CNS Flashcards
Migraine without Aura
Consider migraine without aura if the person has had at least five attacks fulfilling the following criteria:
Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated).
The headache has at least two of the following four characteristics:
Unilateral location.
Pulsating quality.
Moderate or severe pain intensity.
Aggravation by or causing avoidance of routine physical activity (for example walking or climbing stairs).
During the headache at least one of the following; nausea and/or vomiting; photophobia and phonophobia.
Migraine with Aura
Consider migraine with aura if the person has had at least two attacks with at least one or more of:
Visual symptoms such as zigzag lines and/or scotoma— visual aura is the most common type of aura.
Sensory symptoms such as pins and needles.
Speech and/or language symptoms such as aphasia.
Motor weakness.
Brainstem symptoms such as vertigo or diplopia.
Retinal symptoms such as monocular scintillations or scotoma.
At least two of the following four characteristics:
At least one aura symptom spreads gradually over at least 5 minutes, and/or two or more symptoms occur in succession.
Each individual aura symptom lasts 5-60 minutes.
At least one aura symptom is unilateral.
The aura is accompanied, or followed within 60 minutes, by headache.
Tension-type headache
Consider tension-type headache if:
The person has recurrent episodes of headache lasting from 30 minutes to 7 days which is not associated with nausea or vomiting (the headache may also be associated with no more than one of photophobia or phonophobia) and
The headache has at least two of:
Bilateral location.
Pressing or tightening (non-pulsating) quality.
Mild or moderate intensity.
Not aggravated by routine physical activity such as walking or climbing stairs.
Cluster headache
Consider cluster headache if:
The person has had at least five attacks of severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes and
The headache is associated with at least one of: ipsilateral conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid oedema; forehead and facial sweating; forehead and facial flushing; sensation of fullness in the ear; or miosis and/or a sense of restlessness or agitation.
Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active.
Medication overuse headache
Consider medication overuse headache if:
The person has headache occurring on at least 15 days per month and a pre-existing headache disorder.
The person has regularly overused, for more than 3 months, one or more drugs that can be taken for acute and/or symptomatic treatment of headache such as ergotamines, triptans, simple analgesics or opioids.
Headache RED FLAG
new or unexpected headache (sudden severe or over 50)
headache that has changed dramatically
Associated features:
fever/seizure/neck pain/photophobia (?infection)
papilloedema
Neurological deficit
atypical aura (> 1 hr or inc motor symptoms) or new aura when on combined oral contraceptives
Dizziness
Visual disturbances
Vomiting
Treatment Cluster headache
refer as need diagnosis. over 18 years old: Sumatriptan SC (all adults, max 12 mg OD) OR intranasal (18-65 only, max 40mg OD) OR Zolmitriptan intranasal (unlicensed) DO NOT OFFER: Paracetamol NSAIDs opioids ergots oral triptans
Treatment tension-type headache
for > 16:
Paracetamol
aspirin
NSAIDs
Offer person to take a therapeutic dose as soon as
DO NOT offer opioids
Prophylaxis - low dose amitriptyline 10-75mg OD (off-label) or acupuncture.
Treatment medication overuse
refer if overuse involves opioids
Triptans and NSAIDs/paracetamol can be abruptly stop - try for 1/12 (pt will feel worst for weeks after discontinuation)
medication could be reintroduced within 2/12 of stopping.
Diamorphine is painkiller of choice in palliative care - TRUE/FALSE
TRUE - greater solubilty allows greater doses to be administered in lower volumes, esp important for patient presenting with severely frail (very little muscle mass) - emaciated patients
Less nausea and hypotension than morphine
Post-op nausea and vomiting drugs
5HT3-rec antagonist: 1. Cyclizine (antihistamines) droperidol Dexamethasone Prochlorperazine (Phenothiazines) For high risk - give 2 or more with different mechanisms of action.
