1. Primary Care Live -Neurology
Dr Estelle McFadden
MBChB, MRCP, MRCGP
GPwSI, Bradford

2. Headaches

3. 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

4. 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)

5. 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

6. 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

7. 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

8. Commonly asked questions
Will my patient benefit from having a scan, even if I do not think there is intracranial pathology?

9. 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

10. Important messages
Most headaches can be managed effectively in primary care
Headaches are a major cause of morbidity
Specific management of headaches can help

11. Epilepsy

12. 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

13. 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

14. Focal epilepsy – the site of the focus determines the seizure morphology

15. Focal vs Primary Generalised Epilepsy
Focal Epilepsy
Aura
Simple Sz.’s
Complex Partial Sz’s
Secondary Generalised Sz.’s
P.G.E.
Myoclonic Jerks
Absence
Atonic Sz’s
Tonic Sz’s
Tonic-clonic Sz.’s

16. Mortality in epilepsy Up to 1000 deaths a year.
20% more men than women. No change in figures for over a decade
SUDEP = 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

17. 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]

18. 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

19. Dizziness: the management of vertigo: the illusion of movement

20. The Labyrinth NB vertigo is perceived by the brain
± Mismatch of visual, vestibular & proprioceptive cues
± Abnormality of central vestibular processing

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

22. 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

23. 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

24. 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

25. 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 Meniere’s, migraine-associated vertigo
(positional = laying back)

26. 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

27. Epley manoeuvre and Barrel manoeuvre
Positional manoeuvres move debris around the semicircular canals (diameter 0.3 mm) back to the utricule

28. 1 2 3 4 5 6 Hallpike manoeuvre 1-2 Epley manoeuvre 1-6 > 30 s
in each
position 1 2 3 4 5 6

29. 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

30. Web links
website of vestibular disorders association
Google - images – Epley
Epley manoeuvre
The Blackouts Checklist

31. Transient ischaemic attacks

32. 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)

33. 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

34. 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) )

35. ABCD2 score to identify individuals with high early risk of stroke after TIA
AGE
BLOOD PRESSURE
CLINICAL FEATURES
DURATION OF SYMPTOMS
DIABETES MELLITUS
< 60 years
<140/90
Other
<10 mins 1
≥ 60 years
Systolic
>140
and/or
Diastolic
≥ 90
Speech
disturbance
without
weakness
10-59 mins
Yes 2
Unilateral
≥ 60 mins

36. 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

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

38. 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

39. 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)

40. 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 patient’s best interest e.g. bed bound with dementia

41. 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

42. 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

43. Secondary prevention Antiplatelet Anticoagulation
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)

44. Secondary prevention Hypertension Cholesterol
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

45. Lifestyle advice Smoking cessation Alcohol intake Exercise Obesity
Binge drinking associated with increase in blood pressure
Exercise
Obesity