusitis
CSF leaks
Asplenia
Sickle Cell |
|
|
Term
| Who is at risk for Listeria meningitis? |
|
Definition
Immunosuppressed
Older Pts
Chronic illness (renal/hepatic)
Found on meat counters, hot dogs, unpasteurized dairy products |
|
|
Term
| What symptoms of bacterial meningitis are seen in infants? |
|
Definition
Nonspecific
Fever, irritability, vomiting, high-pitched cry, lethargy
Convulsions and bulging fontanae if advanced |
|
|
Term
| What symptoms of bacterial meningitis are seen in adults? |
|
Definition
| URI, sore throat, fever, headache, stiff neck, vomiting, seizures |
|
|
Term
| What would show up on Physical exam for bacterial meningitis? |
|
Definition
High fever
Low BP
petechiae
purpura
stiff neck
signs of other infection |
|
|
Term
| How is Kerning's sign used to test for meningismus? |
|
Definition
Patient lays supine with hip flexed at 90 degrees
+ if can't straighten leg |
|
|
Term
|
Definition
| Passive flexion of neck causes flexion of the knees |
|
|
Term
|
Definition
| Inflammation of meningis -> neck pain-> involuntary contraction of agonist and antagonist muscles to make a splint |
|
|
Term
| What 2 test are especially useful to distinguish septic & aseptic? |
|
Definition
| Serum procalcitonin and CRP are much higher in septic meningitis |
|
|
Term
| T/F Opiates should be given to treat neck stiffness. |
|
Definition
False
will fix it, but are sedating -> coma/stupor |
|
|
Term
| What tests are used to Dx bacterial meningitis? |
|
Definition
CBC (increased PMNs)
electrolytes (correct SIADH)
INR
culture |
|
|
Term
| What should be done before EVERY lumbar puncture? |
|
Definition
CT scan
If there's a cerebral mass, LP could cause herniation |
|
|
Term
| What special tests use CSF to identify the cause of meningitis? |
|
Definition
PCR-16S ribosome = bacterial
Specific Ags for herpes/TB - IgM for acute infection, IgG for chronic |
|
|
Term
| Describe the WBC, glucose, & protein make-up in bacterial CSF. |
|
Definition
Increased neutrophils
Decreased glucose
Increased protein (BBB breakdown) |
|
|
Term
| What causes high lymphocytes, low/normal glucose, and high/normal protein in CSF? |
|
Definition
| Partially treated bacterial meningitis, chronic meningitis, aseptic meningitis, brain abscess, and parameningeal inflammation |
|
|
Term
| What does CSF grossly look like in Meningococcus meningitis? |
|
Definition
|
|
Term
| Tx of bacterial meningitis? |
|
Definition
Steroids First!
antibiotics after 15 minutes
drain CSF if needed to reduce ICP |
|
|
Term
| Should you give antibiotics/steroids to every case of meningitis? |
|
Definition
| Unless you're positive that it's not bacterial, then Yes. Risks of giving them for one day are negliible compared to benefits |
|
|
Term
| What precautions should be taken by any care-takers? |
|
Definition
| Isolate patient and take prophylactic rifampin |
|
|
Term
| What do splinter hemorrhage and distal pupura suggest? |
|
Definition
Septic embolism
(septic endocarditis) |
|
|
Term
| What are four ways in which infectious endocarditis affects the brain? |
|
Definition
1. Sepsis - Metabolic encephalopathy-> confusion, delirium, coma
2. Large cerebral vessel occlusion-> Acute ischemic stroke
3. Focal brain ischemia and inflammation-> abscess fromation
4. Septic embolism of a distal cerebral artery-> focal inflammatory erosion of vessel wall-> aneurysm-> hemorrhage |
|
|
Term
| What's the leading cause of bacterial endocarditis? |
|
Definition
Strep. viridans
(followed by Staph. aureus and Enterococcus) |
|
|
Term
| Why would headaches from ruptured brain abscess hurt more laying down? (Tumor headaches) |
|
Definition
| Cerebral veins are valveless, so laying down counteracts gravity-> increased blood in veins while supine, which causes an exponential increase in pain when ICP is already high |
|
|
Term
| What are some non-neurologic signs of bacterial endocarditis? |
|
Definition
Splinter hemorrhages
Osler's nodes
Janeway lesions
Roth's spots |
|
|
Term
| Tx of bacterial endocarditis? |
|
Definition
| Antibiotics and maybe a new heart valve |
|
|
Term
| What should make you think of brain abscess so you know to order a CT scan? |
|
Definition
Headache, worse lying down
papilledema
seizures
focal neuro deficits (CT/MRI shows mass with surrounding edema) |
|
|
Term
|
Definition
| Drain large abscesses and treat with antibiotics |
|
|
Term
| Symptoms of spinal epidural abscess (SEA)? |
|
Definition
| Pint tenderness, fever, high WBC &ESR, urinary incontinence, lower weakness and sensory loss, Babinski signs, severe pain |
|
|
Term
| What part of the spinal column is usually affected by maetastasis? |
|
Definition
|
|
Term
| What part of the spinal column is usually affected by infection? |
|
Definition
|
|
Term
| What causes 90% of spinal epidural abscesses? |
|
Definition
|
|
Term
|
Definition
Trauma/surgery
osteomyelitis
Sepsis
Dental Work |
|
|
Term
|
Definition
High dose steroids
antibiotics
drainage |
|
|
Term
| Symptoms of Rocky Mountain Spotted Fever (RMSF)? |
|
