Neuro 4

Seizures,Headache, Itis etc Leah Kelly

Future
- Will use more agents to salvage cells and elim oxygen derived free radicals - So use scavengers and antioxidants glutamate antagonists - Nerve gro!th factors and do neural trans"lants - Kee"ing core #ody tem" under $% degrees for %4 hrs

Neuroscience Futures
- &s noted "reviously - less invasive, less time - 'a" out #rain areas and

use "ro#e
- &lso using laser and gamma

(nife for radiosurgery

- )* shunts are im"regnated

!ith anti#iotics to guard against infection valve "ressures can #e re"rogrammed

Im"lanta#le devices

- No! many "rogramma#le devices to deliver analgesics or antis"asmodics to +SF , mor"hine- or .aclofen , s"asticity- +an "lace a remote control over s(in to titrate dose - &lso loo(ing at im"lanting neurotro"hic gro!th factors - &lso doing visual / auditory im"lants in areas of #rain !here deaf or #lind

Seizures
- Initially thot victims sacred then "ossessed - No! as chronic disorder of recurrent electrical discharge

- Seizure is transient change in #ehavior r0t discharge of certain neurons - 1enetic, develo"mental, trauma, +NS infection, &)', tumor, stro(e, degenerative disease - 2%34 #illion cost in direct0indirect costs - 256 of "o"ulation !ith one seizure in lifetime

Seizures
- 26 of "o"ulation as a result "atients have emotional and social stressors and monetary #urden - Family mem#ers !ith fears still in closet

- No! as many in over 75 as *edi - &n ele"togenic focus activated #y tem"erature change, hy"oxia, decreased sodium, decrease sugar, light stimulus

8"ile"sy defined
- Syndrome of recurrent

un"rovo(ed seizures
- Seizures are sudden

e"isodes of neurological dysfunction caused #y a#normal #rain electrical activity

- %4 different (inds

&lso are "sychogenic seizures

- Hysteria, rarely cry or laugh

or thrust
- If you can sto" a lim# #y

holding not neuro

- 8yes are o"en in real

seizure if eyes shut !onder

- Seizures are stereoty"ical

Seizures
- $ grou"s

- Well controlled so 9ust !atch

not too much meds !atch side effects 456

- 'oderately controlled $56 - Not controlled no matter

!hat com#ination - So for some the issues are

grave

Ho! to chart a seizure

- *rodromal "hase oft a!ait it is coming headache, aura, tingly, irritated - &ura smell, light, sound, automatism hel"s localize

- 8"ile"tic +ry from the air movt related to an a#dominal s"asm - Ictal !hat ha""ens in seizure - *ost Ictal !hat ha""ens after the seizure

*atho"hysiology of seizures
- Some trigger causes #urst

of electrical stimulation
- :isru"ts normal nerve

conduction via a#normal de"olarization

- 'alfunction of

hy"ersensitive neurons in cortex and oft lim#ic system !here more hy"ersensitive neurons

*atho"hysiology of seizures
- 'alfunction of hy"ersensitive neurons in cortex and oft lim#ic system !here more hy"ersensitive neurons - Stimulus is "hysiologic odor, music, noise, startle, ;), lights

- So medical management !ill eliminate focus either meds, surgery

Seizure ;erms
- ;onic state of muscular contraction 0or rigidity voluntary muscles contracted< #ody stiff, rigid, !ould fall to floor cry cyanotic, 9a! fixed
- *u"ils are dilated, fixed and this lasts 2 minute

- +lonic s"asmic alternation of rigidity and relaxation "roducing rhythmic movements time !hen incontinent and #it tongue seem to fla" or move a#out

Seizure ;erms
- 1eneralized all over #ody - Focal 9ust in 2 localized area - Ictal the seizure so then "re and "ost ictal - =sed to tal( of aura, "sychomotor, convulse - No! (no! aura is a sim"le "artial seizure that "rogresses into a different ty"e

