based on GP questions

1. Quick Fire Top Neurology Tips
Martin Duddy and Naomi Warren
RVI

2. 1) Brief update on how TIA is now
risk stratified? Is abcd2 out now?
2) Is there a guideline or best
practice on anticoagulation (in af)
for multiple falls with subdural
(chronic or past) -> or would this just
be an individual decision.

3. https://cks.nice.org.uk/stroke-and-tia#!scenario:1

4. 3) when can MS be excluded to
avoid referral?

5. what test reliably rules out MS?
• depends on degree of clinical suspicion
– context important
• composite diagnosis
• normal MRI with significant symptoms (still available to GPs?)
– role of spinal MR
• good story (esp with signs)
– can go to:
• evoked potentials
• LP

6. common presentations
• optic neuritis
• brainstem (trigeminal neuropathy, eye
movement abnormality, vertigo with
brainstem features)
• transverse myelitis
– bilateral
– hemicord syndrome
• Lhermitte’s

8. McDonald 2017 RRMS
• no differentiation between symptomatic and
asymptomatic lesions
• cortical can replace juxtacortical
• OCB can substitute for DIT
• optic nerve still does not count as a site for DIS

9. when to suspect MS in sensory
symptoms
• anatomical distribution
• time course
• linguistics
• concordant motor/autonomic symptoms
• signs

10. 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)

11. management/referral for abnormal
sensation, i.e. pins and needles/numbness
tingling
• clinical context
• is the distribution consistent with:
– peripheral mononeuropathy
• common A&G one
– 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/ swelling

12. How to manage chronic headaches
How to manage severe tension
headache

13. NICE 2012
• Important to make a +ve
diagnosis

14. 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 CRP
Prednisolone 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 Guideline
November 2017
Refer Neurology
emergency clinic
(fax 0191 2824370)
Yes
Yes
No

15. 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

16. Management
• Identify triggers
– Stress/sleep dep/diet
• Withdraw any overused meds
• Headache Diary
• Acute treatment
• Prophylaxis
• A+G

17. Who to refer?
• Unsure of diagnosis
• Atypical migraine
– Motor weakness
– Diplopia
– Poor balance
• If adequate trial propranolol/amitrip
ineffective
• Patient reassurance

18. NICE 2012
• Do not scan primary headaches
for reassurance

19. Guidelines for GPs requesting MRI/CT
for suspected “brain cancer”
Indications:
• Progressive neurological deficit (eg. unilateral weakness,
hemianopia).
• Progressive cognitive deficit or personality change (if atypical
for dementia or mood disorder).
• New onset focal seizures (with or without secondary
generalisation).
NOT for: isolated headache with normal examination
For further advice please contact
naomi.warren@nuth.nhs.uk or
tim.williams@nuth.nhs.uk
If brain tumour detected: if urgent discuss with neurosurgery on call
team and if incidental/non-urgent refer to neuro-oncology MDT.

20. Questions about Ropinirole for use of
Restless legs
• Is this still first line for RLS?
– No – Gabapentin, nocte up to 400mg
• Is there anything that can be done to avoid
augmentation?
– Start low, rotigotine patch?
• Where next?
– Space out? Check lifestyle
• Is there a place for specialist assessment of
RLS?
– Yes – Adam cassidy (SRH) Kirstie Anderson or Sophie West

21. Restless legs and Periodic Limb Movements
of Sleep
 Deep dysaesthesia LL (occ ULs) with circadian pattern and relieved by
movement. 80% have PLMS. 5-10% of population, often familial and
progressive over years
 Associations
 Pregnancy, iron def, dialysis, antidepressants, antipsychotics
 Treatment
 Iron if ferritin below 45
 Decrease nicotine, caffeine, alcohol
 Gabapentin/pregabilin,dopamine agonist (but beware impulse control
disorders), benzodiazepines, opiates, but NOT amitriptyline or
melatonin
 Guidelines on GP team net + RLS-UK