Definition
| Rickettsia attacks vascular endothelial cells-> systemic vasculitis attacks brain parenchyma-> confusion, seizures, focal deficits, petechial rash in extremities, fever, headach, flu-like |
|
|
Term
|
Definition
Normal CSF/mild increase in lymphocytes
IgG/IgM tests
Tick bite Hx |
|
|
Term
|
Definition
|
|
Term
| Sypmtoms of Lyme disease after days, weeks, months? |
|
Definition
Days: Erythema migrans (targetoid rash)
Weeks: Flu-like SS, malaise, arthritis, aseptic meningitis, meningoradiculitis=electric shock sensations in bands
Months: Cognitive declin, encephalopathy, radiculopathy |
|
|
Term
|
Definition
ELISA (confirm with Western blot)
caused by a spirochete |
|
|
Term
|
Definition
| IV ceftriaxone or oral doxycycline |
|
|
Term
| What is a common reservoir of Lyme disase and RMSF? |
|
Definition
|
|
Term
| Symptoms of Syphilis in each of the three stages? |
|
Definition
Primary: Painless genital chancre (3 wks post infection)
Secondary: Maculopapular rash on palms/soles, meningitis, arthritis
Tertiary: Severe skin, bone, heart, and brain complications |
|
|
Term
| What are immunocompromised pts with syphilis at risk for? |
|
Definition
| Greater risk of meningitis and stroke |
|
|
Term
|
Definition
Serum/CSF VDRL
fluorescent treponemal Ab
RPR |
|
|
Term
|
Definition
|
|
Term
| Symptoms of chronic meningitis? |
|
Definition
| Fever, headache, lethargy, poor appetite/weight loss, cranial neuropathy, personality change, cognitive impairment |
|
|
Term
| What produces granulomatous meningitis worst at brain base and how is diagnosed? |
|
Definition
Mycobacterium tuberculosis
Spinal tap and check CSF for acid fast bacilli |
|
|
Term
| What is a consequence of inflammation at the base of the brain? |
|
Definition
| CN entrapment and block of CSF flow-> hydrocephalus |
|
|
Term
| How does TB cause meningitis? |
|
Definition
| Primary lung infection-> miliary TB goes to brain and reactivates years later-> meningitis |
|
|
Term
|
Definition
Cultrue bug (for drug sensitivities)
RNA PCR
CXR
PPD
CSF |
|
|
Term
|
Definition
third world country
HIV
homeless
Alcoholic |
|
|
Term
|
Definition
Isoniazid, Rifampin, Pyrazinamide, and streptomycin or ethambutol
Also Corticosteroids |
|
|
Term
| What causes stiff neck, fever, and headache with no rash, high lymphocytes in CSF, and fairly normal glucose and protein? |
|
Definition
|
|
Term
| T/F Viral meningitis is more common than bacterial. |
|
Definition
|
|
Term
| What are some common causes of viral meningitis? |
|
Definition
| Enteroviruses (Echo, Coxsackie, enterovirus) - 80% |
|
|
Term
| Symptoms of viral meningitis? |
|
Definition
Not as ill as bacterial meningitis
Fever, malaise, headache, stiff neck, low back pain for 10-14 days |
|
|
Term
| What causes recurrent viral meningitis? |
|
Definition
|
|
Term
|
Definition
| increased CSF opening pressure and lymphocytes, negative gram stain |
|
|
Term
|
Definition
|
|
Term
| What can cause increased ICP, lymphocytes, and temperature without any CT masses or abnormal cells in CSF? |
|
Definition
|
|
Term
| at test would asist in the Dx of viral encephalitis? |
|
Definition
| MRI, helps rule out abscess, thrombosis, or hemorrhage |
|
|
Term
| If you suspect viral encehalitis, what should be done? |
|
Definition
| Immediately give acyclovir, if pt goes into coma first, the prognosis is very poor |
|
|
Term
| What are common causes of viral encephalitis? |
|
Definition
Arborvirus (mosquitoes) - 30%
Enteroviruses - 23%
HSV-1 - 27% |
|
|
Term
| What is the clinical course of viral encephalitis? |
|
Definition
| URI-> fever-> headache (mild stiff neck)-> lethargy-> confusion-> seizures-> coma/stupor-> death |
|
|
Term
| Tx for viral encephalitis? |
|
Definition
| Prognosis depends on prompt acyclovir/ganciclovir |
|
|
Term
| What are some important things to remember about herpes encephalitis? |
|
Definition
Curable if Tx early - devastaing if Tx late
Tx should be empirical (acyclovir) before Dx
MRI gives immediate Dx, PCR has many false negatives may resemble bacterial meningitis |
|
|
Term
| Where does Herpes Zoster virus live and lay dormant? |
|
Definition
| In sensory ganglia-> shingles |
|
|
Term
| what's unique about the distribution of shingles? |
|
Definition
| across one or two dermatomes |
|
|
Term
|
Definition
| Pain starting days before and persisting weeks after the rash |
|
|
Term
| what happens if HSV sets up camp in CN V1? |
|
Definition
| It can lead to ulceration of the cornea |
|
|
Term
| What are tow ways HIV can cause neurologic disease? |
|
Definition
Directly cause meningitis (acute of chronic)-> Dementia, myelopathy, neuropathy, and myopathy
Indirectly by decreasing immunity and increase risk for other infections |
|
|
Term
| What's the most common opportunist that causes neurologic disease in AIDS patients? |
|
Definition
| Toxoplasmosis - parasite that preferentially invades the basal ganglia |
|
|
Term
| What hope is there for HIV patients? |
|
Definition
| HAART therapy greatly increase prognosis |
|
|
