Neurology 1 Flashcards
How do migraines typically present?
Recurrent, severe headache which is usually unilateral and throbbing in nature
May be be associated with aura, nausea and photosensitivity
Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
In women may be associated with menstruation
How do tension headaches typically present?
Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
Not aggravated by routine activities of daily living
How do cluster headaches typically present?
Pain occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
Intense pain around one eye (recurrent attacks ‘always’ affect same side)
Patient is restless during an attack
Accompanied by redness, lacrimation, lid swelling
More common in men and smokers
How does temporal arteritis typically present?
Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR
How does a medication overuse headache typically present?
Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity
Give some causes of an acute onset single episode of headache
meningitis / encephalitis
subarachnoid haemorrhage
head injury
sinusitis
glaucoma (acute closed-angle)
Give some causes of chronic headache
chronically raised ICP
Paget’s disease
psychological causes
Give some red flags for a headache
Fever, photophobia or neck stiffness (meningitis)
History of head trauma (haemorrhage)
History of cancer (brain mets)
Postural , triggered by coughing / straining (raised ICP)
Visual disturbance (GCA, glaucoma, tumours)
New-onset neurological deficit
Change in personality
Impaired level of consciousness
What may tension headache be associated with?
Stress
Depression
Alcohol
Skipping meals
Dehydration
How can tension headaches be managed?
Reassurance
Simple analgesia (e.g., ibuprofen or paracetamol)
Low dose amitriptyline is generally first-line for chronic or frequent tension headaches
What is a common trigger for cluster headaches?
drinking alcohol
How should cluster headaches be investigated?
most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache
MRI with gadolinium contrast is the investigation of choice
How should cluster headaches be managed?
NICE recommend seeking specialist advice from a neurologist
acute:
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)
prophylaxis: verapamil
Which patients are most at risk of developing medication overuse headaches?
patients using opioids and triptans are at most risk
How should medication overuse headaches be managed? What is the risk with this?
simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches)
opioid analgesics should be gradually withdrawn
Withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances and anxiety may occur
Headache following lumbar puncture (LP) occurs in approximately one-third of patients.
What features does it present with?
usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position
How can headache following LP be managed?
supportive initially (analgesia, rest)
if pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma
treatment options include: blood patch, epidural saline and IV caffeine
Migraine is a complex neurological condition causing episodes of headache and associated symptoms. It tends to affect women more than men and is most common in young adults.
What are the 4 main types?
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
What are the 5 stages of migraine?
Premonitory or prodromal stage (can begin several days before the headache)
Aura (lasting up to 60 minutes)
Headache stage (lasts 4 to 72 hours)
Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
Postdromal or recovery phase
Give some typical features of migraine
Usually unilateral but can be bilateral
Pounding or throbbing in nature
Photophobia (discomfort with lights)
Phonophobia (discomfort with loud noises)
Osmophobia (discomfort with strong smells)
Aura (visual changes)
Nausea and vomiting
What is aura?
sensory disturbance commonly associated with migraines
Visual symptoms are the most common.
These may be:
Sparks in the vision
Blurred vision
Lines across the vision
Loss of visual fields (e.g., scotoma)
What are hemiplegic migraines?
migraines associated with hemiplegia (unilateral limb weakness). Other symptoms may include ataxia and impaired consciousness
may be familial
can mimic a stroke or TIA so should be investigated urgently
Give some common migraine triggers
Stress
Bright lights
Strong smells
Certain foods (e.g., chocolate, cheese and caffeine)
Dehydration
Menstruation
Disrupted sleep
Trauma
What are the medical options for managing an acute migraine attack?
NSAIDs (e.g., ibuprofen or naproxen)
Paracetamol
Triptans (e.g., sumatriptan)
Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)
What are triptans?
How do they work to treat migraines?
5-HT receptor agonists (they bind to and stimulate serotonin receptors)
They have various mechanisms of action:
Cranial vasoconstriction
Inhibiting the transmission of pain signals
Inhibiting the release of inflammatory neuropeptides
When can you NOT use triptans in migraine mx?
Triptans are taken as soon as a migraine starts and should halt the attack. If the attack resolves and then reoccurs, another dose can be taken. If it does not work the first time, another second dose should NOT be taken for the same attack.
Risks associated with vasoconstriction:
hypertension, coronary artery disease or previous stroke, TIA or MI
What can be used in migraine prophylaxis?
headache diary to identify and avoid triggers
Propranolol (a non-selective BB)
Amitriptyline (TCA)
Topiramate (teratogenic!!!)
CBT, mindfullness and acupuncture may also be used
What is Parkinson’s disease?
a chronic, progressive, degenerative neurological condition leading to disorders of movement
due to reduction in dopamine in the basal ganglia
symptoms are characteristically asymmetrical, with one side of the body affected more
What is the Parkinson’s disease (PD) triad?
Resting tremor
Rigidity (resisting passive movement)
Bradykinesia (slowness of movement)
What factors are thought to be protective against developing PD?
smoking
caffeine
aerobic exercise
What factors are thought to increase risk of developing PD?
Family history
- particularly evident if onset of disease is in people less than 50-years-old
Previous head injury
Outline the pathophsyiology of PD
selective loss of dopaminergic neurons in the substantia nigra = in a reduction in dopaminergic output
What features may PD present with?
Pill-rolling tremor
Cogwheel rigidity
Bradykinesia: movements getting slower and smaller
Shuffling gait , difficulty in initiating movement
Mask-like facies (hypomimia)
Dysarthria and dysphagia
Micrographia
Postural Instability : increased risk of falls!
