Hot Topics in Neurology

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Published on January 7, 2009

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Hot Topics in Neurology : Hot Topics in Neurology Dr Hussam Abu-Seido MRCGP FRCS MRCPCH Consultant Family Medicine Saad Specialist Hospital Bell’s Palsy : Bell’s Palsy UK Prevalence 1 in 5000 pa Most recover completely without treatment but 1 in 6 end up with permanent weakness with associated disfigurement, dysfunction and psychological distress. 1/3 of cases of acute peripheral facial nerve weakness have a recognizable cause e.g. trauma, zoster, diabetes etc Bell’s Palsy : Bell’s Palsy Idiopathic Facial Nerve Paralysis Consider whether to give steroids, antivirals, none or both. Cochrane review in 2004 concluded that neither steroids or antivirals were of proven efficacy. DTB in 2006 stated “no firm conclusions” could be drawn on the efficacy of any drug in Bell’s Palsy. Bell’s Palsy : Bell’s Palsy Recent Scottish RCT (NEJM2007;357:1598), ‘Research Paper of the Year’ (BJGP2008:58;520). July 2008 the DTB revised its conclusions (DTB2008:46;51) Bell’s Palsy : Bell’s Palsy 550 patients presenting to their GP or A&E with unilateral facial nerve weakness of no discernible cause within 72 hours of onset Randomized to: ?Prednisolone 50mg daily for 10 days plus placebo ?Aciclovir plus placebo ?Prednisolone plus aciclovir ?Double Placebo Bell’s Palsy : Bell’s Palsy After 3 months 83% of the prednisolone group had made a full recovery, compared to 64% of the Placebo group (p<0.001,NNT 6) At 9 months the rates were 94.4% prednisolone and 82% placebo (NNT 9) The aciclovir had no effect, either alone or in combination. There is no serious adverse effects Bell’s Palsy : Bell’s Palsy The accompanying editorial points out that another recent Trial has shown benefit for valaciclovir, perhaps due to its better bio-availability. (Otol Neurol2007:28:408) randomized 221 patients within 7 days of an acute Bell’s Palsy to valaciclovir 1 g daily for 5 days plus prednisolone or prednisolone plus placebo. The first group had marginally greater overall rates of recovery (97% versus 90%,p<0.05) Bell’s Palsy : Bell’s Palsy In acute Bell’s Palsy offer prednisolone 50 mg daily for 10 days. Consider adding valaciclovir in severely affected cases. Warn worse prognosis patients that even with treatment, full recovery may not occur. Headache : Headache Headache Management: (BJGP2008:58;77)editorial based on two papers 1 in 20 of our consultations is for headache Effective diagnosis and management are important Headache : Headache BJGP2008:352:102 looked at a cohort of patients presenting in UK primary care with new onset headache to see how they were diagnosed ?70% of patients received no diagnosis of headache type ?We also under-diagnose migraine and over-diagnose tension type headache ?Although TTH is more common in the community we see migraine more as it presents much more often Headache : Headache BJGP2008;352:98 ?Despite effectiveness of migraine prophylaxis, most patients are not offered it ?This study found that patients who had 2 or more migraines a month, only 8% were prescribed prophylaxis yet 55% would use it if it were offered as an option ?Prophylaxis is important not only to relieve the migraine burden, but also to decrease the risk of developing medication overuse chronic headache Tension-type Headache : Tension-type Headache TTH has recently been reviewed (BMJ2008;336:88) Positive diagnosis Key points: ? Bilateral, non-pulsating, pressing, tightening quality. ? Not aggravated by movement ? No migrainous features, photophobia, nausea, vomiting Tension-type Headache : Tension-type Headache Useful definition to distinguish TTH from migraine Migraine is a head pain with associated features whereas TTH is featureless head pain Tension-type Headache : Tension-type Headache Examination should aim to exclude secondary causes Blood pressure measurement Fundoscopy Manual palpation of pericranial muscles and temporal artery Tension-type Headache : Tension-type Headache Imaging ?If pattern is atypical ?If any neurological symptom or sign ?If a generalized illness that cause a space-occupying lesion (e.g. cancer, AIDS) Treatment of Tension-type Headache : Treatment of Tension-type Headache Care is needed with drugs due to the risk of medication overuse and rebound headache Avoid analgesics for 15 days a months or more (10 or more with opiod or combination analgesics) Treatment of Tension-type Headache : Treatment of Tension-type Headache Acute Treatment: (Lancet Neurol 2008:7:70) Best evidence is for NSAIDs, which are better than paracetamol (Ibuprofen 800mg or naproxen 825mg were first choice). Combination with caffeine also have evidence of effectiveness Treatment of Tension-type Headache : Treatment of Tension-type Headache Acute Treatment: Opiods should be avoided because of the risk of overuse headache Treatment of Tension-type Headache : Treatment of Tension-type Headache Preventive Treatment: consider if needing medication weekly ?Tricyclics. Best evidence is for amitryptiline. Start low (10mg-25mg) at night time and build up slowly. ?Tizanidine. Also shown to be effective in doses up to 18mg daily Treatment of Tension-type Headache : Treatment of Tension-type Headache Life Style, non-drug treatment: ?There is little evidence, except some benefit for acupuncture seen in some studies (BMJ2005:331:376) ?A recent review shows no evidence from spinal/neck manipulation Migraine : Migraine The commonest disabling primary headache that presents in Primary care and is under diagnosed Migraine was always thought of as a vascular phenomena and is still often called a vascular headache Migraine : Migraine Current research, including functional brain imaging, reveals a problem in neuronal activation and processing due to functioning ion channels, principally located in the Pons The genetic predisposition to migraine relates to a gene that codes for these ion channels Migraine : Migraine It seems clear that migraine is not a disorder of blood vessels but one of brain function But what about the known association with stroke? (BMJ2008;337:a636) In women there is an association between migraine with aura and subsequent stroke and MI, but this depends on their background cardiovascular risk Migraine : Migraine (BMJ2008;337:a745) editorial. ?It states evidence that aura is a neuronal and glial event of (cortical spreading depression) which leads to secondary changes to cerebral blood flow, hence the increase in vascular risk ?Migraine with aura is a potentially important risk factor for stroke and MI, but it is not clear whether treating migraine modifies this risk Migraine : Migraine Can occur without aura Can be bilateral Bilateral bad throbbing headaches with nausea or mild photophobia is a migraine and not bad TTH Migraine : Migraine The diagnostic criteria for migraine are repeated attacks of headache lasting 4-72 hours with: ?Normal physical examination and no other cause. ?At least 2 of: unilateral pain, throbbing pain, moderate or severe intensity pain, aggravation by movement ?At least 1 of nausea/vomiting or photophobia/phonophobia Migraine : Migraine Red Flags: ?pain of sudden onset ?fever of meningism ?pain with other neurological symptoms or signs ?temporal artery tenderness Management of Migraine : Management of Migraine (BMJ2007;334:254) and (BMJ2006:332:25) Elicit triggers (e.g. food, stress, sleep using a diary). Non-drug measures such as relaxation, acupuncture and massage have been shown to be of some benefit. Management of Migraine : Management of Migraine Drug Treatment: Step I: NSAIDs (e.g. aspirin, ibuprofen) as soon as possible with buccal prochlorperazine for nausea Step II: Consider a parenteral NSAIDs such as diclofenac IM Management of Migraine : Management of Migraine Step III: Triptans (remember contraindicated in children under 12, and in IHD or with high risk for CVD) ?Take when headache starts, not with aura ?Sumatriptan has most evidence, start with 50mg, if necessary increase to 100mg or use nasal spray ?Consider subcutaneous if vomit ?If ineffective, try another type e.g. rizatriptan, zolmitriptan etc Management of Migraine : Management of Migraine Step IV: combination of NSAID and Triptan can be tried (unlike ergotamine which cannot be used with triptans) ?