Primary Care Neuro Lecture slide 1

• NURS 6030 - Advanced Practice Nursing in Primary Care of the Adult
• Neurological Disorders

Learning Objectives

• Describe strategies for evaluation and management of common neurological complaints
• Develop differential diagnoses based on history and physical exam findings
• Identify appropriate treatment and indications for referral

Common Neurological Complaints

• Headaches
• Dizziness
• Weakness
• Paresthesia
• TIA or CVA
• Syncope
• Memory Loss
• Seizures

Headache

• Primary headaches are not symptomatic of an underlying condition
• Secondary headaches have an underlying condition
• Types of primary headaches include:
  • Migraine, more common in women than men
  • Tension-type
  • Cluster

Headache Differentials

• Infectious: Sinusitis, Meningitis, Abscess, Earache, Lyme Disease, COVID-19
• Inflammatory: RA, Temporal arteritis, Trigeminal neuralgia, SLE
• Structural: Tumor, Hemorrhage, Aneurysm, Subdural hematoma
• Metabolic: Thyroid dysfunction, Pheochromocytoma, Sleep apnea
• Other: Pseudotumor cerebri, Trauma

Migraines Epidemiology

• Migraines affect 12% of the general population
• Migraines are more common in woman than men
• Genetics account for 40-50% of individual susceptibility
• Migraine without aura accounts for 75% of migraines

Migraine Presentation

• A migraine is a disorder of recurrent attacks
• Migraines have 4 phases: prodrome, aura, headache, and postdrome

Migraine POUND

• Migraine is 92% likely if 4 or more of the following are present:
  • Pulsatile
  • One day duration
  • Unilateral
  • Nausea or vomiting
  • Disabling intensity

Migraine Triggers

• Common migraine triggers include:
  • Emotional stress (80%)
  • Hormones in women (65%)
  • Not eating (57%)
  • Weather (53%)
  • Sleep disturbances (50%)
  • Odors (44%)
  • Neck pain (38%)
  • Lights (38%)
  • Alcohol (38%)
  • Smoke (36%)
  • Sleeping late (32%)
  • Heat (30%)
  • Food (27%)
  • Exercise (22%)
  • Sexual Activity (5%)

Migraine WITHOUT Aura Criteria

• At least 5 attacks fulfilling criteria B through D are required for diagnosis
• Headache lasting 4-72 hours
• Headache has at least 2 of the following:
  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of physical activity
• During headache at least 1 of the following:
  • Nausea, vomiting or both
  • Photophobia or phonophobia

Migraine WITH Aura Criteria

• At least 2 attacks fulfilling criteria B through C are required for diagnosis
• 1 or more of the following fully reversible aura symptoms: visual, sensory, speech/language, motor, brainstem, retinal
• At least 2 of the following 4: -1 aura symptom spreads >5 min and/or 2 auras occur in succession -Each individual aura symptoms lasts 5 to 60 min -At least 1 aura symptom is unilateral -Aura is accompanied or followed within 60 min by headache

Physical Exam Components

• Vital signs
• Fundoscopic exam
• Palpation of head, neck and sinuses
• Palpate TM joint
• Cardiopulmonary exam
• Examination of cranial nerves
• Evaluation of motor and balance
• Mental Status

Headache Work Up

• Labs: CBC with diff, ESR, Thyroid function, Lyme titer, RH factor
• Imaging: CT or MRI

Diagnostics for Headache

• Choose wisely
• Do not perform imaging in patients with stable headaches who meet criteria for migraine
• Consider in patient's with a red flag or focal neuro deficit
• Ask yourself if you should refer instead

Abortive Pharm Management for Mild to Moderate Migraine Attacks

• NSAIDS
• Acetaminophen
• Aspirin
• Warning about rebound
• It's possible to add an antiemetic

Abortive Pharm Management for Moderate to Severe Migraine Attacks

• Imitrex® (sumatriptan)
• Maxalt ® (rizatriptan)
• Relpax® (eletriptan)
• Zomig ® (zolmitriptan)
• Can combine triptan with NSAID
• Treximet® (sumatriptan + naproxen)

Are Triptans Safe?

