Neurological Disorders: Diagnosis & Treatment

• Unit 9 discusses neurologic disorders within the Medical Education & Training Campus.
• The terminal learning objective is to determine what exams and questions are needed to accurately identify the correct diagnosis and formulate treatment plans for common neurological disorders based on a given patient scenario.
• The enabling learning objectives are to identify common symptoms and treatment for these neurological disorders, given a patient scenario.

Neurological Disorders Covered:

• Headache Overview
• Migraine Headache
• Tension Headache
• Cluster Headache
• Head Injury
• Subarachnoid Hemorrhage
• Seizure
• Guillain-Barré
• Mononeuropathies
• Bell’s Palsy (Facial Nerve Palsy)

Motor Homunculus

• The motor homunculus visually represents the amount and location of cortical tissue devoted to each motor function.
• The image is an inverted caricature revealing this information.

Sensory Areas

• The sensory areas of the brain are represented by a sensory homunculus.

Meninges

• Meninges are the three layers that protect the brain and spinal cord.
• Dura mater is the tough outer covering, containing blood vessels and nerves; it allows for venous drainage of the brain via dural sinuses.
• A subdural hematoma is bleeding underneath the dura mater.
• Arachnoid mater is a thin, web-like covering between the dura and pia mater, lacking vessels.
• Subarachnoid space is between the arachnoid and pia mater.
• A subarachnoid hematoma is bleeding in this space.

Spinal Cord

• The spinal cord is a column of nervous tissue continuous with the brain.
• It extends through the vertebral column.
• It terminates at the level of L1/L2.
• 31 segments give rise to a pair of spinal nerves.

Focused History:

• A focused history helps differentiate between different types of headaches with considerations of OPQRST, including family history, travel, medication use, prior headache history, head injuries, neck stiffness, and neurological changes to thinking, speech, vision, or personality.

Physical Exam:

• A physical exam is crucial to separate harmless headache causes from life-threatening conditions and focuses on HEENT, neck, and the nervous system.
• Perform visual acuity on all headache patients.

Migraine Headache

• Migraine headaches are an episodic primary headache disorder, that is clinical diagnosis
• Auras occur in about 25% of patients and usually happen just before the headache, but can occasionally start after the headache begins.
• Auras involve gradual onset, temporary, neurologic features that can be positive (adding sensory input) or negative (losing sensory input).
• Visual auras are most common with migraine headaches.
• Migraine headache are the most common cause of recurrent moderate to severe headache.
• The 1-year prevalence for men is 6%.
• The 1-year prevalence for women is 18%.
• The current theory suggests that it is a primary neuronal dysfunction that leads to changes to account for a migraine.
• Potential triggers include red wine, skipping meals, excessive stimuli (flashing lights, strong odors), weather changes, hormonal factors, certain foods which vary from person to person.
• Signs and Symptoms are, moderate to severe headache lasting 4 hours to days resolving with sleep.
• Pulsatile or throbbing pain, usually unilateral, but may be bilateral.
• Occasional nausea and vomiting.
• Ssensitivity to light (photophobia), sound (phonophobia), and smells (osmophobia).
• Possible visual auras are also a symptoms
• In a focused history, personal or family history of migraines and known familial and personal triggers are important to note.
• Physical exam requires full neurological evaluation.
• If a patient is experiencing an aura, visual field abnormalities, numbness, speech disturbances, ataxia may be noted.
• Differential diagnoses include tension headache for their tenderness, cluster headache for their recurring patterns, post-concussive headache, and meningitis.
• Medications need preceptor approval.
• Mild headaches can be treated with acetaminophen or NSAIDs.
• If ineffective, consider cafergot or a triptan, but you must contact the preceptor.
• ondansetron or promethazine can be used for nausea/vomiting
• Many providers will have a "headache cocktail’ that includes 1L of IV fluids, 15-50mg of ketorolac IM or IV, and an antiemetic like metoclopramide (10mg IV) for acute treatment
• Be mindful of extrapyramidal side effects of metoclopramide,and consider the addition of 25mg IV diphenhydramine.
• If a patient frequently take analgesics like aspirin, NSAIDs, and Tylenol consider medication overuse headaches and recommend cessation.
• Elimination or avoidance of triggers for migraine can be used,along with behavioral interventions for stress.
• Maintain a written headache journal to document attacks, timing, triggers and treatments.
• Schedule a follow up, if symptoms do not improve in 48 hours after onset.
• Consider EVAC and transfer if headache remains uncontrolled or there is indication of red flag
• In cases of blue directive, Contact Preceptor immediately.

