Neurology: Epilepsy & Headache Flashcards
What 5 types of seizures are generally seen in adults?
1) Generalised tonic-clonic seizures
2) Partial seizures (or focal seizures)
3) Myoclonic seizures
4) Tonic seizures
5) Atonic seizures
Can also have alcohol withdrawal seizures
What are 3 more common seizures in children?
1) Absence seizures
2) Infantile spasms
3) Febrile convulsions
What 3 conditions may have an association with epilepsy?
1) cerebral palsy: around 30% have epilepsy
2) tuberous sclerosis
3) mitochondrial diseases
Who do febrile convusions typically occur in?
Children between the ages of 6 months and 5 years
What are febrile convulsions?
Tonic-clonic seizures that occur in children during a high fever.
When is the peak incidence of alcohol withdrawal seizures?
36 hours following cessation of drinking
What can reduce the risk of alcohol withdrawal seizures?
Benzos
What are psychogenic non-epileptic seizures?
describes patients who present with epileptic-like seizures but do not have characteristic electrical discharges
What may patients with psychogenic non-epileptic seizures have a PMH of?
patients may have a history of mental health problems or a personality disorder
What are ‘generalised’ seizures?
these engage or involve networks on BOTH sides of the brain at the onset
What are ‘focal’ or ‘partial’ seizures?
these start in a specific area, on ONE side of the brain
Types of generalised seizures?
1) tonic-clonic (grand mal)
2) tonic
3) clonic
4) typical absence (petit mal)
5) myoclonic: brief, rapid muscle jerks
6) atonic
Is there a loss of conscioussness in generalised seizures?
Yes
What can generalised seizures be further subdivided into?
Motor (e.g. tonic-clonic) and non-motor (e.g. absence)
What is involved in a tonic clonic seizure?
- tonic (muscle tensing)
- clonic (muscle jerking)
- complete loss of consciousness
- may be tongue biting, incontinence, groaning and irregular breathing
- followed by prolonged post-ictal period
What may patients experience before a tonic clonic seizure?
Patients might experience aura, an abnormal sensation that gives a warning that a seizure will occur
What is the post-ictal period?
Period following seizure where the person is confused, tired, and irritable or low.
Where do partial/focus seizures often occur?
Temporal lobes
Is there a LOC in partial/focus seizures?
no - patients remain awake during partial seizures
Are patients aware during partial/focal seizures?
Yes: remain aware during simple partial seizures
No: lose awareness during complex partial seizures
What symptoms may be associated with partial seizures, depending on the location of the abnormal electrical activity?
1) Déjà vu
2) Strange smells, tastes, sight or sound sensations
3) Unusual emotions
4) Abnormal behaviours
What are myoclonic seizures?
Myoclonic seizures present with sudden, brief muscle contractions, like an abrupt jump or jolt.
Is there a LOC in myoclonic seizures?
No
What can myoclonic seizures occur as part of in children?
juvenile myoclonic epilepsy
What are tonic seizures?
Tonic seizures involve a sudden onset of increased muscle tone, where the entire body stiffens.
This results in a fall if the patient is standing, usually backwards.
What are atonic seizures?
Atonic seizures (causing “drop attacks”) involve a sudden loss of muscle tone, often resulting in a fall.
What may atonic seizures be indicative of?
Lennox-Gastaut syndrome.
When do atonic seizures often begin?
Childhood
Who are absence seizures usually seen in?
Children
What are absence seizures?
The patient becomes blank, stares into space, and then abruptly returns to normal. During the episode, they are unaware of their surroundings and do not respond. These typically last 10 to 20 seconds. Most patients stop having absence seizures as they get older.
What are infantile spasms?
Infantile spasms are also known as West syndrome.
Brief spasms beginning in first few months of life.
Has a poor prognosis.
When do infantile spasms typically start?
First 6 months of life
What are 3 features seen in infantile spasms?
1) Flexion of head, trunk, limbs –> extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
2) Progressive mental handicap
3) EEG: hypsarrhythmia
What is the characteristic EEG feature in infantile spasms?
Hypsarrhythmia
Treatment of infantile spasms?
1) ACTH
2) vigabatrin
prognosis of febrile convulsions?
1) do not usually cause any lasting damage
2) 1/3 will have another febrile convulsion.
