Primary Care Live Neurology

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Primary Care Live -Neurology

• Dr Estelle McFadden
• MBChB, MRCP, MRCGP
• GPwSI, Bradford

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Headaches www.mipca.org.uk
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Why is this important?

• Prevalence of headache is very high (96)
• Most common headaches are tension-type headache
  (TTH), migraine and chronic primary headaches
• Migraine is associated with high economic costs
• Headaches are a frequent reason for GP
  consultation
• However, migraine is under-diagnosed and
  under-treated in the UK

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What should I already know about this condition?

• Most headaches are benign
• Migraine can occur with or without an aura
• Chronic primary headaches usually evolve from
  episodic headaches (migraine or TTH)
• Differential diagnosis of TTH, migraine, chronic
  primary headaches and cluster headache
• Types of secondary (sinister) headaches and
  diagnostic features (RED FLAGS)

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What new evidence so I need to know about?

• Features of medication overuse headache (MOH)
• Topiramate is an effective and generally well
  tolerated new preventive drug for migraine

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Practical management tips

• Seven step process for managing headache
• Screening
• Patient education and eliciting commitment
• Differential diagnosis
• Assessment of illness severity
• Tailoring management to the needs of the
  individual patient
• Proactive, long-term follow up
• A team approach to care

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When should I refer my patient?

• lt5 years or gt60 years
• New-onset or acute headaches
• Single, sudden severe headache
• Progressive headaches
• History of cancer
• Symptoms rash, non-resolving neurological
  deficit, vomiting outside of the headache, scalp
  pain/tenderness, accident/head injury, infection,
  worrisome hypertension
• Uncertain diagnosis
• Refractory to repeated acute and preventive
  treatments
• Very anxious despite reassurance

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Commonly asked questions

• Will my patient benefit from having a scan, even
  if I do not think there is intracranial pathology?

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Common pitfalls

• Misdiagnosing chronic headache as migraine
• Over-treating chronic headaches leading to MOH
• Under-treating migraine relying on analgesics
• Missing unusual primary headache variants
• Blaming headaches solely on stress

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Important messages

• Most headaches can be managed effectively in
  primary care
• Headaches are a major cause of morbidity
• Specific management of headaches can help

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Epilepsy
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Principles of epidemiology

• Incidence rate new cases per year n per
  100,000 per year
• For epilepsy is around 50 per 100,000
• Point prevalence All cases with active epilepsy
  at a point in time n per 1000.
• For epilepsy is 4-7 per 1000
• Active epilepsy to have had a seizure or
  treatment in the last 5 yrs

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Epilepsy seizure types

• Focal Seizures
• 60 of epilepsy
• Focal Cortical Disturbance
• Their origin usually determines the clinical
  picture
• Focal Spikes on EEG

• Primary Generalised Seizures
• Origin unclear either sleep spindles or
  hyper-synchrony
• Commence bilaterally
• Spike and wave
• No aura

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Focal epilepsy the site of the focus determines
the seizure morphology
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Focal vs Primary Generalised Epilepsy

• Focal Epilepsy
• Aura
• Simple Sz.s
• Complex Partial Szs
• Secondary Generalised Sz.s

• P.G.E.
• Myoclonic Jerks
• Absence
• Atonic Szs
• Tonic Szs
• Tonic-clonic Sz.s

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Mortality in epilepsy

• Up to 1000 deaths a year.
• 20 more men than women. No change in figures for
  over a decade
• SUDEP 350-400 a yr in the UK
• Possible cardiac arrhythmias caused by
  channelopathies, bradycardia 2 to apnoea,
  endogenous opioids/endorphins
• External obstruction likely to be a factor in up
  to 70
• May effect up to 1 per 1000 with epilepsy
• 1 per 250 attending a tertiary epilepsy clinic
• If seizures are fully controlled, SMR falls to
  close to normal for the population
• Has been studied in small numbers one was
  during video telemetry

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Epilepsy is not just about seizures

• Social implications are varied and very much lie
  within the remit of General Practice e.g. the
  impact of epilepsy on sexuality
• Hypo sexuality. Surveys suggest 22-67 reduction
  in sexual interest
• Erectile dysfunction occurs in 57 Toone et al
  1989, up to 83 in TLE
• Sexual Functioning in Males 1989
• Previous SI 56 compared to 98 controls
• S.I. in the previous month 43 compared to 91
  in controls
• Previous erectile dysfunction 57 compared to
  18 controls

