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KFP study > Neurology/Headaches > Flashcards

Neurology/Headaches Flashcards

1
Q

SNOOP-4 pneumonic for RED FLAG features of a headache?

A

Systemic features: fever, rash or secondary risks like HIV

Neurological signs (confusion, impaired consciousness)

Onset- sudden?

Older person- new onset headache aged over 50?

Previous headache history - is this new or altered from usual headache

Positional or positional aggravated

Precipitated by the Valsalva manoeuvre

Papilloedema

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2
Q

Typical features of a migraine?

(5)

A

One sided, but not side locked

lasting 4-72 hours

pulsating quality

associated: photopobia, osmophobia, phonophobia

can have an aura that takes 5-20 minutes to develop, lasting 60minutes

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3
Q

Difference between cervicogenic headache vs. cervical radiculopathy vs. cervical myelopathy ?

A

Cervicogenic headache (secondary headache)- caused by dysfunction in bone/soft tissue or disc. Neck usually has reduced ROM. Provoked by neck manoevres

Cervical radiculopathy- caused specifically by nerve root compression or irritation. Usually other signs like pins and needles down the arm or weakness, or reduced tricep reflex.

Cervical myelopathy- EMERGENCY. Midline disc herniation in the cervical spine compressing the spinal cord. Usually have gait issues, maybe up-going plantar reflexes. Needs surgical correction..

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4
Q

List general measures to prevent headaches

(8)

A

Regular sleep schedule

Glycemic control even if not diabetic

Hydration

Limit caffeine intake

Regular cardiovascular exercise

Good workplace ergonomics: screen time, seating, breaks

Relaxation techniques: meditiation, mindfullness, progressive muscular relaxation

Avoidance of known triggers: smoke, alcohol, citrus fruit, perfume

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5
Q

Non pharmacological longer term management for tension type headaches?

(5)

A

Acupuncture (at least 6 treatments)
CBT
Relaxation training
Physiotherapy
Aerobic exercise

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6
Q

Pharmacological management for REGULAR tension headaches. i.e. prophylaxis

A

Amitriptyline or Nortriptyline both 10mg PO nocte, increase by 10mg every week up to 75mg. Review at 8 weeks

Continue for 6 months and then consider deprescribing

(Whilst the eTG might suggest this, BUT it is not TGA approved)

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7
Q

Acute non pharmacological migraine management?

(4)

A

cold packs over the forehead or back of the skull (targeting the supraorbital and greater occipital nerves)

hot packs over the neck and shoulders (targeting the innervation of the scalp)

neck stretches and self-mobilisation

Rest in a quiet dark room

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8
Q

Medication management in acute migraine in an adult?

(3)

A
  1. paracetamol, aspirin, NSAIDs
    Aspirin soluble 900mg PO - wait 4-6 hours before a repeat dose (max 2g in a day)
    -aspirin and ibuprofen are first line. Paracetamol is second line.
    -also note ibuprofen dose 400-600mg, and wait 4-6 hours before repeating Max: 2.4grams / day
    -paracetamol is at normal dosing
  2. Can add antiemetic
    Metoclopramide 10mg PO wait at least 1-2 hours (max dose 30mg/day)
    Domperidone 10-20mg PO (max at 30mg/day)
    Ondansetron 4-8 mg PO (max dose 16mg/day)
  3. Triptan
    Rizatriptan (Maxalt) 10mg PO, 2 hourly (max 30mg/day) ← does have a under the tongue formulation
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9
Q

What is important to remember about triptan usage?

A

A second dose of oral sumatriptan can be given after at least 2 hours if the migraine initially resolved, but then recurred. If the patient has not responded to the first dose of triptan, do not give a second dose for the same migraine attack

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10
Q

Cluster headache acute treatment?

(2)

A
  1. Rizatriptan 10mg orally, immediately, up to 30mg a day, repeated every 2 hours. Do not repeat if no resolution between doses.
  2. 100% oxygen. 15L/min in a tight fitting non rebreather for 20 minutes
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11
Q

What is a trigeminal neuralgia?

