Monday, April 18, 2016

Seizures, Headaches, and Migraines

Seizures, Headaches, and Migraines
Updated: 04/18/2016

Seizures, headaches and migraines are some of the most commonly occurring questions on the PACKRAT, EORE, PANCE, and PANRE. Since they also occur commonly in practice, you’ll definitely want to cover these topics thoroughly. Knowing the subtleties between each and the questions to ask is important not only for your understanding, but so you can treat the patient accordingly with the most appropriate therapy.

While Neurology only makes up 6% of the PANCE, knowing topics like this well can mean the difference between passing and not passing. As I have stated before, one of the best ways to prepare for your exams is through quality question banks and study guides. TrueLearn has introduced an incredible opportunity to work with the PA-student and PA community to help us excel in our didactic education and clinicals, and on our boards. See below for our second post discussing Seizure Disorders and Headaches and Migraines.

Remember from last month that TrueLearn’s SmartBanks include specialized medical content crafted to mirror End of Rotation Exams (EORs), the PACKRAT, the PANCE and the PANRE. This means that the best test writers have come together to write questions that not only get your juices flowing, but challenge you to think critically - the most important characteristic of great PAs.

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Disclosure: I am not an employee of TrueLearn.
Seizure Disorders - sudden abnormal discharge of electrical activity
  • Epilepsy - syndrome of recurrent, idiopathic seizures
  • In seizures, duration of unconsciousness tends to be longer than in syncope (momentary)
  • In syncope, bladder control is retained, but lost in seizures
  • Causes: four Ms and four Is
    • Metabolic and electrolyte disturbances - hyponatremia, water intoxication, hypoglycemia and hyperglycemia, hypocalcemia, uremia, thyroid storm, hyperthermia
    • Mass lesions - brain mets, primary brain tumors, hemorrhage
    • Missing drugs
      • Non-compliance with anticonvulsants (most common reason)
      • Acute withdrawal from alcohol, benzos, barbituates
    • Miscellaneous
      • Pseudoseizures - psychiatric in origin
      • Eclampsia
      • Hypertensive encephalopathy
    • Intoxication - cocaine, lithium
    • Infection - septic shock, bacterial or viral meningitis, brain abscess
    • Ischemia - stroke, TIA (common in elderly)
    • Increased ICP due to trauma
  • Diagnosis
    • If known epileptic → check anticonvulsant levels
    • If first seizure
      • CBC, CMP (LFTs), blood glucose, renal function tests, serum calcium, urinalysis
      • EEG: most helpful diagnostic test, abnormal pattern is not diagnostic alone
      • CT scan of head: r/o structural lesions
      • MRI of brain with and without gadolinium: more sensitive than CT for structural changes
      • LP/blood cultures if febrile
      • Pregnancy test - before initiating anticonvulsants!!!
  • Treatment
    • ABCs first, secure airway and roll patient to side
    • Known epileptics
      • Check for non-compliance of anticonvulsant, check levels
      • If persistent with monotherapy, increase dose of first anticonvulsant until signs of toxicity appear → add second drug if seizures uncontrolled
      • If controlled → continue regimen x 2 years, then taper
    • First seizure
      • EEG with neurology consult
      • Anticonvulsant therapy
      • If normal EEG, recurrence low (15%) compared to abnormal EEG (41%)
      • Do not treat patients with single seizure - start antiepileptics if EEG abnormal, MRI abnormal or status epilepticus

Partial Seizures (70%), begins in one part of brain (temporal) and produces symptoms referable to region of cortex involved
  • May evolve into generalized seizures (called Secondary Generalized)
Consciousness intact
Seizure - localized, but may evolve
May involve transient unilateral clonic-tonic movement
EKG: localized disturbances
1. Phenytoin and carbamazepine
2. Alternatives - phenobarbital, depakote, primidone
Consciousness impaired
Postictal confusion
Automatisms (last 1-3 mins): purposeless, involuntary, repetitive movements (lip smacking, chewing)
Olfactory and gustatory hallucinations

