Primary Care Live -Neurology

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

www.mipca.org.uk
 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
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)
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
 Practical management tips

Seven step process for managing headache

1. Screening
2. Patient education and eliciting commitment
3. Differential diagnosis
4. Assessment of illness severity
5. Tailoring management to the needs of the individual
patient
6. Proactive, long-term follow up
7. A team approach to care
When should I refer my patient?

<5 years or >60 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
 Commonly asked questions

Will my patient benefit from having a scan,

even if I do not think there is intracranial
pathology?
 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
 Important messages

Most headaches can be managed

effectively in primary care
Headaches are a major cause of morbidity
Specific management of headaches can
help
Epilepsy
 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
 Epilepsy seizure types

Focal Seizures Primary

60% of epilepsy Generalised
Focal Cortical Seizures
Disturbance Origin unclear either
Their origin usually sleep spindles or
determines the hyper-synchrony
clinical picture Commence bilaterally
Focal Spikes on EEG Spike and wave
No aura
Focal epilepsy the site of the focus
determines the seizure morphology
Focal vs Primary Generalised Epilepsy

Focal Epilepsy P.G.E.

Aura Myoclonic Jerks
Simple Sz.s Absence
Complex Partial Szs Atonic Szs
Secondary Tonic Szs
Generalised Sz.s Tonic-clonic Sz.s
 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
 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]
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
Dizziness: the management of
vertigo: the illusion of
movement
 The Labyrinth

NB vertigo is perceived by the brain

- Mismatch of visual, vestibular & proprioceptive cues
- Abnormality of central vestibular processing
 Epidemiology

6-25% UK population complain of

dizziness at some point

After viral vestibular neuronitis (idiopathic)

benign paroxysmal positional vertigo is
most common cause
 Vertigo
Differential 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
 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
 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
 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)
 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
 Epley manoeuvre and Barrel
manoeuvre

Positional manoeuvres move debris around the semicircular

canals (diameter 0.3 mm) back to the utricule
Hallpike manoeuvre > 30 s
1-2 in each
Epley manoeuvre position
1-6
1 2

3 4

5 6
 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
 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
Transient ischaemic attacks
 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)
 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
 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)
 ABCD2 score to identify individuals
with high early risk of stroke after TIA
SCORE AGE BLOOD CLINICAL DURATION DIABETES
PRESSURE FEATURES OF MELLITUS
SYMPTOMS

0 < 60 <140/90 Other <10 mins

years

1 60 Systolic Speech 10-59 mins Yes

years >140 disturbance
and/or without
Diastolic weakness
90

2 Unilateral 60 mins
weakness
 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
 Presentation of TIA
ANTERIOR VS POSTERIOR ISCHAEMIA
Carotid Vertebrobasilar
(80% TIAs) (20%TIAs)
Motor Contralateral weakness Bilateral or shifting weakness
Paralysis Paralysis
Clumsiness Clumsiness
Ataxia
Imbalance without vertigo
Sensory Contra lateral numbness, Bilateral or shifting numbness
Pins and needles Pins and needles
Sensory loss Sensory loss
Speech Dysphasia Dysarthria
dysarthria
Visual Ipsilateral monocular Diplopia
blindness Partial or complete blindness in both
Contralateral homonymous visual fields
hemianopia
Other Combination of above Vertigo
Dysphagia
 Management of TIA
urgent 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
 Management of TIA: High risk

High risk of subsequent stroke in < 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 A&E (not referred back to GP)
 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
 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
 Treatment of TIA

Carotid endarterectomy for >70% 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
 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)
 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
 Lifestyle advice

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