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Nickie Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope
OUTLINE
I. Primary Headache
A. Migraine International Classification of headache Disorders 2nd Ed. (1st revision)
B. Tension-Type Headache
C. Cluster Headache and other TAC PRIMARY HEADACHES
D. Other Primary Headache
II. Secondary Headache
A. Attributed to Head and Neck Trauma I. Migraine
B. Attributed to Cranial or Cervical Vascular Disorder
C. Attributed to Nonvascular Intracranial Disorder A. Migraine without Aura
D. Attributed to Substance or its Withdrawal
E. Attributed to infection Diagnostic Criteria:
F. Attributed to Disorder of Homeostasis a. At least 5 attacks fulfilling criteria B-D
G. Attributed to Disorder of cranium, neck, eyes, etc b. Headache attacks lasting 4-72 h (untreated or
H. Attributed to Psychiatric Disorder
unsuccessfully treated)
III. Cranial Neuralgias, Central and Primary Facial Pain and other
Headache c. Headache has ≥2 of the following characteristics
A. Cranial Neuralgias and central causes of pain Unilateral location
B. Other headache, Cranial Neuralgia, Central and Primary Pulsating quality
Facial Pain Moderate or severe pain intensity
IV. Dizziness and Vertigo Aggravation by or causing avoidance of routine
V. Limb Wekness physical activity
VI. Disorder of Gait d. During headache ≥1 of the following:
Nausea and/or vomiting
Photophobia and phonophobia
e. Not Attributed to another Disorder
Notes:
If <5 attacks but criteria B-E otherwise met, code as
probable migraine without aura
When attacks occur on ≥15 days per month for >3 mos.
Code as migraine without aura + Chronic migraine
Pulsating means varying with the heartbeat
In children,
Attacks may last 1-72 h
Occipital headache requires caution
In young children,
Photophobia and/or phonophobia may be inferred from
their behaviour
Diagnostic Criteria:
a. At least 2 attacks fulfilling criterion B
b. Migraine aura fulfilling criterion B and C for one of the
subtypes
c. Not attributed to another disorder
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Subtypes include: Heachache fulfilling criteria B-D for Migraine without
aura begins during the aura or follows onset of aura
1. Typical Aura with Migraine Headache within 60 min
Most migraine aura are associated with headache fullfilling d. At least one 1st or 2nd degree relative fulfills these criteria
criteria for migraine without aura e. Not attributed to another disease
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E. Complications of Migraine II. Tension-Type Headache
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C. Chronic tension-type headache III. Cluster Headache and other Trigeminal Autonomic Cephalalgia
1. Probable Infrequent Episodic TTH For TAC, chronic is not used until the condition has been unremitting
for more than 1 year.
Diagnostic Criteria:
a. Episodes fulfilling all but one criteria A-D for Infrequent B. Paroxysmal Hemicrania
episodic TTH
b. Episode do not fulfill criteria for migraine without aura Diagnostic Criteria:
c. Not attributed to another disorder a. At least 20 attacks fulfilling criteria B-D
b. Attacks of severe unilateral orbital, supraorbital or temporal pain
2. Probable Frequent Episodic TTH lasting 2-30 min
c. Headache is accompanied by >/=1 of the following:
Diagnostic Criteria: ipsilateral conjunctival injection and/or lacrimation
a. Episodes fulfilling all but one criteria A-D for Frequent ipsilateral nasal congestion and/or rhinorrhoea
episodic TTH ipsilateral eyelid oedema
b. Episode do not fulfill criteria for migraine without aura ipsilateral forehead and facial sweating
c. Not attributed to another disorder ipsilateral miosis and/or ptosis
d. Attacks have a frequency >5/d for > half of the time,although
3. Probable Chronic TTH periods with lower frequency may occur
e. Attacks are prevented completely by therapeutic dosesof
Diagnostic Criteria: indomethacin
Same as Chronic TTH except: f. Not attributed to another disorder
e. Not attributed to another disorder but there is, or has been
within the last 2 months, medication overuse fulfilling
criterion B for any of the subtypes of Medication-overuse
headache
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Subtypes: b. Occurs during sexual activity and incerases with sexual
excitement
1. Episodic Paroxysmal Hemicrania c. Not attributed to another disorder
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Notes: Headache Danger Signals on PE:
New daily persistent headache has many similarities to chronic Abnormal vital signs especially fever or hypertension
TTH Altered level of consciousness