1. Phenytoin and carbamazepine
2. Alternatives - phenobarbital, depakote, primidone

Generalized Seizure - loss of consciousness; disruption of electrical activity in entire brain
Tonic Clonic (Grand Mal)
Bilaterally symmetric & without focal onset
-Begins with sudden LOC, “falls to ground”
-Tonic phase: rigid, trunk and limb extension occurs, may become apneic
-Clonic phase: muscular jerking of limbs and body for 30 seconds
-Patient becomes flaccid & comatose before regaining consciousness
-Postictal confusion & drowsiness, lasts hours (mean: 10-30 mins)
Other features: tongue biting, vomiting, apnea, incontinence (feces, urine)
EKG: generalized high amplitude, rapid spiking
1. Phenytoin and carbamazepine
2. Alternatives - phenobarbital, depakote, primidone
Absence (Petit Mal)
-School aged children, resolves as you age
-Disengage from current activity and “stare into space” - then returns to activity
-Patient looks “absent minded” during episodes which are confused with “daydreaming”
-Brief (lasts few seconds), but quite frequent (100 times/day)
-Impairment of consciousness but no loss of postural tone or continence, and no postictal confusion
-Minor clonic activity (eye blinks, head nodding, 45%)
EKG: spike and wave activity
1. Ethosuximide
2. Depakote (valproic acid)
Secondary Generalized
Partial seizures that evolve into generalized seizures

Status Epilepticus - prolonged, sustained unconsciousness with persistent convulsive activity in seizing patient lasting longer than 30 minutes OR 2+ sequential seizures without full recovery of consciousness between seizures.
  • Medical emergency - mortality is 20%
  • May be caused by poor compliance with meds, alcohol withdrawal, intracranial infection, neoplasm, metabolic disorder, drug overdose
  • Management: establishing an airway, giving IV diazepam, IV phenytoin, and 50 mg dextrose
    • Resistant cases: IV phenobarbital

Migraines, Tension Headaches, Cluster Headaches
  • Aggravators of migraines: menstruation, stress, anxiety, lack of sleep, drugs/foods (chocolate, cheese, alcohol, smoking, OCPs), weather changes
  • Visual aura in migraine: bilateral homonymous scotoma; bright, flashing, crescent shaped images with jagged edges appear on a page, obscuring the underlying print, lasts 10-20 minutes
Migraines with aura (15%)
“classic migraine”
Autosomal dominant with incomplete penetrance
Serotonin depletion
Women > Men
(+) family history
1. Visual aura: flashing lights, scotomata, visual distortions

1. Acute migraines
--NSAIDs, Tylenol, DHE or a Triptan
--DHE (5-HT1) agonist: highly effective
--Sumatriptan (5-HT1 agonist): rapid and effective, 1-2 times/week

2. Prophylaxis
--Avoid precipitants
--TCAs and Propranolol (most effective)
--Verapamil, Depakote, Methysergide
Migraines without aura (85%) “common migraine”

1. Prodromal phase (30%)
-Excitation or inhibition of CNS: elation, excitability, increased appetite or craving for foods, depression, irritability, sleepiness, fatigue
2. Severe, throbbing, unilateral headache
-Lasts 4-72 hours
-Generalized over entire head, lasting for days
-Aggravated by coughing, physical activity, or bending down
-”throbbing, dull, achy”
3. Nausea, vomiting (90%), photophobia, increased sense of smell

Menstrual migraines
Occurs 2 days before menstruation and last day of menses, estrogen withdrawal

Estrogen supplementation
Status migrainosus

Lasts >72 hours and does not resolve spontaneously

Tension Headaches
Unknown cause
Worsens throughout the day
Precipitants: anxiety, depression, stress
1. Pain - steady, aching, “vise-like” and encircles entire head (tight band-like), generalized but most intense around neck or back of head
2. Tightness in posterior neck muscles

Find causal factors, evaluate for depression or anxiety
Reduce stress
Mild/Mod: NSAIDs, Tylenol, ASA
Severe: migraine meds appropriate
Cluster Headaches
Middle-aged men

1. Episodic (90%) - last 2-3 months, with remissions of months to years
2. Chronic cluster headaches (10%) - last 1-2 years, headaches do not remit
1. Excruciating periorbital pain (“behind the eye”) - almost always unilateral
2. Deep, burning, searing, or stabbing pain
3. Ipsilateral lacrimation, facial flushing, nasal stuffiness/discharge
4. Begins few hours after patient goes to bed, lasts 30-90 minutes, awakens from sleep (daytime cluster headaches occur)
5. Occur nightly 2-3 months, then disappear
6. Worse with alcohol and sleep

