Neurology/Headaches Flashcards
SNOOP-4 pneumonic for RED FLAG features of a headache?
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
Typical features of a migraine?
(5)
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
Difference between cervicogenic headache vs. cervical radiculopathy vs. cervical myelopathy ?
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..
List general measures to prevent headaches
(8)
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
Non pharmacological longer term management for tension type headaches?
(5)
Acupuncture (at least 6 treatments)
CBT
Relaxation training
Physiotherapy
Aerobic exercise
Pharmacological management for REGULAR tension headaches. i.e. prophylaxis
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)
Acute non pharmacological migraine management?
(4)
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
Medication management in acute migraine in an adult?
(3)
- 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 - 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) - Triptan
Rizatriptan (Maxalt) 10mg PO, 2 hourly (max 30mg/day) ← does have a under the tongue formulation
What is important to remember about triptan usage?
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
Cluster headache acute treatment?
(2)
- Rizatriptan 10mg orally, immediately, up to 30mg a day, repeated every 2 hours. Do not repeat if no resolution between doses.
- 100% oxygen. 15L/min in a tight fitting non rebreather for 20 minutes
What is a trigeminal neuralgia?
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
Management steps for trigeminal neuralgia?
- Imaging of ganglion
- 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) - Refer to surgery
Prophylactic treatment for Tension Headaches?
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
Give examples of triggers for a migraine.
(7)
You’ll want to avoid or limit:
Citrus foods
Tomatoes
Aspartame products
MSG
Fatigue
Exertion
Hormonal Changes
Medications for Migraine prophylaxis
Taking into account Best evidence and associated conditions:
hypertension/obesity/diabetes
Insomnia
anxiety
depression
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.
Cluster headache prevention medication.
And what important beside test to do before each dose increase?
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)
List some lifestyle interventions to help prevent migraines.
(6)
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
What is secondary management after a stroke?
(8)
- Tailor towards pathogenesis
- Screen and treat for diabetes
- Encourage good dietary and exercise habits (SNAP)
- Treat any hypertension (most important)
- Aspirin 100mg orally, daily, lifelong (or clopidogrel 75mg, oral, daily). Initially can be on both for 90 days.
- Anti-coagulate if raised CHA2DSVA2 score.
- High dose statin even if cholesterol is normal
- Follow up for any carotid stenosis (most like carotid U/S or CT angio already done in ED).
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?
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
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)
FBC, EUC, LFT
Fasting lipids, good glucose
ESR/CRP
CT brain or MRI (within 48 hours)
Carotid imaging
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?
> 50% stenosis
What is the target systolic BP for someone with a stroke or TIA?
systolic aimed between 120-130
What makes up the diagnostic criteria for Parkinson’s disease?
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.
What are non motor symptoms in Parkinson’s disease?
(6)
Fatigue
Neuropsych (depression, anxiety, psychosis)
Sleep disturbance
Autonomic: bowel, bladder, sexual dysfunction
Pain and other sensory issues
Dysphagia
What medication can a GP start for Parkinson’s disease, and when should it be initiated?
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).
Which medications should be avoided in person’s with parkinson’s disease?
Metoclopramide and Prochlorperazine
What 3 conditions can lead to restless legs?
(PIE)
Pregnancy
Iron deficiency
End stage kidney disease
what is the symptom description of restless legs?
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
What 3 lifestyle changes can help treat restless legs, if symptoms are mild?
- Physical exercise
- Good sleep practices
- good dietary or other Iron Intake. Aiming ferritin > 50
What dose of dopaminergic drug is used to treat restless legs?
levodopa+carbidopa 100+25 to 200+50 mg orally, before bedtime when needed.
Apart from a dopamine agonist what can you use for more severe symptoms of restless legs?
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.
What in room tests can you do for a seizure presentation?
urine dipstick
fingerprick BGL
Can a GP order a rebatable MRI for a seizure?
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
What are triggers of a seizure?
(6)
Sleep deprivation
Overuse of alcohol
Fever
Intercurrent illness
Severe sustained stress
Combination of the above
What advice can you give after a first seizure?
(6)
first aid measures
Workplace safety consideration
Avoid Sleep deprivation
Regular exercise
Stress management
Some evidence for a ketogenic diet (high fat)
Avoid alcohol
What are the main causes for peripheral neuropathy or symptoms typical of peripheral neuropathy?
(5)
- Diabetes Mellitus
- thyroid disease
- B12 deficiency
- Local / focal neuropathies like median nerve entrapment in carpal tunnel
- connective tissue disease/ vasculitities
What investigation can you to for peripheral neuropathy?
Nerve conduction studies (speed of reaction) with electromyogram (signals given off at rest versus movement)
What does the ABCD score measure, and what are it’s components?
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
Outline three (3) risk factors that would increase the likelihood of a child developing subsequent epilepsy following a febrile seizure.
A family history of epilepsy
A history of a neurodevelopmental problem
A history of a prolonged febrile seizure
A history of febrile status epilepticus