• Cardiovascular risk:
  • Selective for cranial arteries
  • Should not be given to patients with known vascular dz
• Drug interactions
  • Contraindicated with ergotamines & MAO inhibitors
• Pregnancy: -Not studied but sumatriptan considered low risl

Absolute Contraindications for Triptans

• Hemiplegic migraine
• Basilar migraine
• Ischemic stroke
• Ischemic heart disease
• Prinzmetal's angina
• Uncontrolled HTN

In Office Options for Migraine

• Sumatriptan 6mg subq
• Ketorolac 30-60mg IM
• Diphenhydramine 12.5-25mg IM
• Dexamethasone 12-25mg IM

Non-Pharm Management for Migraine

• Relaxation training
• Biofeedback
• Acupuncture
• Cognitive behavioral therapy

Preventive Pharm Management for Migraine

• Goal is to decrease headache intensity and frequency
• Consider when appropriate
• Examples:
  • Beta blockers: propranolol
  • Antidepressants: SSRIs or tricyclic (amitriptyline)
  • Anticonvulsants: topiramate, valproate
  • Calcitonin gene related peptide

Alternatives for Prevention of Migraine

• Butterbur 150mg BID
• Coenzyme Q10 100mg TID
• Feverfew 6.25mg TID
• Magnesium 600mg QD

Medication Overuse Headaches

• Common culprits:
  • Opioids
  • Butalbital combos
  • Caffeine combos
  • NSAIDs
• Prevention:
  • Do not take these meds more than 10 days/month
  • Consider prophylactic med for primary headache disorder

Approach to Treatment for Headache

• Educate patient about condition
• Use migraine specific agents
• Use non-oral route with early nausea/vomiting
• Consider self administer rescue med
• Guard against medication overuse headaches
• Know that headache types can overlap

Headache Misconceptions

• Sinus headache?
• Eye strain?
• Hypertension??

Tension Type Headaches

• Classified by frequency
• Etiology:
  • Multifactorial
  • Heightened sensitivity
  • Precranial muscle tenderness
• Precipitating factors: Stress and mental tension
• Relationship with migraine?

Tension Type Headache Criteria

• Must have at least 2 of the following:
  • Bilateral location
  • Pressing or tightening (non-pulsing quality)
  • Mild to moderate intensity
  • Not aggravated by physical activity
• Must have both of the following:
  • No nausea or vomiting
  • No photophobia or phonophobia

Differentials for Tension-Type Headaches

• Brain tumor
• Sinus headache
• Medication overuse headache
• Migraine
• Arthritis
• TMJ
• Non-ergonomic work station

Acute Treatment Options for Tension-Type Headaches

• Simple analgesics:
  • NSAIDs
  • Aspirin
  • Combine with caffeine
• Caution about medication overuse headache
• Triptans may be effective for patients with co-existing migraine

Preventive Treatment Options for Tension-Type Headaches

• Pharm with Best Evidence:
  • Effexor® (venlafaxine)
  • Elavil® (amitriptyline)
• Pharm with Limited Evidence:
  • Topamax® (topiramate)
  • Neurontin® (gabapentin)
• Behavioral/complementary:
  • Biofeedback, relaxation
  • Acupuncture provides modest benefit
  • Trigger point injections
  • Botulinum toxin injections

Cluster Headache

• Trigeminal autonomic cephalalgias
  • Unilateral severe headache attacks with autonomic symptoms
  • More common in men than women
• Differentials:
  • Trigeminal neuralgia
  • Alternate headache syndrome
  • Meningioma
  • Nasopharyngeal carcinoma
  • AVM
• Neuroimaging suggested to rule out secondary diagnosis

Cluster Headache Criteria

• At least 5 attacks fulfilling criteria B through D
• Severe unilateral orbital, supraorbital or temporal pain
• Either or both of the following:
  • At least 1 of the following ipsilateral symptoms: conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, forehead and facial sweating or flushing, sensation or fullness in the ear, miosis or pitosis
  • A sense of restlessness or agitation

Cluster Headache Treatment

• Acute episode:
  • 100% oxygen
  • Subq Sumatriptan
• Preventaive:
  • Verapamil (240-320mg QD but may go up to 480-960mg QD)
  • Glucocorticoids during initiation of verapamil
  • Topiramate can be effective add on to verapamil
  • Nerve blocks for refractory cases
• Refer