Describe the tremor seen in PD
‘Pill-rolling’ resting tremor, 4-6 hertz frequency
Usually unilateral or worse on one side than another
Exacerbated by rest, and improves when a person engages in purposeful actions
Exaggerated when the other hand is being used to do something else (can ask someone to mime painting a fence)
How does muscle rigidity in PD manifest for the patient?
muscular stiffness, stooped posture, and reduced arm swing when walking
What may a patient who is experiencing bradykinesia due to PD describe in the history?
reduction in manual dexterity of finger movements (e.g. fastening buttons, picking up small items), difficulty standing from a seated position, and troubles when walking (e.g. dragging feet)
What non-motor sxs may a patient with PD experience?
Depression
Sleep disturbance and insomnia
Loss of the sense of smell (anosmia)
Cognitive impairment and memory problems
How can you differentiate between a Parkinson’s tremor and a Benign Essential tremor?
How may Parkinson’s Disease be investigated and diagnosed?
Usually a clinical diagnosis: UK Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria
Investigations to differentiate from other disorders:
Single photon emission computed tomography (SPECT) to distinguish Parkinson’s disease from an essential tremor and Parkinsonism
Structural MRI to exclude structural abnormalities as the cause of the symptoms
What is the diagnostic criteria for PD?
Presence of bradykinesia plus at least one of the following:
* Muscular rigidity
* Resting tremor (4-6 Hz frequency)
* Postural instability (not caused by a visual, vestibular, cerebellar or proprioceptive dysfunction)
Give some ddx for PD
Essential tremor
Multiple system atrophy
Lewy-body dementia
Secondary Parkinsonism
What are the similarities and differences between Multiple System Atrophy and PD?
Similarities:
Both may initially present with Parkinsonian features
Both may respond to levodopa therapy
Both have an element of autonomic dysfunction (although more pronounced in MSA)
Differences:
In MSA, there is usually cerebellar involvement, which is part of the exclusion criteria for Parkinson’s disease
Cognition is well preserved in MSA
What are the differences between Lewy-Body dementia and PD?
In Lewy-body dementia, the dementia usually occurs alongside, or prior to, the development of parkinsonism (and must occur no later than a year after onset of motor symptoms)
In PD, motor symptoms appear before cognitive decline
What may cause secondary Parkinsonism?
Drug induced: Anti-psychotics and anti-emetic drugs which act via dopaminergic antagonism
Vascular: due to multiple infarcts affecting the basal ganglia
How can drug-induced Parkinsonism be differentiated from PD?
Can be distinguished via a thorough medication history
Other movement disorders also caused by these drugs can help differentiate, such as akathisia, tardive dyskinesia and acute dystonia
Usually causes symmetrical symptoms (PD is asymmetrical)
How can vascular Parkinsonism be differentiated from PD?
Usually can be identified via a thorough history and radiological findings
Probably step-wise progression rather than continuous
What are the treatment options for PD?
Levodopa (combined with peripheral decarboxylase inhibitors)
COMT inhibitors
Dopamine agonists
Monoamine oxidase-B inhibitors
What is Levodopa?
precursor to dopamine which is converted both in the CNS and periphery
can be taken orally
patients may build a tolerance so not usually given first line
What are the main side effects of Levodopa?
Dyskinesia:
Dystonia (where excessive muscle contraction leads to abnormal postures or exaggerated movements)
Chorea (abnormal involuntary movements that can be jerking and random)
Athetosis (involuntary twisting or writhing movements, usually in the fingers, hands or feet)
What can be used to manage dyskinesia associated with levodopa?
Amantadine - a glutamate antagonist
Give some examples of Monoamine oxidase B (MAO-B) inhibitors. How do they work?
rasagiline and selegiline
inhibitors of MAO-B which degrades dopamine, therefore increasing the amount of circulating dopamine available
used to delay the use of levodopa, then in combination with levodopa to reduce the “end of dose” worsening of symptoms
Dopamine agonists mimic the action of dopamine in the basal ganglia, stimulating the dopamine receptors.
Give some examples
Bromocriptine
Pergolide
Cabergoline
What is the main side effect of prolonged use of dopamine agonists?
Pulmonary fibrosis
What are COMT Inhibitors (e.g. entacapone)? How do they work?
inhibitors of catechol-o-methyltransferase (COMT) enzyme which metabolises levodopa in both the body and brain
Entacapone is taken with levodopa (and a decarboxylase inhibitor) to slow the breakdown of the levodopa in the brain
Extends the effective duration of the levodopa
The first-line treatment for early stage Parkinson’s disease depends on what?
depends on the impact of the motor symptoms on the patient’s quality of life
If motor symptoms impact on quality of life - levodopa
If motor symptoms do not impact on quality of life - dopamine agonist, levodopa or MAO-B inhibitors
What can you use to help guide which medications to use to manage someone’s PD?
The patient’s current symptom profile
Patient age (UptoDate indicate that for patients over 65-years-old, levodopa is better tolerated than dopamine agonists)
Current co-morbidities and existing medications (need to consider the risk of polypharmacy and medication interactions)
Possible risks and side effects of each medication
What can be used as an adjuvant to medical therapy for PD?
Deep brain stimulation- if sxs not controlled by medication
Physio
Speech therapy
Occupational therapy
What complications may be experienced by patients with PD?
Autonomic dysfunction
Recurrent falls
Cognitive impairment
Autonomic dysfunction occurs when the autonomic nervous system fails to work appropriately, and may be seen in patients with progressive PD.
How may this manifest?
Postural hypotension with no compensatory tachycardia
- dizziness, light-headedness and subsequent falls
Constipation
-due to dysregulated colonic smooth muscle activity
Urinary dysfunction
- increased urinary frequency and urgency
Why are patients with PD at 2 fold greater risk of falls than their peers?
postural instability and impaired corrective reflexes
orthostatic hypotension