Transcript Document 7374909

Primary Care Live -Neurology
Dr Estelle McFadden
MBChB, MRCP, MRCGP
GPwSI, Bradford
Headaches
www.mipca.org.uk
Why is this important?
• Prevalence of headache is very high (96%)
– Most common headaches are tension-type headache
(TTH), migraine and chronic primary headaches
– Migraine is associated with high economic costs
• Headaches are a frequent reason for GP
consultation
– However, migraine is under-diagnosed and undertreated in the UK
What should I already know about this
condition?
• Most headaches are benign
• Migraine can occur with or without an aura
• Chronic primary headaches usually evolve from
episodic headaches (migraine or TTH)
• Differential diagnosis of TTH, migraine, chronic
primary headaches and cluster headache
• Types of secondary (sinister) headaches and
diagnostic features (RED FLAGS)
What new evidence so I need to know
about?
• Features of medication overuse headache
(MOH)
• Topiramate is an effective and generally
well tolerated new preventive drug for
migraine
Practical management tips
•
Seven step process for managing headache
1.
2.
3.
4.
5.
Screening
Patient education and eliciting commitment
Differential diagnosis
Assessment of illness severity
Tailoring management to the needs of the individual
patient
6. Proactive, long-term follow up
7. A team approach to care
When should I refer my patient?
• <5 years or >60 years
• New-onset or acute headaches
– Single, sudden severe headache
• Progressive headaches
• History of cancer
• Symptoms: rash, non-resolving neurological deficit,
vomiting outside of the headache, scalp pain/tenderness,
accident/head injury, infection, worrisome hypertension
• Uncertain diagnosis
• Refractory to repeated acute and preventive treatments
• Very anxious despite reassurance
Commonly asked questions
• Will my patient benefit from having a scan,
even if I do not think there is intracranial
pathology?
Common pitfalls
• Misdiagnosing chronic headache as
migraine
• Over-treating chronic headaches leading
to MOH
• Under-treating migraine – relying on
analgesics
• Missing unusual primary headache
variants
• Blaming headaches solely on stress
Important messages
• Most headaches can be managed
effectively in primary care
• Headaches are a major cause of morbidity
• Specific management of headaches can
help
Epilepsy
Principles of epidemiology
• Incidence rate = new cases per year [n per
100,000 per year]
• For epilepsy is around 50 per 100,000
• Point prevalence = All cases with active
epilepsy at a point in time [n per 1000].
• For epilepsy is 4-7 per 1000
• Active epilepsy = to have had a seizure or
treatment in the last 5 yrs
Epilepsy seizure types
• Focal Seizures
• 60% of epilepsy
• Focal Cortical
Disturbance
• Their origin usually
determines the
clinical picture
• Focal Spikes on EEG
Primary
Generalised
Seizures
• Origin unclear either
sleep spindles or
hyper-synchrony
• Commence bilaterally
• Spike and wave
• No aura
Focal epilepsy – the site of the focus
determines the seizure morphology
Focal vs Primary Generalised Epilepsy
Focal Epilepsy
• Aura
• Simple Sz.’s
• Complex Partial Sz’s
• Secondary
Generalised Sz.’s
P.G.E.
• Myoclonic Jerks
• Absence
• Atonic Sz’s
• Tonic Sz’s
• Tonic-clonic Sz.’s
Mortality in epilepsy
– Up to 1000 deaths a year.