Case Studies

• 24 year old female with Headaches x3 months, unilateral, pulsing/throbbing that lasts for a day, better with sleep, nauseated, has to close eyes against pain (7/10), worse prior to menstrual cycle, aided some by NSAIDs, with normal exam
• 24 year old female with Headaches off and on, worse around finals time, all over head, feels like a vice grip, sometimes pain in neck, Headache usually a few hours, Pain 5/10, no associated symptoms, helped some by NSAIDs, with normal exam
• 31 year old male with onset of a severe headache in the past day, difficulty turning head, vomiting, can't keep any food or fluids down, no significant medical history other than seasonal allergies, never had headaches
• 78 year old female with sudden onset confusion within the past 6 hours, found by daughter after falling in home, takes blood pressure medication, history of breast cancer

Cranial Nerve Disorders: Bell's Palsy

• Acute unilateral peripheral facial palsy
• Viral causation most popular theory
• More common in young and middle aged adults Risk factors:
  • 3rd trimester
  • 1st week post partum
  • Diabetes
  • Hypo-thyroid
  • Recent URI
  • Obesity
  • Family History

Bell's Palsy: Presentation

• Onset:
  • Acute and progressive
  • Paralysis usually by 48 hours
• Symptoms:
  • Smooth forehead
  • Flattened nasolabial fold
  • Asymmetric smile
  • Tearing, drooling, post-auricular pain
  • Tinnitus
  • Dysgeusia
  • Hyperacusis
• Sparing of forehead muscles on affected side is suggestive of a central lesion

Bell's Palsy: Diagnostics and Differentials

• Diagnostics:
  • Lab: Consider Lyme titer
  • Imaging: Only in atypical presentation or bilateral nerve palsies
  • Degree of facial paralysis: House-Brackmann scale
  • Photographic record
• Differentials:
  • Stroke, Tumor, MS
  • Lyme, Guillian-Barre
  • Otitis media, mastoiditis
  • Ramsay-Hunt, Zoster
  • Pregnancy
  • Diabetes, hypothyroidism
  • Trauma

Bell's Palsy: Management

• Refer for atypical presentation, pregnancy, corneal abrasion, CNS involvement
• Prednisone 60mg for 5 days and Co-administer acyclovir 400mg QD for 7 days
• Eye care:
  • Lubricating eye drops
  • Protective glasses
  • Tape closed at night
• Complications:
  • Depression
  • Loss of vision
  • Hearing loss

Cerebral Vascular Events

• Ischemic and hemorrhagic stroke: TIA or ACVS
• Symptom recognition:
  • Weakness
  • Numbness
  • Paralysis
  • Severe headache
  • Impairment in cognition, speech, EOM, LOC
  • Emotional lability, aphasia, alexia, agraphia
• Prevention:
  • Risk factor reduction
  • Stroke symptoms recognition and emergency treatment
• Follow-up:
  • Address each physical impairment
  • Assess motor, sensory, perceptual, cognitive, speech

Differentials for Cerebral Vascular Events

• Migraine
• Seizure
• Tumor
• Syncope
• Transient global amnesia
• Subdural or epidural hematoma
• Systemic or neurologic infection
• Hypoglycemia
• Arrhythmia
• Hyperventilation
• Drug overdose
• Cardiac arrest
• Conversion disorder
• Panic attack

Dizziness and Vertigo

• What is it?: True vertigo, Lightheadedness/syncope, Imbalance
• Causes: Vestibular, Neuro, Cardiovascular, Psych
• Physical exam: HEENT, Cardiac, Neuro
• TITRATE: Timing, Triggers, Targeted exam
• Labs: CBC, TSH, B12, RPR, electrolytes, basic metabolic screen, glucose
• Imaging? : Abnormal neuro findings, Progressive unilateral hearing loss
• Audiometry: Performed if any hearing loss
• Holter: If any suggestion of cardiac etiology
• Management: Fall risk, Antiemetics, Vestibular rehab, Refer
• Peripheral vestibular dysfunction: 40%
• Presyncope or Disequilibrium, Multicausal: 25%
• Psychiatric: 15%
• Central cause, Stroke: 10%
• Unclear etiology: 10%
• In older adults, stroke is the most common cause of dizziness

Seizures

• 2.2 million with epilepsy in US
• More common in men than women
• Genetic predisposition
• Seizure can be isolated event where neurons produce excessive electrical charges in brain
• Common causes in adults: Medications, trauma, infections, brain lesions; Strokes common cause of epilepsy in the elderly
• Diagnosis: Primarily historical, look for post-ictal signs

