Headaches, Migraines, and Neurological Disorders: A Comprehensive Guide, Exams of Advanced Education

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CMN 568 - Unit 5 Exam with complete

solutions

Diminution of headache in response to typical migraine therapies (e.g. seratonin receptor antagonists or ketorolac) does not rule out _________________ as underlying cause? - Answer- Subarachnoid hemorrhage or meningitis Mcphee p 39 IMMEDIATE TREATMENT: Vascular events - Answer- + Intracranial hemorrhage

• Thrombosis
• Cavernous sinus thrombosis
• Vasculitis
• Malignant hypertension
• Arterial dissection
• Aneurysm McPhee p 39 IMMEDIATE TREATMENT: Infections - Answer- + Abscess
• Encephalitis
• Meningitis Mc Phee p 39 Causes of headache that require IMMEDIATE TREATMENT - Answer- + Vascular events
• Infections
• Intracranial masses
• Preeclampsia
• Carbon monoxide poisioning McPhee p 39 "Thunderclap headache" is the classic presentation of what condition? - Answer- Subarachnoid hemorrhage! Should precipitate IMMEDIATE workup! McPhee p 39

New headache in a patient > ________________ years or with ___________________ (condition) should warrant IMMEDIATE neuroimaging. - Answer- + > 50years

• HIV infection McPhee p 39 Headache patients with hx of hypertension (esp uncontrolled htn) should be examined for other features of WHAT? - Answer- Malignant hypertension McPhee p 39 Headache associated with pregnancy? - Answer- Preeclampsia McPhee p 39 Episodic headache associated with triad of hypertension, heart palpitations and sweats is suggestive of __________________. - Answer- Pheochromocytoma McPhee p 39 Symptoms for diagnosis or ruling out migraine in the absence of "classic" presentation (e.g. scintillating scotomoa, unilateral ha, photophobia and n/v)? - Answer- Symtoms: Nausea, photophobia, phonophobia and exacerbation with physical activtiy THREE OR MORE = MIGRAINE < THREE = r/o MIGRAINE McPhee p 39 Critical components of physical exam for complaint of HA? - Answer- + Vital signs
• Complete neuro exam
• Vision testing (with funduscopic exam) McPhee p 40 Kernig and Brudzinski signs are indicative of what? - Answer- Meningeal irritation McPhee p 40 Scalp and temporal artery tenderness should be performed on pts with HA who are > ______________ years. - Answer- > 60 McPhee p 40 Components of visual exam for pt presenting with HA? - Answer- + Visual acuity (Snellen)

• Ocular gaze (Motor test - 9 positions)
• Visual fields (Cover test - central/periph vision)
• Pupillary defects (Size, dilation)
• Optic disks
• Retinal vein pulsations McPhee p 40 Pt with HA and diminished visual acuity suggests.... - Answer- + Glaucoma
• Temporal arteritis
• Optic neuritis McPhee p 40 Pt with HA and ophthalmoplegia or visual field defects suggests.... - Answer- + Venous sinus thrombosis
• Tumor
• Aneurysm McPhee p 40 Pt with HA and hypertension, "cotton wool spots", flame hemorrhages and disk swelling suggests.... - Answer- + Acute severe hypertensive retinopathy McPhee p 40 Pt with HA and ipsilateral ptosis and miosis suggests.... - Answer- Horner syndrome AND/OR carotid artery dissection McPhee p 40 Pt with HA and papilledema or absent retinal venous pulsations suggests.... - Answer- ↑ ICP
• Follow with neuroimaging prior to performing lumbar puncture McPhee p 40 ANY abnormality on neuro exam (esp mental status) of pt with HA warrants.... - Answer-
• EMERGENT neuroimaging McPhee p 40 Ottawa criteria for evaluation of pts presenting with acute non-traumatic headache for signs of subarachnoid hemorrhage - Answer- + ≥ 40 years of age
• Neck pain/stiffness
• Witnessed loss of consciousness

• Onset during exertion
• Thunderclap headache
• Limited neck flexion on examination McPhee p 41 What kind of early treatment of diagnosed migraine or migraine-like headache can abort or provide significant relief of symptoms? - Answer- + NSAIDs (e.g. ketorolac)
• Triptans McPhee p 41 What types of headaches may respond well to high-flow O2 therapy? - Answer- ALL types McPhee p 41 What types of headaches should be referred? - Answer- + Frequent migraines not responsive to std tx
• Migraines with atypical features
• Chronic daily ha r/t medication overuse McPhee p 41 Primary headache syndromes? - Answer- + Migraine
• Tension-type headache
• Cluster headache McPhee p 986 Secondary causes of headache? - Answer- Some examples:
• Intracranial lesions
• Head injury
• Cervical spondylosis
• Dental/ocular disease
• TMJ dysfunction
• Sinusitis
• Hypertension
• Depression McPhee p 986 Common age of onset of migraines? - Answer- Adolescence or early adult life McPhee p 986

