headache with neuro symptoms

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Below are the symptoms of an otherwise healthy 18 yr old woman, with no “unusual” medical history. She has had 2 MRI’s in the last 3 years, and a balance test less than a year ago. She has also had an ECG within the last year. All of these tests have shown a perfectly healthy “neuro profile”. The only unusual aspect of her childhood was that she used to faint occasionally when she was only 6 to 9 years old……often while playing on the school “monkey bars”, and often resulting in a broken bone (i.e. elbow, ankle, etc.)…..she hadn’t had any more fainting episodes until November 2010 @ age 16……which usually occurred at her desk in school.
I think it is some sort of seizure disorder. What are your thoughts guys and gals?


The most frequent symptom I have can occur anywhere from one to twenty times a day. It is rare that at least one will not happen in a day, but this is possible. It’s hard for me to keep count, and I have never really tried, so one to twenty is a reasonable average. There are no warning signs that one of these episodes is about to exist. All of a sudden I will notice that things seem different and confusing….this is probably the hardest to explain. It seems that I never know when something is starting to happen, but rather that oh something happened. In the front of my head, between my temples I feel a fuzzy almost heat like sensation. It does not hurt. When I become aware in a few short seconds that something has happened, I also notice that It’s harder for me to process things. Once again, there is no pain associated with this though I feel as though any function that is normally easy is all of a sudden not. My surroundings are difficult to understand, It’s difficult to talk (stutter), and understand what someone has said, It is difficult to move my hands and legs as I normally would without thinking, time seems to go at a different pace, it is even difficult to understand my own body. I will feel like I have a deep stare (like daydreaming), but I cannot control it, I cannot snap out of it, though I am usually completely aware that I am in this state. The cognitive effects are most apparent after one of these episodes has already occurred, I have noticed it is still difficult to talk, drive, or remember anything that I once have. I have forgotten a lesson for school completely that I have already studied an two hours before, I have forgotten a family member already said goodbye and left the house. This can occur during any activity. I have had it happened while, hanging out with a friend, in the shower, driving, reading, eating, working out, anything. Because of this, It’s now been clear to me that there is nothing that correlates with this. I have kept note of my sleep level, time of day, caffeine level, the food I eat, temperatures, my emotions, whether my mind is working heavily or not, menstrual cycle, and nothing affects or changes the way that this episode happens.
Now long over a year, it has also been clear to me that there is no correlation with those similar aspects to any other symptom. Other frequently occurring sensations are also hard to explain. During the day, I will randomly feel this tingling sensation over my body. This does not happen before, directly after or during the episode that I just explained. And this sensation actually hurts. I could describe it as burning, pricking, biting but no word exactly describes it perfectly, but maybe a combination of those. This will last very shortly when it does happen, but the level of pain is very high. It can occur in multiple places; hands, legs, shoulders, head, arms, or it could shoot up my whole back. Sometimes this will happen very few times during the week, and sometimes it will happen all throughout a day.
This same sensation will happen in my head, like an ice pick headache. It probably lasts ten seconds to five minutes. This will happen randomly throughout the day. It feels as if something is stinging/stabbing, this does not feel like a burning sensation. Sometimes I will also get a pulling/squeezing sensation in the mid/back section of my head. This is more rare but it will last longer (30min –couple hours).
Also throughout every day, my joints will ache and sting. On some occasions it feels as if it is not just my joints, and for instance, my whole arm and leg will deeply ache in the bone in a very excruciating way. When just my joints hurt, they may get stiff or even cause me to stop what I’m doing (writing, playing piano), or drop a dish. But this does not just affect my hands (although mostly hands and elbows), it will affect my knees and occasionally in my hips. Once again like the other symptoms, some days its worse and sometimes it’s fine.
Another thing that frequently occurs is getting diarrhea. Usually with someone this would happen just after certain things that one would eat, or an excess of water or soup. But, this once again has no correlation. This usually happens five or six days out of a week. Sometimes in a day it can happen multiple and multiple times. When this happens I will sometimes feel as though I am blacking out (but I don’t) and very shaky. This doesn’t hurt, but it’s annoying.
Sometimes (maybe twice per week, varies) I will feel very dizzy. It is not the same dizziness one feels when they are nauseas or lightheaded. It feels as if the room is ocean like, and cannot stay leveled. It is normally the room around me, and not me, though sometimes I will feel as if I am the only thing dizzy and this is a spinning sensation.
Finally, another frequently occurring symptom (every day like the rest) is a common ear ring. I have never noticed it with a headache or other sensation. It will also happen randomly and a lot during the day, it affects both ears, though never at the same time. A ringing will start (like after a concert…but with no noise) and after a couple minutes that hearing on that side will go out for another couple minutes. This usually never hurts, it’s also just annoying.
Things that occur very rarely would be extreme headaches, and fainting spells. The fainting will not have any association with no food or water or exercise or common onsets that I could think of. It does not hurt ( because I am aware that it will happen…so I can find a couch or bed) though its rather inconvenient. Sometimes before I pass out, my heart will feel heavy.

