neurology: HA, dizziness, Vertigo – Flashcards
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brain tumor
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onset of HA after age 50 is more likely what?
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non-contrast CT and lumbar puncture
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what procedures are most useful for evaluating HA?
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when suspect SAH or other intracranial lesion
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what is non-contrast CT indicated in HA pt?
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coritcal or dural venous sinus thrombosis, hypertensive encephalopathy, carotid/vertebral dissection
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what less common causes of HA are not detected on CT?
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suspicious of meningitis/encephalitis, SAH or rarely, to evaluate increased intracranial pressure
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when would you order a lumbar puncture in HA?
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blood and lots of RBCs in the CSF
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what would SAH show in lumbar puncture?
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ischemic changes
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when may you order an MRI of the brain?
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CT or x-ray for skull fractures
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what would you order to see osseous fractors or other osseous pathology?
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Battle's sign is indicative of a basilar skull fracture;
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brusing behind the ear is indicative of what type of skull fracture? what is this called?
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Raccoon eyes
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what other physical finding is indicative of basilar skull fracture?
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without aura
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what are more common migraine with or without aura?
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hemicranial and throbbing/pulsatile; can be bilateral; worse behind eye or ear; scalp can be sensitive; duration can be 4-24 hrs
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what are clinical characterisitcs of migraine? typical duration?
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pain with things that normally wouldn't cause pain for ex. touching scalp with cotton-tipped applicator
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what does cutaneious allodynia mean?
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pregnancy and middle-age
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when do migraines tend to decrease?
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bright light, noise, tension, alcohol, lack of sleep, change in weather
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what are common migraine triggers?
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triptans, ergotamine, NSAIDs,
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common treatment of migraines
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propranolo or amitrytline for prevention
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what drugs are used for prevention of migraines?
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scintallating lights, visual loss and scotomas, dysphasia, unilateral paresthesia, weakness, vertigo,
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what additional associated features are seen in migraine with aura or neurological migraine?
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The Root of Migraine Pain − Hypothesis: 1. Cortical spreading depression is triggered by neurons prone to hyperexcitability. 2. These neurons release substances that activate peripheral nerves, which send pain signals to the trigeminal nucleus in the brain stem. 3. The trigeminal nucleus conveys signals to the thalamus, which relays them to the sensory cortex, involved in the sensation of pain. http://www.scientificamerican.com/article.cfm?id=the-root-of-migraine-pain
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What is the hypothesis for the root of migraine pain?
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Auras have been found to stem from cortical spreading depression: a wave of excessive signaling across large areas of brain, followed by abnormal silence in the previously overactive areas. The spreading moves across the cortex at the rate of 2-3 millimeters a minute and has recently been captured by brain-imaging technology.
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What Causes Auras - Brainstorms:
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true
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suffers of migraines are more prone to "ice-cream HAs": true or false
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aspirin, acetominopaic, NSAIDS small amounts of codeine or oxycodone(opioids) with aspirin or acetominophen (only in those with no dependency/addiction history)
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what drugs are often used at the time of prodrome to prevent migraine?
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sumatriptan- serotonin-agonist, triptans and ergot alkaloids
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what are some drugs used to control severe migraine attacks?
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aura and precipitating neurological sxs could be indicative of a neurological pathology
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why is it necessary to wait to administer these drugs until the migraine HA begins in someone with aura?
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not in pts with vascular conditions, (angina, TIAs, strokes, ischemic bowel) not with uncontrolled HTN Not within 24hrs of another medication including another of the same kind
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warnings with sumatriptan- serotonin-agonist, triptans ?
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restrict the blood vessels by acting on the 5HT1 receptor subtypes (are selective for this receptor only)
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how do sumatriptan- serotonin-agonists work?
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Alpha-adrenergic agonist with strong serotonin receptor affinity and vasoconstrictive action.
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what is the mechanism of action of ergot alkaloids?
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caffeine
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what can enhance the effect of ergot alkaloids?
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no not advisable
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is repeated use of the ergot alkaloids okay?