Symptoms of migrainous headaches - Answer- + Usually lateral, can be generalized

• Usually throbbing, can be dull
• Can be associated with anorexia, n/v, photophobia, phonophobia, osmophobia, cognitive impairment, blurring of vision
• Build up gradually and last ≥ 7 hours
• Visual disturbances may precede or accompany HA
• Triggered by emotional/physical stress, lack of/excess sleep, missed meals, specific foods, ETOH, bright lights, loud noise, menstruation, use of oral contraceptives McPhee 986- Symptoms of basilar artery migraine - Answer- + Blindness/visual disturbances throughout both visual fields
• Dysarthria
• Dysequilibrium
• Tinnitus
• Perioral/distal paresthesias
• transient loss/impairment of consciousness or confusional state. McPhee 987 Symptomatic therapy for migraines - Answer- 1) Rest in darkened room + analgesic (aspirin, acetaminophen, ibuprofen, naproxen) taken right away

2. Prescription therapy Prevention of medication overuse headaches - Answer- 1) Limit simple analgesics to ≤ 15 days per month
3. Limit combination analgesics to ≤ 10 days per month McPhee p 987 Main classes of prescription medications used for migraine therapy - Answer- 1) Ergotamines
4. Triptans McPhee p 987 MIGRAINE: Cafergot - Answer- + Generic name -- Ergotamine tartrate (1 mg) + caffeine (100 mg)

• Class -- Ergotamines
• Indications for use -- Onset of migraine headache
• Contraindications -- Avoid during pregnancy, in pts with CV risk factors, and pts taking potent CYP3a4 inhibitors
• Common side effects

• Dosage -- 1-2 tablets at onset of migraine or warning symptoms, followed by 1 tablet q 30 minutes if needed, up to 6 tablets per attack. NO MORE THAN 10 days per month! McPhee p 987 MIGRAINE or CLUSTER HA: Sumatriptan - Answer- + Generic name -- Sumpatriptan
• Class -- Triptan
• Indications for use -- Used to abort migraine attacks or as treatment for cluster HA
• Contraindications --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease
• Common side effects -- Nausea and vomiting
• Dosage for migraine -- SQ, 4-6 mg once, repeat after 2 hours if needed; max dose 12 mg/24 hours --Nasal and PO avajilable, but less effective r/t slower absorption Dosage for cluster HA --SQ 6mg or IN 20 mg/spray McPhee p 987 MIGRAINE or CLUSTER HA: Zolmitriptan - Answer- + Generic name -- Zolmitriptan
• Class -- Triptan
• Indications for use -- Used to abort migraine attacks AND for immediate tx of migraine; also for tx of cluster HA
• Contraindications --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease
• Common side effects -- Nausea and vomiting
• Dosage for MIGRAINE -- PO, 5 mg initially and relief usually occurs within 1 hour. May repeat ONCE after 2 hours. Dosage for CLUSTER HA -- IN, 5 or 10 mg/spray McPhee p 987 MIGRAINE or CLUSTER HA or TRIGEMINAL NEURALGIA: Topiramate - Answer- + Generic name -- Topiramate
• Class -- Anticonvulsant
• Indications for use -- Prophylaxis for migraine and cluster HA

• Contraindications --CAUTION if use of CNS depressant, use of ETOH, depression, suicidal ideation, hepatic impairment
• Common side effects -- Somnolence, nausea, dyspepsia, irreiability, dizziness, ataxia, nystagmuse, diplopia, glaucoma, renal calculi, weight loss, hypohidrosis, hyperthermia
• Dosage for MIGRAINE -- PO, 100 mg divided twice daily Dosage for CLUSTER HA -- PO, 100-400 mg daily Dosage for TRIGEMINAL NEURALGIA -- PO, 50 mg BID McPhee p 988 Valproic acid (not FDA approved for migraine) - Answer- + Generic name -- Valproic acid
• Class -- Anticonvulsant
• Indications for use -- Prophylaxis for migraine -- Tx of mania
• Contraindications -- CONTRAINDICATED in hepatic disease or impairment, pregnancy -- CAUTION in peds, elderly, renal impairment, head injury, hx of hepatic disease
• Common side effects -- N/V, diarrhea, drowsiness, alopecia, weight gain, hepatotoxicity, thrombocytopenia, tremor, pancreatitis. Blood/liver/glucose tests at 2, 4, 12 weeks initially.
• Interactions -- Aspirin will ↑ valproate levels -- Carbamezepine or phenytoin will ↓ valproate levels -- Valproate will ↑ warfarin levels!
• Dosage -- PO, 500 - 1000 mg divided twice daily McPhee p 988, 1094 Candesartan (not FDA approved for migraine) - Answer- + Generic name -- Candesartan
• Class -- Angiotensin receptor blocker

