Migraine: Assessment
- It is crucial for patients to describe their headache by detailing the duration, quality, and location of the pain.
- A medication profile is essential, including any medications previously used for headache control. If over-the-counter (OTC) medications are taken, the number used per month should be noted.
- A targeted physical examination is important for ruling out harmful secondary headache pathologies and for confirming information from the patient’s history.
- Typically, examination findings in primary headache disorders are within normal limits.
- Key aspects of the physical examination include:
- Funduscopic and pupillary assessment
- Auscultation of the carotid and vertebral arteries
- Mental status examination
- Palpation of the head, neck, and temporal arteries
- Evaluation for neck stiffness, focal weakness, sensory loss, and gait
- Vital signs
- Problematic Findings:
- Onset of headache after age 50
- Asymmetry in pupillary responses
- Decreased deep tendon reflexes
- Description of the headache as “the worst ever experienced”
- Personality changes
- Onset of a new or different headache
- Headaches that progressively worsen
- Papilledema
- Painful temporal arteries
- Diagnosis:
- If the diagnosis is unclear or if the history or physical findings raise concerns, diagnostic studies should be used to distinguish primary headache from secondary conditions.
- Blood tests are generally not indicated but may include a complete blood count (CBC) to rule out anemia or an infectious process, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to help exclude temporal arteritis, and thyroid function tests to check for thyroid dysfunction.
- In some cases, Lyme titer or rheumatoid factors may also be appropriate.
- Practice Guidelines:
- Follow three principles for diagnostic testing:
- Avoid testing if it will not change the patient’s management.
- Testing is not needed if the patient is not significantly more likely than the general public to have an abnormality.
- Testing may be warranted if a patient is overly concerned about a serious condition causing the headaches.
- Neuroimaging should be considered when serious signs or symptoms are present but is not indicated if the patient has had these headaches for years, has no focal neurologic signs, and if the headache improves without analgesics.
- Follow three principles for diagnostic testing:
- Treatment:
- Nonpharmacological Measures:
- Behavior modification, biofeedback, acupressure, management of headache triggers, and a wellness program.
- Preventive Therapy:
- Suitable for patients who struggle to manage their attacks, experience more than four headaches per month, or have attacks that are prolonged and refractory to medication.
- Preventive therapy is given daily to decrease headache intensity and frequency.
- Anticonvulsants such as divalproex sodium (Depakote), gabapentin (Neurontin), and topiramate (Topamax) may be used due to the connection between epilepsy and migraines.
- Calcium channel blockers like diltiazem (Cardizem) and amlodipine (Norvasc) may be beneficial for patients with cold hands, Raynaud phenomenon, or hypertension.
- Beta blockers such as propranolol (Inderal) or atenolol may be chosen for patients with palpitations due to mitral valve prolapse or panic disorders but should be avoided in asthmatic patients.
- For sleep issues or persistent shoulder pain, a tricyclic antidepressant like amitriptyline (Elavil) may be prescribed.
- Nonpharmacological Measures:
- Abortive Therapy:
- Used to manage the intensity and duration of pain during an attack and associated symptoms like nausea and vomiting.
- Severe migraines or cluster attacks that peak quickly may require parenteral or nasal therapy.
- Simple analgesics, such as acetaminophen and aspirin, can be first-line treatments for mild to moderate headaches.
- Caffeine combinations (Excedrin, Anacin) can enhance absorption and analgesia.
- When simple analgesics fail, combining them with a short-acting barbiturate like butalbital (Fioricet, Fiorinal, Esgic) may be effective.
- NSAIDs are useful for treating acute attacks; naproxen sodium (Anaprox DS, Aleve) has a longer half-life and better safety profile, and metoclopramide can improve their absorption.
- Ergot derivatives (ergotamine tartrate, dihydroergotamine) are effective for moderate to severe attacks that resist simple or combination analgesics.
- Triptans, developed around 20 years ago, have provided relief for many migraine and cluster headache patients within a short time.
Dementia: Assessment
- The physical examination should focus on neurological signs, blood pressure, carotid bruits, and the assessment of cognition, mood, function, and behavior.
- Screening Tools:
- The Katz Index of Independence in Activities of Daily Living or the “get up and go” test can evaluate function.
- Cognitive evaluation tools include the Folstein Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Mini-Cog.
- Other tools include the General Practitioner Assessment of Cognition (GPCOG) and the Memory Impairment Screen (MIS).
- These tools allow for year-to-year score comparisons, providing families with an objective description of disease progression. Monitoring changes in behavior, particularly anxiety, restlessness, aggression, delusions, hallucinations, and wandering, is also important.
- Diagnosis:
- Diagnostic evaluation should determine if a reversible condition is contributing to or causing cognitive decline.
- Essential tests include CBC, thyroid-stimulating hormone (TSH) concentration, vitamin B12 and folate levels, and a metabolic screen.
- Medications with measurable levels, such as digoxin, carbamazepine (Tegretol), theophylline, and divalproex sodium (Depakote), should be measured.
- Imaging studies, though useful in identifying mass lesions, vascular lesions, or infections, do not confirm a dementia diagnosis. A baseline brain imaging study, preferably non-contrast-enhanced computed tomography (CT), is recommended.
- Magnetic resonance imaging (MRI) may be preferred for better resolution, especially for patients with primary attentional or frontal temporal syndromes, or when subcortical pathology or stroke is suspected.
- Treatment:
- Management depends on the disease stage, with goals including treating correctable factors that impair cognition to improve daily functioning and delay disability.
- Supplementation with 2000 IU of vitamin E daily is reasonable.
- Two classes of drugs approved by the FDA for treating cognitive symptoms of dementia are cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists:
- Cholinesterase Inhibitors: Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne) can treat mild to moderate dementia in Alzheimer’s disease and vascular dementia. Choice depends on cost, delivery mode (patch, pill, or liquid), patient tolerance, and provider experience.