1. Acute attacks
a. Sumatriptan (Imitrex)
b. O2 inhalation

2. Prophylaxis
  1. Most responsive to Verapamil
  2. Ergotamine, methysergide, lithium, steroids
  3. Resolution of headaches within 1 week

TrueLearn’s Neurology Sample Questions
Question 1: A 45-year-old male is brought to the emergency department by ambulance after having a witnessed seizure. He is currently alert, but not oriented to himself or his surroundings. After his initial assessment, he begins to seize violently. He is given 5mg of midazolam intravenously yet continues to seize. An additional 10 mg of midazolam is administered intravenously, yet the patient continues to shake violently. Vitals reveal a blood pressure of 190/100 mmHg, a heart rate of 130/min, a respiratory rate of 44/min, and a room air oxygen saturation of 88%. The most appropriate course of action is

  1. call for a stat neurology consultation
  2. continue using benzodiazepines intravenously until his seizure stops
  3. prepare to intubate the patient using propofol as the induction agent
  4. provide bag-valve-mask ventilation until his seizure stops
  5. roll him on his side to prevent aspiration

This is an example of status epilepticus (SE). Current definition of SE is more than 30 minutes of continuous seizure activity, or two or more sequential seizures without full recovery of consciousness between seizures. This patient had two sequential seizures without clearing from his post-ictal state, followed by continued seizure activity following high dose benzodiazepines. Benzodiazepines are the first line treatment for seizures. When this fails, one must resort to the ABC’s of patient care. This patient has no ability to control his airway if he continues to seize. Immediate recognition of this is critical. Intubation is indicated for airway protection. Propofol is the induction agent of choice because it is a powerful anti-epileptic drug (AED) as well as a commonly used induction agent for rapid-sequence-intubation.

Answer A: Call for a stat neurology consultation is incorrect. The patient needs immediate stabilization of his airway. Remember the ABCs. Airway, breathing, and circulation come before all else. Once the patient is stabilized (via intubation and sedation), you have a high priority to call neurology for continuation of care.
Answer B: Benzodiazepines are the first line treatment for seizures, and are effective in the majority of cases. This patient has failed high dose treatment with a benzodiazepine, and continues to seize. Therefore a different medication should be used. Frequently used alternatives are phenobarbital and propofol, which are both powerful medications used to suppress seizure activity. When using either of these medications, the respiratory drive will be decreased and therefore intubation is usually required.
Answer D: Bag-valve-mask (BVM) ventilation will not help this patient. In fact, forcing breaths into this patient will likely only induce aspiration and possibly produce aspiration pneumonitis. His oxygen saturation should be maintained by simple nasal cannula or non-rebreather mask that will not force air into the trachea or esophagus.
Answer E: This patient requires immediate protection of his airway. Rolling him onto his side may transiently help prevent aspiration, but has done nothing to treat the underlying pathology. A patient in SE can inhale saliva, blood and gastric contents regardless of the way they are positioned, thus making this answer incorrect.

Bottom Line: Status epilepticus is defined as more than 30 minutes of continuous seizure activity or two or more sequential seizures without full recovery of consciousness between seizures. Management includes high dose benzodiazepines and management of the ABCs.

TrueLearn Insight : Remember the ABCs in all patients who are critically ill. You will have distractions and other management possibilities. When in doubt, be aggressive about protecting the patient by ensuring they have adequate airway protection/patency, spontaneous breathing, and adequate circulation. Do not move on until these are stable.
For more information, see:
Arif H, Hirsch L. Treatment of Status Epilepticus. Semin Neurol 2008;28:342–354.
Ayala C, Spellberg B. Boards and Wards. 4th Ed. Philadelphia, PA; Lippincott Williams & Wilkins; 2010: 378-379. "Status epilepticus" on Medscape.