3) slightly increase the risk of developing epilepsy.
Link between febrile convulsions and epilepsy?
Febrile convulsions slightly increase the risk of epilepsy
Differentials for a seizure?
1) Vasovagal syncope (fainting)
2) Hypoglycaemia
3) Pseudoseizures (non-epileptic attacks)
4) Cardiac syncope (e.g., arrhythmias or structural heart disease)
5) Hemiplegic migraine
6) TIA
1st line investigations in epislepy?
1) An electroencephalogram (EEG)
2) MRI brain
Purpose of MRI brain in epilepsy/seizures?
MRI brain is used to diagnose structural pathology (e.g., tumours).
Additional investigations in epilepsy/seizures?
1) Blood glucose for hypoglycaemia and diabetes
2) ECG
3) Serum electrolytes
4) Blood cultures, urine cultures and lumbar puncture: where sepsis, encephalitis or meningitis is suspected
Driving following a 1st seizure?
Generally patients cannot drive for 6 months following a seizure
Driving in patients with established epilepsy?
patients with established epilepsy must be fit free for 12 months before being able to drive
General safety precautions in epilepsy:
1) The DVLA will remove their driving licence until specific criteria are met (e.g., being seizure-free for one year)
2) Taking showers rather than baths (drowning is a major risk in epilepsy)
3) Particular caution with swimming, heights, traffic and dangerous equipment
Give 4 examples of antiepileptics
1) Sodium valproate
2) Carbamazepine
3) Lamotrigine
4) Phenytoin
Mechanism of sodium valproate?
Increases GABA activity
Indications for sodium valproate?
1) Generalised tonic clonic seizures in males
2) Generalised tonic clonic seizures in women WHO CANNOT HAVE CHILDREN
1st line antiepileptic in women who are able to have children?
Lamotrigine or Levetiracetam
Why is sodium valproate not used in women of reproductive age?
Teratogenic - can cause neural tube defects and developmental delay.
When can sodium valproate be used in women of reproductive age?
Unless there are no suitable alternatives and strict criteria are met –> Valproate Pregnancy Prevention Programme is in place
Side effects of sodium valproate?
1) Teratogenic (harmful in pregnancy)
2) Liver damage and hepatitis
3) Hair loss (regrowth may be curly)
4) Tremor
5) Reduce fertility
6) Ataxia
7) Increased appetite and weight gain
1st & 2nd line antiepileptics in partial/focal seizures?
1st –> Lamotrigine or Levetiracetam
2nd –> carbamazepine
Mechanism of carbamazepine?
Binds to sodium channels increasing their refractory period
How does sodium valproate interact with the P450 system?
Is a P450 enzyme inhibitor
How does carbamazepine interact with the P450 system?
P450 enzyme inducer
Side effects of carbamazepine?
1) dizziness and ataxia
2) drowsiness
3) leucopenia and agranulocytosis
4) syndrome of inappropriate ADH secretion
5) visual disturbances (especially diplopia)
Which antiepileptic can cause SIADH?
Carbamazepine
1st line antiepileptics in myoclonic seizures?
Men & women who cannot have children –> sodium valproate
Women of reproductive age –> Levetiracetam
1st line antiepileptics in tonic and atonic seizures?
Men & women who cannot have children –> sodium valproate
Women of reproductive age –> Lamotrigine
1st line antiepileptics in absence seizures?
Men & women who cannot have children –> ethosuximide
Women of reproductive age –> ethosuximide
Side effects of phenytoin?
- dizziness and ataxia
- drowsiness
- gingival hyperplasia, hirsutism, coarsening of facial features
- megaloblastic anaemia
- peripheral neuropathy
- enhanced vitamin D metabolism causing osteomalacia
- lymphadenopathy
N.B. - no longer used first-line due to side-effect profile
Define status epilepticus
Either:
1) A seizure lasting more than 5 minutes
or
2) Multiple seizures without regaining consciousness in the interim
Management of status epilepticus?
ABCDE approach:
1) Securing the airway
2) Giving high-concentration oxygen
3) Checking blood glucose levels
4) Gaining intravenous access (inserting a cannula)
Medical treatment:
1) A benzodiazepine first-line, repeated after 5-10 minutes if the seizure continues
2) 2nd line (after two doses of benzodiazepine) are IV levetiracetam, phenytoin or sodium valproate)
3) 3rd line: phenobarbital or general anaesthesia
2nd line options in status epilepticus (if 2 doses of benzos haven’t worked)?
