178
CHAPTER
14
Neurologic Disorders
James M. Taft
Learning Objectives
After reading this chapter, the healthcare provider will be
able to do the following:
• Providepertinentpatientinformationregardingthe
signs,symptoms,diagnosis,andtreatmentofhead-
aches, epilepsy, cerebrovascular accidents (CVAs),
Alzheimer’s disease (AD), and Parkinson’s disease
(PD).
• Identifyappropriatepatienteducationmaterialsfor
neurologicdisorders.
Main Points
• Eighty-vepercentofpatientswithmigrainehead-
acheshaveapositivefamilyhistory.
• Morethan50percentofseizuresarisefromthetem-
porallobeandcancausesleepdisturbances,difculty
with memory, emotional problems, tinnitus, abnor-
malsmells,ordifcultywithvisualprocessing.
• Thereareabout700,000newstrokesperyear;about
150,000arefatal.
• BecauseoftheagingoftheUSpopulation,ADisnow
themostcommonformofdementiainthecountry.
• PDusuallybeginsbetweenages40and70years,with
apeakinthesixthdecadeoflife.
Headaches
General Characteristics
Headaches are classied as primary or secondary. Pri-
maryheadachesincludemigraine,tension,andcluster.
Secondaryheadachesarefromtrauma,structurallesions,
meningitis, substance withdrawal, stroke, hemorrhage,
sinus problems,or dental disease. Theindicationfor a
headacheworkupisbasedonthehistoryandphysical
exam(Table 14–1).Primaryheadachesarethemostcom-
mon typeof headaches, and they are discussed inthis
chapter (Table 14–2).
Signs, Symptoms, and Diagnosis
Eighty-ve percentofpatients withmigraine headaches
have a positive family history.
1
A migraine headache is
causedbyvasodilatation(enlargementofbloodvessels),
which causesthe release ofchemicals fromnervebers
thatcoilaroundthelargearteriesofthebrain.Theincreas-
ingenlargementofthearteriescausesthepain.Thehead-
aches usually have a unilateral throbbing, pounding pain
with nausea, vomiting, and photophobia. Patients can
haveavisualaura,suchasashinglightsorwavylines.
Patientshavepostheadachefatigueordifcultythinking.
Although this is the classic presentation, many patients
have bilateral pressure or chronic frontal pressure with
Table 14–1
Indications for Headache Workup
First/worst headache•
Abrupt-onset headache•
Progression or fundamental change in pattern•
New headache in those younger than age 5 years •
or older than age 50 years
New headache with cancer, immunosuppression•
Medication/alcohol use•
Headache with syncope or seizure•
Headache triggered by exertion, Valsalva maneuver, •
or sex
Neurologic symptoms longer than 1 hour in duration•
Abnormal general or neurologic examination•
Source: Data from International Headache Society. The international clas-
sication of headache disorders. Cephalalgia. 2004;24(suppl 1):8–160.
Chapter 14: Neurologic Disorders 179
Table 14–2
Common Headaches
Type Presentation Occurrence Treatment
Tension No prodrome
Bilateral, bandlike
Variable intensity
Gradual onset
Dull, aching, not throbbing
Intermittent or daily
May last several hours to
several days
Topical hot or cold packs
Relaxation therapy
NSAIDs
Muscle relaxants
Antidepressants
Migraine Prodrome or aura
Unilateral or bilateral
Moderate to severe intensity
Throbbing
Often associated with nausea
and vomiting
One to 10 attacks per month
May last 4–24 hours
Abortive:
Sumatriptan •
NSAIDs •
Prophylactic:
TCAs •
Propranolol •
Lithium carbonate •
Cluster Explosive onset, frequently
awakens from sleep
Unilateral, periorbital
Severe intensity
Associated with lacrimation
and nasal congestion on the
affected side
One to 8 attacks per day
Clusters last 7–14 weeks
Usually occur at same time
each day
Symptomatic:
Oxygen •
Sumatriptan •
Intranasal lidocaine •
Prophylactic:
Verapamil •
Steroids •
Lithium carbonate •
Divalproex sodium•
Sinus Unilateral or bilateral
Usually supercial to affected
sinus
Mild to moderate intensity
Dull, pressurelike
Often associated with
nasal congestion and
purulent drainage
Antibiotics
NSAIDs
Decongestants
Nasal steroids
Note: NSAID: nonsteroidal anti-inammatory drug; TCA: tricyclic antidepressant.
Table 14–3
Trigger Factors for Migraines
Stress •
Odors•
Lack of sleep•
Weather changes•
Skipping meals•
Menstruation•
Food (red wine, aged cheese, nitrates in meats, •
aspartame, monosodium glutamate)
Caffeine•
associatednauseaandphotophobia.Therearemanyfac-
torsortriggersformigraineheadaches.Itisimportantto
identifythem,butsomepatientsmaynothaveanytriggers
(
Table 14–3).
Althoughtensionheadachesarethemostfrequenttype
of headache, their exact cause is not known. The most
likelycause is contractionofthe muscles thatcoverthe
skull.Tensionheadachesusuallycauseabandlikepressure
andcanbeassociatedwithmildnausea;however,thereis
novomitingorphotophobia.Thepaincanradiatetothe
neckandshoulders.Acarefulhistory,includingthepsy-
chologicalstressofajob,family,and/orabuse,isimpor-
tant because these can be contributing factors. Patients
may also have anxiety or depression. In older patients
cervicalarthritismaybeacontributingfactor.
Clusterheadachesareattacksofsevereunilateralpain
(describedas an icepick or hotpokersensation) inthe
orbitalareaortemporalregion.Theygenerallylast15to

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