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Psychosocial impact of epilepsy

• Psychiatric
• Depression Up to 2/3 of PWE are depressed, with
  2 reduced libido and effects of antidepressants
• Anxiety self medicate with alcohol
• Psychosocial
• In one study 1988 of 92 patients with poorly
  controlled epilepsy
• 68 Had no friends
• 34 Never had a true friendship
• 57 Never had a steady relationship

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Dizziness the management of vertigo the
illusion of movement
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The Labyrinth

• NB vertigo is perceived by the brain
• Mismatch of visual, vestibular
  proprioceptive cues
• Abnormality of central vestibular processing

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Epidemiology

• 6-25 UK population complain of dizziness at some
  point
• After viral vestibular neuronitis (idiopathic)
  benign paroxysmal positional vertigo is most
  common cause

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VertigoDifferential diagnosis for acute onset
of first attack cardiac or brain or ear

• Viral vestibular neuronitis (idiopathic)
• common, usually self limiting
• acute
• symptomatic management with rest, avoidance of
  provocative manoeuvres, short course of
  vestibular sedatives
• Benign Paroxysmal Positional Vertigo
• Increase physical activity, Epley, precipitate
  vertigo, core stability muscle
• activity
• Iatrogenic, e.g. diuretics
• Cardiovascular, Hypotension, Myocardial
  Infarction, Cardiac dysrhythmia
• Cerebrovascular Vertebrobasilar TIA, posterior
  fossa CVA, migraine
• Psychogenic

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Red Flags

• If history inadequate
• Presume cardiovascular till proven otherwise
• ECG, cardiac enzymes, cardiac monitor, ECHO, tilt
  table, carotid sinus massage
• If cardiac symptoms present before, during or
  after arrange cardiac tests especially while
  symptomatic
• Altered consciousness, behavioural change
• Exclude epilepsy
• Exclude cardiac/cardiovascular causes
• The Blackouts Checklist (refs)
• Vomiting

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Vertigo and the neck

• Compression of vertebral arteries expect
  multiple neurological symptoms tinnitus
  hearing loss
• very rare cause of recurrent vertigo
• Carotid sinus hypersensitivity
• Relatively common, but causes falls NOT vertigo
• Cervicogenic vertigo proprioceptive
  dysfunction desensitization to neck
  stimuli vestibular failure
• Not common

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Nystagmus

• Transient Positional nystagmus WITH vertigo
  think BPV
• Positional nystagmus NO vertigo brain stem
  lesion
• If present when patient sitting up
• Usually indicates cerebellar involvement
• Rarely present with ACUTE peripheral vestibular
  lesion
• Viral labyrinthitis first 1-3 days
• During attack of Menieres, migraine-associated
  vertigo
• 
  (positional laying back)

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Benign Positional Vertigo

• Diagnosed ONLY by the Hallpike manoeuvre or by
  the lateral canal manoeuvre
• Must be performed in the acute phase
• Curative manoeuvres
• Epley
• Barrel

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Epley manoeuvre and Barrel manoeuvre
Positional manoeuvres move debris around the
semicircular canals (diameter 0.3 mm) back to the
utricule
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Hallpike manoeuvre 1-2 Epley manoeuvre 1-6
gt 30 s in each position
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The best policy A team approach

• General practice, elderly medicine, neurology,
  cardiology, audiological medicine
• Rehabilitation team physiotherapy, cognitive
  behaviour therapy, occupational therapy, exercise
  therapy, activities in the community
• Open access to Audiological Physician by patients
  already seen to finalise diagnosis and expedite
  treatment

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Web links

• www.vestibular.org website of vestibular
  disorders association
• www.dizziness-and-balance.com
• Google - images Epley
• www.youtube.com
• Epley manoeuvre
• www.stars.org.uk
• The Blackouts Checklist

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Transient ischaemic attacks
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Definition

• Transient ischaemic attack (TIA) is defined as an
  acute loss of focal cerebral or ocular function
  with symptoms lasting less than 24 hours and
  which is thought to be due to inadequate cerebral
  or ocular blood supply as a result of low blood
  flow, thrombosis, or embolism associated with
  diseases of the blood vessels, heart, or blood
  (Hankey and Warlow 1994)

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TIA or stroke?