Unique in that headache is daily and unremitting from, or almost Meningeal irritation
from,the moment of onset Papilledema or fundal hemorrhage
A clear recall of such onset is necessary for the diagnosis Uneuqal pupils
If there is or has been within the lat 2 mo medication overuse Weakness or sensory loss in the face and limbs
fulfilling criterion B for any of the subtypes of medication-overuse Reflex asymmetry or abnormal plantar response
headache, the diagnosis cannot be new daily persistent headache Clumsiness or loss of balance
Tender, poorly-pulsatile cranial arteries
V. Attributed to Infection
Headache Danger Signals on History:
Sudden onset of new severe headache A. Intracranial infection
Progressively worsening headaches B. Systemic infection
Onset with exertion, coughing, straining, and/or sexual activity C. HIV/AIDS
Onset after age 50 D. Chronic post-infection headache
Associated with drowsiness, chronic malaise, myalgia, arthralgia, fever,
progressive visual disturbances, weakness, clumsiness, and loss of
balance
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VI. Attributed to Disorder of Homeostasis d. (replacing D and E) A causative lesion, other than vascular
compression, has been demonstrated by special
A. Hypoxia and/or hypercapnia investigations and/or fossa exploration
B. Dialysis headache
C. Arterial hypertension B. Glossopharyngeal neuralgia
D. Hypothyroidism C. Nervus intermedius neuralgia
E. Fasting D. Superior laryngeal neuralgia
F. Cardiac Cephalagia E. Nasociliary neuralgia
G. Disorder of Homeostasis F. Supraorbital neuralgia
G. Other terminal branch neuralgia
VII. Attributed to Disorder of Cranium, Neck, Eyes, Ears, Nose, H. Occipital neuralgia
Sinuses, Teeth, Mouth and other Facial or Cranial Structures I. Neck-tongue syndrome
J. External compression headache
A. Disorder of cranial bone K. Cold-stimulus headache
B. Disorder of neck L. Constant pain caused by compression, irritation or distortion of cranial
C. Disorder of eyes nerves or upper cervical roots by structural lesions
D. Disorder of ears M. Optic neuritis
E. Rhinosinusitis N. Ocular diabetic neuropathy
F. Disorde of teeth, jaws or related structures O. Head or facial pain attributed to herpes zoster
G. Temporomandibular (TMJ) disorder P. Tolosa-Hunt syndrome
H. Other disorder of the above Q. Opthalmoplegic migraine
A. Trigeminal neuralgia II. Other headache, cranial neuralgia, central or primary facial pain
Diagnostic Criteria:
a. Paroxysmal attacks of pain lasting from a fraction of 1 sec to
2 min, affecting one or more divisions of the trigeminal nerve Dizziness
and fulfilling criteria B and C a term that patient may use to describe vertigo, faintness,
b. Pain has ≥1 of the following characteristics: disorientation, drowsiness, light-headedness, visual disturbances
Intense, sharp, superficial or stabbing or even legs unsteadiness
Precipitated from trigger areas or by trigger factors
c. Attacks are stereotyped in the individual patient Vertigo
d. There is no clinically evident neurologic deficit illusion or hallucination of movement
e. Not attributed to another disorder the perceived movement may be rotational, swaying, rocking, or
heaving in quality
2. Symptomatic Trigeminal Neuralgia
Vertigo is either peripheral or central
Diagnostic Criteria: Vertigo from supranuclear lesion is uncommon, therefore the main
Same as #1 except: consideration would be between
a. Paroxysmal attacks of pain lasting from a fraction of 1 sec to a peripheral lesion (labyrinthine, vestibular nerve or ganglion)
2 min, with or without persistence aching between brainstem lesion
paroxysm, affecting one or more divisions of the trigeminal cerebellar lesion
nerve and fulfilling criteria B and C vertigo is usually not the sole manifestation of a brainstem disease –
always look for ipsilateral cranial nerve deficits and contralateral
pyramidal signs
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in vertigo due to cerebellar lesions, there may be signs of ipsilateral Symptom Brainstem lesions Cerebellar lesions
incoordination which are absent in peripheral vestibular lesions May be Brainstem connections
Vertigo
vertigo may be the sole manifestation of vestibular dysfunction, this can prolonged involved
be confirmed by neuro-otological testings Nystagmus Vertical Horizontal (coarse)
(fast phase) nystagmus (towards the lesion)
Differential Diagnosis for Vertigo: Gait Hemiparesis Ataxia on side of the lesion
Usually
A. Labyrinthine failure Hearing Unaffected
unaffected
Meniere’s disease Ipsilateral
Benign Positional Vertigo cranial nerve
Labyrinthitis Unilateral cerebellar signs
