Neurology Shared Learning for GPs

26th May 2016

GP liaison• Education

– Feb 25th

– May 26th

• Communication/referrals– A+G– Routine clinics– Rapid access clinics

• Pathways– Headache (almost done)– Tremor/PD (next)

naomi.warren@nuth.nhs.uknaomiwarren@nhs.net

Outline•

• Programme   • 9:15 Introduction   • 9:20 Seizures and seizure mimics • Shan Ellawala 

• 10:10 Small group teaching • Case discussions  TW, MD, JG, NW, KP 

 • 11:10 Coffee

 • 11:30 Atypical headache • Joe Guadagno

• 12:10 Quick fire top neurology tips (based on requests from GPs) • Naomi Warren and Martin Duddy

• 12:50 Close

Neurology Q+A for GPs

Drs Naomi Warren + Martin DuddyRVI

26th May 2016naomi.warren@nuth.nhs.uk

How to manage chronic headaches

How to manage severe tension headache

NICE 2012

• Important to make a +ve diagnosis

NICE 2012

• Do not scan primary headaches for reassurance

Adult with Headache

Emergency symptoms?1 Refer to appropriate on-call hospital team

Red flags?3

Use Advice & Guidance Service or refer general neurology

Can you make a diagnosis of

primary headache disorder?

Prescribe acute treatment (< 10 days/month)4

Refer to headache clinic

Inadequate response to migraine preventatives. Is it

chronic daily headache (>15/7 per month)?Use headache diary

Migraine or tension headache4 ?

Giant cell arteritis?2

• Encourage patient understanding: direct to www.migrainetrust.org ; supply with patient headache leaflets and diaries• If relevant, consider stopping combined oral contraceptive. Note: combined OCP is contraindicated in migraine with aura• Ensure not overusing analgesics or triptans6:  Occurs if any of acutes being taken on average >2 days per week. Also similar effect from

caffeine. Warn patient may get worse before get better (usually only for days). But may take up to 3 months for full reset.Migraine prophylaxis: Beneficial lifestyle modifiers for headaches (regular sleep, fixed wake times, hydration, cut out caffeine, trigger

avoidance, stress management techniques, normalise BMI, daily aerobic exercise)Consider prevention if >4/7 per month: try the following for 3 months at the highest tolerated target dose before judging efficacy:-a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg a day;b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE:

teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression.

c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg nocte, titrated up to 50-70mg; if natural products preferred: riboflavin 400mg - patients source or acupuncture

Tension Type Headaches: Many believe part of migraine spectrum. Treat as such (often no treatment needed), but watch analgesic overuse.

Cluster headache?5

Try acute treatments5

Check ESR and CRPPrednisolone 60mg o.d. immediately

Consider urgent referral to rheumatology as appropriate2 (Need temporal artery biopsy within 2

weeks of starting prednisolone)

Yes

Yes

No

No

No

No

Yes

Northern East Headache Management GuidelineNovember 2015

Refer Neurology emergency clinic

(fax 0191 2824370)

Yes

Yes

No

Migraine - misdiagnoses 50% misdiagnosed

4-72 hrs – can be longer 75% neck pain <33% vomiting Often coexist Chronic - 15 days/month over 3/12 – features of

tension/MOH

Management

• Identify triggers– Stress/sleep dep/diet

• Massage/acupuncture etc• Withdraw any overused meds• Headache Diary

Management

Acute:ASA 900mg NSAIDs – ibuprofen (dicofenac pr)+/-Antiemetics

Domperidone/metoclop bestOcc codeine? *cautionCombination asa + caffeine + para

TriptansFor use at onset headacheEffective in 50%Delivery methods

Oral – all – sumatriptan cheapestS/L – riza + zolmitriptanS/C or nasal - sumatriptan

If no response try alternativeCombination with ASA/NSAID

C/I IHD or severe hypertensionCaution with hemiplegic migraine

Prophylaxis – general principles

• Given if affecting QOL• Titrated slowly• Trial 6-8 weeks• If effective consider withdrawal after 6-

12/12

Prophylaxis

• Propranolol LA 80mg - 240mg– Caution asthma, bradycardia, PVD

• Topiramate 25mg – 50mg bd– Caution kidney stones/depression/teratogenicity?

• Amitriptyline 10mg – 75mg– Good if chronic/mixed

• Valproate 800-1200mg/day– Caution young women

• Gabapentin up to 2400mg/day• Pizotifen minimal benefit

Alternatives:

• Atenolol/metoprolol• Nortripyline• Venlafaxine 75-150mg

• Bo tox • recent license chronic

migraine• >3 prior Tx• No MOH

Who to refer?

• Unsure of diagnosis• Atypical migraine– Motor weakness– Diplopia– Poor balance

• If adequate trial propranolol/amitrip ineffective

• Patient reassurance

Benign tremor management

Differential Diagnosis

• Drugs– Da blocking drugs

• Antipsychotics• Antiemetics

– Inhalers – B agonists– Ca channel blockers– Li– Valproate– Digoxin

• etc

• PD

• Thyrotoxicosis– Check TFTs

• Anxiety

• ET

• Dystonic

Essential Tremor• Activity• Bimodal age onset• ½ alcohol benefit• ½ FH• Postural/action, symmetrical 4-12 Hz• +/- head (late), jaw, voice• Treatment– Propranolol LA 80mg – 240mg, Topiramate 25mg –

100mg– primidone, gbp. – Rarely: deep brain stimulation

Peripheral neuropathy – history, investigations and who to refer?

• Sensory (occ motor) disturbance feet • Feet before hands• Worse at rest/night• Exam – reduced/absent AJ• Investigations:– Glucose, HBA1C, TFT, B12, Folate, ESR, Autoantibodies,

Igs and electrophoresis• Refer – if motor symptoms +/or significant

sensory symptoms and no cause found

CTS/ulnar

CTS – most common cause of sensory disturbance hands – night + carryingThumb abduction/sensory

Open access NCS

Ulnar – small muscles hand/sensory

Refer neurology

GP Q&A

Dr Martin DuddyConsultant NeurologistRoyal Victoria Infirmary

Newcastle upon Tyne, UK

review of how to do a quick neuro exam

• “brief neuro exam 2016”• U of Birmingham; David Nicholl

• https://www.youtube.com/watch?v=q56WgXvn0iU

what test reliably rules out MS?

• composite diagnosis

• depends on degree of clinical suspicion

• normal MRI with significant symptoms– role of spinal MR

• good story (esp with signs)– evoked potentials– LP

when to suspect MS in sensory symptoms

• anatomical distribution

• time course

• linguistics

• concordant motor/autonomic symptoms

• signs

MS: common pitfalls in dx, e.g. what’s been missed by GPs

• sensitivity/specificity• misdiagnosed past episodes• missed symptoms– bladder/bowel– erectile dysfunction– Lhermitte’s– Uthoff’s (heat-sensitive symptomatology)

management/referral for abnormal sensation, i.e. pins and needles/numbness tingling

• clinical context• is the distribution consistent with:

– peripheral mononeuropathy– peripheral neuropathy– radicular pathology– myelopathy– central disease

• does the time course suggest pathological process?• congruent motor/autonomic/reflex changes• is the presentation predominantly neurological?

– pain/ fatigue/ anxiety