Tension Headache

• Tension Headaches are the most prevalent Headache in the general population
• stress and mental tension are identified as the most common precipitants.
• In signs and symptoms, mild to moderate, generalized pain will be usually present without incapacitation, nausea, or photophobia of a migraine.
• The pain will be typically bilateral, described as band or vise-like, non-throbbing, not aggravated by routine physical activity.
• Review potential triggers such as Sleep disturbances, stress, TMJ dysfunction, neck pain, eye strain in focused history.
• A Physical Exam requires full neurological exam Muscle tenderness in the head, neck or shoulders will usually be present.
• Differential diagnosis includes Migraine headache due to presence of photophobia, phonophobia, nausea/vomiting, Post-concussive, follows head injury (refer), Meningitis due to fever, and neck pain.
• For tension headache, one can administer acetaminophen or NSAID immediately.
• A form of treatment is the Battlefield Acupuncture (BFA).
• One should identify and address potential triggers including: Sleep irregularities,Poor posture, Emotional stressors, TMJ dysfunction, Neck pain/eyestrain.
• One of the best treatments to consider is to: Reduce stress, regulate sleep cycle, eat regular meals, hydrate Always suggest patient to: Avoid triggers if possible, increase exercise, avoid tobacco and alcohol. This should improve condition at present state.
• Recommended follow up include if symptoms do not improve within 48 hours, consider getting or giving EVAC/transfer if headache remains uncontrolled or increases in severity.

Cluster Headache

• Cluster headache are headaches marked by excruciating unilateral periorbital/temporal pain with ipsilateral autonomic symptoms such as ptosis, lacrimation, rhinorrhea, nasal congestion
• Patients will usually experience ≥ 1 attack/day for 1-3 months followed by remission for months to years
• Patients typically will show agitated behavior such as pacing, yelling or thrashing.
• In signs and Symptoms, it is found that pain is always unilateral and occurs on the same side of the head in an orbitotemporal distribution that is often described as sharp of stabbing.
• Attacks can be recurrent. often lasting multiple clusters,
• Peak within minutes and usually subside spontaneously within 30 minutes to an hour
• The Head pain May wake patient from sleep
• Commonly affects men from 20-40 years old
• The Physical exam In terms of differential diagnogsis: Tension headache : pericular tenderness Band like", tight quality, dally headaches, worse with stress/latigue, most intense at neck, can overlap with migraine. Migraine Headache , Post Concussive or potentially Meningitis.
• Cluster Headache patients can adminster a subcutaneous or intranasal triptan
• Give 100% oxygen via non-rebreather mask at 12-15 L/min for 15-20 minutes.
• Attacks of cluster headaches Patient follow up can be for - Reduce stress, regulate sleep cycle, eat regular meals, hydrate
• Ask if not many known triggers.
• Daily preventative medication is indicated ifheadaches are frequent causing severe disability Follow up actions:
• Requires Work up: EVAC/transfer

Head injuries

• According to The American Association for the Surgery of Trauma, trauma is the leading cause of death for individuals up to the age of 45 years. A Field screening should be done for traumatic brain injury and concussion as they can cause long-standing complications.
• Worrisome sign and Symptoms : Common headache worrisome symptoms
• Nausea and vomiting
• Dizziness, blurred vision, weakness
• Aphasia (trouble finding/understanding words)
• Problems with balance and coordination Seizure issues
• A CT(scanning) is important in demonstrating intracranial Hemorrhage ,or displacement of midline structures.
• Always check Glascow Coma Scale
• Ask military Acute conussion evaluation 2 questions
• Evaluate for TBI - Can be access on health.mil
• Complete neurological exam - Level of conusciousness.
• Concussion or diffuse injury should be evaulvated
• Review: conciousness loss or if there were seizures or symptoms such as headaches before conciousssness

Subarachndoid Hemorrhage

• Always consider trauma
• Nontraumatic spontaneous hemorrhage frequently results from the rupture of an arterial saccular ("berry') aneurysm or from an arteriovenous malformation.
• Patient History are useful from the signs and symptoms:
• Rarely. some patients report a history of a sudden and severe headache that precedes a major SAH occurring days to weeks prior to aneurysm rupture.
• Always ask about thunderclap sensations
• Note irritability , confusion , coma , or death as hemorrhage

Seizures

• Uncommon - about 2/3 won't have another seizure after a first episode, but 2% of adults have a seizure in their life point
• Alchol or drug assocated seizures and withdrwal can be a cause for etiologies in seizure

Bells Palsy

• Check for History of tick exposure
• Differentiate bell with lyme , lesions, or tumors

Based on current slides, more information will be needed for:

• Subarachnoid Hemorrhage-
• Seizure
• Guillain-Barré
• Mononeuropathies
• Bell’s Palsy (Facial Nerve Palsy)