Revision - Epilepsy & Headache Flashcards
What age do febcons typically occur in?
6m - 5y
What happens in a myoclonic seizure?
Sudden, brief muscle contractions
What happens in a tonic vs atonic seizure?
Tonic - sudden increase in muscle tone
Atonic - sudden loss of muscle tone (drop attack)
What may atonic seizures be indicative of?
Lennox-Gastaut syndrome
When do infantile spasms typically start?
First 6m of life
What 3 features are seen in infantile spasms?
1) Flexion of trunk, limbs –> extension of arms (Salaam attack)
2) Progressive mental handicap
3) EEG: hypsarrhythmia
Mx of infantile spasms?
1) ACTH
2) Vigabatrin
Driving following 1st seizure vs established epilepsy?
1st seizure - must not drive for 6 months
Established epilepsy - must be seizure free for a year
Mechanism of sodium valproate?
Increases GABA
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
How does sodium valproate interact with the P450 system?
Inhibitor
How does carbamazepine interact with the P450 system?
Inducer
Side effects of carbamazepine?
1) dizziness and ataxia
2) drowsiness
3) leucopenia and agranulocytosis
4) SIADH
5) visual disturbances (especially diplopia)
Which antiepileptic can cause SIADH?
Carbamazepine
1st line antiepileptics in myoclonic seizures?
Men - sodium valproate
Women - levetiracetam
1st line antiepileptics in tonic and atonic seizures?
Men - sodium valproate
Women - lamotrigine
1st line antiepileptics in absence seizures?
Men & women –> ethosuximide
What type of anaemia can phenytoin cause?
Megaloblastic
Mx of status epilepticus? (if IV access)
ABCDE
1) IV lorazepam 4mg
wait 5 mins
2) IV lorazepam 4mg
wait 5 mins
3) IV levetiracetam (or phenytoin or valproate)
What obs is always essential in a seizure?
Blood glucose
1st line mx of status epilepticus if no IV access?
Buccal or IM midazolam 10mg
Or rectal diazepam 10mg
1st line management of generalised tonic-clonic seizures in males and females?
Males - sodium valproate
Females - lamotrigine or levetiracetam
Which antiepileptic may exacerbate absence seizures?
Carbamazepine
What location seizure may there be paraesthesia?
Parietal lobe
What location seizure may there be flashes/floaters?
Occipital lobe
first-line for chronic or frequent tension headaches?
Amitriptyline
Management of prolonged (over 10 days) cases of sinusitis?
1) Steroid nasal spray
2) Abx (phenoxymethylpenicillin first-line)
3) 3) Leukotriene inhibitors e.g. montelukast
What are hormonal headaches related to?
Low oestrogen
Tend to occur 2 before and the first 3 days of the menstrual period
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
What is cervical spondylosis?
Degenerative changes in the cervical spine
Presentation of cervical spondylosis?
1) Neck pain worse on movement
2) Headache
What condition is trigeminal neuralgia associated with?
MS
What 4 main types can migraine be categorised into?
1) Migraine without aura
2) Migraine with aura
3) Hemiplegic migraine
4) Silent migraine
What is a silent migraine?
Migraine with aura but WITHOUT a headache
What is the main feature of hemiplegic migraines?
Unilateral limb weakness
What is familial hemiplegic migraine?
An autosomal dominant genetic condition characterised by hemiplegic migraines that run in families.
Management of acute migraine?
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 class of drug are triptans?
5-HT3 agonists (stimulate serotonin receptors)
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.
What are the main contraindications to triptans?
Related to risks of vasoconstriction associated with triptans:
- 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) Propanolol
2) Amitriptyline
3) Topiramate (teratogenic)
What is a medical prophylaxis management for menstrual migraines?
Prophylactic triptans
How long do clusters typically last?
4-12 weeks, up to 4 episodes a day
Investigation of choice in cluster headaches?
MRI with gadolinium contrast
Management of an acute attack of a cluster headache?
1) High flow 100% O2
2) Triptans
1st line drug for prophylaxis of cluster headaches?
Verapamil
What makes a febrile convulsion ‘complex’?
