DIZZINESS

Many different sensations are described as dizziness. These include light-headedness, muzziness and faintness. First decide whether the patient is experiencing true vertigo, which is a subjective sensation of rotation, either of the patient or the surroundings. It is often accompanied by nausea, and nystagmus is a common finding.

LABYRINTHITIS

Diagnosis

Labyrinthitis is the commonest cause of true vertigo in general practice. Apart from nausea and vomiting and possible nystagmus, there are no other symptoms or signs. Features such as hearing loss or tinnitus suggest Ménière’s disease or acoustic neuroma. Focal neurological signs suggest an intracerebral pathology.

Management

• Reassure the patient that the condition is not due to a tumour, is common and that it resolves completely.

• Explain that the symptoms will be severe for 2–3 days and tend to resolve within 2–3 weeks. Labyrinthitis is probably due to inflammation of the inner ear and it is often recurrent.

• If symptomatic treatment is required, prescribe prochlorperazine 5 mg po tds or give 12.5 mg im if the patient is vomiting.

• Advise patients not to drive until symptoms are adequately controlled. Group 2 license holders are banned from driving for at least a year after symptoms have been controlled if they have suffered uncontrolled, disabling giddiness.

Tip

Referral to a neurologist or ENT consultant is indicated if the diagnosis is in doubt, if other features suggest an alternative diagnosis or if symptoms do not settle within 6 weeks.

HEADACHE

Ninety per cent of headaches are tension headaches; 10 % of the population have migraines. It is estimated that 0.004% of headaches are due to serious pathology.

Diagnosis

Examination

• BP

• fundi

• neck muscles

• cervical spine movements

• temporal arteries.

Management

Referral.

Indications for referral are:

• any of the above serious features

• failure to improve with adequate treatment

• uncertain diagnosis if the headaches are disabling

• patient’s insistence.

MIGRAINE

Migraine affects 10 % of the population. It can cause significant disability.

Features of migraines

• Headache is usually unilateral, aching, pulsating and worse on activity.

• Possible occurrence of nausea, vomiting, photophobia and phonophobia.

• Last from 4 to 72 hours and are recurrent.

• Visual disturbance in 20%.

Examination should be normal.

Management

• Discuss trigger factors: dietary factors, e.g. missed meals, caffeine, chocolate, cheese, alcohol; tiredness and stress; unaccustomed exercise; hormonal factors, e.g. menstrual periods, contraceptive pill, menopause; environmental factors, e.g. noise and temperature variations, wind, bright or flickering lights, strong smells.

• Analgesics are the first line of treatment, e.g. paracetamol, codeine, dihydrocodeine and NSAIDs.

• Antiemetics are also often required, e.g. metoclopramide.

• Combinations of analgesics and antiemetics are available, e.g. Migraleve.

• For severe attacks consider a 5-HT agonist, e.g. sumatriptan 50–100 mg po or 20 mg (one spray) intranasally.

Prophylaxis

For the patient experiencing frequent repeat attacks, say >2 attacks per month, consider the need for prophylaxis, e.g. propranolol 40 mg bd or tds or pizotifen 1.5–3 mg nocte or a tricyclic antidepressant (even when the patient is not obviously depressed).

FACIAL PAIN

The common causes of facial pain in general practice are:

• sinusitis

• temporomandibular joint dysfunction

• ear infections

• trigeminal neuralgia

• dental infection or impaction

• submandibular lymphadenopathy

• mumps

• migraine.

A rare, but important, cause of facial pain is temporal arteritis.

Tip

Often the cause of a patient’s facial pain cannot be neatly categorised. Patients with depression can present with a facial pain that is probably psychosomatic (see p. 297).

BELL’S PALSY

Bell’s palsy is the idiopathic palsy of the facial nerve (VII) resulting in a unilateral facial weakness or paralysis. It may be preceded by pain behind the ear, but usually presents as a painless facial paralysis.

CEREBROVASCULAR ACCIDENT (CVA)

Among a GP’s average list of 2000 patients there will be 3–4 strokes per year and about one transient ischaemic attack (TIA). The majority are either thromboembolic (70%) or haemorrhagic (20%).

Tip

An acute stroke is defined as a rapid onset of clinically evident focal cerebral deficit lasting more than 24 hours, with no obvious cause.

Management

Referral.

In general, all patients with acute strokes should be admitted to hospital urgently. Early CT/MRI scanning, thrombolysis or anticoagulation and antiplatelet therapy can all help prevent further attacks.

However, patients whose quality of life is poor, such as some severely disabled nursing-home residents, may not need admitting if they stand to gain little or nothing from this action.

Prescribing.

For non-haemorrhagic stroke start the patient on aspirin 75 mg od, consider e.g. an ACE inhibitor such as ramipril 2.5 mg increasing to 10 mg a day, and a statin (see p. 150). In addition to aspirin for antiplatelet activity, prescribe dipyridamole m/r 200 mg bd for the 2 years following each ischaemic event. If the patient is allergic to aspirin, prescribe clopidogrel 75 mg od instead.

Prognosis.

There is a 10% annual risk of a serious vascular event after a stroke, e.g. a further stroke, MI or death. This risk is reduced by 25% with the use of aspirin.

Tip

Be encouraging and optimistic with stroke patients about their functional recovery, which can be slow. Little improvement at 6 weeks, however, carries a poor prognosis, with permanent disability likely.

Patients can resume driving after at least 1 month following a stroke if recovery is satisfactory. Patients should inform the Driver and Vehicle Licensing Agency after this time if there is anything more than minor limb dysfunction.