Risk factors for N+V post-op
female sex
non-smoker
hx postoperative N+V/motion sickness
use of opioids
Anti-emetics C/I in Parkinson’s
metoclopramide Prochlorperazine Chlorpromazine Droperidol Promethazine ALL CARRY EPSE Ondansetron is C/I with apomoprhine
Dispersible anti-parkison med
Co-Beneldopa (Madopar) is the only one available in dispersible form
used for NG/PEG
When switching from M/R levodopa to dispersible form - reduce dose by 30%
When switching the prev preparation of levodopa should be discontinued 12 hrs prior
Anti-emetics in Chemotherapy
5HT3 - Ondesantron, Granisetron ,Palonosetron
Dexamethasone (with metoclopramide, prochlorperazine, lorazepam or 5HT3 antagonist)
Lorazepam
High risk emesis: Aprepitant, fosaprepitant, rolapitant (in addition to dexamethasone + 5HT3 antagonist)
PreTreatment N+V in chemo
Dexamethasone
Lorazepam
Treatment delayed symptoms of N+V in chemo
moderate risk emesis: Dexamethasone + 5HT3
High risk: Aprepitant, Dexamethasone, 5HT3
Rolapitant and metoclopramide also effective
Prevention anticipatory N+V in chemo
Lorazepam due to its anxioloitic, sedative and amnesic effects.
S+S of Reye’s syndrome
Initially: persistent effortless vomiting
tiredness + listlessness (lack interest)
Drowsiness
rapid breathing
Seizures
As the condition progresses:
irritability, irrational or aggressive behaviour
Delirium (severe anxiety, hallucinations)
Coma
Blood test: LFT’s and WCC.
DOACS and spinal epidurals
ALL DOACS are not recommended to be given when pt is on spinal epidural as there is a risk of lumbar haemorrhage which could lead to paralysis.
Risk is increased with indwelling epidural catheter.
No evidence of risk with LWMH.
NSAIDs associated with less GI S/E
COX-2 inhibitors have less S/E
1. Ibuprofen
NSAIDs associated with less CV S/E
Naproxen is considered one with least CV S/E
low dose ibuprofen (1.2g daily or less)
NSAIDs associated with high CV S/E
Diclofenac
High dose Ibuprofen (2.4 g daily or more than 1.2 g)
aceclofenac
etoricoxib
NSAIDs associated with high GI S/E
Piroxicam
Ketoprofen
ketorolac trometamol
NSAIDs with an intermediate GI S/E
Naproxen
Diclofenac
Indometacin
Codeine for sport-related injury
Okay in a non-pregnant> 12 yrs old pt who does not have middle eastern or African Ethiopian background Not licensed under 12 Think appropriateness (ie: RICE/ paracetamol/NSAID 1st) Not to give in pregnant or breastfeeding (avoid due to neonatal dependence or risk of gastric stasis and inhalation pneumonia in labour) (Avoid in breastfeeding) Pt from middle eastern or Ethiopian/African origin is a 30% chance of being fast metabolizers of codeine.
Aspirin for pain
mild to moderate pain: PO: 300-900mg QDS ev 4 hrs MAX 4g OD PR: 450-900mg ev 4 hrs MAX 3.6g OD Acute migraine: 900mg STAT
Neuropathic pain treatment
Neuropathic pain: - amitriptyline - pregabalin - nortriptyline - Gabapentin opioids also used in some cases for topical local preparations: lidocaine or capsaicin (intense burning sensation when first put on so not always manageable) Trigeminal neuralgia: surgery carbamazepine phenytoin IV chronic facial pain: tricyclic antidepressant - refer to spe
Co-beneldopa and co-careldopa MOA
levodopa releases dopamine which helps parkisons symptoms
benserazide and carbidopa stops levodopa from being broken down in other parts of the body
treatment migraine
simple analgesia:
Ibuprofen - 400mg or inc to 600mg if ineffective
Paracetamol 1g
aspirin 600mg
Triptan with or without simple analgesia
1st - Sumatriptan 50-100mg
if vomiting offer intranasal or S/C (secondary care)
consider metoclopramide or prochlorperazine - anti-emetic even without symptoms N+V
take as soon as migraine sets, for triptans take as soon as headache start and not at the start of aura
DO NOT offer opioids
pharmacological prophylaxis of migraines
propanolol 80-160mg OD in divided doses
Topiramate 50-100mg OD in divided doses - NOT FOR PREGNANCY NEED TO BE ON PPP!