A

Unilateral shock like pain in the trigeminal distribution of V2 aV3 mainly.
Triggered by touch, or chewing, brushing teeth or even exposure to cold winds
Mainly women aged 40-70

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12
Q

Management steps for trigeminal neuralgia?

A
  1. Imaging of ganglion
  2. Carbamazepine MR 100mg PO BD, increase every 7 days up to 400mg BD (800mg a day)
    Second line oxycarbammazepine
    Third line: Pregabalin 75mg PO nocte, increase every 3-7 days up to 300mg BD (i.e 600mg in a day)
  3. Refer to surgery
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13
Q

Prophylactic treatment for Tension Headaches?

A

Amitriptyline or Nortriptyline both 10mg PO nocte, increase by 10mg every week up to 75mg. Review at 8 weeks

or

If Preventative measures don’t work after 8- 12 weeks then try

Mirtazapine 15-30mg nocte review after 8-12 weeks
Venlafaxine 75mg PO mane with food (up to 150mg). Review in 8-12 weeks

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14
Q

Give examples of triggers for a migraine.

(7)

A

You’ll want to avoid or limit:

Citrus foods
Tomatoes
Aspartame products
MSG
Fatigue
Exertion
Hormonal Changes

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15
Q

Medications for Migraine prophylaxis

Taking into account Best evidence and associated conditions:

hypertension/obesity/diabetes
Insomnia
anxiety
depression

A

Level A evidence and TGA approved is Propranolol 20mg PO Nocte (increase weekly by 20mg if needed, max 160mg in divided doses)

HTN/obesity/diabetes use Candersatan 4mg PO daily (increase weekly by 4mg, max 32mg)

Anxiety- propranolol

Depression- any SSRI/SNRI, dosing as per depression e.g
Sertraline 50mg, orally, daily, increasing by 25mg to a max of 200mg daily.

Insomnia
Amitriptyline 10mg PO nocte (increase 10mg weekly, max 75mg) Continue maximum tolerated dose for 8-12 weeks then review.

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16
Q

Cluster headache prevention medication.

And what important beside test to do before each dose increase?

A

Verapamil IR 80mg PO TDS 2 weeks → 120mg TDS 2 weeks → 160mg TDS
(should repeat ECG before each dosing change and only increase if ECG is completely NSR. Heart block may not appear until 10 days after the first dosing)

17
Q

List some lifestyle interventions to help prevent migraines.

(6)

A

Regular exercise
Address anxiety and depression
Address sleep practices and sleep hygiene
Stress management
Avoidance of triggers (exertion, MSG, citrus foods etc)
Reduction of caffeine intake

18
Q

What is secondary management after a stroke?

(8)

A
  1. Tailor towards pathogenesis
  2. Screen and treat for diabetes
  3. Encourage good dietary and exercise habits (SNAP)
  4. Treat any hypertension (most important)
  5. Aspirin 100mg orally, daily, lifelong (or clopidogrel 75mg, oral, daily). Initially can be on both for 90 days.
  6. Anti-coagulate if raised CHA2DSVA2 score.
  7. High dose statin even if cholesterol is normal
  8. Follow up for any carotid stenosis (most like carotid U/S or CT angio already done in ED).
19
Q

In a person with a Transient Ischemic attack, who would qualify as needing urgent (within 24 hours) referral to a stroke unit/rapid response TIA clinic?

A

If a patient with a TIA has ANY of the below, then an urgent referral should be done:

ABCD2 score >4
Atrial Fibrillation
Crescendo TIA (2 or more within a week)
Carotid bruit

20
Q

If a patient with a TIA is not deemed high risk (needing urgent referral in 24 hours), then what investigations should the GP initiate?

(5)

A

FBC, EUC, LFT
Fasting lipids, good glucose
ESR/CRP
CT brain or MRI (within 48 hours)
Carotid imaging

21
Q

If a person with a TIA has an U/S and it shows a carotid stenosis, what is the cut off mark that requires urgent endarterectomy within 2 weeks?

A

> 50% stenosis

22
Q

What is the target systolic BP for someone with a stroke or TIA?

A

systolic aimed between 120-130

23
Q

What makes up the diagnostic criteria for Parkinson’s disease?

A

Bradykinesia PLUS only one (or more) of the following:

-muscular rigidity

-4-6 hz resting tremor

-postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction.

