1. HA, Seizures, Neuropathy
NURS 870 – 2016

2. Objectives
Following this lecture, students will understand the approach to: 1. The Patient with Headaches 2. The patient with Seizures 3. The patient with Neuropathy

3. I. heaDaches

4. i. Headache sources Intracranial
Mass Lesions – progressive HA, worse when laying down, straining
Subarachnoid Hemorrhage – sudden onset, worst HA of life
Brain tumor and abscess – persistent, localized HA
Chronic subdural hematoma – subtle, following head trauma followed by symptom-free period, then later neuro deficits
Pseudotumor Cerebri – mimics tumor, often in obese, young women – have papilledema on fundoscopic exam

5. i. Headache sources Intracranial Nonmigraine Cerebrovascular Sources
Ischemic events
Arteriovenous malformation – acute or chronic

6. AVM

7. i. Headache sources Migraine – See Katlyn’s presentation!
Most HAs seen in primary care are migraine
Get a good history (HA diaries very helpful)
Daily prophylaxis when indicated (Goroll p. 1195)
Increased stroke risk – manage risk factors

8. i. Headache sources Meningitis– See Sarah’s presentation!
Get good HPI – fever, exposures
All patients say “I have a stiff neck” - look for nuchal rigidity
Most meningitis is viral in young people
College students – high index of suspicious for bacterial (meningococcal disease) – high mortality, prophylaxis for close contacts

9. i. Headache sources - EXTRAcranial
Extracranial– skin, fascia, muscles & vessels of scalp
Tension-Type – with stress, bilateral, band-like
Sinusitis – purulent discharge? Most self-reported sinus HAs are actually migraine
Giant Cell Arteritis– older patients, scalp hurts when combing hair, check ESR, if missed, can lead to blindness
TMJ – See Jessica’s presentation!
Cluster Headache – middle age men, periodicity, accompanied by ipsilateral lacrimation, nasal stuffiness, facial flushing. Often start a few hours after going to bed

10. Headache HPI
New Onset Neurologic deficits? Neck stiffness? Worst HA of life? Recurrent Get clinical course – progressively worse? Or waxes and wanes? Get associated symptoms Location and quality? Aggravating/precipitating factors?

11. Headache PE
Focus on ENT Focus on Neuro Exam

12. Headache - who really needs the CT?
Worse HA ever (especially if +meningeal signs) New neurologic deficits Evidence of increased intracranial pressure;

13. Headache - meningeal irritation?
CT brain
Lumbar puncture
Efficacy: Meningeal signs
Do not rely on these signs due to low efficacy
Kernig's Sign and Brudzinski's Sign
Test Sensitivity: 5%
Test Specificity: 95%
Nuchal Rigidity
Test Sensitivity: 30%
Test Specificity: 68%
References
Thomas (2002) Clin Infect Dis 35: [PubMed]

14. Headache - meningeal irritation?
Efficacy: Meningeal signs
Do not rely on these signs due to low efficacy
Kernig's Sign and Brudzinski's Sign
Test Sensitivity: 5%
Test Specificity: 95%
Nuchal Rigidity – can’t flex neck to chest
Test Sensitivity: 30%
Test Specificity: 68%
References
Thomas (2002) Clin Infect Dis 35: [PubMed]

15. III. Neuropathy
Nerve Root Syndromes
Paresthesia & Weakness

16. III. Neuropathy – Upper ext nerve roots
Cervical
Radiculopathy (pain, numbness, tingling) and
Myelopathy (weakness, clonus, hyperreflexia)
Brachial Plexus Neuritis – severe upper shoulder & arm pain followed by weakness - after vaccination or other viral illness
Thoracic Outlet Syndrome – affects 4th & 5th fingers
Long Thoracic Nerve Entrapment – lifting or heavy backpacks
Carpal Tunnel – Phalen & Tinel signs
Ulnar Nerve Entrapment – from repetition like tennis, music
Radial Nerve Injuries – injury in axilla – from crutches, etc

18. III. Neuropathy – Lower ext nerve roots
Lower Extremity
Radiculopathy (pain, numbness, tingling) and
Myelopathy (weakness, clonus, hyperreflexia)
Lateral Femoral Cutaneous Nerve Compression – burning in lateral thigh
Femoral Neuropathy – sudden onset of pain quickly followed by numbness, weakness
Sciatic Nerve Syndromes
Lumbar Disk Syndromes

19. III. Neuropathy – Paresthesia & Weakness
Motor Polyneuropathy -- Guillain-Barré syndrome
Often follows infection by: Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and Mycoplasma pneumoniae
progression of ascending weakness over a few days in conjunction with a loss of deep tendon reflexes
A small increase in risk (estimated at 2 per million) is associated with use of some H1N1 influenza vaccines

20. III. Neuropathy – Paresthesia & Weakness
Sensory and Mixed Polyneuropathies
Amyloidosis
paraneoplastic syndromes
vitamin B6 excess
Sjögren syndrome
More common in primary care:
Deficiencies of B vitamins,
renal failure
Hypothyroidism
AIDS,
and genetic conditions such as Charcot-Marie-Tooth

21. III. Neuropathy – lab workup
Consider these based on risk factors:
CBC
ESR or CRP
CMP
TSH
B12
homocysteine
ANA
Hepatitis panel
HIV screen

22. III. Neuropathy – lab workup
The EMG:
when weakness due to primary muscle or neuromuscular junction disease is suspected
to differentiate between demyelinating disease and axonal polyneuropathy or between root or plexus and more-distal nerve trunk involvement

23. III. Neuropathy – Rx – based on etiology
Treat underlying viral cause
Narcotics do not work well for nerve pain
For DM neuropathy & post herpetic neuralgia, try gabapentin or duloxetine
Try lidocaine patch or Capsaicin cream
Tricyclic antidepressants: amitriptyline, SNRIs
Refer!