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Effectiveness equal to that of the triptans (70-75% response rate if given early).
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how does efficacy compare b/t ergot alkaloids and triptans?
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Do not use ERGot with other CYP 3A4 inhibitors( protease inhibitors and macrolide antibiotics) b/c increase risk of vasospasm; not for chronic daily use
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what medications do you not want to combine with ergots?
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hallucinations, seizures and dry gangreen= ergotism
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what is a potential side-effect from too high a does of ergots?
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intense, orbiotemporal, unilateral, non-throbbing; pain may quickly worsen and peak in 5-10 mins; usually nocturnal after falling asleep;
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characteristics of a cluster HA
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males; typically adolescent
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what sex is more at risk for cluster HA?
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foods high in nitrites
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what types of foods may potentiate cluster HA?
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lacrimation, stuffed nostril, rhinnorrhea, injected conjunctiva, flushed face, ptosis
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what are some associated features with cluster HA?
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Tx: pure oxygen, sumatriptan, ergotamine before anticipated attack
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conventional tx of cluster HA?
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adult women
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who is more prone to tension HAs?
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Pressure (nonthrobbing), tightness,aching; provoked by fatigue and nervous strain; associated features: depression, worry, anxiety
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characteristics of tension HAs? provoking factors and associated features?
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antianxiety or antidepressent drugs
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conventional treatment of tension HAs?
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mm contraction in the head, neck and shoulders
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what is the most common cause of tension HAs?
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meningeal irritation: any age, both sexes; rapid evolution; single episode; no provoking factors; stiff neck on forward bending
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meningial irritation sxs indicative of meningitis or SAH?
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meningeal irritation
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positive kernig and brudinski signs are indicative of what?
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Brain tumor HA: both sexes, all ages; awakens pts; CSF doesn't circulate as well while supine and under force of gravity increased pressure; usually occurs once in a lifetime and no provoking factors but possibly position; seizures can be a presenting sign of a brain tumor- if you someone with a seizure for first time consider brain tumor in ddx; treatment: mannitol - decreases the intracranial pressure from the tumor being there
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characteristics of brain tumor
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Unilateral or bilateral; usually temporal; any sex; usually older than 50 yo; Throbbing; palpate the temporal arteries- enlarged contour and firm to palpation; severe at night; persists from weeks to mths and no provoking factors; will feel generally unwell; intermittant, then continuous; persists for weeks to mths; may feel unwell, low-grade fever, wt loss, possible jaw claudication and increased ESR
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Temporal arteritis HA?
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temporal arteritis
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what type of HA is more seen in people older than 50?
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temporal arteries are most common; others include opthalmic, facial, lingual, occipital
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what arteries are implicated in temporal arteritis?
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Giant Cell Arteritis
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temporal arteritis is a type of what class of Arteritis?
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thickening off the tunica medica; inflammatory cells invading into the tuniac medica and giant cells seen in areas of the internal elastic membrane
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what would be visible on biopsy in the inflammatory condition of giant cell arteritis?
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− polymyalgia rheumatica (PMR)
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with what other inflammatory condition can temporal arteritis be associated?
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Most common presenting symptoms of temporal arteritis (in descending order): 1) Headache, 2) PMR, 3) Fever, 4) Visual symptoms without loss of vision, 5) Weakness, malaise and fatigue
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what are the most common presenting sxs of temporal arteritis?
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temporal arteritis b/c can lead to blindness
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what is more dangerous, temporal arteritis or PMR?
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− Both most common in white persons of northern European ancestry
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what ancestry is most prone to temporal arteritis and PMR?
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temporal arteritis
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what can cause a rapid and immediate blindness?
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administer corticosteroids to prevent blindness that once lost is seldom recoverable
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what should you do if any suspicion of temporal arteritis?
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Food allergy/intolerance - many, but cow's milk (#1), wheat, chocolate, egg, orange and benzoic acid are most common in migraine. Dietary amines - foods such as chocolate, cheese, beer and wine contain histamine or other vasoactive compounds that have a vasodilatory effect.
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what foods are often implicated in migraines?