• Indications for use - Prophylaxis of migraine
• Contraindications -- CONTRAINDICATED in pregnancy, pts < 1 year old -- CAUTION in renal or hepatic impairment, hyponatremia
• Common side effects -- Dizziness, cough, diarrhea, fatigue
• Dosage -- PO, 8 - 32 mg once daily McPhee p 988 Guanfacine - Answer- + Generic name -- Guanfacine
• Class -- Cardiovascular, alpha-2 adrenergic receptor agonist
• Indications for use -- Prophylaxis of migraine
• Contraindications -- CAUTION in elderly, hepatic/renal impairment, CV disease or hx, CAD, recent MI
• Common side effects -- Dry mouth, somnolence, dizziness, constipation, erectile dysfunction
• Dosage -- PO, 1 mg once daily McPhee p 988 Propranolol (and other ß-adrenergic antagonists) - Answer- + Generic name -- propranolol
• Class -- Beta blocker
• Indications for use - Prophylaxis of migraine
• Contraindications -- CONTRAINDICATIONS -- Bradycardia or heart block w/o pacemaker, bronchial asthma -- CAUTION in elderly, 2nd/3rd trimester of pregnancy, rena/hepatic impairment, PVD, DM, thyroid disorder
• Common side effects -- Fatigue, dizziness, hypotension, bradycardia, depression, insomnia, n/v, constipation
• Dosage -- PO, 80 - 240 mg, divided 2 to 4 times daily McPhee p 988 MIGRAINE AND CLUSTER HA: Verapamil (and other calcium channel antagonists) - Answer- + Generic name -- verapamil
• Class -- Calcium channel blocker
• Indications for use -- Prophylaxis of migraine and cluster HA
• Contraindications -- CONTRAINDICATED in pts with severe LV dysfunction, AV block, atrial fib/flutter, severe hypotension -- CAUTION in CHF, bradycardia, hepatic/renal impairment, GERD, changes in smoking habit, elderly
• Common side effects -- HA, hypotension, flushing edema, constipation. (Monitor PR interval with ECG)

• Dosage in MIGRAINE -- PO, 120 - 240 mg, divided 3 times daily Dosage in CLUSTER HA -- PO, start at 240 mg daily, increase by 80 mg q2 weeks to 960 mg daily McPhee p 988 Which triptan is good for pts with prolonged attacks or attacks provoked by menstrual periods? - Answer- Eletriptan
• Contraindications --AVOID in pregnancy, pts with hemiplegic or basilar migraine, pts with risk factors for stroke (e.g. uncontrolled HTN, prior stroke or TIA, DM, hypercholesterrolemia, obesity) -- CAUTION in pts with controlled HTN -- CONTRAINDICATED in pts with coronary or peripheral vascular disease
• Common side effects -- Nausea and vomiting
• Dosage -- PO, 20-40 mg at onset, may repeat ONCE after 2 hours (MAXIMUM DOSE = 80 mg/24 hours) McPhee p 987 Why should opioids be avoided in tx of migraines - Answer- ↑ rates of rebound HA and tendency to develop medication overuse HA McPhee p 987 When is preventive tx of migraines indicated? - Answer- + Migraines occur > 2-3 times per month, OR
• Significant disability is associated with attacks McPhee p 987 Amitryptaline - Answer- + Generic name -- Amitriptyline
• Class -- Tricyclic antidepressant
• Indications for use -- Prophylaxis of migraine
• Contraindications -- CONTRAINDICATED in recovery from acute MI -- CAUTION in pts < 25 years old, elderly, hepatic impairment, QT issues, torsades, bradycardia, urinary retention, asthma, DM, thyroid disorder, bipolar disorder, schizophrenia, Parkinsons
• Common side effects -- Sedation, dry mouth, constipation, weight gain, blurred vision, edema, hypotension, urinary retention
• Dosage -- PO, 10 - 150 mg at bedtime McPhee p 988

Venlafaxine - Answer- + Generic name -- venlafaxine (Effexor)

• Class -- Serotonin-norepinephine reuptake inhibitors (SNRI)
• Indications for use -- Prophylaxis of migraine -- Depression
• Contraindications -- CAUTION in concurrent CNS depressant use, ETOH use, pts < 25 years, elderly, pregnancy 3rd trimester, renal/hepatic impairment, bleeding risk, HTN, hyperthyroid, recent MI
• Common side effects - HA, nausea, somnolence, dry mouth, dizziness, diaphoresis, sexual dysfunction, anxiety, weight loss, tinnitus, insomnia, nervousness, HTN (monitor BP)
• Dosage -- MIGRAINE -- PO, 37.5 - 150 mg extended release once daily -- DEPRESSION -- More effective with doses > 200 mg/day PO.
• Notes -- Few drug-drug interactions. -- No significant anticholinergic side effects -- ↑ risk of lethal arrhythmias compared to SSRIs but ↓ risk than TCAs. McPhee p 988, 1090 TRIGEMINAL NEURALGIA: Phenytoin - Answer- + Generic name - phenytoin
• Class -- Antiseizure
• Indications for use - Tx of trigeminal neuralgia
• Contraindications CONTRAINDICATED in sinus bradycardia, SA block, AV block CAUTION in CV disease, hypotension, ETOH use, elderly, renal/hepatic impairment, DM, thyroid disease, depression
• Common side effects - Nystagmus, ataxia, sedatino, confusion, blood dyscrasias, SLE, peripheral neuropathy
• Dosage -- PO, 200 - 400 mg daily McPHee p 990 Carbamazepine - Answer- + Generic name - Carbamazepine
• Class - Antiseizure