palsies
Motion sickness Other signs from an ipsilateral cerebellar
Contralateral
hemispheric lesion
pyramidal
B. Vestibular Nerve lesions involvement
Vestibular neuronitis
Investigations in Cases of Vertigo:
C. Cerebellopontine angle lesions
Acoustic neuroma A. Hallpike Maneuver
Granulomatous diseases
Vascular lesions performed with patient sitting on a bed, and asked to fall
backwards so that his head is below the plane of his body
D. Brainstem lesions the positioned head is turned 30 degrees to the affected side and
Brainstem stroke syndrome the patient is asked to look to the turned side
Demyelinating Diseases after a latent period of few seconds, vertigo may be experienced
Neoplastic infiltration there’s accompanying torsional nystagmus with upper pole
beating towards the floor
E. Cerebellar diseases the direction of the nystagmus are reversed on sitting up again
Example:
a. canal paresis (peripheral lesion)
no response to irrigation of the external meatus
Labyrinthine lesions
Nerve lesions
Vestibular ganglion lesion
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b. directional preponderance Patterns of LMN Weakness:
Brainstem vestibular nuclei lesion
I. Anterior Horn Cell diseases
may be diffused or confined to restricted group of muscles
Causes:
Weakness in the limbs can result from pathology anywhere along the genetic (Spinal muscular atrophy)
UMN pathway (cortex, subcortical fibers, brainstem, spinal cord), from Idiopathic (ALS)
lesions in the LMN (anterior horn cells, nerve roots, plexus, peripheral Infectious (Poliomyelitis)
nerves) or from disorders arising from the NMJ or the muscles Toxic (chemical exposure, eg. Triorthocresylphosphate)
Patterns of Motor Weakness due to UMN Lesion: II. Radiculopathy (root lesions) and Plexopathy (plexus lesions)
a root lesion will cause muscle weakness in the corresponding
I. Spastic hemiparesis and ipsilateral facial weakness myotome
if the dorsal roots are also involved, there will be accompanying
a. hemispheric cortex: sensory loss in defined dermatomal distribution
aphasia (dominant hemisphere) a plexus lesion will cause weakness in muscles innervated by a
involvement of the face and arm alone, or number of nerve roots which comprise the plexus
leg alone, depending on the site of the lesion accompanying sensory loss over several dermatomes may be
b. internal capsule: present
dense hemiplegia
c. upper brainstem: Examples of Plexopathies:
upper cranial nerve palsies
certain characteristic sensory changes A. Brachial Plexus
a. Erb’s palsy (C5-6)
II. Spastic hemiparesis and contralateral facial weakness upper plexus injury (loss of shoulder abduction and
elbow flexion
a. Lower brainstem involvement b. Klumpke’s palsy (C8-T1)
Lower cranial nerve palsies lower plexus injury (loss of function of the intrinsic
certain characteristic sensory changes muscles of the hand and long flexors and extensors of
the fingers)
III. Spastic hemiparesis sparing the face c. Thoracic outlet syndrome
the brachial plexus and the subclavian artery are
a. Unilateral upper cervical cord lesions compressed by fibrous band or a cervical rib
Brown-Sequard syndrome d. Neuralgic amyotrophy
acute brachial plexus neuropathy which may follow
IV. Spastic quadriparesis infections, vaccination, or surgery; accompanied by
severe pain
a. Lower brainstem lesions
Lower cranial nerve palsies depending on the site of the B. Lumbosacral Plexus
lesion a. Lesions in the lumbosacral plexus includes:
b. High cervical cord lesions trauma following abdominal surgery or pelvic surgery
No cranial nerve deficits neoplastic infiltration
Loss of sensory modalities below the site of the lesion granulomatous lesions
compression due to aortic aneurysm
V. Spastic Paraparesis
III. Disorders of the peripheral nerves
a. Thoracic cord lesions
Loss of all sensory modalities below the level of the lesion a. Mononeuropathy
disease of a single peripheral nerve
VI. Spastic monoparesis Carpal Tunnel syndrome
b. Multifocal neuropathy (Mononeuropathy multiplex)
a. Unilateral thoracic cord lesion many single peripheral nerves are involved
Brown-Sequard syndrome at the thoracic level Diabetic neuropathy, Sarcoidosis, Leprosy
c. Polyneuropathy (Peripheral neuropathy)
more widespread involvement of the peripheral nerves
typically in a symmetric distal distribution
GBS, Vit B12 deficiency
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IV. Disorders of the neuromuscular junction (NMJ) Causes:
the weakness predominantly affects the proximal muscles Spinal Cord diseases / compression
may be become widespread in advanced stages Spinal trauma or surgery