(JAMA2007:297;1443) Large RCT showing evidence for combination of sumatriptan-naproxen versus the agents singly or placebo ?Oral sumatriptan 85mg and naproxen 500mg in a fixed dose tablet. This was significantly better than placebo of either monotherapy for headache relief at 2 hours Management of Migraine : Management of Migraine Step V: Emergency treatment at home IM diclofenac and chlorpromazine Management of Migraine : Management of Migraine Prophylactic Treatment: ?beta-blockers if no contraindications e.g.atenolol, propranolol ?AEDs e.g.valproate and topiramate (also evidence for tricyclics) ?gabapentin Management of Migraine : Management of Migraine Topiramate has recently been licensed for migraine prophylaxis and a recent review or RCTs has shown it to be effective and well tolerated at a dose of 100mg a day Interestingly there is also evidence for lisinopril and candesartan but not for verapamil Management of Migraine : Management of Migraine The NHS Clinical Knowledge Summary for migraine states the following are not recommended for prophylaxis: ?Pizotifen, as evidence for effectiveness is poor and use limited by adverse effects ?Clonidine, no better than placebo and may cause depression and insomnia ?SSRI, evidence inconclusive ?Verapamil. Evidence limited for migraine (but works in cluster) Cluster Headache : Cluster Headache (BJGP2006:56:486) editorial summed up cluster headache in its title: “ cluster headache in primary care: unmissable, underdiagnosed, and undertreated” Although rare compared with migraine, cluster headache is one of the most painful conditions we ever see, yet it is often not diagnosed in primary care But the management is very different from migraine hence accurate diagnosis is essential Cluster Headache : Cluster Headache It is characterized by attacks of severe, recurrent, unilateral pain occurring during clusters of 6-12 weeks. There are ipsilateral autonomic features and a circadian rhythm. They usually occur daily More common in men and smokers Pain is often described as intolerable The headaches last 15 minutes to 3 hours Cluster Headache : Cluster Headache Alcohol, exercise, heat, and nitroglycerine are recognized triggers Management of Cluster Headache : Management of Cluster Headache The most effective abortive agents: ?subcutaneous sumatriptan 6mg is the drug of choice with a high response rate, and can be used up to twice daily throughout the cluster without fear of rebound ?There is also evidence for sumatriptan and zolmitriptan nasal spray ?100% Oxygen inhalation at 7-10 L/min for 15-20 minutes is effective in the majority of sufferers ?Opiates, NSAIDs and analgesics have no role in acute management Management of Cluster Headache : Management of Cluster Headache Preventive treatment during short, infrequent clusters Prednisolone is effective, 1mg/kg to a maximum dose of 60mg daily for 5 days, then decreasing by 10mg every 3 days Management of Cluster Headache : Management of Cluster Headache Preventive treatment for patients with longer or more frequent clusters: ?Verapamil is the drug of choice ?AEDs like topiramate and gabapentin are used, but have less evidence for efficacy Management of Cluster Headache : Management of Cluster Headache Obviously unusual features warrant referral, but otherwise stable, intermittent cluster can be managed in primary care HEADACHE: CONCLUSIONS : HEADACHE: CONCLUSIONS We often fail to diagnose headache type “migraine is head pain with associated features whereas TTH is featureless head pain” TTH: we should introduce preventive treatment early to avoid medication overuse headache HEADACHE: CONCLUSIONS : HEADACHE: CONCLUSIONS Acute migraine: If triptan alone is ineffective, sumatriptan plus NSAID is more effective than either agent alone Prophylaxis in migraine is under-used. Topiramate 100mg is effective and well tolerated HEADACHE: CONCLUSIONS : HEADACHE: CONCLUSIONS Cluster is much rarer, but easily diagnosed and can be managed in primary care Prednisolone is effective during clusters HEADACHE: CONCLUSIONS : HEADACHE: CONCLUSIONS We see one every day, so try a more active approach in headache diagnosis and management Remember migraine does not have to be unilateral or have an aura Introduce preventive treatment in frequent TTH Try topiramate as migraine prophylaxis in patient intolerant of beta blockers

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