Seizures
- One seizure does not make a diagnosis of epilepsy

- 8"ile"sy is a recurrent seizure "resentation 256 of "o"ulation !ill seize once and never again exam"le in 8;>H !ithdra!al, tumors, liver and (idney "ro#lems, hy"oxia, hy"oglycemia, lo! sodium, lo! calcium, lo! magnesium - &lso sedative !ithdra!al - Severe slee" de"rivation

;he danger of seizures

- Increased need for &;* and

oxygen !hich is ra"idly de"leted

- ;hen get #uild u" of lactic

acid
- 'a9or hy"oxia !h leads to

<<<
- .rain gets de"leted - So in those areas ??33

:ifferent "resentations
- :e"ends on area of #rain motor, sensory, emotional, #ehavioral, "erce"tual - 'ay0not lose consciousness

- ;em"oral< "sychic, hallucinations, motionless, oral automatism, laughing s"ells, #elching, a"hasia, confusion, unilateral t!itching - Frontal (ic(0thrash, head0eye aversion, a"hasia, dizzy and staring, "osturing

:ifferent "resentations
- *arietal severe vertigo,

nausea, num#ness, tonic u""er lim#, tingling, loss of #ody a!areness

- >cci"ital #lurred vision,

seeing colors, eye #lin(ing, nystagmus, visual hallucination

;!o ty"es
- Sim"le *artial occur in @46 focal, localized neuron discharges in only 2 "art of #rain
- No loss of consciousness often #rief, "t a!are of environment - >ften seems li(e aura !eird ache, noise - 'otor have 9ac(sonian march - Somatosensory olfactory or auditory - *sychic dA9B vu or fear - Sim"le "artial

*artial or 1eneraliized
- +om"lex "artial
- L>+ is im"aired may #egin a sim"le and "rogress

- 1eneralized a#normal

discharge s"reads from 2 hemis"here to another involves entire cortex all #rain loss of consciousness

Sim"le *artial
- Sim"le no loss consciousness one area #rain

- 'otor, sensory, mixed, autonomic oft is motor !ith turning, "osture change and sensory !eirdities a!a(e, arm moves "iloerect - >ld Cac(sonian !as a focal motor seizure that marches thru a motor segment0dermatome

- *artial
- #ut motor, sensory or other changes that involve a larger area if "osterior frontal lo#e !ould seen motor involvt of o"" side??if anterior "arietal then in sensory cortex !ith no motor - *resentation

+om"lex *artial
- ;his is most common ty"e in adult

- &lt consciousness !ith some memory loss - Fum#le, "ic(, clinically manifest the site firing - &utomatisms, motor activity - Last 24 secs to $ minutes - ;em"oral lo#e is one su#set of this of get a somatosensory "henom

Secondarily generalized
#egin as sim"le or com"lex "artial seizures then generalized to #oth sides of the #rain - ;his is the aura !h then #ecomes something else

- :onDt !a(e u" so fast from this "ost ictal confusion - 8x"ect some focal motor deficits often on the left side "ost seizure - Last $5 secs to 2%5 secs

*rimarily generalized
- Im"aired consciousness no mal or aura - +ognitive confusion, &ffect strange #ehaviors - *sychosensory automatisms or "sychomotor che!, smac(, stereoty"ical !eirds

- 1eneralized means !ides"read involvement of #oth hemis"heres - &#sence, myoclonic , shoc(y 9er(s-, clonic, tonic clonic, atonic ,loss of tone-

*etit 'al or &#sence

- =sually seen in childhood

rarely last longer than 25 secs

- .ut also seen in adults - &#ru"t loss of

consciousness during !hich ongoing activity is sto""ed

- Cust s"ace out some!here

else

- 'ay thin( have learning

disa#ilities

;onic +lonic 1rand 'al

- >nly 256 are this ty"e - :uration usually a#out $ minutes in tonic are stiff0rigid then follo!ed #y clonic 9er(ing !hen are cyanotic and a"neic - +an occur daily, monthly or yearly - Lasts % 4 minutes and then are "ost ictal or unres"onsive - +ould slee" for several hours - &l!ays tired, de"ressed / confused after!ard