• Indications for use -- Tx of trigeminal neuralgia -- Tx of bipolar in pts who cannot take lithium (doesn't work or ↑ side effects)
• Contraindications CONTRAINDICATED in pts using MAOIs, bone marrow depression, sensitivity to TCAs CAUTION in CNS depressant use, ETOH use, elderly, asian, hepatic/renal impairment, CV disease, arrhythmia risk (MONITOR WITH serial blood counts and LFTs)
• Common side effects -- Nystragmus, dysarthria, diplopia, ataxia, drasiness, nausea, hepatoxicity, hyponatremia
• Interactions -- Will ↑ carbamazepine levels! -- NSAIDs (except aspirin), erythromycin, isoniazid, some CCBs (verapamil and diltiazem, but not nifedipine), fluoxetine, cimetidine (Tagamet).
• Dosage -- Trigeminal neuralgia: 400 - 1600 mg (immediate or extended release) divided in 2 daily doses -- Bipolar: Start at 400-600 PO daily and increase to 800 - 1600 PO daily. McPhee p 990, 1096 Clomipramine - Answer- + Generic name - Clomipramine
• Class - Tricyclic antidepressants (TCAs)
• Indications for use - OCD in adults
• Contraindications CONTRAINDICATED IN acute MI recovery CAUTION IN elderly, < 25 years, GI/GU obstruction, urinary retention, seizure disorder, thyrpid disease, DM, asthma, hepatic/renal impairment, bipolar disorder, ETOH abuse, suicide risk.
• Common side effects - Xerostomia, drowsiness, tremor, dizziness, HA, consiptaion, fatigue, n/v, etc.
• Dosage -- OCD: 150-250 mg PO qhs (Start at 25 mg po QD and increase gradually over weeks) NOTE for OCD: Check plasma levels 2-3 weeks after a dose of 50 mg/day is reached to keep plasma levels ↓ 500 ng/mL to avoid toxicity Fluoxetine - Answer- + Generic name - Fluoxetine
• Class -- SSRI
• Indications for use -- OCD in adults -- Depression
• Contraindications

CAUTION IN ETOH use, concurrent CNS depressant use, elderly, pts < 25 years, pregnancy 3rd trimester, hepatic impairment, QT issues, bradycardia, DM

• Common side effects -- Insomnia, nausea, HA, diarrhea, libido ↓, dirrhea, anorexia, somnolence, anxiety, can ↑ serum concentrations of some meds.
• Dosage -- OCD: Up to 60-80 mg day (start at 20 qd and increase after several weeks. taper to d/c) -- Depression: Starting dose of 10 mg/day for 1 week, before increasing to avg daily dose of 20 mg/day. McPhee xxx, 1089 Desvenlafaxine - Answer- + Generic name
• Class
• Indications for use
• Contraindications
• Common side effects
• Dosage Lithium - Answer- + Generic name - Lithium
• Class - Antipsychotic
• Indications for use -- Tx of mania, bipolar disease
• Contraindications -- CAUTION - Breastfeeding, elderly, renal issues, thyroid disease, ETOH use
• Common side effects -- EARLY: Mild GI sx, fine tremors, slight weakness and sedation. Moderate polyuria and polydipsia. Thyroid and kidney issues sometimes (check function at 4 -6 month intervals) -- LONG TERM: Cogwheel rigidity and sometimes EPS.
• Interactions -- ↑ lithium levels! AVOID thiazide diuretics (loop ok), ACEI, fluoxetine, ibuprofen, K- sparing diuretics
• Dosage -- Bipolar/Manic disorder: start at 300 mg po bid or tid, measure trough after 5 days, 12 hours after last dose. Peak serum levels in 1 - 3 hours. McPhee p 1094- Lorazepam - Answer- + Generic name - Lorazepam (valium)

• Class - Benzodiazepine
• Indications for use -- INSOMNIA
• Contraindications
• Common side effects
• Dosage -- INSOMNIA: 0.5 mg PO nightly Duration and withdrawal of prophylactic migraine medications - Answer- Once a drug is found to help, it should be continued for several months. If patient remains headache- free, the dose should be TAPERED AND EVENTUALLY WITHDRAWN. McPhee p 988 Most common type of primary headache disorder? - Answer- Tension-type headache McPhee p 988 Symptoms of tension type headache - Answer- + Pericranial tenderness
• Poor concentration
• Daily headaches which are "vise-like" but not pulsatile
• Exacerbated by emotional stress, fatigue, noise or glare.
• Usually generalize, but may be more intense about neck or back of head and associated with focal neuro symptoms. NOTE: Triptans are NOT indicated for this type of HA. McPhee p 988 Symtoms of cluster headaches - Answer- + Episodes of severe, unilateral periorbital pain occurring daily for several weeks
• Frequently accompanied by one or more of following: Ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of eye, Horner syndrome (ptosis, pupillary meiosis, facial anhidrosis/hypohydrosis)
• Restlessness/agitation during attacks
• Often occur at night, waking patient
• Last between 15 minutes to 3 hours
• Remission can last for weeks or months, but will recur.
• Bouts may last for 4 - 8 weeks and recur several times a year.
• Triggers can be ETOH, stress, glare, ingestion of specific foods