- > 15 mins
- more focal features e.g. movement limited to only one side of the body
- recur within 24 hours or within the same illness
- prolonged post-ictal period
Incomplete immunisation against which 2 pathogens are a risk factor for CNS infection in children?
1) Strep. pneumoniae
2) H. influenzae
What is Todd’s paresis?
Transient hemiparesis following a seizure.
This is a potential short-term complication of complex or focal seizures in particular, and usually subsides completely within 48 hours.
What lobe is affected in a Jacksonian march?
Frontal lobe
What lobe is affected in a seizure with postictal weakness?
Frontal
When are myoclonic jerks in JME most common?
Shortly after waking or following sleep deprivation
What is the typical age of onset of JME?
Teenage years, more common in girls
What is management of JME?
usually good response to sodium valproate
What 2 medications does management of infantile spasms involve?
1) Prednisolone
2) Vigabatrin
What is Lennox-Gastaut syndrome?
Features?
EEG finding?
Multiple seizure types.
Features:
- atypical absences, falls, jerks
- 90% moderate-severe mental handicap
EEG –> slow spike
What EEG feature is seen in Lennox-Gastaut?
Slow spike
What may be beneficial in the management of Lennox-Gastaut syndrome?
Ketogenic diet
What is benign rolandic epilepsy?
Features?
Most common in childhood, more common in males.
Features: paraesthesia (e.g. unilateral face), usually on waking up.
Notable side effects of carbamazepine?
1) Agranulocytosis
2) Aplastic anaemia
3) Induces the P450 system so there are many drug interactions
Notable side effects of phenytoin?
1) Folate and vitamin D deficiency
2) Megaloblastic anaemia (folate deficiency)
3) Osteomalacia (vitamin D deficiency)
Notable side effects of ethosuximide?
1) night terrors
2) rashes
Which antiepileptic can cause night terrors?
Ethosuximide
Which antiepileptic can cause hair loss?
Sodium valproate
Are antiepileptics safe in breastfeeding?
Yes - most are safe
Key side effect of doxycycline?
Photosensitivity
What is the most common cause of 1ary headache in children?
Migraine without aura
How long can an episode of cluster headache last?
15 mins to 2 hours
What lobe is affected in a seizure featuring post-ictal dysphasia?
Temporal lobe
Visual field defect caused by pituitary adenoma vs craniopharyngioma?
Pituitary adenoma - bitemporal superior quadrantanopia
Craniopharyngioma - bitemporal inferior quadrantanopia
What is the most common complication of roseola infantum?
Febrile convulsion
Headache linked to valsalva manoeuvres?
Raised ICP until proven otherwise
What dose of lorazepam is given in status epilepticus?
4mg
What medication may specialists consider prescribing as rescue medication for recurrent febrile seizures?
Buccal midazolam or rectal diazepam
How can a posterior communicating artery aneurysm affect the eyes?
Can cause a painful CN III (oculomotor) nerve palsy:
- ptosis
- diplopia
- lateral deviation of eye
Compression of the oculomotor nerve at the junction of the posterior communicating artery and the internal carotid artery.
What blood test can be used to differentiate between a true seizure and a pseudoseizure?
Prolactin
EEG feature of benign rolandic epilepsy?
Centrotemporal spikes
What is benign rolandic epilepsy characterised by?
Partial seizures at night
When should parents be advised to call an ambulance in a febcon?
> 5 mins
What is used for cluster headache prophylaxis?
Verapamil
Mx of medication overuse headaches?
simple analgesia + triptans: stop abruptly
opioid analgesia: withdraw gradually
How are triptans given in the acute mx of a cluster headache?
SC
Onset of pseudo vs true seizures?
Pseudo - gradual onset
True - sudden onset
What triad of features is seen in PD?
1) Tremor
2) Bradykinesia
3) Rigidity
Are the symptoms of PD characteristically symmetrical or asymmetrical?
Asymmetrical
Is PD more common in men or women?
2x more common in men
What is the frequency of the tremor in PD?
3-5 Hz
When is the tremor in PD most marked?
At rest
When the patient is distracted: e.g. Performing a task with the other hand (e.g., miming the act of painting a fence) exaggerates the tremor.
When does the tremor in PD improve?
With voluntary movement
