Neurology - Epilepsy & Headache Flashcards
Conditions that have associations with epilepsy.
- cerebral palsy
- tuberous sclerosis
- mitochondrial diseases
Causes of seizures.
- febrile convulsions
- alcohol withdrawal
- psychogenic non-epileptic seizures
- epilepsy
What are febrile convulsions?
Seizures provoked by fever in otherwise healthy children - typically occurring between the ages of 6 months and 5 years.
Clinical features of febrile convulsions.
- early in viral infection
- seizures are brief <5 mins
- tonic-clonic seizure
Features of simple febrile convulsion.
- lasts <15 minutes
- generalised seizure
- no recurrence within 24 hours
- complete recovery within an hour
Features of complex febrile seizure.
- lasts 15-30 minutes
- focal seizure
- may have repeat seizures within 24 hours
Features of febrile status epilepticus.
- lasts >30 minutes
Management of febrile seizure.
Children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics.
Ongoing management:
- call ambulance if seizure >5 minutes
- regular antipyretics
- benzodiazepines if recurrent convulsions
Prognosis of febrile seizures.
a) risk of further febrile convulsion
b) risk of epilepsy
a) 1 in 3
b) no increased risk in simple febrile seizure; increased risk if complex febrile seizure
Pathophysiology of alcohol withdrawal seizures.
Chronic alcohol consumption enhanced GABA mediated inhibition in the CNS.
Acute alcohol cessation leads to decreased inhibitory GABA, increasing the risk of seizure.
How are alcohol withdrawal seizures prevented?
- weaning from alcohol
- benzodiazepines given following cessation
What are psychogenic non-epileptic seizures?
A patient who presents with epileptic-like seizures but do not have characteristic electrical discharges.
Patients may have a history of mental health problems or personality disorder.
What are focal seizures?
A seizure that starts in a specific area, on one side of the brain.
This leads to functional impairment.
Level of awareness can vary.
Localising features of focal seizures.
Temporal lobe.
- rising epigastric sensation
- deja vu
- hallucinations
- lip smacking
- lip grabbing
- lip plucking
Localising features of focal seizures.
Frontal lobe.
- head / leg movements
- posturing
- post-ictal weakness
- Jacksonian march
Localising features of focal seizures.
Parietal lobe.
Paraesthesia
Localising features of focal seizures.
Occipital lobe.
Floaters / flashes
What are generalised seizures?
A seizure that involves networks on both sides of the brain at onset, causing immediate loss of consciousness.
Divided into motor (tonic-clonic) and non-motor (absence).
Signs and symptoms of siezures.
- tonic / clonic
- focal signs
- bite tongue
- urinary incontinence
- post-ictal phase of around 15 minutes
Investigating epilepsy.
- EEG
- MRI
NICE guidelines recommend starting antiepileptics after the first seizure when any of the following are present:
- neurological deficit
- brain imaging shows structural abnormality
- EEG shows epileptic activity
- patient preference
Drug treatment for
Generalised tonic-clonic seizures.
Male: sodium valporate
Female: lamotrigine or levetiracetam
Drug treatment for
Focal seizures.
First line: lamotrigine or levetiracetam
Second line: carbamazepine
Drug treatment for
Absence seizures.
First line: ethosuximide
NB: Carbamazepine may exacerbate absence seizures.
Drug treatment for
Myoclonic seizures.
Males: sodium valporate
Females: levetiracetam
Drug treatment for
Tonic / atonic seizures.
Males: sodium valporate
Females: lamotrigine
What contraception is generally preferred for women taking anti-epileptics?
UKMEC1: depo-provera, IUD, IUS
UKMEC2: implant
How should women with epilepsy who want to have children be managed?
Risks of uncontrolled epilepsy during pregnancy generally outweighs the risk of medication to the fetus.
Advise to take folic acid 5mg per day well before pregnancy, to minimise neural tube defects.
Which antiepileptics are preferred in pregnancy?
Carbamazepine and lamotrigine.
Studies to date show the rate of congenital malformations are low.
Is breast feeding safe when taking antiepileptics?
Yes - apart from barbiturates (e.g. amobarbital).
What advise is given to pregnant women taking phenytoin?
Prescription of vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
What is essential tremor?
An autosomal dominant condition affecting both upper limbs, causing a benign tremor.
Features:
- worse if arms outstretched
- improved by alcohol and rest
- most common cause of head tremor
Management of essential tremor.
First line: propranolol
Second line: primidone
What is chronic fatigue syndrome?
3 or more months of disabling fatigue affecting mental and physical function, in the absence of other disease which may explain symptoms.
Features of chronic fatigue syndrome.
- fatigue
- insomnia / hypersomnia
- muscle and/or joint pain
- headache
- sore throat
- general malaise
- dizziness
- nausea
- palpitations
Investigation of chronic fatigue syndrome.
Exclude other causes of fatigue:
- FBC (?anaemia)
- U&Es
- LFTs
- glucose
- TFTs
- ESR / CRP
- calcium
- CK
- ferritin
- coeliac screening
- urinalysis
Management of chronic fatigue syndrome.