McPhee p 989 Distinction between cluster headaches and other trigeminal autonomic cephalgias? - Answer- Both have UNILATERAL periorbial pain associated with ipsilateral autonomic symptoms. Cluster headaches have DIFFERENT attack duration, frequency and HIGH responsiveness to indomethacin McPhee p 989 Other than cluster headaches, name other trigeminal autonomic cephalgias? - Answer-

• Hemicrania continua
• Paroxysmal hemicranias
• Short-lasting neuralgiform headache attacks with conjunctival injection and tearing McPhee p 989 Treatment of cluster headache attack? - Answer- + PO meds are generally ineffective
• SOMETIME effective: -- SQ or INTRANASAL sumatriptan -- 100% O2 via non-rebreather mask -- INTRANASAL zolmatriptan -- Dihydroergotamine (IM/IV) or viscous lidocaine (intranasal) McPhee p 989 Prophylaxis of cluster headaches - Answer- + PO meds -- Lithium carbonate (start at 300 mg daily, titrate up to total daily dose of 900-1200 mg as tolerated) -- Verapamil (start at 240 mg daily, increase by 80 mg q2weeks to 960 mg daily -- MONITOR WITH ECG for changes in PR interval) -- Topirimate (100-400 mg daily) McPhee p 989 What medications can be given as "transitional therapy" for 2 weeks or so until prophylactic medications for cluster HA become effective? - Answer- + Prednisone -- 60 mg daily for 5 days, followed by gradual withdrawal over 7 - 10 days.
• Ergotamine tartrate -- 0.5 - 1 mg nightly via rectal suppository, 2 mg daily PO, or 0. mg TID SQ five days per week. McPhee p 989

What is a post-traumatic HA? - Answer- + Occurs after a closed head injury.

• Usually appears within a day or so following injury, may worsen over ensuing weeks, and gradually subsides
• HA which START 1-2 weeks after injury are probably not directly attributable to injury McPhee p 989 What is a primary cough HA? - Answer- + Severe head pain produced by coughing, lasting for a few minutes or less
• CT and MRI scans should be done in all cases to check for lesions or tumors, and should be repeated annually for several years.
• Symptoms may clear after lumbar puncture McPhee p 989 Features of HA due to intracranial mass lesions - Answer- + New or worsening HA in middle or later life (should prompt for brain imaging)
• Pain may be worse upon lyind down, awaken pt at night or peak in morning after overnight recumbency.
• Sx suggestive of infection or malignancy include: fever, night sweats and weightloss; immunocompromise; hx or malignancy McPHee p 989 In approximately HALF of pts with chronic dialy HA, _____________ is responsible. - Answer- + Medication overuse NOTE: Initiating migraine preventive tx EARLY permits withdrawal of analgesics and eventual relief of HA McPhee 990 When to refer pt with sx of HA? - Answer- + Thunderclap onset
• Increasing HA unresponsive to simple measures
• Hx of trauma, HTN, fever, visual changes
• Presence of neuro signs or scalp tenderness McPhee p 990 ESSENTIALS OF DIAGNOSIS: Trigeminal neuralgia - Answer- + Brief episodes of stabbing ffacial pain
• Pain in territory of 2nd and 3rd division of trigeminal nerve
• Pain exacerbated by touch :McPHee p 990

Types of pts most commonly affected by trigeminal neuralgia - Answer- + Women more often than men

• Middle/later life McPhee p 989 Differential dx for trigeminal neuralgia - Answer- + Multiple sclerosis -- Suspect when < 40 years of age
• Other neoplasm when symptoms are BILATERAL McPhee p 990 Clinical findings in trigeminal neuralgia - Answer- + Sudden lancinating facial pain
• Commonly located near one side of mouth
• Pain shoots toward ear, eye or nostril on same side McPhee p 990 Atypical facial pain - Patient profile and treatment - Answer- + Common in middle-aged women, many of them depressed
• Trials of simple analgesics and TCAs, carbamazepine, phenytoin; although response is often disappointing. McPhee p 991 Glossopharyngeal neuralgia - Symptoms and tx - Answer- + Symptoms: Trigeminal neuralgia-like pain occurs in throat, near tonsillar fossa and sometimes deep in ear and at back of tongue
• Pain may be precipiated by yawning, swallowing, chewing, talking and is cometimes accompanied by syncope
• No underlying structural issue, often. MS is sometimes responsible
• Oxcarbasepine and carbamazepine are tx of choice McPHee p 991 Postherpetic neuralgia - Patient profile, symptoms and treatment - Answer- + Occurs in 15% of pts with hx of shingles (usually when rash is severe and when 1st division of trigeminal nerve is affected)
• WITHIN 72 hours of rash onset, reduce post-herpetic neuralgia by ALMOST HALF with: -- Acyclovir (800 mg 5 times daily) -- Valacyclovir (1000 mg TID)
• Topical application of capsacian cream and topical lidocaine may be helpful. McPHee p 991

Other causes of facial pain - Answer- + TMJ dysfunction -- Tenderness of mastication muscles and pain begins with chewing