IV levetiracetam, phenytoin or sodium valproate
Options for benzos in status epilepticus?
1) Buccal midazolam (10mg)
2) Rectal diazepam (10mg)
3) Intravenous lorazepam (4mg)
When would you start antiepileptics in epilepsy?
Most neurologists now start antiepileptics following a 2nd epileptic seizure.
Most neurologists now start antiepileptics following a 2nd epileptic seizure.
In what circumstances would you suggest starting antiepileptics after the first seizure?
1) the patient has a neurological deficit
2) brain imaging shows a structural abnormality
3) the EEG shows unequivocal epileptic activity
4) the patient or their family or carers consider the risk of having a further seizure unacceptable
1st line management of generalised tonic-clonic seizures in males and females?
Males: sodium valproate
Females: lamotrigine or levetiracetam
Which women may be offered sodium valproate?
girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
1st & 2nd line management of focal seizures?
1st line: lamotrigine or levetiracetam
2nd line: carbamazepine, oxcarbazepine or zonisamide
1st & 2nd line management of absence seizures (petit mal)?
1st: ethosuximide
2nd:
- males: sodium valproate
- females: lamotrigine or levetiracetam
Which antiepileptic may exacerbate absence seizures?
carbamazepine
1st line management of myoclonic seizures in males & females?
Males: sodium valproate
Females: levetiracetam
1st line management of tonic or atonic seizures in males & females?
Males: sodium valproate
females: lamotrigine
In the hospital setting, which benzo is typically given?
IV lorazepam
What is a focal to bilateral seizure?
starts on one side of the brain in a specific area before spreading to both lobes
What type of seizure has lip smacking?
Complex focal seizures/temporal lobe focal seizures
Focal seizures in the temporal lobe often have an aura.
Typical features of this aura?
1) typically a rising epigastric sensation
2) also psychic or experiential phenomena, such as déjà vu, jamais vu
3) less commonly hallucinations (auditory/gustatory/olfactory)
What are complex focal seizures typically preceded by?
a simple focal seizure (aura)
What location seizure may there be flashes/floaters?
Occipital lobe (visual) focal seizure
What location seizure may there be paraesthesia?
Parietal lobe (sensory)
what are the safest antiepileptics in pregnancy?
Lamotrigine and levetiracetam
Give some important causes of headaches
1) Migraine
2) Tension headache
3) Cluster headache
4) Temporal arteritis
5) Medication overuse headache
Other causes of an acute single headache episode:
- meningitis
- encephalitis
- subarachnoid haemorrhage
- head injury
- sinusitis
- glaucoma (acute closed-angle)
- tropical illness e.g. Malaria
Other causes of a chronic headache:
- chronically raised ICP
- Paget’s disease
- psychological
- trigeminal neuralgia
- cervical spondylosis
Red flags in headache?
Fever, photophobia, neck stiffness: meningitis, encephalitis or brain abscess
New neuro symptoms: haemorrhage or tumours
Visual disturbance: giant cell arteritis, glaucoma or tumours
Sudden onset occipital headache: SAH
Worse on coughing or straining: raised ICP
Postural, worse on standing, lying or bending over: raised ICP
Vomiting: raised ICP or carbon monoxide poisoning
History of trauma: intracranial haemorrhage
History of cancer: brain mets
Pregancy: pre-eclampsia
What is an important investigation in headaches?
Fundoscopy for papilloedema –> suggests raised ICP (seen in brain tumour, benign intracranial hypertension or an intracranial bleed).
Presentation of a tension headache?
Very common.
They typically cause a mild ache or pressure in a band-like pattern around the head. They develop and resolve gradually and do not produce visual changes.
What may tension headaches be associated with?
Stress
Depression
Alcohol
Skipping meals
Dehydration
Management of tension headaches?
1) Reassurance
2) Simple analgesia (e.g., ibuprofen or paracetamol)
first-line for chronic or frequent tension headaches?
Amitriptyline
2ary headaches vs tension headaches?
