CNS Flashcards
What is the treatment pathway for episodic tension-type headache (TTH)?
- Offer simple pain relief: Paracetamol, NSAIDs or aspirin
- Advise to take therapeutic dose when episode begins
- Identify and treat any comorbidities associated with TTH:
- Stress
- Insomnia
- Mood disorders
What is the treatment pathway for chronic tension-type headache (TTH)?
(Same for acute and general treatment)
- Pain relief with Paracetamol, NSAIDs or aspirin
- Low dose amitriptyline 10-75mg daily (prophylaxis)
- Make headache diary (If coexistence with migraine suspected)
- Acupuncture over 5–8 weeks
What does epidural mean?
Above/outside the dura, same effect as a spinal block, it just doesn’t deliver the drugs in to the cerebrospinal fluid directly.
How can we treat raised intracranial pressure?
Think conservative measures first, then medical and surgical
- Keep neck straight (helps drainage)
- Head tilt (helps drainage)
- Hyperventilation(reduces CO2, which has a vasodilator effect)
- Sedation (Barbiturate coma with phenobarbitone reduces metabolic demands)
- Fluids (maintain osmolarity and volume, prevent cerebral oedema)
- Mannitol (osmotic diuretic, draws water from the brain to reduce oedema)
- Decompressive craniectomy
- CSF drain
What is the acute treatment pathway for migraine?
We treat the symptoms: Pain, N&V
- Aspirin 900mg dispersible or Paracetamol 1g If patient has N&V (signs of gastric paresis)
- Antiemetic: Domperidone, prochlorperazine or metoclopramide (improves medication absorption)
- Tristan: one dose of sumatriptan, zolmitriptan (CI = TIA, IHD, MI, HTN)
What are the requirements to qualify for prophylactic treatment of migraine?
- QOL severely affected by condition
- 2+ episodes per month
- Episodes don’t respond to acute treatment
- Frequent/long/uncomfortable aura occurs
What is first line prophylactic treatment for migraine?
Beta blockers or Low dose amitryptaline
If it’s menstrual: Transdermal oestrogen patch before menstruation
What is the second line prophylactic treatment for migraine?
Sodium valproate or topirimate
Antiepileptics
What is the treatment pathway for bacterial meningitis?
1st line= Ceftriaxone, CT head and steroids
- Antibiotic: Ceftriaxone or cefotaxime (3rd generation cephalosporin)
Or: benzylpenicillin if in GP setting - CT head (exclude encephalitis)
- Add Dexamethasone
Other:
4. If patient is over 60 add amoxicillin
- If meningitis is Penicillin resistant = vancomycin or rifampicin
- If patient is allergic to penicillin or cephalosporin: chloramphenicol with dexamethasone
- If patient is over 60 and allergic to penicillin or cephalosporin: add co-trimoxazole
What is first line treatment for tension headache?
NSAIDs or Paracetamol
Second line = acupuncture referral
What is the treatment pathway for acute cluster headache treatment?
- High flow oxygen
- IV/nasal Sumatriptan
- Prednisalone 60mg PO for one week
What is the prophylactic treatment for cluster headache?
Verapamil
- a class four anti-arrhythmic agent CCB acting as an inotrope
- reduces heart rate and blood pressure
- unlike normal CCBs it doesn’t just cause vasodilation
What is treatment for cluster headache?
Verapamil and analgesia
What is the treatment pathway for giant cell arteritis?
Only one pathway
Oral prednisolone:
1. GCA + visual symptoms =60 mg one-off dose
2. GCA = 40 to 60 mg daily
Ophthalmology referral
- Assess response within 48 hours
- Start aspirin 75 mg daily
- Start a PPI - omeprazole 20mg
6.Advise the person:
To seek urgent (same-day) medical attention if they develop any visual disturbances (such as visual loss, double vision, or visual field defects).
What is first line treatment for status epilepticus?
Benzodiazepines: IV lorazepam or buccaneers midazolam
When treating epilepsy in women what is a major obstacle?
Epilepsy medications are mostly all teratogenic, any woman of child-bearing age treated for epilepsy should be given careful consideration before pregnancy.
Sodium valproate is the most teratogenic of the medications.
What is the treatment for generalised onset tonic-clonic seizures?
(First line) Sodium valproate or lamotrigine
Treat with one drug only and build up dose slowly until maximum dose reached or seizures controlled.
What is the treatment for focal onset seizures?
(First line) Carbamazepine or lamotrigine
Treat with one drug only and build up dose slowly until maximum dose reached or seizures controlled.
What is the treatment for absence seizures?
(First line) sodium valproate or ethosuximide.
Treat with one drug only and build up dose slowly until maximum dose reached or seizures controlled.
What is the treatment for myoclonic seizures?
(First line) sodium valproate.
Treat with one drug only and build up dose slowly until maximum dose reached or seizures controlled.
What is the treatment for atonic or tonic seizures?
(First line) sodium valproate or lamotrigine.
Treat with one drug only and build up dose slowly until maximum dose reached or seizures controlled.
When can anti-epileptic medication be started immediately?
Only if risk of recurrence is high:
Structural brain lesion
Focal CNS deficit
Unequivocal epileptiform EEG
How long must a patient be seizure free before they can drive again?
One year
They must inform the DVLA immediately
Do you normally monitor anti-epileptic medication blood levels?
No
Only circumstances requiring testing: Non-adherence Suspected toxicity Adjustment of phenytoin dose Management of interactions (other drugs) Status epilepticus Organ failure