1rand 'al
- ;onic "hase
- shrill cry !ith rigidity, o"isthotonos, arms extended, "u"ils dilated and unreactive, decreased heart rate

- +lonic "hase
- #egins and ends suddenly - Euic( #ilateral 9er(ing movements that last only a minute or so

- *ost Ictal
- 'uscles flaccid, consciousness returns gradually, amnesia a#out seizure

'yoclonic / &tonic
- 'yoclonic Short single

a#ru"t muscle contractions

- &tonic loss of muscle tone

and dro" to floor so ris( for in9ury

*seudoseizures
- +linical "resentations of seizure li(e #ehavior not accom"anied #y a#normal 881s - >ft seen in "sych hx of !ith a#use, #ulimia - >ft triggered #y stressful situations usually only !hen others "resent oft "elvic thrusting, crying, disoriented - >ft hard to diagnose may occur !ith e"ile"sy - :o not #ecome incontinent

*seudo or *sychogenic seizures %

- not necessarily under voluntary control the secondary gain is not al!ays a""arent - ;hese "ts need anxiolytics and antide"ressants - High correlation to "hysical and sexual a#use - 'ay also have real seizures - &fter real seizures !ill have very high "rolactin levels if dra! #lood !ithin 24 minutes

Status 8"ile"ticus

- '8:I+&L 8'8F18N+G - +ere#ral meta# rate is $ 4Hnormal so get edema - No recovery to #aseline so continual discharge and #uild u" of acidosis - 1et a line ,NS- and air!ay stat did "t ta(e meds - 1et lytes, .=N, glucose, &8: drug levels, tox screen - Longer it lasts more use of glucose more danger of I+*

Status
- &ctivity lasts $5 minutes

could #e tonic clonic or even "artial, sensory, a#sence

- >ft ha""ens !ith sto""ing

of anticonvulsants
- +lear air!ay turn to side

"re"are to intu#ate

'eds for Status 8"ile"ticus

&tivan ,loraze"am,- occasionally )alium or "heno#ar# also may#e muscle #loc(ade
- &tivan #etter than valium coz less li"id solu#le and longer half life drug of choice 4 mg I)

- :ilantin is not sedating #ut can irritate and give this after the #enzo hy"otension,

Seizure meds

- +ere#yx fos"heytoin !hich

#ecomes :ilantin in 24 min #ut can give faster than :ilantin #ut no local irritat #eyond "erineal "aresthesias %5 mg0(g at 245 mg0min

Fe#rile +onvulsions
- Seizures that occur during

e"isodes of high fever often in early childhood

- See in 46 of all (ids

- If localized and last longer

than $5 minutes increased ris( of e"ile"sy

- +an "revent !ith

anti"yretics

8;>H !ithdra!al
- In $$6 of heavy drin(ers @

$5 hrs " sto" 8;>H

- Will continue 4Ihrs - :; $ 4 days J !ith

agitation, hallucinations / autonomic insta#lity

- Will give )*& #ut not

effective

8lderly
- Highest incidence of ne!

onset
- &fter stro(, head trauma,

dementia, 8;>H
- 'onothera"y at lo! doses - Ho! does med affect "t

Seizure +ausation
- From +NS infections, oral

a#cess, neurosurgery, ear infections

- .rain trauma contusions,

lacerations, hematoma

- >ften first sign of #rain

tumors cause irritation to cortex

- >ft occur in clusters from

drug induction, concurrent illness

So a seizure !or(u"
- &ll get same testing - HH !hat are "reci"itants fever, in9ury, slee" de"rivation, drugs, hy"erventilation - 1et +;, S(ull H ray, #lood glucose, lytes, calcium , - 881 to locate focus and identify ty"e

- >ften !ill need to go to an e"ile"sy monitoring un it

- ;ime synched digital video !ith a digital 881

Seizure +are
- Never leave alone and "rotect from in9ury - *rovide "rivacy - If out of #ed ease to floor and "rotect head - Loosen clothing roll to side to "revent as"iration - :onDt force air!ay - ;hen remain calm and reorient