Administration

Quality and Outcomes Framework for Stroke/TIA

• Record the smoking status annually and offer cessation advice to smokers.

• Achieve a blood pressure of 150/90 or below.

• Achieve a cholesterol of 5 mmol/l or below.

• Prescribe aspirin or an alternative antiplatelet drug.

• Give an annual flu jab.

TRANSIENT ISCHAEMIC ATTACK (TIA)

• Full recovery of all the neurological signs should occur within 24 hours.

• Examine the patient for signs of cardiac arrhythmias (see p. 165), heart murmurs and carotid bruits.

• Check BP.

• Blood for FBC, ESR, C&Es, glucose and lipids.

• ECG.

• Prescribing – As for CVA (see p. 280).

Patients with suspected TIAs should be referred urgently to the local stroke clinic for brain imaging, carotid Doppler or angiography and cardiac echo.

Administration

Quality and Outcomes Framework for TIA

As for stroke (CVA), above.

TREMOR

Benign essential tremor is very common in general practice. Other common causes of tremor in general practice are Parkinson’s syndrome, anxiety and thyrotoxicosis. Rare causes include the cerebellar disorders.

Categories of tremor

There are essentially three:

• positional tremors, e.g. essential, anxiety and thyrotoxicosis tremors

• the resting tremor of Parkinson’s syndrome

• the intention tremor of cerebellar disorders.

RESTING TREMOR

See Parkinson’s syndrome, below.

INTENTION TREMOR

Refer all cases of intention tremor, in order to exclude a cerebellar tumour. Other features may include:

PARKINSON’S DISEASE

One per cent of people over 60 years of age have Parkinson’s disease.

Management

• If possible, stop any drugs which may be causing Parkinsonism, e.g. phenothiazines and butyrophenones

• If Parkinson’s disease is suspected, referral to a neurologist with an interest in the condition should be made as soon as possible. L-dopa with a dopa decarboxylase inhibitor, e.g. Madopar, is the main drug in the treatment of Parkinson’s disease. It is best in patients with marked bradykinesia.

• General support can be usefully provided in general practice. Consider physiotherapy, speech therapy and occupational therapy, Social Services, Attendance Allowance and day hospital. Emotional support and carer support are also important.

• Look out for depression (see p. 292) and dementia (see p. 303), both of which are more common in Parkinson’s disease.

• Alterations to specialist-initiated drug treatments should be by liaison with specialist services.

FALLS

Falls are common in the elderly and have a multitude of possible causes:

• Visual: cataract, macular degeneration, refractive error.

• Environmental: loose carpet, steps.

• Musculoskeletal: parkinsonism, arthritis.

• Drugs: postural hypotension.

• Cardiac: arrhythmia, heart block.

• Neurological: TIA, epilepsy.

• Circulatory: vertebrobasilar insufficiency.

EPILEPSY

The GP with the average list of 2000 patients might expect to have about eight patients with epilepsy.

Management

Counselling after a diagnosis of epilepsy has been made

MULTIPLE SCLEROSIS

The average GP’s list of 2000 patients will contain one or two patients with multiple sclerosis.

The mean age of onset is 35 years, with a range, commonly, of between 20 and 40 years of age.

Diagnosis

Examination.

Examination of the relevant part of the nervous system may reveal objective signs. A full neurological examination would be very time-consuming for a GP, but may demonstrate further signs of demyelination.

Tip

Physical examination is often normal in the initial stages of multiple sclerosis. It is a sad but well-recognised phenomenon that patients with their first episode of demyelination are often labelled as hysterical.

Management

All suspected cases should be referred for a neurological opinion.

Prognosis.

Fifteen years from presentation, approximately one-third of patients with multiple sclerosis will be severely disabled, but another third will be unrestricted by disability.

The average life expectancy is 25 years from presentation.

Long-term care

• Close communication with the patient’s neurologist is important, especially if the patient relapses or deteriorates.

• Physiotherapy is useful for contractures, immobility and poor posture.

• Occupational therapy helps with the activities of daily living.

• A social worker can help with employment matters, allowances and re-housing.

• For the treatment of spasticity, consider physiotherapy. Treatment with baclofen or dantrolene may be useful.

• Flexion deformities also may be helped by physiotherapy. Consider an orthopaedic referral if the patient is handicapped by deformities.

• Paroxysmal pain can be a problem in neuritis. Consider the use of carbamazepine, phenytoin or gabapentin.

• Constipation can be helped by ensuring an adequate fluid intake, bulking agents, suppositories or enemas.

• Obesity can be a problem for any patient with prolonged immobility. Consider referral to a dietician.

• Urinary problems are common in multiple sclerosis. Antibiotics for urinary tract infections may be needed. Try anticholinergics for bladder instability, e.g. oxybutynin 5 mg tds. An opinion from a urology specialist may be needed. Catheterisation is occasionally required.

• Sexual dysfunction is common in multiple sclerosis. Consider sildenafil, or referral for counselling or a urology opinion.

• The Driver and Vehicle Licensing Agency should be informed by the patient. A disabled parking permit should be applied for if appropriate.

• Depression is almost inevitable at some point in the life of every patient with multiple sclerosis (see p. 292). Stress in the carer is also common and is often overlooked.

HEAD INJURY

Patients with mild head injuries present commonly to GPs, often out of hours, and usually, initially, over the telephone. The decisions of whether to visit and whether to refer to A&E depend on the risk of the missed skull fracture.

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