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Some enzymes: phenolsulfotransferase (breaks down serotonin and other vasoactive amines in circulation)levels are low often and flavonoids like in red wine are inhibitors of this enzyme that are already low leading to more serotonin being arround diamine oxidase, an enzyme that breaks down histamine in the lining of the small intestine, are also lower in individuals sensitive to dietary histamine. Diamine oxidase is thought to be a vitamin B6-dependent enzyme; compounds that antagonize vitamin B6 also inhibit diamine oxidase.
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what enzymes are often found to be low in migraine sufferers?
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there are contradictions
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what is the role of serotonin in migraines? excess or deficient?
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B6
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what nutrient may help in migraines?
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food coloring, some meds (dopamine, penacillamines, etc.), OCPs, alcohol and excessive protein
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what are some agents that antagonize B6 and may be implicated in migraines?
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histamine free diet, B6, Vitamin C, quercetin
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what are useful tx for histamine induced HA?
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hypoglycemia, excess sodium, aspartame, dairy in those with lactose intolerance
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what are other triggers for migraines?
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− 5-Hydroxytryptophan - increases serotonin and may increase endorphin;doses as low as 200 mg./day effective.
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what is the moa of 5HTP in migraine treatment?
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− Essential fatty acids - proposed mechanisms of action include reduced platelet serotonin release, modulation of prostaglandin synthesis and diminution of cerebral vasospasm. Conflicting studies.
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are EFAs helpful with migraine?
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Riboflavin: possible deficit of mitochondrial energy metabolism in migraine; riboflavin is a precursor of flavin mononucleotide and flavin adenine dinucleotide. oral dose of 400mg; maximal effect after 3 mths; this may already by in the multivitamin- look at doses
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what is moa of riboflavin in migraines?
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Co Q10 - 100 mg. TID is superior to placebo for prophylaxis.
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what nutrient was shown to be more effective than placebo for migraine profalaxis?
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maintains vascular tone and prevents neuronal excitability
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what is the moa of magnesium in migraines?
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b6, CoQ10, magnesium, EFAs, riboflavin, 5HTP
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what nutrients are helpful in migraine?
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Tanacetum parthenium (feverfew)
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what botanical was shown in human studies to help with migraine?
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Proposed MOA: inhibition of serotonin release, inhibition of prostaglandin synthesis and platelet aggregation, inhibition of PMN degranulation and phagocytosis of neutrophils and inhibition of mast cell release of histamine.
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MOA of feverfew in migraines?
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- Well-tolerated, but oral ulcerations and GI symptoms most common adverse event (mild and reversible) Avoid or use with caution in patients on anticoagulants. Avoid in patients with ragweed and chamomile allergies.
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what are some warnings to the use of feverfew?
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ginger
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what botanical has a proposed role in tx of migraines but no studies thus far?
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Petasides hybridus (common butterbur)
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what botanical is often given prophalaxically for migraines?
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Use only extracts with the pyrrolizidine alkaloids removed, as they are thought to be hepatotoxic and carcinogenic
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what is the caution with Petasides hybridus (common butterbur)?
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Leukotriene synthesis inhibited by the active principles petasine and isopetasine
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what is the moa of butterbur in migraine?
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for 4-6 mths
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how long to you have to give butterbur?
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melatonin; but can also induce HA in some estrodial and progesterone
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what hormones can be helpful potentially with migraines?
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1. increase at menarche 2. associated with menses in 60% 3. decrease with pregnancy 4. OCPs induce, improve, exacerbate 5. may improve or worsen with menopause
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what is the relationship of migraines to hormones?
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not really more helpful for tension HA
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is physical medicine helpful in migraines?
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Transcutaneous Electrical Stimulation (TENS)
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what therapy is effective in the treatment of both migraine and tension HA?
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Thermal Biofeedback and Relaxation
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what are the most widely used non-drug modalities for tx of migraines?
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Acupuncture - has been found to reduce frequency of episodes by approximately 50%; may involve the regulation of serotonin levels rather than endorphins
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what was the reduction rate in migraine treated with acupuncture?