+harting in Seizure

- >nset !hen, !hat doing, !hat accom"anied, automatisms, cry etc - :uration exact timings, !hen head turned, !hen "ost ictal, incontinent - 'otor activity "rogression, rigidity, 9er(ing, eyes and tongue - L>+ is arousa#leK +an tal(K :istracti#leK - *u"ilsK ;eeth clenchedK Fes"irationsK +ontinenceK - ;hen note changes for su#seLuent timeframe

Seizure 'eds &8:s

- &ll sta#ilize cell mem#rane #y altering trans"ort of Na, K, +a

- Feduce res"onse to incoming stimuli, reduce s"read, etc

- Need holistic a""roach to find the #est - ;hin( (inetics, side effects, serum levels, half lives - Worry a#out Status 8"ile"ticus in "regnancy and times of stress - &ll < dro!siness, sedation, allergy, 1I u"set - Ne! meds oft so story !ill change

.asic 'eds

- 1rand 'al :ilntina, ;egretol, :e"a(ene, *heno#ar# ,generics- *heno#ar# is dulling

- &#sence 8thosuximide, :e"a(ote, Klono"in - +om"lex0Sim"le *artialM ;egretol, :e"a(ote, :ilantin

- ;rile"tal, Ke""ra, Nonegran

- >ft large loading doses give til get side effects !atch serum levels - Loo( at #lood level correlated !ith clinical res"onse

&nticonvulsants
- What has least side effects

- Ne! variants !ith less effects :ilantin< ne! Fos"hentoin

- :ilantin !ith #ig gums, hairy, thic( s(in

- ;egretol no! extended relief HL - 'ysoline, :e"a(ene, :e"a(ote, Klono"in, Narontin, - 1a#a"entin, Lamictal 'ysoline :e"a(ote is good for all of the seizures #ut hair loss and !eight gain

Ne!er 'eds
- Lamictal augmenting, !orry Stevens Cohnson syndrome
- Sto" at first sign of rash

- 1a#a"entin Neurontin also for "ain, mood, fe! drug drug interaction - ;o"iramate ,;o"amax- mess !ith cognition, s"eech - ;rile"tal li(e ;egretol #ut not autoinduction so stay more clear, no "445 enzymes
- +an ta(e .iaxin

*otiga
- Seeing more no! than older

ones

- Potiga ,ezoga#ine-

<"otassium channel agent3 &lso !or(s on amma amino #utyric acid ,1&.&- is an inhi#itory neurotransmitter that may hel" su""ress seizure activity3
- *otiga is s"ecifically

indicated as ad9unctive treatment of "artial onset seizures in adults3

Ke""ra
- =sing a lot does have a lot

of side effects

- :e"ression is a #ig one - No need for levels

vim"at
- Vimpat is an orally availa#le

anticonvulsant3 It selectively enhances slo! inactivation of sodium and ,+F'* %-3

- Vimpat for "artial onset

seizures in "atients !ith e"ile"sy aged 2@O3

- )im"at oral and I)

Seizure meds

- 'ost have levels and need

to #e monitored closely
- :ilantin 25 %5 mg0ml - ;egretol 7 25 - :e"a(ote 45 255 - 'any hit at !#cs, chec( this

in your med #oo(

Interventions in seizures
- 'ay do surgery resect the area, cut the cor"us callosum or ma(e little cuts into cortex 46 !ill need a#lative surgery to destroy focus - .ut for N=FSIN1

- Remove objects, loosen clothes, keep flat, protect head, maintain airway - Provide privacy, chart it all - Make sure suction available, IV access, O

Seizure interventions
- Stay calm and chec( for

medi alert #racelet

- ;ime the seizure - &#sence time and re"ort - ;onic clonic turn on side

and cushion head remove glasses and o#9ects

:uring Seizure

- *lace on side to "revent

as"iration
- Head tilt chin lift maneuver

to facilitate air!ay "atency

- Nothing in mouth if arrive

after seizure #egins

;onic clonic
- Note "osition

*atient 8ducation
- *atients and family mem#ers - Feduce exacer#ating factors 8;>H, stress, consti"ation, diarrhea, slee" de"rivation, flashing lights