Seizure Differentials

• Cardiac: Syncope, Arrhythmias, TIA/CVA, AVM
• Neuro: Migraine, Transient amnesia, Movement disorder, Tumor, Head trauma Metabolic: Toxic ingestion, Alcohol use or withdrawal, Hyperventilation
• Other: Infections of CNS, Febrile seizure, Psychogenic, Sleep deprivation

Parkinson's Disease

• When to suspect: Tremor, rigidity, bradykinesia, postural disturbances
• Neuro referral: Neuroprotection; Symptom management: Meds, surgery
• Primary care management: Fall risk, home safety issues, health promotion
• Consider alternate diagnosis: Falls at presentation, Poor response to Levodopa, Symmetric motor signs, Rapid progression, - Lack of tremor, Dysautonomia early in dz course

Meningitis

• Risk factors include: prior skull fracture or neurosurgery, sickle cell disease, asplenia, alcoholism, HIV.
• 44% of patients will present with a fever, headache, and stiff neck.
• Nausea, vomiting, and photophobia are common symptoms. -Altered consciousness, seizures, and hypotension can also occur.
• Prevention includes MCV4 and MPSV4, and Pneumovax.

Multiple Sclerosis

• Chronic progressive inflammatory disease of CNS
• Possible risk factors include: low vitamin D, Exposure to Epstein-Barr, and Smoking
• Presentation: Focal neural deficit, Eye pain or visual disturbance, and Paresthesias or weakness of limbs
• Differentials: Lyme, Lupus, Migraine, Disc Disease, B12 Deficiency, Somatization, Alcohol Use

Delirium

• Presentation includes disturbance in attention, consciousness, and cognition which develops over hours to days
• Diagnosis: distinguish between organic and psychiatric symptoms
• Management: Identify underlying medical condition

Delirium: Diagnostics and Differentials

• Diagnostics:
  • Complete blood count
  • Basic metabolic panel
  • Thyroid function
  • Blood and urine tox screens
  • Medication levels
  • Urinalysis and culture
  • Chest x-ray
  • MRI or CT?
• Differentials:
  • Infections
  • MI
  • Anemia
  • CVA/TIA
  • Dehydration
  • Vitamin deficiency
  • Anticholinergics
• Narcotics

Dementia

• 5 million people in US
• Alzheimer's is 6th leading cause of death in US
• Presentation: Memory loss, personality changes, language disturbances, difficulty with independent living
• Classification: Mild cognitive impairment (MCI), Alzheimer's, Vascular Dementia, Lewy Body

Dementia: Differentials

• Depression
• Hypothyroidism
• Medication
• Liver disease
• Vitamin deficiency

Dementia Prevention

• Multimodality risk factor reduction:
  • Physical exercise
  • Cognitive training
  • Vascular risk factor reduction
  • Control hypertension
• What has not been proven?
  • Omega-3 fatty acids
  • Mediterranean diet*
  • Alcohol
• Vitamin supplementation

Fibromyalgia

• Widespread musculoskeletal pain and fatigue:
  • Disorder of pain regulation, central sensitization
  • Tenderness in anatomic areas
• Management includes:
  • Exercise program
  • Pharm therapy: tricyclics, SNRI's, muscle relaxors, anticonvulsants
• History of chronic widespread pain for > 3 months
• Rule out other conditions
• Physical exam: neuro, sleep and mood
• Labs: CBC, ESR, CRP, TSH
• Confirm presence of tender points (? Need 11 of 18)
• Confirm diagnosis

Shingles

• Prevention!: Zostavax for adults > 60 years old who have a history of shingles
• Clinical diagnosis: Pain usually precedes rash along dermatome
• Management: Antiviral agents (famciclovir, acyclovir, valcyclovir); Acute pain relief (prednisone 60mg/day with taper over 3wk)
• Post herpetic neuralgia: Pain that is present 3 months after disease; Gabapentin is best agent

Paresthesia and Neuropathy

• Differentials: Arterial disease, B12 deficiency, Nerve entrapment, TIA, Shingles, Exclude non diabetic etiologies
• Management: Treat underlying cause, Tricyclics, anticonvulsants, and consider pain referral

Monofilament Testing

• Quantitative measurement of simple sensation
• A foot able to sense monofilament is protected
• Apply monofilament to skin with enough force for it to buckle
• Generally test 6 sites

Neuro Exam

• Components: Mental status, Cranial nerves, Motor/coordination, Sensory system, and Reflexes