Secondary headaches give a similar presentation to a tension headache but with a clear cause
Causes of 2ary headaches?
1) Infections (e.g., viral upper respiratory tract infection)
2) Obstructive sleep apnoea
3) Pre-eclampsia
4) Head injury
5) Carbon monoxide poisoning
What is sinusitis?
Sinusitis refers to inflammation of the paranasal sinuses in the face.
Presentation of sinusitis?
- pain and pressure following a recent viral URT infection
- tenderness and swelling on palpation of the affected areas
Management of prolonged (over 10 days) cases of sinusitis?
1) Steroid nasal spray
2) Antibiotics (phenoxymethylpenicillin first-line)
3) Leukotriene inhibitors e.g. montelukast
1st line Abx in prolonged sinusitis?
phenoxymethylpenicillin
What is a medication overuse headache?
Medication-overuse headache (also called analgesic headache) is a headache caused by frequent analgesia use.
What are hormonal headaches related to?
Low oestrogen
Presentation of hormonal headaches?
1) similar features to migraines
2) unilateral
3) pulsatile
4) associated with nausea
They are sometimes called menstrual migraines.
When do hormonal headaches typically occur?
1) Two days before and the first three days of the menstrual period
2) In the perimenopausal period
3) Early pregnancy (headaches in the second half of pregnancy should prompt investigations for pre-eclampsia)
When should a headache in pregnancy prompt investigations for pre-eclampsia?
In the 2nd half of pregnancy
Treatment options in hormonal headaches?
1) Triptans
2) NSAIDs (e.g., mefenamic acid)
What is cervical spondylosis?
a common condition caused by degenerative changes in the cervical spine.
Presentation of cervical spondylosis?
1) neck pain - worse on movement
2) headaches
What is trigeminal neuroalgia?
Trigeminal neuralgia causes intense facial pain in the distribution of the trigeminal nerve which has 3 branches:
1) Ophthalmic (V1)
2) Maxillary (V2)
3) Mandibular (V3)
Trigeminal neuralgia can affect any combination of the branches.
Presentation of trigeminal neuralgia?
1) intense facial pain
2) unilateral (90%)
What condition is trigeminal neuralgia associated with?
multiple sclerosis.
Describe the pain in trigeminal neuralgia
The pain comes on suddenly and can last seconds to hours.
It may be described as an electricity-like, shooting, stabbing or burning pain.
It may be triggered by touch, taking, eating, shaving or cold. Attacks may worsen over time.
1st line medication for trigeminal neuralgia?
Carbamazepine
What is a migraine?
Recurrent, severe headache which is usually unilateral and throbbing in nature
Who are migraines more common in?
- women
- teenagers & young adults
What 4 main types can migraine be categorised into?
1) Migraine without aura
2) Migraine with aura
3) Silent migraine (migraine with aura but without a headache)
4) Hemiplegic migraine
What is a silent migraine?
migraine with aura but without a headache
What are the 5 stages of a migraine?
1) Premonitory or prodromal stage (can begin several days before the headache)
2) Aura (lasting up to 60 minutes)
3) Headache stage (lasts 4 to 72 hours)
4) Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
5) Postdromal or recovery phase
These stages vary between patients. Some patients may only experience one or two of the stages.
Features of a migraine?
- severe, throbbing headache
- unilateral
- associated with nausea, photophobia, phonophobia and osmophobia
- patients characteristically go to a darkened, quiet room during an attack
- may be precipitated by an aura
Common triggers for a migraine?
- tiredness, stress
- alcohol
- combined oral contraceptive pill
- lack of food or dehydration
- foods e.g. cheese, chocolate, red wines, citrus fruits
- menstruation
- bright lights
- strong smells
- disrupted sleep
What may the prodromal stage of a migraine involve?
may involve days of subtle symptoms (e.g., yawning, fatigue or mood change) before the headache starts.
How long do migraines typically last?
Between 4 and 72 hours
What is phonophobia?
discomfort with loud noises
What is osmophobia?
discomfort with strong smells
What is an aura?
Include temporary visual or other disturbances that usually strike before other migraine symptoms Visual symptoms are the most common.
What features can be seen in an aura?