24
Q

What are non motor symptoms in Parkinson’s disease?

(6)

A

Fatigue

Neuropsych (depression, anxiety, psychosis)

Sleep disturbance

Autonomic: bowel, bladder, sexual dysfunction

Pain and other sensory issues

Dysphagia

25
Q

What medication can a GP start for Parkinson’s disease, and when should it be initiated?

A

levodopa+carbidopa 50+12.5 mg orally, 3 times daily, increasing to 100+25 mg 3 times daily over 1 to 2 weeks

Second line is pramipexole, there are other options too.

The decision to start treatment in patients again relies on patient preference, the severity of both non-motor and motor disability and related impairment in quality of life (social or physical).

26
Q

Which medications should be avoided in person’s with parkinson’s disease?

A

Metoclopramide and Prochlorperazine

27
Q

What 3 conditions can lead to restless legs?

(PIE)

A

Pregnancy

Iron deficiency

End stage kidney disease

28
Q

what is the symptom description of restless legs?

A

Usually leg (+/-) arm discomfort, usually at rest when LYING (not usually when sitting), followed by an urge to move the body part. The sensation itself has a WIDE range of descriptions and variation, and sometimes cannot be described well by the patient.
It can be unilateral or bilateral

29
Q

What 3 lifestyle changes can help treat restless legs, if symptoms are mild?

A
  1. Physical exercise
  2. Good sleep practices
  3. good dietary or other Iron Intake. Aiming ferritin > 50
30
Q

What dose of dopaminergic drug is used to treat restless legs?

A

levodopa+carbidopa 100+25 to 200+50 mg orally, before bedtime when needed.

31
Q

Apart from a dopamine agonist what can you use for more severe symptoms of restless legs?

A

gabapentin 100 to 300 mg orally, once daily at night. Gradually increase dose every 3 to 7 days as tolerated and according to response, up to 2400 mg daily

Or

pregabalin 75 mg orally, once daily at night. If needed, gradually increase dose every 3 to 7 days as tolerated and according to response, up to 450 mg daily.

32
Q

What in room tests can you do for a seizure presentation?

A

urine dipstick

fingerprick BGL

33
Q

Can a GP order a rebatable MRI for a seizure?

A

Yes, it is MBS rebatable.

MRI - scan of head for a patient 16 years or older, after a request by a medical practitioner (other than a specialist or consultant physician), for any of the following:

(a) unexplained seizure(s);
(b) unexplained chronic headache with suspected intracranial pathology

34
Q

What are triggers of a seizure?

(6)

A

Sleep deprivation

Overuse of alcohol

Fever

Intercurrent illness

Severe sustained stress

Combination of the above

35
Q

What advice can you give after a first seizure?

(6)

A

first aid measures

Workplace safety consideration

Avoid Sleep deprivation

Regular exercise

Stress management

Some evidence for a ketogenic diet (high fat)

Avoid alcohol

36
Q

What are the main causes for peripheral neuropathy or symptoms typical of peripheral neuropathy?

(5)

A
  1. Diabetes Mellitus
  2. thyroid disease
  3. B12 deficiency
  4. Local / focal neuropathies like median nerve entrapment in carpal tunnel
  5. connective tissue disease/ vasculitities
37
Q

What investigation can you to for peripheral neuropathy?

A

Nerve conduction studies (speed of reaction) with electromyogram (signals given off at rest versus movement)

38
Q

What does the ABCD score measure, and what are it’s components?

A

It’s to assess those with vague symptoms suspicious of a TIA that might become a stroke.

Age > 60 =1

BP (>140/>90) =1

Clinical Motor or speech symptoms (different things score a different point).
—Speech disturbance without weakness =1
—unilateral weakness (+/- speech disturbance) = 2

Symptoms that last > 1 hour = 2, 10-59 min = 1, <10 = 0

Diabetes = 1

Any score > 4 should be admitted

39
Q

Outline three (3) risk factors that would increase the likelihood of a child developing subsequent epilepsy following a febrile seizure.

A

A family history of epilepsy

A history of a neurodevelopmental problem

A history of a prolonged febrile seizure

A history of febrile status epilepticus

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