- Non com"liance !ith meds canDt drive unless seizure free for 2 year - ;each family !hat to do "rotections - 1o to 8F if "rolonged seizure activity maintain seizure calendar

>n admission
- &s( !hat seizure is li(e - :id you ta(e your meds

today ho! !ell are you controlled

- Let me (no! if feel aura, or

"rodromal

- Ho! !ould you "ad rails - &ir!ay at #edside - Feduce stimulation

8"ile"sy 8valuation
- Loo( at medical Hx3, freLuency / character of seizures - +ontinuous 881 monitoring, drug levels, scans and neuro"sych - Slee" on #lue sheets !ith continuous monitoring - >ft monitor tech to !atch 0family - 'ay !ithdra! &8:s antie"ile"tic drugs

- "lace s"henoid electrodes, +;, 'FI, S*8+;, W&:&

+ontinuous 881
- >ver %$ scal" electrodes held on !ith colloidin no crPme rinse - >cc im"lant su# s(in in s"henoid area - ;hen :+ or ta"er seizure meds get to hy"erventilate or exercise - Neuro"sych eval c hand eye memory, conc, attent, s"atial - So also !ill need #aseline cognitive function in case of loss "ost o"

Im"lications

- So you never leave then alone centers have cameras - :riving restrictions must #e 2 $ years seizure free - No s!imming alone, !atch #i(e, "o!er tools - Sho!er vs3 tu# - 'edic alert - &void alcohol, avoid coffee, !atch fatigue, consti"ation

Seizure Surgery
- % million &mericans are victims - 2022 !ill have a seizure sometime

- Surgery is o"tion for 25 %46 of "artial seizure ty"es es"3 tem"oral lo#e - Will locate seizure focus to see if can safely resect - =su3 done at com"rehensive e"ile"sy ctr3

)agal Nerve Stimulator

- *acema(er li(e "ulse generator !hich gives intermittent stimulation %4 hrs day0 on $5 secs off 4 min - .attery life of I 2% yrs - Seems to sto" the seizure via retrograde stimulation

- ;hey can activate it on demand !hen ex"erience and aura

Ketogenic diet
- Ketosis as formation of

(etones so this diet maintains this as in &t(ins to alter use of car#s as #ody fuel
- Seems to "revent seizures

in some (ids

+oming
- 8arly !arning devices that monitor #rain for change leading to seizures

- 8"ile"sy +ontrol System 'edtronic closed loo" systems !ith microchi"s to analyze li(e "acer li(e I+:s tiny eeg !hen see a#norm activity send message to ant nucleus in thalamus so this !ill send counte!aves via electrodes - In trials S&N;8 trial

Infections
- .acterial, viral, fungal, "arasitic - +lass #y !here occur or #y ty"e of organism - &ll itises are diffuse #rain issues so have generalized sym"toms

- Watch for I+* from increased #lood volume increased tissue #ul( - +an come on ra"idly or more slo!ly

+are in itises
- Isolate the "ro#lem and give anti#iotic or antiviral on time - &ssess / treat for I+* cool, hy"erventilate, oxygenate - *rotect from in9ury - Linen changes, fluid 0lyte status - Isolation - Watch com"lications #edrest !atch for "osturing

- :ar(, Luiet room , meningeal irritation

'eningitis
- Is inflammation of meninges !ith s!elling, change in neuro signs - Inflammation of arachnoid, "ia, dura - If hit #rain then also cord coz meninges - Ho! does organism get in #lood, trauma, mouth, nose colonizes #y dro"let or contact - .acterial or viral
- >nce form exudate inflames and changes arteries

'eningitis 'eningitis
- 2Q255,555 can #e ra"idly

fatal des"ite anti#iotics college students high ris(

- *ro"hylax close contacts

!ith rifam"in, ci"ro or ceftriaxone

- Ne! meningitis vaccine

tetravalent 'enactra

'eningitis
- medical emergency <can #e fatal es"3 if #acterial !ho""ing anti#iotics

