Neurology: Reflex Anoxic Seizures; Headaches in Children; Flashcards
Describe what is meant by a reflex anoxic seizure [1]
How do they typically present? [2]
Reflex anoxic seizures (RAS) are a common non-epileptic paroxysmal event in infants and preschool-aged children, but can occur at any age.
They are classically provoked by a sudden distressing stimulus, which causes loss of consciousness followed by stiffening and brief clonic movements affecting some or all limb
Describe the basic pathophysiology of a reflex anoxic seizure [1]
The underlying pathophysiology is a vagal-induced brief cardiac asystole with resultant transient cerebral hypoperfusion caused by a sudden distressing stimulus
Describe the presentation of a reflx anoxic seizure [+]
- During the episode, the child becomes suddenly pale and limp, will fall if standing and loses consciousness.
- This is followed by stiffening and clonic jerking of the limbs.
- The episode is usually brief (30-60 seconds) and recovery is rapid.
- There may also be upward eye deviation and urinary incontinence.
- Rapid recovery
What is the only definitive managment of a reflexic anoxic seizure? [1]
Pacemaker insertion is the only definitive treatment and is only used for frequent, severe cases.3 4
Describe the pattern of a tension headache [3]
Classically they produce a **mild ache across **the forehead and pain or pressure in a band-like pattern around the head
- occurs in symmetrical pattern
- comes on and resolve gradually and DON’’T produce visual changes or pulsating sensations
- non-pulsatile
- may be related to stress
What is the definition of a chronic tension-type headache? [1]
Chronic tension-type headache is defined as a tension headache occur on 15 or more days per month.
The ICHD categorizes tension-type headaches according to the frequency of attacks.
What are these? [3]
Infrequent episodic:
- less than 1 day of headache per month.
Frequent episodic
- at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
Chronic:
- 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.
NB: This is for adults
What is the mx of a tension type headache? [+]
ZtF:
- Management is with reassurance, analgesia, regular meals, avoiding dehydration and reducing stress.
PM (adults)
acute treatment:
- aspirin, paracetamol or an NSAID are first-line
prophylaxis:
- NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
- low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache.
- The 2012 NICE guidelines do not however support this approach ‘…there was not enough evidence to recommend pharmacological prophylactic treatment for tension-type headaches. The GDG considered that pure tension-type headache requiring prophylaxis is rare. Assessment is likely to uncover coexisting migraine symptomatology with a possible diagnosis of chronic migraine.’
What are the different types of migraines? [5]
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
Abdominal migraine
Which of the following is most common?
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
Abdominal migraine
Migraine without aura
Describe the differences in presentation of migraine without aura and with aura [+]
Migraine without aura:
* It is characterised by moderate to severe pulsating headache lasting between 4 and 72 hours, usually unilateral in location. Other symptoms include:
* Photophobia and phonophobia
* Nausea or vomiting
* Aggravation by routine physical activity
Migraine with aura
* About one quarter of individuals with migraines experience an ‘aura’, a complex of neurological symptoms that precede the headache phase.
* Typical aura: Visual, sensory, speech or language, motor, brainstem or retinal symptoms preceding the headache phase.
Describe what is meant by a hemiplagic migraine? [1]
Hemiplegic migraine: A subtype of migraine with aura characterised by reversible motor weakness as part of the aura.
Describe what is meant by complicated migraines [+]
Describe what the three types are [3]
Complicated migraines:
This includes several subtypes where migraines appear to directly cause neurological damage or other complications.
Migrainous infarction:
- An ischemic stroke that occurs during a typical attack of migraine with aura.
Migraine aura-triggered seizure:
- A seizure triggered by a migraine with aura
Persistent aura without infarction:
- Aura symptoms that last for one week or more, without evidence of stroke on neuroimagin
Migraines present differently to tension headaches. Symptoms tend to be [+]
Unilateral
More severe
Throbbing in nature
Take longer to resolve
Visual aura
Photophobia and phonophobia
Nausea and vomiting
Abdominal pain
‘classic’ migraine attacks are precipitated by an aura. These occur in around one-third of migraine patients
- typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma
What are the investigations for migraines [+]
Migraines are typically diagnosed based on clinical history and physical examination, thus investigations are not usually necessary in the primary care setting.
However, if secondary causes of headache are suspected or there is an atypical presentation, further investigations may be warranted:
Neuroimaging:
- Neuroimaging is not routinely recommended for patients with migraine as per NICE guidelines. It should only be considered if there are clinical features suggestive of significant neurological pathology such as sudden onset of severe headache (thunderclap headache), new neurological deficits, change in personality or mental status, seizures or signs of elevated intracranial pressure.
Blood tests:
- Routine blood tests including full blood count, electrolytes, liver function tests and thyroid function tests can be useful to exclude systemic conditions that might present with headaches such as anaemia, electrolyte imbalance, liver disease or thyroid disorders.
The International Headache Society has produced the which diagnostic criteria for migraine without aura? [5]
Which aura symptoms are atypical and may prompt further investigation/referral? [5]
- motor weakness
- double vision
- visual symptoms affecting only one eye
- poor balance
- decreased level of consciousness.
Describe the acute Mx of migraines in children [5]
Ztf:
* Rest, fluids and low stimulus environment
* Paracetamol
* Ibuprofen
* Sumatriptan
* Antiemetics, such as domperidone (unless contraindicated)
PM:
first-line: offer combination therapy with
* an oral triptan and an NSAID, or
* an oral triptan and paracetamol
* for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
* if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan
caution should be exercised when prescribing metoclopramide to young patients as [] may develop
caution should be exercised when prescribing metoclopramide to young patients as acute dystonic reactions may develop
Describe the prophylactic treatment for migraines [+]
PM:
NICE advise one of the following:
* propranolol
* topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
* amitriptyline
* if these measures fail NICE recommends ‘a course of up to 10 sessions of acupuncture over 5-8 weeks’
ZtF:
* Propranolol (avoid in asthma)
* Pizotifen (often causes drowsiness)
* Topiramate (girls with child bearing potential need highly effective contraception as it is very teratogenic).
Children are more likely than adults to suffer with a condition called [] migraine.
Describe the presentation [4]
Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. They present with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal. There may be associated:
* Nausea and vomiting
* Anorexia
* Headache
* Pallor
What is a key thing to think about a cause of headache in children? [1]
Therefore, how should you investigate them? [4]
Infections can cause headaches in children. In a child with a new headache, always check for symptoms and signs of a viral upper respiratory tract infection, otitis media, sinusitis and tonsillitis. The headache should resolve along with the infection. Paracetamol and ibuprofen can be helpful for symptomatic relief.
