Neuro

• Triptans
• Ergotamine-caffiene (Cafergot
• Isometheptene-dichloralphenazone-acetaminophen (Midrin)
• Butalbital-acetaminophen (Fioicet)
• NSAIDs (ASA, ibuprofen, naproxen, ketoprofen)

• Topirmate (Topamax)
• Propanolol
• Timolol
• Calcium channel blockers
• TCA - used as off label

• Triptans (Serotonin 5HT1 receptor agonists
• - Almotriptan (Axert)
• - Naratriptan (Amerge)
• - Sumatriptan (Imitrex)
• - Zolmitriptan (Zomig)
• Ergotamine -
• - dihydroergotamine (Migranal)

• Topiramate (Topomax)
• Propanolol (inderal LA)
• Timolol

• patients with coronary artery disease
• patients with poorly controlled hypertension
• Triptans are vasoconstrictors therefore can cause rise in BP and increase risk for Stroke

No, avoid concomitant use of triptans and ergotamine within a 24 hour period

• Triptans are Pregnancy Cat. C (benefits vs. risk must be weighed)
• Ergotamine are Pregnancy Cat. X (Avoid use in pregnancy)

A disorder of the 5th cranial nerve (trigeminal nerve) which produces severe pain in the lip, gum, cheek, and/or face

Compression of the 5th cranial nerve from unknown causes, tumors or vascular malformations

• severe pain in the lip, face, mouth, gum, cheek
• wincing
• pain may be in "bursts", with pain free period after bursts
• pain may be elicited by touch, changes in temperature or a light breeze on the cheek
• lacrimation
• flushing
• salivation
• May initially thought to be of dental origin. very unbearable

• Carbamazepine (anticonvulsants)
• 100mg PO BID

• Carbamazepine
• Pregnant Category D (not safe to use)
• Check carbamazepine levels
• Check LFT and CBC
• monitor for hyponatremia and decrease WBC or platelet counts, discontinue if evidence of bone marrow depression occurs

A sudden, brief loss of consciousness with a spontaneous recovery

• 1. Vasovagal - decrease cardiac output from peripheral vasodilation and bradycardia
• 2. Orthostatic hypotension - due to medications, hypovolemia, autonomic dysfunction
• 3. Situational Syncope - due to coughing, micturition or defecation
• 4. Cardiac - due to sudden decrease in cardiac output (aortic stenosis, arhythmias)
• 5. Carotid sinus syncope - manual pressure/stimulation of the carotid arteries
• 6. other causes - depression, ETOH, Drug abuse, psychogenic, subclavian steal syndrome, cardiomyopathy

• CMP
• ECG
• BP in both arms (difference of 20 mm Hg or more considered abnormal)
• Orthostatic Vital Signs
• Flexion/Extension of neck 10 times to stimulate vertebrobasilar insufficiency
• Flexion/extension of arms to stimulate sx of subclavian steal syndrome
• Neuro exam (CT, MRI, EEG if abnormal)
• Cardiac Exam
• Tilt testing

• normal findings are systolic pressure decrease of less than 10 mmHg
• increase in diastolic 2-5 mmHg
• increase in heart rate 5-20 beats
• (if HR does not increase, consider cardiac origin)

• Prevention - rise slowly from lying or sitting or standing
• Nonpharmacologic Mgmt -
• elevate patients leg if due to vasovagal or hypotension
• elastic support stockings to prevent orthostatic hypotension
• change position slowly
• increased sodium intake to help expand volume

• Vasovagal syncope may present in pregnant women from compression of the vena cava and aorta
• positioning the pregnant woman on her left side should relieve the compression and the symptoms

TIA - a sudden onset of neurological deficits which is caused by cerebral ischemia and lasts less than 24 hours

• atherosclerotic disease within the brain and/or carotid arteries
• microemboli from atrial fibrillation, cardiac valve disorders
• hypercoagulable states
• could be spontaneous
• cerebral artery vasospasm
• use of oral contraceptive

• Antiplatelet therapy (clopidogrel 75mg QD)
• ACE inhibitors
• Statins
• ASA or Ticlopidine (Ticlid 250mg BID)

• control their blood pressure, lipids and diabetes
• smoking cessations
• endarterectomy

• a transient alteration in behavior with or without loss of consciousness, sensory perception, motor function and/or autonomic function.
• seizures are due to excessive rate of neuronal discharges
• seizures which are recurrent are termed epilepsy

Status Epilepticus

• Partial - begins with motor symptoms characterized by recurrent contractions of muscles in one part of the body
• - Simple - consciousness not impaired, Jacksonian-type seizures begin in one part of the body and progress to contiguous body parts over seconds or minutes
• - Complex - consciousness impaired
• - Mixed - begin as simple or partial and evolve into generalized tonic/clonic; consciousness impaired
• Generalized - bilaterally symmetrical but without local onset
• - Absence (Petit Mal) - brief arrest of activity and loss of consciousness
• - Atypical absence
• - Myoclonic - muscle movements are repetitive
• - Tonic Clonic
• - Tonic, clonic or atonic seizures

Meningitis: inflammation of the brain and spinal cord caused by infection with bacteria, viruses and fungi. Occasionally parasites are responsible for meningitis

• Bacterial (strep pneumoniae - most common)
• Viral (enterovirus- most common)
• Fungal

Cryptococcal meningitis - most common meningitis seen in immunocomprised adults, especially those with AIDS

• recent URI
• neck pain/stiff neck
• headache, fever
• nausea and vomiting, especially in children
• decreased level of consciousness
• seizures
• meningococcemia rash
• nuchal rigidity
• postitive Kernig and Brudzinksi signs

• irritable
• sleeping more than usual
• cries when moved
• cries inconsolably

Kernig Sign - complete extension of leg causes neck pain and flexion

• Brudzinski sign - flexion of legs when neck is passively flexed.
• (passively flex patient neck, if infection is present, patient will bend their legs)

• Headache
• fever
• stiff neck
• photophobia
• rash
• seizures
• illness last 2-6 days

• worsening headaches over a period of days
• vomiting for days or weeks

• Lumbar puncture: CSF may be turbid, presence of WBC's and elevated protein levels
• CSF decrease glucose if bacterial
• CSF Gram stain and cultures: presence of infectious agent
• CBC: elevated WBC
• Blood cultures: positive 80% of time

• Abx specific for culture
• Empiric Treatment: Ampicillin PLUS 3rd generation cephalosporin; may need to add aminglycoside
• Dexamethasone: may decrease morbidity and mortality
• Antipyretics
• Analgesics for headache
• Antiemetics
• Antivirals not recommended.

a disease of the central nervous system which is slow and progressive. It is characterized by demyelination of nerve cells in the brain and spinal cord which produces a variety of neurologi deficits

• paraesthesias in extremities, weakness or clumsiness of a hand or leg
• stiffness or unusual fatigability of a limb
• transient blindness or pain in the eye
• nystagmus common
• speech may be slow with hesitancy at beginning of word
• mild emotional disturbances (apathy, lack of judgment, emotional lability) due to scattered CNS involvment
• difficulty with bladder control
• deep tendon reflexes increased; superficial reflexes dimished
• Charcot's triad (scanning speech, nystagmus, tremor) common in later stages of disease

• avoid factors which precipitate attacks (hot weather, fatigue)
• Goals of pharmacologic treatment are to slow disease progression, improve symptoms and decrease relapses.
• No current therapy is completely effective