• Giant cell arteritis -- pain develops progressively with mastication
• Sinusitis and ear infections -- Pt has hx of respiratory infection, fever and sometimes nasal/aural discharge
• Glacuoma - Pain in periorbital region
• Cardiac issues - Jaw pain may be related to MI or angina pectoris, especially when precipitated by exertaion and when radiating. McPhee p 991 Most common cause of subarachnoid hemorrage - Answer- Trauma. Prognosis depends on severity of head injury McPhee p 1007 Cause of spontaneous subarachnoid hemorrhage - Answer- Non-traumatic, frequently results from rupture of arterial sacular ("berry") aneurysm, or from an AVM. McPhee p 1007 S/S of subarachnoid hemorrhage - Answer- + Thunderclap headache of severity never before experienced
• Followed by N/v and a loss or impairment of consciousness that can either be transient or progress toward coma and death
• If consciousness is regained, pt is often confused and irritable and may show other signs of altered mental status.
• Neuro exam reveals nuchal rigity and other signs of meningeal irritation McPhee p 1007- Signs of aneurysm prior to rupture - Answer- + Usually asymptomatic unless they compress adjacent structures.
• Some pts have headaches with nausea and neck stiffness a few hours or days before massive hemorrhage occurs. (r/t "warning leaks") McPhee p 1008 What patients are most at risk for subarachnoid hemorrhage? - Answer- + Older age
• Female
• Non-white
• Hypertensive
• Smoker
• ↑ ETOH consumption
• Previous symptoms
• Posterior circulation aneurysms

• Larger aneurysms McPhee p 1008 What kind of imaging should be done when subarachnoid hemorrhage is suspected? - Answer- + CT scan (preferably with CT angiography) IMMEDIATELY. -- If CT is normal, CSF must be examined for presence of blood or xanthochromia before discounting possibility of subarachnoid hemorrhage. (< 2000 RBC is unlikely due to subarachnoid hemorrhage). McPhee p 1008 Causes of pseudotumor cerebri - Answer- 1) Thrombosis of transverse venous sinus as a complication of otitis media or chronic mastoiditis

2. Sagittal sinus thrombosis
3. Chronic pulmonary disease
4. Lupus
5. Uremia
6. Endocrine disturbances such as hypoparathyroidism, hypthyroidism or Addison disease
7. Vitamin A toxicity
8. Use of tetracycline or oral contraceptives
9. Occasionally withdrawal of long term corticosteroids McPhee p 1018 ESSENTIALS OF DIAGNOSIS: Pseudotumor cerebri - Answer- + HA, worse on straining

• Viscual obscurations or diplopia may occur
• Examination reveals papilledema
• Abducens palsy is commonly present (6th nerve palsy causes eye to turn out) McPhee p 1018 Name for idiopathic pseudotumor cerebri and patients most often affected? - Answer- + Idiopathic intracranial HTN
• Most commonly affects overweight women aged 20 - McPhee p 1018 Signs/symptoms of pseudotumor cerebri - Answer- + HA
• Diplopia and other visual disturbances due to papilledema and abducens nerve dysfunction
• Some pts have pulse-synchronous tinnitus

NOTE: Exam reveals papilledema and some enlargement of blind spots, but patients otherwise look well. McPhee p 1018 Common imaging results for pseudotumor cerebri? - Answer- + Usually no evidence of a space-occupying lesion is seen

• CT/MRI reveal normal or small ventricles
• Sometimes stenosis of one or more of the venous sinuses will be observed McPhee p 1018 Lab findings in pseudotumor cerebri - Answer- Lumbar puncture can confirm presence of intracranial HTN but CSF is normal McPhee p 1018 Treatment of psuedotumor cerebri - Answer- + Medications to reduce production of CSF to ↓ ICP. Some examples -- Acetazolamide (250-500 mg PO TID, increasing slowly to maintenance dose of up to 4000 mg daily divided 2 to 4 times per day) -- Topiramate (also causes weight loss) -- Furosemide (can be used as adjunct tx)
• Sometimes CSF is drawn off to ↓ ICP. Shunts are sometimes inserted. McPhee p 1018 When to refer/admit pts with suspected pseudotumor cerebri - Answer- + REFER all patients
• ADMIT pts with worsening vision requiring shunt placement or optic nerve sheath fenestration. McPhee p 1018 ESSENTIALS OF DIAGNOSIS: Adjustment disorders - Answer- + Anxiety or depression in reaction to an identifable stress, though out of proportion to the severity of the stressor
• Symptoms not as serious as a major depressive episode or as chronic as a generalized anxiety disorder. McPhee p 1059 Differential diagnoses for adjustment disorder - Answer- + Anxiety disorders
• Mood disorders
• bereavement

• Other stress disorders (e.g. PTSD)
• Personality disorders exacerbated by stress
• Somatic disorders with psychic overlay NOTE: Adjustment disorders are wholly situational and usually resolve when the stressor resolves or the individual effectively adapts to the situation. McPhee p 1059 An adjustment disorder occurs within ________________________ (time period) of an identifiable stressor. - Answer- + 3 months Treatments for adjustment disorder - Answer- 1) Behavioral (e.g stress reduction techniques to mitigate symptoms when recognized to keep them from blowing up, keeping log of stress precipitators, relaxation, mindfulness, exercise