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Most likely neurocardiogenic syncope (i.e. vaso-vagal),

Psych referral


Seems like if they were seizures, neuro would have been all over that with an EEG, along with the rest if her negative mega-work up.

At some point, someone will likely slap the "pseudoseizure" label on her and start an anti-epileptic.

I would avoid opiates in this patient at all costs.
 
Sounds like a good candidate for 24 hour EEG and cardiac monitor. If these events really occur 20 times a day they could definitely be captured.

I'm guessing any overnight sleep lab could do this. If it hasn't already been done.

HOWEVER the summary of her narrative is frequent and random:

1. seizures/conscious blackouts
2. stabbing head pain
3. whole body tingles/burning or excruciating aches
4. diarrhea with accompanying vasovagal response.
5. dizzy spells
6. tinnitus
7. fainting spells

Which makes me think this psychogenic. Too many problems to have a single organic cause. Seizures don't give you excruciating limb pain or joint aches. Or diarrhea.
 
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what is cuicss Steve? She is in my office for pain management and because the neurologist could not help her.
 
what is cuicss Steve? She is in my office for pain management and because the neurologist could not help her.

She hates her overbearing mother.

CUICSS = Crazy Uncle in Clown Suit Syndrome.

You cannot help her with procedures or drugs. Send to another Neurologist. Their job is to Dx stuff that they can rarely treat.
 
Just a resident, but wil soon to be a pain fellow. Iam just going to take a stab it it. I agree with lobelsteve. Sounds more like an seizure. Maybe Petit Mal? The those usually starts during childhood. Seizure duration is short. usually 1 - 5 mins long. I thought majority of these seizure occurs in the thalamus. Maybe its proximity to the midbrain would affect conciousness because its near the reticular formation? The vasovagal episodes because its near the hypothalamus and thus affecting the parasympathetic nervous system? The midbrain area is near Cranial nerve V and VII hence the headaches and tinnitis? So I think my diffrential ddx :

1. Seizures - EEG monitoring may give diagnosis
2. Possible Cardiac? Agree with other posters to do holter
3. Conversion/ Malingering? - Psyc eval if all fails

Just an anes resident btw, if there any neuro/pain guys here plz dont butcher me. :D
 
sounds like a good candidate for 24 hour eeg and cardiac monitor. If these events really occur 20 times a day they could definitely be captured.

I'm guessing any overnight sleep lab could do this. If it hasn't already been done.

However the summary of her narrative is frequent and random:

1. Seizures/conscious blackouts
2. Stabbing head pain
3. Whole body tingles/burning or excruciating aches
4. Diarrhea with accompanying vasovagal response.
5. Dizzy spells
6. Tinnitus
7. Fainting spells

which makes me think this psychogenic. Too many problems to have a single organic cause. Seizures don't give you excruciating limb pain or joint aches. Or diarrhea.

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