Amitryptilline 25mg-75mg ON
DO NOT offer gabapentin or pregabalin
Bromocriptine BNF
Cabergoline BNF
Pergolide BNF
is an ergot alakaloid (inc dopamine, inh prolactin)
Used for the treatment of parkinson’s disease and suppression lactation
MHRA: pulmonary retroperitoneal and pericardial fibrotic reactions (fibrotic deposition in valves = inflammation) - MUST EXCLUDE CARDIAC VALVULOPATHY exc if for lactation suppression (much smaller doses)
MHRA: dopamine rec agonist associated with impulse control disorder - excessive gambling, binge eating, hypersexuality
C/I: X Cardiac valvulopathy
X Hypertension in post-partum or during pregnancy
X Cardiac disorder (severe) for lactation suppression
X mental disorders (severe) for lactation suppression
Xhypersensitivity to ergot alkaloids
S/E for lactation suppression - hypertension (discontinue immediately), MI, stroke, seizures (both sometimes preceded by severe headache or visual disturbances), mental disorder, unremitting headache (discontinue immediately), signs CNS toxicity (discontinue immediately), hypotension (esp at beginning)
GI bleed - withdraw if GI bleed seen, !in hx PEPTIC ULCER
CONTRACEPTION required (may inc prolactin conc)
Avoid BREASTFEEDING 5 days after stop (bromocriptine), avoid completely (cabergoline)
Adjust in HEPATIC IMPAIRMENT
Monitoring: pituitary enlargement (check not tumour)
Fibrotic disease
BP for HTN few days after starting and after dose inc
NEVER ABRUPTLY STOP ANTIPARKISON DRUGS
Caution DRIVING - sudden sleep onset and excessive daytime sleepiness
Counselling sodium valproate
women of childbearing age - must be part of PPP - od not stop taking it without talking to your dr - pharmacist must ensure that women has a patient card
blood or hepatic disorder - recognise symptoms of blood or hepatic disorders - seek immediate medical attention - persistent vomiting and abdominal pain, anorexia, jaundice, oedema, malaise, drowsiness, loss of seizure control
pancreatic disorder - seek immediate medical attention if symptoms of nausea, vomiting, abdominal pain dev
treatment neuropathic pain
- Amitriptylline
- Pregabalin
- Amitriptylline and Pregabalin
- norytriptilline and gabapentin are also options
- opioids may work (tramadol, morphine, oxycodone) but require spe review exc tramadol so use first till spe review
if pt NBM: topical anaesthetics (lidocaine plasters and capsaicin but risk of burning with capsaicin)
Sumatritan BNF
X in elderly
X in children
C/I X in CV pb (ie: HTN, MI, etc..)
S/E, hypersensitivity reaction: STOP if symptoms of heat, heaviness, pressure or tightness of chest or throat
!Caution in hepatic impairment reduce dose
OTC: for prev diagnosed migraine sell 50 mg, max 100mg OD
Baclofen BNF
anti spasmodic
X peptic ulcer, local or systemic infection
!in hx peptic ulcer, elderly, parkinson
S/E: anti-muscarinic s/e, hypotension
RENAL IMPAIRMENT:
excreted via kidney, care esp when eGFR under 15
gradually discontinue over 1-2 weeks - risks hyperthermia, psychiatric symptoms, convulsions
DO NOT GIVE WITH: Levodopa (inc s/e),
1st gen antipsychotic
block dopamine d2 in the brain
cause EPSE symptoms and raised prolactin
group 1: chlorpromazine, promazine hydrochloride - v.sedative effect, moderate antimuscarinic and EPSE
group 2: pericyazine - moderate sedation but fewer EPSE than gr 1 and 3
group 3: prochlorperazine - less sedating and antimuscarinic but v.EPSE
Haloperidol - same than group 3
flupentixol and zuclopenthixol - moderate sedation, antimuscarinic and EPSE
pimozide and sulpiride - reduced sedation, antimuscarinic and EPSE
2nd gen anripsychotic
amisulpride - renal imp but no BP effect
aripiprazole - does not affect BP
clozapine - manufacturer monitoring system
olanzapine - risk of CNS and resp depression after , injection, monitor for 4 hrs. Monitor blood lipids, weight, blood gluc
paliperidone - renal impairment
quetiapine - hepatic impairment
risperidone - hepatic impairment
antipsychotic with least weight gain
amisulpride aripiprazole haloperidol sulpiride trifluoperazine
antipsychotic with least diabetes S/E
haloperidol
fluphenazine decanoate
amisulpride
aripiprazole