2. Social (clarifying problem in the patient's psychosocial context to allow pt to view it in proper fram and facilitate decision making to mitigate stressor)
3. Psychological (Supportive psychotherapy -- usually not long term -- to help pt develop coping mechanisms. Cognitive/behavioral therapy has also shown useful.)
4. Medical (Sedatives for SHORT TIME to provide relief from acute anxiety sx. Also, short-term SSRIs targeting dysphoria and anxiety might be helpful.) McPhee p 1060 ESSENTIALS OF DIAGNOSIS: PTSD - Answer- + Exposure to traumatic or life- threatening event

• Flashacks, intrusive images and nightmares in which pt re-experiences event
• Avoidance symptoms (e.g. social, numbing) and avoidance of triggers
• Increased vigilance, such as startle response and difficulty falling asleep
• Symptoms impair functioning McPhee p 1060 PTSD is more common when associated with WHAT TYPE of injury? - Answer- PHYSICAL, rather than psychological. McPhee p 1060 Confirming dx of PTSD lies in the ability to do WHAT? - Answer- Identify the hx of exposure to actual or perceived life-threatening event, serious injury or sexual violence McPhee p 1060 Useful screening instruments for PTSD - Answer- + Primary Care PTSD Screen
• PTSD Checklist

McPhee p 1060 In 75% of cases of PTSD, it occurs with comorbid existence of WHAT OTHER disorders? - Answer- + Depression

• Panic disorder NOTE: There is considerable overlap in symptoms between the three. McPhee p 1061 Types/duration of psychotherapy as tx for PTSD - Answer- + Psychotherapy should begin as soon as possible after the event and should be brief (8 - 11 sessions) as soon as individual feels safe.
• Types of psychotherapy which have proven useful: -- Cognitive processing therapy -- Prolonged exposure therapy -- Eye-movement desensitization reprocessing McPhee p 1061 What kind of medications are useful in ameliorating depresssion, panic attacks, sleep disruption and startle responses in PTSD pts? - Answer- SSRIs
• They are the only class of meds approved for tx of PTSD
• Examples: Sertraline (Zoloft), paroxetine (Paxil) McPhee p 1061 Other types of medications often used to treat peripheral symptoms of PTSD - Answer-
• Beta blockers - Helps with anxiety (e.g. propranolol)
• Noradrenergic agents - Help with hyperarousal (e.g. clonadine)
• α-adrenergic blockers - Decrease nightmares (e.g. prazosin)
• Antiseizure medications - Mitigate impulsivity and difficulty with anger management (e.g. carbamazepine)
• Benzodiazepines - Reduce anxiety and panic attacks but CAUTION WITH DEPENDENCE (e.g. clonazepam) NOTE: 2nd generation antipsychotics have not proven useful. McPhee p 1061 ESSENTIALS OF DIAGNOSIS: Anxiety disorders - Answer- + Three primary types: Generalized anxiety disorder, panic disorders, phobic disorders
• Persistent excessive anxiety or chronic fear and associated behavioral disturbances
• Somatic symptoms referable to the autonomic nervous system or to a specific organ system (e.g. dyspneal, palpitations, paresthesias)
• Not limited to an adjustment disorder

• Not a result of physical disorders, other psychiatric conditions (e.g. schizophrenia) or drug abuse
• Anxiety disorders may be long standing and difficult to treat. McPhee p 1062 Clinical Findings and treatment: Generalized Anxiety Disorder - Answer- FINDINGS
• Anxiety symptoms of apprehension, worry, irritability, difficulty in concentrating, insomnia or somatic complaines are present more days than not for at least 6 months
• Focus of anxiety can be a number of everyday activities TREATMENT
• Antidepressants (includings SSRI, SNRI) are 1st line medications, but may take awhile to start working. --Venlafaxine and duloxetine (SNRIs) are approved for tx of GAD. Start low and titrate upward -- Escitalopram and paroxetine (SSRIs) are also approved for GAD. -- TCAs and MAOIs are 2nd or 3rd line tx.
• Benzodiazepines can provide immediate symptom relief but can lead to dependence. --Diazepam and clorazepate are most rapidly absorbed PO. --Lorazepam is better for use in elderly and pts with liver dysfunction. -- Avoid long acting benzos (e.g. flurazepam and diazepam) in older adults r/t long half- lives. OTHER TREATMENT
• Cognitive behavioral tx appears to work. McPhee p 1063-4 Clinical Findings and treatment: Panic Disorder - Answer- FINDINGS:
• Recurrent, unpredicable episodes of intense surges of anxiety accompanie by marked physiologic manifestations.
• Key to diagnosis is psychic pain individual expresses.
• Onset usually < 25 years, female to male ratio is 2:1
• Consider MI, phyochromocytoma, hyperthyroid and drug reactions in differential dx TREATMENT - MEDICATION
• Antidepressants are 1st line treatment --- Fluoxetine, paroxetine and sertraline (SSRIs) are approved for panic disorder --- Venlafaxine (SNRI) is approved for panic disorder
• Benzos are best used early in tx, because dependence is possible. --- Taper meds like clonazepam and alprazolam after antidepressant starts working. --- Paradoxical reactions to short-acting benzos have been reported. --- Reversal agent is flumazenil.