– 20% more men than women. No change in figures for over a
decade
– SUDEP = 350-400 a yr in the UK
– Possible cardiac arrhythmias caused by channelopathies,
bradycardia 2’ to apnoea, endogenous opioids/endorphins
– External obstruction likely to be a factor in up to 70%
– May effect up to 1 per 1000 with epilepsy
– 1 per 250 attending a tertiary epilepsy clinic
– If seizures are fully controlled, SMR falls to close to normal
for the population
– Has been studied in small numbers – one was during video
telemetry
Epilepsy is not just about seizures
•
Social implications are varied and very much lie within
the remit of General Practice e.g. the impact of epilepsy
on sexuality
•
Hypo sexuality. Surveys suggest 22-67% reduction in
sexual interest
•
Erectile dysfunction – occurs in 57% [Toone et al 1989],
up to 83% in TLE
•
Sexual Functioning in Males [1989]
–
–
–
Previous SI 56% [compared to 98% controls]
S.I. in the previous month 43% [compared to 91% in controls]
Previous erectile dysfunction 57% [compared to 18% controls]
Psychosocial impact of epilepsy
•
Psychiatric
–
–
•
•
Depression – Up to 2/3 of PWE are depressed, with
2’ reduced libido and effects of antidepressants
Anxiety – self medicate with alcohol
Psychosocial
In one study [1988] of 92 patients with poorly
controlled epilepsy
–
–
–
68% Had no friends
34% Never had a “true” friendship
57% Never had a steady relationship
Dizziness: the management of
vertigo: the illusion of
movement
The Labyrinth
NB vertigo is perceived by the brain
- ± Mismatch of visual, vestibular & proprioceptive cues
- ± Abnormality of central vestibular processing
Epidemiology
• 6-25% UK population complain of
dizziness at some point
• After viral vestibular neuronitis (idiopathic)
benign paroxysmal positional vertigo is
most common cause
Vertigo
Differential diagnosis for acute onset
of first attack – cardiac or brain or ear
•
Viral vestibular neuronitis (idiopathic)
– common, usually self limiting
– acute
– symptomatic management with rest, avoidance of provocative
manoeuvres, short course of vestibular sedatives
–
• Benign Paroxysmal Positional Vertigo
– Increase physical activity, Epley, precipitate vertigo, core stability muscle
activity
•
Iatrogenic, e.g. diuretics
•
Cardiovascular, Hypotension, Myocardial Infarction, Cardiac dysrhythmia
•
Cerebrovascular Vertebrobasilar TIA, posterior fossa CVA, migraine
•
Psychogenic
Red Flags
• If history inadequate
– Presume cardiovascular till proven otherwise
• ECG, cardiac enzymes, cardiac monitor, ECHO, tilt table,
carotid sinus massage
• If cardiac symptoms present before, during or
after arrange cardiac tests especially while
symptomatic
• Altered consciousness, behavioural change
– Exclude epilepsy
– Exclude cardiac/cardiovascular causes
– The Blackouts Checklist (refs)
• Vomiting
Vertigo and the neck
• Compression of vertebral arteries
expect multiple neurological symptoms;
tinnitus & hearing loss
– very rare cause of recurrent vertigo
• Carotid sinus hypersensitivity
– Relatively common, but causes falls NOT vertigo
• Cervicogenic vertigo
proprioceptive dysfunction
desensitization to neck stimuli
vestibular failure
Not common
Nystagmus
• Transient Positional nystagmus WITH vertigo –
think BPV
• Positional nystagmus NO vertigo – brain stem
lesion
• If present when patient sitting up
– Usually indicates cerebellar involvement
– Rarely present with ACUTE peripheral
vestibular lesion
• Viral labyrinthitis first 1-3 days
• During attack of Meniere’s, migraineassociated vertigo
(positional = laying back)
Benign Positional Vertigo
• Diagnosed ONLY by the Hallpike
manoeuvre or by the lateral canal
manoeuvre
– Must be performed in the acute phase
• Curative manoeuvres
– Epley
– Barrel
Epley manoeuvre and Barrel
manoeuvre
Positional manoeuvres move debris around the semicircular
canals (diameter 0.3 mm) back to the utricule
Hallpike manoeuvre
1-2
Epley manoeuvre
1-6
> 30 s
in each
position
1
2
3
4
5
6
The best policy: A team approach
• General practice, elderly medicine, neurology,
cardiology, audiological medicine
• Rehabilitation team: physiotherapy, cognitive
behaviour therapy, occupational therapy,
exercise therapy, activities in the community
• Open access to Audiological Physician by
patients already seen – to finalise diagnosis and
expedite treatment
Web links
• www.vestibular.org website of vestibular
disorders association
• www.dizziness-and-balance.com
• Google - images – Epley
• www.youtube.com
– Epley manoeuvre
• www.stars.org.uk
– The Blackouts Checklist
Transient ischaemic attacks
Definition
• Transient ischaemic attack (TIA) is
defined as an acute loss of focal cerebral
or ocular function with symptoms lasting
less than 24 hours and which is thought to
be due to inadequate cerebral or ocular
blood supply as a result of low blood flow,
thrombosis, or embolism associated with
diseases of the blood vessels, heart, or
blood (Hankey and Warlow 1994)
TIA or stroke?