- Loo( for signs of I+* < fluid lea(s from dilated vessels "ressure sho!s as headache, N/), res"iratory change, "u"il change, ocular movements - &lso see confusion, hallucinations, delirium - &ny ne! "legia, "aralysis, chec( muscle tone

'ore 'eningitis
- >ften a "etechial rash

Signs of meningeal irritation

- Nuchal rigidity - *hoto"ho#ia

- >"isthotonus

Kernig
- KernigRs sign "t is flat flex

thigh and get hamstring s"asm as leg cannot extend

.rudzins(i
- .rudzin(i sign hold chest do!n, elevate head do cruncher and thighs flex at hi"

&gain meningeal assess

- Loo( for meningeal signs
- *hoto"ho#ia

- >"isthotonos - *etechial rash - .rudzins(i - Kernig

.acterial 'eningitis
- 'ost commonly in childhood serious and lethal in 2st year - Hard to "ic( u" - &ny #acterium is causative #ut orgs are "articular to age - S/S vary !ith age, organism, duration - +ommunica#le til no cocci "resent in discharge

.acterial meningitis

- SH vague irrita#le, vomit,

lethargy, anorexia, fever

- headache, ; 252 25$,

confusion may seize

- need anti#iosis immediately - anti"yretic coz shiver

increases #rain meta#olism

'a(ing :x of #acterial 'eningitis

- *neumococcus - +SF "ressure is elevated / too cloudy
- +SF !ill have "rotein, increased W.+s, decreased sugar

- Need s"eed of treatment can die !ithin I 2% hrs - &nti#iotics< hi doses and give on time - Fifam"in or other that crosses #lood #rain #arrier

)iral 'eningitis
- &lso called ase"tic usu $

days "rodromal
- >ft is +oc(sac(ie or

oral0fecal s"read
- See headache, fever,

normal glucose in +SF

- No meds here although K

Symmetrel, Noviraxes

Intervention )iral 'eningitis or .acterial

- comfort for restless, irrita#ility, "hoto"ho#ia - "rivate room if #acterial !hat is an isolation room - limit visitors, little movt s"ace activities, sedate - &deLuate nutrition and fluids ma(e sure I) is on time - *o"sicleRs, !t, I/>, lytes - su""ortive care rest and slee"

SeLuelae meningitis
- if viral it is su""ortive care - seLuelae otitis,

hydroce"halus, deafness, retardation, seizures

)accine 'eningitis
- )accines r ; cell inde" stim

mature lym"hocytes
- Ne! vaccine is 'enactra

and still is 'enomune hits most of grou"s #ut no good in (ids under %

- 2 su# E dose 534 ml can

get "ain at site

8nce"halitis
- can #e viral, #acterial, fungal, "arasitic most viral - fulminating fe#rile disease rare #ut fatal - )iral as !estern eLuine, "olio, cytomegalo, +oc(sac(ie, her"es ence"halitis - her"es as "rimary, re infection or activation of latent infection
- her"es in aids "atient 456

- SH !orse if older or cold climate

- %46 of "o"ulation have HS) 2 as a cold sore attac(s "reci" #y stress, fever, sun, etc

8nce"halitis
- :N& from #ody fluids re"licates in cell nucleus - can #e localized or travel - ;a" #acterial is clouded viral is clear - initial +; !ill #e negative - 4 days !ill get mass effec

:H of 8nce"halitis

- HS) virus no! v is

"olymerase chain reaction test to +SF may see increase "rotein and increased +SF "ressure

;H of viral ence"halitis
- need to treat &S&* to "revent neuro damage - I) acyclovir for @ 24 days - early ;x !ill result in survival - can still get com"lications and residual damage

- headache, fatigue, tremors, seizures - ma9or nsg :x is altered cere#ral tissue "erfusion - may :ilantin load to !hy

Her"es ence"halitis
- HS) latent in trigeminal nerve - travels to middle / ant #rain in tem"oral and or#ital cortex - lyses neuron 0 alters mitochondria, (ills cell - get hemorrhage, cere#ral edema, I+* consciousness / "u"il change, delirium, coma < herniation