Energy management with support from a healthcare professional / occupational therapy.
Refer to specialist CFS service.
Exercise programme overseen by CFS specialist team.
Cognitive behavioural therapy - supportive rather than curative.
Risk factors for cluster headaches.
- male sex
- smoking
- alcohol
Features of cluster headache.
- intense sharp, stabbing pain around one eye
- occurring once or twice a day
- episodes 15 minutes to 2 hours
- nasal stuffiness
- miosis / ptosis in some
Investigations of cluster headaches.
MRI with gadolinium contrast is imaging of choice.
Some patients will have underlying brain lesions even if the clinical symptoms are typical of a cluster headache.
Acute management of cluster headache.
- 100% oxygen (80% response rate in 15 mins)
- subcutaneous triptan (75% response rate in 15 mins)
Prophylaxis of cluster headaches.
Verapamil
Emerging evidence to support a tapering dose of prednisolone.
What is fibromyalgia?
A syndrome of widespread pain throughout the body, with tender points at specific anatomical sites.
The cause is unknown.
Features of fibromyalgia.
- chronic widespread pain
- lethargy
- cognitive impairment
- sleep disturbance
- headaches
- dizziness
Management of fibromyalgia.
- explanation of condition
- aerobic exercise
- cognitive behavioural therapy
- medications (e.g. pregabalin, duloxetine, amitriptyline)
Features of a tension headache.
- tight band around the head
- bilateral sensation of pressure
- may be related to stress
Management of tension headache.
First line:
- aspirin
- paracetamol
- NSAID
Can use low-dose amitriptyline for prophylaxis.
What is temporal arteritis?
A vasculitis of unknown cause that affects medium and large sized vessels.
Usually affects the temporal artery.
Associations of temporal arteritis.
Polymyalgia rheumatica
Complications of temporal arteritis.
- visual loss (permanent)
Features of temporal arteritis.
- headache
- jaw claudication
- visual changes / visual loss
- tender, palpable temporal artery
- lethargy
Vision testing in temporal arteritis.
Occlusion of the posterior cilliary artery results in ischaemia of the optic nerve head.
Fundoscopy shows a swollen pale disk and blurred margins.
Investigations of temporal arteritis.
- raised inflammatory markers (ESR, CRP)
- temporal artery biopsy
- CK and EMG normal
Treatment of temporal arteritis.
Immediate high-dose prednisolone* with tapering dose.
Urgent opthalmology review.
*co-prescribe PPI and bisphosphonates.
Features of a migraine.
- severe, unilateral, throbbing headache
- associated with nausea, photophobia and phonophobia
- precipitated by an aura
Triggers for a migraine attack.
- tiredness
- stress
- alcohol
- COCP
- lack of food / dehydration
- cheese, chocolate, red wine, citrus fruits
- menstruation
- bright lights
What is a hemiplegic migraine?
A variant of migraine in which motor weakness if a manifestation of aura.
Acute management of migraines.
First line: triptans and paracetamol.
Prophylaxis of migraines.
Prophylaxis given if migraines have a significant impact on quality of life and daily function.
First line: propranolol or amitriptyline
NB: possibly a role for acupuncture.
Management principles of a migraine during pregnancy.
- paracetamol 1g is first-line
- NSAIDs can be used second-line in the first and second trimester
- avoid aspirin and opioids such as codeine during pregnancy
Management principles of a migraine associated with menstruation.
SIGN recommends that women are treated with:
- mefanamic acid
- combination of aspirin, paracetamol and caffeine
Triptans are also recommended in the acute situation
Features of medication overuse headache.
- present for >15 days per month
- developed or worsened while taking regular symptomatic medication
- patients using opioids and triptans most at risk
Management of medication overuse headache.
- simple analgesics and triptans should be withdrawn abruptly
- opioid analgesics should be gradually withdrawn
Causes of secondary headaches.
- infections
- obstructive sleep apnoea
- pre-eclampsia
- head injury
- carbon monoxide poisoning
Headache differentials.
- meningitis
- encephalitis
- subarachnoid haemorrhage
- head injury
- sinusitis
- glaucoma
- Paget’s disease
- space occupying lesion
Red flags of headache.
- fever, photophobia or neck stiffness
- new neurological symptoms
- visual disturbance
- ‘thunderclap’ headache
- worse on cough or straining
- vomiting
- history of trauma
- history of cancer
- pregnancy
Examination of any patient with a headache.
Always do fundoscopy to look for papilloedema.
Define status epilepticus.
- seizure lasting more than 5 minutes
- multiple seizures without regaining consciousness in the interim
Management of status epilepticus.
- Benzodiazepine, repeated after 5 minutes
- Phenytoin
- Barbital or general anaesthesia
Options for benzodiazepines in status epilepticus.
- buccal midazolam (10mg)
- rectal diazepam (10mg)
- IV lorazepam (4mg)