Question 2: A 46-year-old man with a history of hypertension visits your office and complains of frequent headaches over the past year. The pain generally begins behind the right eye and expands throughout his skull as time progresses. The pain is constant, severe, and persists for hours or days. The headaches are not preceded by visual perceptions of flashing lights or zigzag lines. He does not experience muscle weakness, difficulty speaking, or dizziness. Occasionally the patient experiences nausea during the headaches, but he does not vomit. Caffeine sometimes helps diminish the pain. He is most comfortable lying in a dark, quiet room until the pain subsides. On physical examination, his heart rate is 90 beats/minute, respiration rate is 12 breaths/minute, and blood pressure is 182/96 mm Hg. His neurological exam is benign and non-focal. Other than a chronic cough that has improved since he stopped taking his blood pressure medication, the patient has no other medical problems or symptoms. Which of the following would be the best prophylactic treatment option?

  1. Captopril
  2. Losartan
  3. Propranolol
  4. Sumatriptan
  5. Venlafaxine

The patient’s headaches are consistent with common migraine, also known as migraine without aura. The absence of preceding visual disturbances (zigzag lines, flashing lights) or motor weakness excludes the diagnosis of migraine with aura. The absence of dizziness or difficulty speaking generally excludes basilar migraine. Beta-blockers such as propranolol are often used for migraine prophylaxis. Propranolol is also a good choice considering this patient has a history of hypertension and demonstrates elevated blood pressure on exam. He has been non-compliant with his previous antihypertensive, likely an ACE inhibitor (angiotensin converting enzyme inhibitor), which elevates bradykinin levels and can lead to chronic cough.

Answer A: Captopril (ACE inhibitor) is likely similar to his previous hypertension medication and would cause his cough to return; additionally, it is not effective for migraine.
Answer B: Losartan (angiotensin receptor blocker) is effective against hypertension but would not be useful for migraine.
Answer D: Sumatriptan is very effective for migraine headaches, but as this patient also suffers from hypertension, propranolol is a better choice. It also would be a good abortive therapy but is not effective as prophylaxis.
Answer E: Venlafaxine has gained recognition for its efficacy with migraines, but it generally is not used as a first-line therapy unless the patient also suffers from a depressive disorder.

Bottom Line: In patients with migraine and uncontrolled hypertension, either a beta-blocker (propranolol) or calcium channel blocker (verapamil) would be the most logical medication to prescribe as each demonstrates efficacy in both conditions.

TrueLearn Insight :
1) Imaging is generally unnecessary in patients with headache unless there is focal neurological change, suspicion of acute intracranial process, or suspicion of basilar migraine.
2) Although caffeine can help alleviate symptoms for some migraine sufferers, its use can also contribute to migraine headaches and hypertension.
For more information, see "Preventive treatment of migraine in adults"

Question 3: A 45-year-old man is pacing in the emergency department waiting room and complaining of headache. He says that this is the fifth headache he has had this week, and he rushed to be seen because the last four went away before he could get to the doctor. The pain is 8/10 in severity and it feels “like being stabbed in the eye,” always on the right. He says he had pain like this several years ago when he had a series of severe headaches over the period of about a month, but they had gone away. He has tried taking aspirin, ibuprofen, and acetaminophen but does not feel they have helped. His past history is significant for an inguinal hernia that was repaired seven years ago. His mother suffers from acute angle-closure glaucoma and migraine and his father died of a myocardial infarction at the age of 47. He does not smoke and drinks alcohol occasionally. On examination his right eye is injected and there is right-sided ptosis. Fundoscopic examination is normal. Which of the following is the next best step in management?

  1. Head CT
  2. High-flow oxygen
  3. Intranasal sumatriptan
  4. Lithium carbonate
  5. Lumbar puncture

The patient’s history and exam are classic for cluster headache (severe unilateral stabbing pain, with injection and lacrimation of the ipsilateral eye, often with ptosis and miosis), which is treated acutely with high-flow oxygen.

Answers A and E: He does not need a head CT or lumbar puncture as the diagnosis is clear and there is no evidence of acute intracranial process.
Answer C: Intranasal or injected sumatriptan is appropriate after initiating oxygen therapy.
Answer D: Lithium carbonate has been suggested as a preventive medication for cluster headache but is not used to abort an acute attack.

Bottom Line: Cluster headache presents with severe unilateral stabbing pain, and injection and lacrimation of the eye on the affected side. It occurs in clusters of several headaches spaced closely in time. Be able to distinguish between types of headache. It will guide workup and treatment decisions. For more information, see

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