- signs de"end on area of #rain infected

Her"es ence"halitis
- initially loo( li(e flu< headache, malaise, fever / vomiting - memory im"airment / "ersonality change if get frontal lo#e - dementia from degeneration of nerve cells !ith cognitive slo!ing - tem"oral lo#e !ith terror, auditory, visual or olfactory hallucinations,ne! aggression - seizures, hemi"aresis, a"hasia, visual field defects

Headaches
- Gour does this !ell so read it text - ;ension
- :ull achy, #ilateral tight head and nec( - Start slo!ly, middle of day a stress headache - 'ild mod to severe muscle contraction *'S, middle age, remove source of stim - >;+ "re"s !or( !ell also heat, ice"ac(, sho!er, slee", exercise

Headaches
- +luster headache

- Fare, more common in men, starts

suddenly

- *ain #ehind eye, excruciating - Nose and eye on side get red, s!ollen - Last a#out 44 mins same time each day
for 4 I !ee(s

- Fun in family in a cluster "eriod r0t

smo(ing

- &lcohol can exacer#ated - 8yes #ulge even !ith "tonsis - &utonomic features - ;reat !ith meds and a shot or inhalation
med - Infovin, Lithium, .eta#loc(ers

Headache as Inflammation
- see

'igraine
- Lots of ne! stuff here and ne! meds #oo( is out of date changes in serotonin !hen hi vessels shrin( !hen lo!, vessels s!ell and cause "ain - 'igraine oft under treated and underdiagnosed hard to ma(e :x - 'igraineurs - +hronic disease @56 have genetic association usu #egins in childhood or adolescence "ea(s in mid 45Ds - 'a9or im"act on !or(ers

'igraine

- syndrome of "rolonged "ainful headache and disa#ling autonomic sym"toms !ith nausea / vomiting - ;hro##ing, dull "ain on one or #oth sides - ;ummy ache or vomit
- &nnoyed #y noise, light, smells, - ;ired, confused, stuffy nose - Stiff nec( - :izzy - +lassic !ith aura, of 24 or so minutes, common do not

'igraine 'nemonic Sultans

- Severe - =nilateral - ;hro##ing - &ctivity !orsens - With Nausea - With light sensitivity - &ura< reversi#le, gradual,

'igraine
- "ain

Sym"toms of 'igraine

- *rolonged "ainful headache !ith eLually disa#ling autonomic Sx3 li(e N/) - With or !ithout aura or "rodrome - Without aura most common unilateral "ulsatile , "hoto"ho#ia, hy"er react to sound and smell - *rodrome os de"ression, eu"horia, irrita#le, restless, still

'igraine !ith aura

- )isual distur#ance !ith

scintillating lights or scotoma, hemi"aresis, hemisensory issues, a"hasia

- ;riggers are caffeine, stress,

lac( of slee", exertion, menses, 8;>H

'igraine
- tt"Q00!!!3youtu#e3com0!atc

hKvMyNrSCoeI4!g
- htt"Q00!!!3youtu#e3com0!at

chKvMl1C%HFC.H'I

;riggers of migraine

- &ged, cured meat hot dogs, lunch

meat

- &ged cheese - Fed !ine - &s"artame - &vocado - .eans - +affeine, chocolate - Sour cream, #uttermil( - Figs, 'S1, nuts, "eanut #utter - >nions, "a"aya - *assion fruit, "ea"ods - >lives, "ic(les - Faisins, red "lums - Sauer(raut - Sno! "eas

- Soy sauce

*athogenesis of 'igraine
- $ different theories "ro# a #it of all $ - )ascular< !ith reactive "ainful vasodilation, "erivascular inflammation - Neurogenic inflammation neuro"e"tide released to "erivascular inflammation - =nsta#le serotogenic neurotransmission serotonin is an inhi#itor and stim rece"tors "ro#a#ly leads to release of inflammatory mediators

8ffect of drug over usage

- Narro! !indo! 9ust at headache onset that migraine meds !or( - If miss this then !ill #e in futile catch u" mode - ;hen get refractory headache !h is chronic re#ound, or daily headache - &lso get tolerant to the sym"toms and the meds

Non *harmaceuticals
- Fi#oflavin ,455mg-,

chelated magnesium, Feverfe!