• Brief episode of rapidly developing neurological
dysfunction with no apparent cause other than of
vascular origin with symptoms resolving
completely within 24 hours
• MR scans have shown that those with symptoms
lasting more than 1 hour show cerebral
infarction i.e. a stroke
– Definition may be changed to symptoms resolving
completely within 1 hour
• TIA is the only warning that a stroke is imminent
• Estimated 30,000 new TIAs per year
Risk of stroke following TIA
• Most patients who have a TIA have a short
benign course but up to 20% will have a stroke
within the next 90 days
• Half of those who will have a stroke will do so in
the first seven days after their TIA
(Coull A, Lovett JK & Rothwell PM on behalf of the Oxofrd VAscualr Study, 2004, Early risk of stroke after a TIA or minor stroke in
population-based incidence study, BMJ, 328, 326-8)
• Risk of a stroke following a TIA varies
• ABCD2 risk stratification tool helps identify those
at highest risk of a stroke
(Johnston SC, Rothwell PM et al The Lancet 2007; (369) 283-292)
ABCD2 score to identify individuals
with high early risk of stroke after TIA
SCORE
AGE
BLOOD
PRESSURE
CLINICAL
FEATURES
DURATION
OF
SYMPTOMS
0
< 60
years
<140/90
Other
<10 mins
1
≥ 60
years
Systolic
>140
and/or
Diastolic
≥ 90
Speech
10-59 mins
disturbance
without
weakness
2
Unilateral
weakness
≥ 60 mins
DIABETES
MELLITUS
Yes
Risk of stroke following TIA
• HIGH
Score 6-7 = 8.1% 2 day risk
• MODERATE Score 4-5 = 4.1% 2 day risk
• LOW
Score 0-3 = 1.0% 2 day risk
• More than one TIA in seven days also at
high risk of stroke
Presentation of TIA
ANTERIOR VS POSTERIOR ISCHAEMIA
Carotid
(80% TIAs)
Vertebrobasilar
(20%TIAs)
Motor
Contralateral weakness
Paralysis
Clumsiness
Bilateral or shifting weakness
Paralysis
Clumsiness
Ataxia
Imbalance without vertigo
Sensory
Contra lateral numbness,
Pins and needles
Sensory loss
Bilateral or shifting numbness
Pins and needles
Sensory loss
Speech
Dysphasia
dysarthria
Dysarthria
Visual
Ipsilateral monocular
blindness
Contralateral homonymous
hemianopia
Diplopia
Partial or complete blindness in both
visual fields
Other
Combination of above
Vertigo
Dysphagia
Management of TIA
urgent medical admission
• As TIA is a retrospective diagnosis then if
they are symptomatic at the time of
presentation then refer for emergency
admission to an acute stroke unit
• In a centre offering thrombolysis, those still
symptomatic at 3 hours may be eligible for
thrombolysis
Management of TIA: High risk
• High risk of subsequent stroke in < 2 days if:
– ABCD2 score ≥4
– More than one TIA in seven days
• Require assessment and treatment within 24
hours
– ?admit as urgent medical admission
– Refer to rapid access neurovascular clinic, one stop
shop with strong advice to seek urgent medical
referral (via 999) in the event of symptoms returning
or new symptoms i.e. develop a stroke AND give
300mg aspirin if not already on regular aspirin
– To be treated or referred if presenting to Out Of Hours
services or A&E (not referred back to GP)
Management of TIA: Low risk
• All other TIAs
• Should be given 300mg aspirin (if not taking regular
aspirin already)
• Those attending out of hours must be treated and not
referred back to their GP to avoid delays
• Need prompt referral to a rapid access neurovascular
clinic (referrals for TIA are excluded from Choose and
Book as considered to be a medical emergency) and to
be seen within SEVEN days
• UNLESS
– Presenting several weeks after event (still refer)
– Treatment not felt to be in patient’s best interest e.g. bed bound
with dementia
Assessment of TIA
• Carotid imaging should be performed at initial
assessment (and not delayed for more than 24
hours in high risk patients and those with carotid
territory minor stroke)
– Doppler ultrasound
– MR including angiography, diffusion weighted
imaging, gradient echo imaging
– CT
• Where indicated
– ECG
– Echocardiogram
Treatment of TIA
• Carotid endarterectomy for >70% stenosis
– Recommendation this becomes a surgical emergency
– Stroke prevention benefits lost if treatment delayed
– Should be performed within
• 48 hours in high risk patient
• 28 days to prevent stroke
• Atrial fibrillation and other arrhythmias
– Anticoagulation unless contra-indications
– Aspirin 75 – 300mg daily
– Treatment of arrhythmia
Secondary prevention
• Antiplatelet
– Aspirin 75mg – 300mg plus dipyridamole MR
200mg bd for 2 years following event then
aspirin alone
– Clopidogrel alone if aspirin intolerance or
sensitivity
• Anticoagulation
– Anticoagulant if arrhythmia unless
contraindication (high risk of falls, recent GI
bleed)
Secondary prevention
• Hypertension
– Risk of stroke halves with every 10mmHg fall
in diastolic blood pressure even in
normotensive patients
• Cholesterol
– Equal benefit of simvastatin 40mg across all
those who had had a stroke or TIA down to
baseline 3.5mmol/l total cholesterol
Lifestyle advice
• Smoking cessation
• Alcohol intake
– Binge drinking associated with increase in
blood pressure
• Exercise
• Obesity