- Sparks in the vision
- Blurred vision
- Lines across the vision
- Loss of visual fields (e.g., scotoma)
- Sensation changes e.g. tingling or numbness
- Language symptoms e.g. dysphasia (difficulty speaking)
What is the main feature of hemiplegic migraines?
hemiplegia (unilateral limb weakness).
Features of hemiplegic migraines?
1) Hemiplegia
2) Ataxia (loss of coordination)
3) Impaired consciousness
What is familial hemiplegic migraine?
An autosomal dominant genetic condition characterised by hemiplegic migraines that run in families.
Management of acute migraine?
Often retreating to a dark, quiet room and sleeping.
Medical:
1) NSAIDs (e.g., ibuprofen or naproxen)
2) Paracetamol
3) Triptans (e.g., sumatriptan)
4) Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)
What is it important to rule out in a hemiplegic migraine?
Stroke/TIA as can present similarly
Are opiates used in migraines?
No - may make the condition worse.
What class of drug are triptans?
5-HT receptor agonists (they bind to and stimulate serotonin receptors)
When are triptans taken in migraines?
As soon as migraine starts - should halt the attack
Can a 2nd dose of triptans be taken for a migraine 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.
Contraindications to triptans?
The main contraindications relate to risks associated with vasoconstriction:
- HTN
- Coronary artery disease
- Previous stroke, TIA or MI
What prophylactic medications can be used to reduce the frequency and severity of migraine attacks?
1) Propranolol (a non-selective beta blocker)
2) Amitriptyline (a tricyclic antidepressant)
3) Topiramate (teratogenic and very effective contraception is needed)
Non-medical prophylaxis options in migraines?
1) Cognitive behavioural therapy
2) Mindfulness and meditation
3) Acupuncture
4) Vitamin B2 (riboflavin)
What is a medical prophylaxis management for menstrual migraines?
Prophylactic triptans (e.g., frovatriptan or zolmitriptan)
Migraines and the menopause?
Migraines tend to become less frequent and severe or stop altogether with time, particularly after menopause.
Migrains and stroke?
Migraines are associated with a slightly increased risk of stroke, particularly when associated with aura.
What increases the risk of stroke in those with migraines?
The risk of stroke is further increased with the combined contraceptive pill, making them a contraindication to the combined pill.
1st & 2nd line medical management of migraines in pregnancy?
1st: Paracetamol
2nd: NSAIDs can be used in the first and second trimester
Avoid aspirin and opioids such as codeine during pregnancy
What is a cluster headache?
Cluster headaches are severe and unbearable unilateral headaches, usually centred around the eye.
Risk factors for cluster headaches?
- Male
- Smoking
- Alcohol may trigger attack
Features of a cluster headache?
- Intense sharp, stabbing pain around one eye
- accompanied by redness,
- lacrimation, lid swelling
- nasal stuffiness
- miosis and ptosis in a minority
Describe pain in cluster headaches
- pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
- the patient is restless and agitated during an attack due to the severity
How long do clusters typically last?
4-12 weeks
For example, a patient may suffer 3-4 episodes a day for weeks or months, followed by a pain-free period lasting several years. Attacks last between 15 minutes and 3 hours.
Investigation of choice in cluster headaches?
MRI with gadolinium contrast
Triggers for a cluster headache?
alcohol, strong smells or exercise.
Management of an acute attack of a cluster headache?
1) Triptans (e.g., subcutaneous or intranasal sumatriptan)
2) High-flow 100% oxygen (may be kept at home)
1st line drug for prophylaxis of cluster headaches?
verapamil (calcium channel blocker)
Other options for prophylaxis of cluster headaches:
1) Occipital nerve block
2) Prednisolone (e.g., a short course to break the cycle during clusters)
3) Lithium
Important aspects to cover in epilepsy consultation?
- Seizure control
- Medications, side effects & compliance
- Impact on work, study, leisure
- Relevant education – safety in water, avoiding triggers/risk factors
- If woman: contraception, planning pregnancy etc
- Driving
- Management of seizures (for carers also) and emergency medication
- Osteoporosis risk certain meds
- Leaflets & websites
- General health assessment – smoking, alcohol,BMI, BP, STI and cervical screening – as appropriate
What are some triggers for seizures?
- alcohol
- drugs
- missing meds
- sleep deprivation
- stress
- light sensitivity
- head injury