- Slee" and meals,

#iofeed#ac(, massage, acu"uncture, hy"nosis

'gmt drugs
- *ro"hylactic agents M antagonists of 4H; serotonin sta#ilize ions, inflammation - &#ortive agentsMagonists of the rece"tors
- Need early treatment / high enough dose - So Narcotic analgesics, NS&I:3 8rgot get re#ound must ta(e immediately and can coz nausea - :H8 dihydroergotamine < venoconstrictor T a long half life / no ris( of addiction or re#ound

- Will soon #e availa#le as a nasal s"ray

&#ortive ;hera"y in 8F
- I) ;oradol - I) ;horazine - I) :H8 ergot - S+ Imitrex - *henergan or +om"azine

;ri"tans / .eta .loc(ers

- No! 4 of them 4H;2.02: agonists

- )asoconstriction su""ress nause, confusion - Sumatri"tan, Imitrex-,Nolmitri"ta n, ,Nomig-Fizatri"tan , 'axalt-, Naratri"tan ,&merge-, &lmotri"tan ,&xert-, Fravatri"tan ,Frova- Fel"ax and &xert are long acting

- . #loc(ade
- Inderal LS

- &nticonvulsants ;o"amax may#e )*&, Neurontin

;ri"tans
- Li(e Imitrex this is a 4 H;2 agonist that is nonsedating oral, su#L, or in9ect

- :oesnDt modify cere#ral flo! - Has intrinsic antiemetic effect - Wor(s in minutes - @56 recover in 2 hr I56 in % hrs - :onDt have to ta(e early and give after aura !hen "ain #egins - Wor(s on "ain, N/), "hoto"ho#ia - = stay alert, no re#ound headache

;ri"tans
- +anDt use these in +&:,

H;N or those on SSFI coz !ill get serotonin syndrome

- Some are ta#s, others

dissolve
- Naratri"tan has a long half

life and fe! side effects

>ther meds
- +odeine0fiorinal are out of date and dangerous
- Narcotics are only moderately effective and sedating - &ctually increase nausea

- .eta .loc(ers
- Not good for "ro"hylaxis

- :e"a(ote
- No! a""roved for "ro"hylaxis coz is a 1&.& agonist reduces do"amine, ;o"amax

;etanus
- life threatening #ut com"letely "reventa#le usu "uncture !ounds and lacerations - usu in elderly in non immunized - incu#ates %O !ee(s - clostridium tetanii gram "ositive, s"ore forming anaero#e soil0dust 0!ater "roduces neurotoxin that causes s(eletal muscle hy"ertonicity

;etanus %

- enters thru !oundM s"ores can lie dormant til activate to "roduce a tetanolysin !h affects the autonomic NS - !ith cardiac dysrythmias, unsta#le .* and "ro#lems of "ulse and fever - tetanos"as"asmin #loc(s neurotransmitter &+H / disinhi#iting the s"inal cord reflex arcs so that you get uncontrolled tetanos"asms

;etanus %
- o"isthotonus from s"asm of #ac( and nec(

- canRt ma(e enuf anti toxin so must have immunization loc(9a!, hy"er rigidity, hy"erreflexia, dys"hagia, 1I dysfunction, cardiac dysrythmias

;etanus $
- air!ays < laryngos"asm com"romise in res" failure, thus lungs at issue - may need intu#ation / #enzodiaze"ines to give neuromuscular #loc(ade - also give ;acrium neuromusc #loc(ing agent and (ee" "aralyzed

- same idea of dar(, non simulating environment, analgesia and anxiolytics

;etanus $
- since affects sym"athetic NS !ill get unsta#le rate, rhythm / fever - !atch immo#ility, de#ride !ound - tetanus immune glo#ulin $55 units I' at intervals to neutralize any toxin left in #ody - idea is #ooster E 25 years for life

.rain a#cess

- residue or infection,

meningitis, ence"halitis