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Yes Hydrotherapy: already taken pharmaceuticals and along with that do arm and foot baths along with ice massage to the head X 20 mins; decrease in intensity and frequency of the HAs
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Is hydrotherapy beneficial tx in migraines?
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have to figure out if it is: - Vertigo? − Disequilibrium? − Presyncope? − Nonspecified lightheadedness? distinguish b/t CNS vs. PNS causes
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when pt complains of dizziness what must doc do?
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no
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is dizziness a medical term?
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the feeling or sensation of movement. Described by patient as swaying, spinning, whirling, leaning or tilting. Central and peripheral pathways related to vestibular apparatus involved
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what is vertigo?
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presyncope
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pt describes impending loss of consciousness as if about to faint and sensation of lightheadedness or "graying out" how would you describe this in medical terms?
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disequilibrium
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- a sense of imbalance without a sensation of motion.
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Caused by various problems, such as decreased proprioception in the peripheral neuropathy of diabetic patients or decreased vision
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what are some causes of disequilibrium?
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Hyperventilation syndrome, anxiety and other psychiatric diagnoses.
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nonspecific lightheadedness is described, what are some common ddx?
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Romberg test: feet together and hands to side; 30sec eyes closed and then 30sec eyes open; stand close and have one hand infront and one behind in case they begin to fall
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describe the Romberg test
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no, not if feet are still planted
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is swaying a positive Romberg?
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what is dividing line between pathological swaying and non-pathological swaying: not clearly defined; if you have to catch the person that is positive - if they reach out; if have to take a step out to rebalance some say that is positive; if they are able to keep feet planted and not looking like they are going to fall down that is negative; so swaying in itself is not a positive
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what is a positive Romberg?
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disequilibrium (not vertigo)
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a sense of imbalance without a sense of motion is most likely what in medical terms?
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central although it is less common
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what is more concerning, central or peripheral vertigo?
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mild intensity of the vertigo, CN findings, vertical nystagmus, no nystagmus with fatigue, tinnitis is rare
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what are some sxs of central vertigo?
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central
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a finding of vertical nystagmus makes you suspicious for what type of vertigo?
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severe intensity of vertigo, tinnitus is common, no CN findings, no vertical nystagmus, horizontal nystagmus, nystagmus with fatigue
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sxs of peripheral vertigo?
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vertebrobasilar insufficiency, brainstem or cerebellar infarct, and cerebellopontine angle tumors
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what are some causes of central vertigo?
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Benign Paroxysmal Positional Vertigo (BPPV)
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what is the most common cause of peripheral vertigo?
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rapid onset with change in head position lasting 30-60 secs; acute onset of sxs after rolling over, gazing upward, bending forward; increased risk with age
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what are the characteristics of BPPV?
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− Cause in 80% is the accumulation of free-floating calcium carbonate particulate debris that forms a plug in the posterior semicircular canal
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what is most common cause of BPPV
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Dix-Hallpike
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what manuver would you do to distinguish BPPV from central cause of vertigo?
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cannalith/epli manuver repositioning
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what manuver can you do to help correct BPPV?
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Duration of vertigo and nausea/vomiting is hrs vs. seconds in BPPV and has a sensation of "fullness" in affecteed ear unlike BPPV with a flutuating sensorineural hearing loss and tinnitis
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what distinguishes menier's vs. BPPV?
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Peripheral nervous system disorder resulting from an increase in endolymph volume (endolymphatic hydrops) -distention results in vertigo and the increased pressure on hair cells results in hearing loss
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what is the pathophysiology of meniere's dz?
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bed rest
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what is the most effective treatment for meniere's dz during an acute attack?
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antihistamines
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what category of drugs are used for meniere's dz in more protracted cases?
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BPPV
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vestibular rehabilitation is strongly indicated tx for what condition?
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no because not due to vestibular problem
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would vestibular rehab help someone with a cause of dizziness due to low blood pressure or TIA?
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Helps the brain use certain visual and proprioceptive cues to maintain balance and gait.
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what is vestibular rehab?
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