Neurological Dilemmas in Primary Care David Clark, DO dclark@oregonneurology.com When to test? How to test? Pitfalls in testing? When to treat? How to treat? How long to treat?
Neurological Dilemmas Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures Headache When to image? Secondary headaches with normal imaging Primary Headache treatments Medication Overuse Headaches
21M College Student 4 year history of recurrent déjà vu 2 months ago, lost consciousness. Awoke on the floor an undetermined time later. Did not seek medical attention This AM, sitting in class, felt profound déjà vu followed by loss of consciousness Onlookers describe a fall and generalized shaking movement lasting 60 seconds Followed by confusion lasting minutes What do you want to do?
Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures
Seizure-when to treat 2 unprovoked seizures 1 seizure with high risk of recurrence No seizure with high risk of having one
Those with 1 seizure who are at high risk for recurrence
Those with 0 seizures who are at high risk for seizure
When to stop the seizure medication Lower risk of seizure recurrence Idiopathic etiology Normal mentation Normal neurologic exam Seizure free interval >2 years Normalized EEG at 2 years Higher risk of seizure recurrence Symptomatic etiology Abnormal neurologic exam JME EEG abnormalities
Psychogenic Nonepileptic Seizures Features suggestive of nonepileptic seizures Resistance to antiepileptic medications Stress as a trigger More likely to occur with an audience Side-to-side shaking Bilateral asynchronous movements Weeping or stuttering Arching the back No post ictal confusion
Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures
Headache When to image? Secondary headaches with normal imaging Migraine Headache Treatment When is abortive treatment okay When is preventative treatment considered Medication Overuse Headaches Prevention Treatment
When to image a headache Postgrad Med. 1997 May;101(5):46-50, 55-6, 62-4.
Brain parenchymal imaging CT Pros Quick and accessible Good for blood and bone Cons Radiation Lower parenchymal resolution MRI Pros Better parenchymal resolution No radiation Cons Claustrophobia Table weight limit Access may be limited in some communities
Angiography/Venography MRA/MRV CTA/CTV Catheter angiography/venography
68F headache began three months ago, gradually worsening
68F headache began three months ago, gradually worsening
23M thunderclap headache following a basketball game
23M thunderclap headache following a basketball game
69M abrupt headache, diplopia and then left eye vision loss
69M abrupt headache, diplopia and then left eye vision loss
Headache with normal imaging?
38F neck/head pain for 10 days, then recurrent ataxia 44M with 7 days of neck pain, then recurrent transient speech difficulty
38F neck/head pain for 10 days, then recurrent ataxia 44M with 7 days of neck pain, then recurrent transient speech difficulty
Double Lumen Cervical Artery Dissection
Cervical Artery Dissection Carotid Artery Pain, neck or face Horners Syndrome Ischemia Retinal Hemispheric Hemisensory Hemiparesis Vertebral Artery Pain, neck or head Ischemia Ataxia Diplopia Hemisensory Hiccups Horners
21M with recurrent thunderclap headaches Using marijuana, triptan Initial MRI normal
21M with recurrent thunderclap headaches Using marijuana, triptan Reversible Cerebral Vasoconstriction Syndrome HA (thunderclap) Nausea/vomiting Confusion Blur Risk for SAH and focal ischemia DDx vasculitis
33F two weeks post partum Severe holocephalic headache Left facial numbness Normal MRI brain
Cerebral Venous Sinus Thrombosis F>M Peripartum Hormonal contraceptives Tobacco Smoker Hypercoagulable
68F Headaches 4 weeks of: Jaw claudication Scalp tenderness Fever Myalgias Weight Loss Night sweats Labs ESR 97 (Normal <30) CRP 12 (Normal <0.5) Platelets 550,000
68F Headaches Temporal Arteritis (Giant Cell Arteritis)
32F three months of daily headaches BMI 39 Transient visual obscurations Pulse Synchronous Tinnitus Postural Headache, worse supine Photopsia
Idiopathic Intracranial Hypertension Pseudotumor Cerebri
MRI negative secondary headaches Consider angiography or venography Consider fundus evaluation Consider checking inflammatory markers (ESR, CRP)
Migraine-Preventative strategies Lifestyle Trigger avoidance Foods Bright light Strong odors Regular exercise Stress management Sleep quality Hydration
Migraine As needed Abortive Therapy 2 days/week Triptans Sumatriptan, Rizatriptan, etc NSAIDs Anti-emetics No more than 2-3 days/week Daily Preventative Therapy When headaches are 2 days/week Antiepileptics (topiramate) Antidepressants (amitriptyline) β blockers (propranolol) CCB (verapamil) OTC (magnesium, Vitamin B2) Abortive Therapy Preventative Therapy Two headache days/week
Medication Overuse Headache HA 15 days/month Regular medication overuse for 3 months HA developed or markedly worsened during medication overuse Overuse 3 days/week for at least 3 months
Summary Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures Headache When to image? Secondary headaches with normal imaging Primary Headache treatments Medication Overuse Headaches