in myasthenia, ocular muscles are characteristically affected Birth injuries or congenital deformities (eg Cerebral
the outstanding feature: easily fatiguable muscles Palsy, Spina bifida)
wasting is relatively uncommon; reflexes are frequently normal Multiple Sclerosis (MS)
Myasthenia gravis Motor neuron Diseases (eg ALS, Primary lateral Sclerosis)
Lambert-Eaton Myasthenic Syndrome Parasaggital meningiomas
Botulism Subacute Combined Degeneration of the Cord
Drug-induced NMJ malfunction
D. Pakinsonian Gait
V. Disorders of muscles stooped posture and loss of arm swing
in myopathies, limb weakness is bilateral and proximal in the steps are short and the shuffling (festinating gait)
upper and/or lower limbs there may be difficulty starting, stopping, and turning
muscle wasting may be severe and is restricted to the weak having started walking, patient leans forward and the pace
muscle quickens, as though the patient has to catch up on himself
groups
tone is reduced and is proportional to the muscle wasting E. Gait of Sensory Ataxia
Progressive Muscular Dystrophies (Duchenne) due to impaired proprioception by lesions involving the peripheral
Inflammatory Myopathies (Polymyositis) nerves, posterior root, dorsal columns of the spinal cord, or the
ascending fibers to the parietal lobes
the gait is “stamping” (shoe soles are equally worn out)
Causes:
Posterior Spinal Cord lesions
A. Cerebellar Ataxia
Vit. B12 deficiency
patient stands and walks on a wide-based gait (the feet spaced
Tabes dorsalis
widelyapart)
Cervical Spondylosis
gait is unsteady, with irregularity of stride
MS
trunk sways and the patient may veer towards one side
in mild cases, the only manifestation of gait disturbance may be
Sensory peripheral neuropathies include:
difficulty walking heel-toe in a straight line
Hereditary
always look for cerebellar signs in the limbs; ataxia of gait may
Charcot-Marie-Tooth disease
be the only sign of cerebellar dysfunction (midline cerebellar
Metabolic
lesions
Diabetic Neuropathy
Causes: Inflammatory
Multiple Sclerosis GBS
Alcoholic Cerebellar Degeneration Malignancy
Anticonvulsant therapy paraneoplstic Syndrome
Posterior Fossa Tumors Toxic
Cerebellar Paraneoplastic Syndromes alcohol, drugs
Hereditary Cerebellar Ataxias
F. Steppage Gait
B. Hemiparetic Gait arises from weakness of the pretibial and peroneal muscles of the
there is a characteristic posture on one side (flexion of the upper LMN-type
limb and extension on the lower limb patient has “footdrop” and is unable to dorsiflex and evert the foot
the extended lower limb moves stiffly and is swung round in a leg is lifted high on walking so that the toes clear the ground
semicircle to avoid scraping the foot across the floor (the outer on striking the floor, there is “slapping” noise (shoe soles are worn
sole of the shoe is become worn) in the anterior and lateral aspects)
Causes:
Causes:
Charcot-Marie-Tooth disease (bilateral footdrop)
Cerebral hemispheric stroke syndromes
Fibular fracture (lateral popliteal nerve palsy)
Infiltrating neoplasms (Glioblastoma multiforme)
Anterior horn cell disease (Poliomyeltis)
Traumatic Head Injury
G. Myopathic Gait
C. Spastic Gait
waddling gait; due to weakness of the proximal muscles of the
seen in patients who have spastic paraparesis or bilateral
lower limb girdle
hemiplegia
weight is alternately placed on each leg, with the opposite hip and
legs move slowly and stiffly, the thighs are strongly adducted
one side of the trunk tilting up towards the weight-bearing side,
suchthat the legs may cross as the patient walks (scissor gait)
the weak gluteal muscles cannot stabilize the weight-bearing hip
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Causes:
Muscular Dystrophies (eg. Duchenne, Becker’s)
Endocrine Myopathies (eg Cushing’s Disease)
Metabolic Myopathies (eg. Periodic paralysis)
Inflammatory Myopathies
H. Apraxic Gait
Walks with feet placed apart, and with small, hesitant steps
“walking on ice”
there is difficulty initiation of walking, and with advances cases, as
if the patient is stuck to the floor
due to frontal lobe disease; look for primitive frontal reflexes
Causes:
Bilateral subcortical stroke
Normal-pressure hydrocephalus
Alzheimer diseases
Frontal Subdural hematoma
Frontal lobe tumors
I. Antalgic Gait
arises from pain (painful hip or knee) due to arthritis
Patient tend to weight-bear mainly on the affected side
tendency to hobble
J. Hysterial Gait
does not conform to any of the mentioned abnormal gait
may take a number of forms and is variable in character
no abnormal formal neurological deficits
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