- NMDA Receptor Antagonist: Memantine (Namenda) can be used in combination with a cholinesterase inhibitor for moderate to severe dementia. Although these medications do not alter the disease course, they delay or slow the worsening of symptoms.
- Depressive symptoms are generally treated with selective serotonin reuptake inhibitors (SSRIs). Citalopram, in particular, can improve neuropsychiatric symptoms like agitation, at doses not exceeding 20 mg/day.
Delirium: Assessment
- A neurological examination is crucial to exclude trauma and focal signs indicative of central nervous system disturbances, such as traumatic brain injury, tumor, stroke, or seizure.
- Careful observation of the patient’s gait, level of consciousness, speech, appearance, and interactions with others is essential in establishing a diagnosis.
- Assessment Tools:
- The Delirium Rating Scale–Revised Version 15 and the Confusion Assessment Method (CAM) are specifically developed for delirium diagnosis.
- The CAM is the most widely used tool for evaluating delirium presence.
- The CAM-S (Delirium Severity Tool) allows clinicians to monitor changes in the patient’s symptoms over time.
- Diagnosis:
- Multiple medical conditions may contribute to delirium development, including substance intoxication or withdrawal.
- Diagnostic imaging, such as CT or MRI of the head, lumbar puncture, and laboratory studies including CBC, basic metabolic profile, thyroid function tests, drug and alcohol levels, and urine culture and sensitivity, should be performed.
- Treatment:
- Definitive care focuses on identifying and treating the underlying causes.
- Palliative care addresses symptoms such as agitation, restlessness, and hallucinations.
- Antipsychotic medications, such as haloperidol and droperidol, may help control agitation and psychosis.
- Newer antipsychotics like risperidone, quetiapine, and olanzapine can be used in small doses for short-term behavior management when safety is compromised.
- Benzodiazepines are useful for treating alcohol and sedative withdrawal.
- Due to increased risks of cerebrovascular events and death in dementia patients, “black box” warnings exist for risperidone, olanzapine, and aripiprazole. Risks and benefits must be discussed with patients and caregivers before using these drugs.
Post-Concussion Syndrome (PCS): Assessment
- The hallmark symptoms of concussion are confusion and amnesia, which can occur with or without preceding loss of consciousness. These symptoms may appear immediately after the injury or several minutes later. Importantly, the alteration in mental status characteristic of concussion can occur without loss of consciousness.
- Neurological Assessment:
- Patients should describe the incident in detail, including events leading up to and immediately following the injury.
- A symptom checklist, such as the Standardized Assessment of Concussion (SAC), can be helpful.
- A mental status examination should assess short-term memory, attention, and concentration.
- A neurological examination should include, at minimum, an assessment of cranial nerves III through VII (extraocular movements, pupillary reactivity, face sensation, and movement), limb strength, coordination, and gait.
- Diagnosis:
- A CT scan may be done based on current criteria. Diagnosis of PCS is usually made later on a clinical basis.
- A CT scan is not necessarily required for every patient. However, if the patient or family reports loss of consciousness and at least one of the following—headache, vomiting, age over 60, drug or alcohol intoxication, short-term memory deficits, trauma above the clavicle, post-trauma seizure, GCS score <15, or coagulopathy—a CT scan should be performed.
- Treatment:
- Patients may be discharged home if observation is available, along with proper patient evaluation instructions.
- Patients with mild TBI and a negative head CT can also be discharged home with appropriate instructions.
- Patients should be informed about post-traumatic or post-concussion syndrome, which, while not life-threatening, can disable a patient for weeks, months, or even years. Symptoms may include headache, tinnitus, memory loss, dizziness, giddiness, poor concentration, emotional lability, irritability, disturbed sleep, fatigue, and decreased libido. These symptoms typically last 2 to 6 weeks but can persist longer.
- Treatment includes rest, reassurance, and analgesics. It is also crucial that patients return to work as soon as possible, even if a reduced workload is necessary. However, athletes diagnosed with a concussion should not return to physical activity until the concussion has fully resolved.
Traumatic Brain Injury (TBI): Assessment
- Patients with head trauma can fluctuate between being awake and alert to being comatose and in respiratory distress.
- The patient’s circulation, airway, breathing, and cervical spine must be evaluated and stabilized.
- Initial observation should focus on the patient’s level of consciousness, oxygen saturation, vital signs, and Glasgow Coma Scale (GCS) score determination.
- Extremities should be examined for injuries and symmetric movement.
- A thorough neurological examination is necessary to assess brain injury, focal deficits, and patient stability. The exam should include mental status, memory, concentration, cranial nerves, motor strength and tone, deep tendon reflexes, and when possible, finger-to-nose test, deep tendon reflexes, gait, and Romberg test. The skull should also be examined for fractures, penetrating injuries, lacerations, or cerebrospinal fluid (CSF) drainage.
- Clinical Signs of Skull Fracture:
- Raccoon sign (bruising around the orbit)
- Battle sign
- Blood in the external auditory canal
- Normal neurological examination findings do not eliminate the possibility of brain injury. The severity of the injury and prognosis is indicated by the amount of retrograde or post-traumatic amnesia.
- Diagnosis:
- Pulse oximetry and continuous vital signs monitoring.
- Cervical spine x-ray examination is necessary because patients with head injuries may have associated cervical spine fractures.
- Non-enhanced head CT scan or x-ray study is indicated for patients with depressed or deteriorating levels of consciousness, skull fractures, neurological deficits, open head wounds, penetrating head injuries, amnesia, or high risk of intracranial injury.
- Older patients and those on anticoagulants or antiplatelet thera