OTHER TREATMENT

• Cognitive behavioral tx appears to work.
• Peer support groups. NOTE: In acute panic attacks, SSRIs are initial medication of choice. Benzos can manage symptoms as antidepressant is titrated upward. Beta blockers have also been successful in resistant cases. McPhee p 1063-4 Clinical Findings and treatment: Phobic Disorder - Answer- FINDINGS:
• Fear of a specific object or situation
• Rule out all underlying medication disorders TREATMENT:
• SSRIs (e.g. paroxetine, sertraline and fluoxamine) are used.
• Certain phobias may respond to moderate doses of beta blockers.
• Behavioral therapies such as systematic desensitaivation have been successful. McPhee p 1063-4 ESSENTIALS OF DIAGNOSIS: OCD and related disorders - Answer- + Preoccupations and rituals (repetitive psych9ologically triggere behaviors) that are distressing to the individual
• Symptoms are excessive or persi+ stent beyond potentially developmentally normal periods McPhee p 1066 Treatment for OCD in adults - Answer- +BEHAVIORAL/PSYCHOLOGICAL ++ Behavior modificatyion with systematic desensitization which involves gradually exposing patient to his fears to help manage anxiety. --- Do research to help educate patient and family and help with desensitization ++ "Thought-stopping"
• PHARMACOLOGY ++SSRIs and TCAs are recommended, but may take up to 12 weeks to take effect. -- Clomipramine (TCA) - Primary med. Same dose as with depression. OR can be used as low dose adjunct to SSRI, but caution with seratonin syndrome. -- Fluoxetine (SSRI) - Primary med. higher dose than with depression ++ Antipsychotics and topiramate may be used as adjuncts to SSRIs in treatment- resistant cases.
• OTHER ++ Work with employer to facilitate leave for recovery

McPhee p 1066-7 Conversion disorder - Answer- + Conversion of psychic conflict into physical symptoms commonly co-occurs wtih panic disorder or depression. (e.g. paralysis for panic disorder) McPhee p 1067 Somatic symptom disorder - Answer- + Previously known as hypochondriasis

• Characterized by one or more somatic symptoms associated with significant distress or disability.
• HIgh level of anxiety about health
• Usually chronic
• Major depression is an important consideration in differential diagnosis
• Usually occurs before age 30, and is 10 times more common in women. McPhee p 1067-8 Factitious disorders - Answer- + Symptoms are produced CONSCIOUSLY
• Self-induced or described symptoms or false physical or lab findings for purpose of deceiving clinicians or other health care personnel. Also known as "Munchausen's" -- Examples: Self-mutilation, fever, hemorrhage, hypoglycemia, seizures, etc.
• Disorders can be imposed on another person (previously known as "Munchausen's by proxy") for perceived psychological benefit of the first person.
• "Doctor shopping" is common in these pts McPhee p 1068 Treatment of somatic symptom disorders - Answer- MEDICAL
• Pt's distress is REAL
• Just because no organic basis can be found, does not mean that it is necessarily a mental disease. -- Find connection with events in a patient's life. Ask them to keep a diary. --Regular, frequent, short appts. -- ONE CLINICIAN should be primary. PSYCHOLOGICAL
• Pragmatic current changes, rather than exploration of earlier events which patient may not relate to current distress.
• Group therapy sometimes helpful
• Hypnosis used early can help
• Early psych consultation for factitious disorders is indicated. -- Joint consult with primary clinician and psychiatrics -- Double bind ("either its something i can fix with this tx, or it's a factitious disorder for which you will need psych treatment")

BEHAVIORAL

• Biofeedback -- e.g. using electronic stethoscopie to amplify ↑ peristalsis so pt can recognize and learn to identify and change sounds. SOCIAL
• Family members should come for appts with pt.
• Ongoing communication with employer may be important. NOTE: Prognosis better if primary clinician can intervene early before situation deteriorates. McPhee p 1068-9 ESSENTIALS OF DIAGNOSIS: Chronic pain disorders - Answer- + Chronic complaints of pain
• Symptoms frequently exceed signs
• Minimal relief with standard tx
• History of having seen many clinicians
• Frequent use of several nonspecific medications NOTE: Counterproductive to speculate whether or not pain is real. IT IS REAL TO PATIENT. McPhee p 1069 Components of chronic pain syndrome - Answer- + Anatomic changes
• Chronic anxiety and depression
• Anger
• Changed lifestyle McPhee p 1069 Chronic pain patients have a marked ____________ in pain threshhold. - Answer- + decrease McPhee p 1069 Cornerstone to a unified approach to chronic pain syndromes is __________________________________. - Answer- A comprehensive behavioral program. McPhee p 1069 In the case of chronic pain, the clinician must shift from the idea of biomedical care to ________________________. - Answer- Ongoing care of the patient.