• Brief episode of rapidly developing neurological
  dysfunction with no apparent cause other than of
  vascular origin with symptoms resolving
  completely within 24 hours
• MR scans have shown that those with symptoms
  lasting more than 1 hour show cerebral infarction
  i.e. a stroke
• Definition may be changed to symptoms resolving
  completely within 1 hour
• TIA is the only warning that a stroke is imminent
• Estimated 30,000 new TIAs per year

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Risk of stroke following TIA

• Most patients who have a TIA have a short benign
  course but up to 20 will have a stroke within
  the next 90 days
• Half of those who will have a stroke will do so
  in the first seven days after their TIA
• (Coull A, Lovett JK Rothwell PM on behalf of
  the Oxofrd VAscualr Study, 2004, Early risk of
  stroke after a TIA or minor stroke in
  population-based incidence study, BMJ, 328,
  326-8)
• Risk of a stroke following a TIA varies
• ABCD2 risk stratification tool helps identify
  those at highest risk of a stroke
• (Johnston SC, Rothwell PM et al The Lancet 2007
  (369) 283-292)

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ABCD2 score to identify individuals with high
early risk of stroke after TIA
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Risk of stroke following TIA

• HIGH Score 6-7 8.1 2 day risk
• MODERATE Score 4-5 4.1 2 day risk
• LOW Score 0-3 1.0 2 day risk
• More than one TIA in seven days also at high risk
  of stroke

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Presentation of TIA
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Management of TIAurgent medical admission

• As TIA is a retrospective diagnosis then if they
  are symptomatic at the time of presentation then
  refer for emergency admission to an acute stroke
  unit
• In a centre offering thrombolysis, those still
  symptomatic at 3 hours may be eligible for
  thrombolysis

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Management of TIA High risk

• High risk of subsequent stroke in lt 2 days if
• ABCD2 score 4
• More than one TIA in seven days
• Require assessment and treatment within 24 hours
• ?admit as urgent medical admission
• Refer to rapid access neurovascular clinic, one
  stop shop with strong advice to seek urgent
  medical referral (via 999) in the event of
  symptoms returning or new symptoms i.e. develop a
  stroke AND give 300mg aspirin if not already on
  regular aspirin
• To be treated or referred if presenting to Out Of
  Hours services or AE (not referred back to GP)

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Management of TIA Low risk

• All other TIAs
• Should be given 300mg aspirin (if not taking
  regular aspirin already)
• Those attending out of hours must be treated and
  not referred back to their GP to avoid delays
• Need prompt referral to a rapid access
  neurovascular clinic (referrals for TIA are
  excluded from Choose and Book as considered to be
  a medical emergency) and to be seen within SEVEN
  days
• UNLESS
• Presenting several weeks after event (still
  refer)
• Treatment not felt to be in patients best
  interest e.g. bed bound with dementia

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Assessment of TIA

• Carotid imaging should be performed at initial
  assessment (and not delayed for more than 24
  hours in high risk patients and those with
  carotid territory minor stroke)
• Doppler ultrasound
• MR including angiography, diffusion weighted
  imaging, gradient echo imaging
• CT
• Where indicated
• ECG
• Echocardiogram

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Treatment of TIA

• Carotid endarterectomy for gt70 stenosis
• Recommendation this becomes a surgical emergency
• Stroke prevention benefits lost if treatment
  delayed
• Should be performed within
• 48 hours in high risk patient
• 28 days to prevent stroke
• Atrial fibrillation and other arrhythmias
• Anticoagulation unless contra-indications
• Aspirin 75 300mg daily
• Treatment of arrhythmia

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Secondary prevention

• Antiplatelet
• Aspirin 75mg 300mg plus dipyridamole MR 200mg
  bd for 2 years following event then aspirin alone
• Clopidogrel alone if aspirin intolerance or
  sensitivity
• Anticoagulation
• Anticoagulant if arrhythmia unless
  contraindication (high risk of falls, recent GI
  bleed)

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Secondary prevention

• Hypertension
• Risk of stroke halves with every 10mmHg fall in
  diastolic blood pressure even in normotensive
  patients
• Cholesterol
• Equal benefit of simvastatin 40mg across all
  those who had had a stroke or TIA down to
  baseline 3.5mmol/l total cholesterol

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Lifestyle advice

• Smoking cessation
• Alcohol intake
• Binge drinking associated with increase in blood
  pressure
• Exercise
• Obesity