18: NEUROLOGY

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CHAPTER 18 NEUROLOGY

Dizziness
Headache
Facial pain
Bell’s palsy
Cerebrovascular accident (CVA)
Transient ischaemic attack (TIA)
Tremor
Parkinson’s disease
Falls
Epilepsy
Multiple sclerosis
Head injury

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.

Causes of true vertigo

• Common: labyrinthitis, benign positional vertigo.
• Rare:

– brainstem stroke/TIA
– vertebrobasilar insufficiency
– Ménière’s disease
– acoustic neuroma
– multiple sclerosis.

Causes of other types of dizziness

• Infections, e.g. flu-like illnesses and URTIs
• anxiety and depression (see pp. 294 and 292)
• syncope (see p. 163).

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

Causes of headache

• Common:

– tension headache
– associated with URTI
– migraine
– depression.

• Rare:

– tumour
– subarachnoid haemorrhage
– subdural haemorrhage
– meningitis
– giant cell arteritis.

Tip

Often the cause of a headache cannot be neatly classified. As long as there are no features of serious disease (see below), reassurance and a ‘wait and see’ approach are reasonable.

Indicators of more serious disease in headache

• Sudden onset.
• New, severe headache.
• Progressively worsening headache.
• Onset of headaches after the age of 50.
• Altered level of consciousness.
• Recent head injury.
• Abnormal physical findings, especially focal neurology.
• Meningism.
• Tender temporal arteries.

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.

TENSION HEADACHE

The features of tension headaches are:

• chronic, frequent and recurrent
• moderately severe
• generalised
• described as a tight band of pressure
• absence of nausea generally
• scalp tenderness in places.

Examination is otherwise normal.

Management

Reassurance, relaxation and analgesics are often all that are necessary (see anxiety, p. 294).

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).

TEMPOROMANDIBULAR JOINT DYSFUNCTION

Diagnosis

The patient complains of pain in front of the ear, exacerbated by eating and often accompanied by clicking.

Management

• Reassurance that the condition is benign and temporary is often all that is required.
• Advising patients to alter their bite by chewing on the other side of the mouth is useful.
• Advise patients to avoid very chewy food, e.g. hard crusts.
• NSAIDs are sometimes required for more painful episodes.
• Severe cases, involving locking of the jaw, may need referral to a dentist or faciomaxillary surgeon.

TRIGEMINAL NEURALGIA

Diagnosis

The patient complains of severe, stabbing or burning pain in the distribution of one or more of the three branches of the trigeminal nerve (V). It is unilateral and made worse even on lightly touching the skin or on exposure to cold wind.

Management

• Simple analgesics are often all that is required, as most cases get better within a few weeks.
• Carbamazepine 100 mg od, increased to 400 mg tds according to response, taken during the acute stages.
• Treatment of depression, if present, may be indicated (see p. 292).
• Referral to a neurologist may be indicated if the above measures fail. Some patients benefit from injection or surgical resection of the affected trigeminal nerve branch.

OTHER CAUSES

Sinusitis

See p. 217.

Earache

See p. 212.

Dental infection or impaction

Refer to the patient’s dentist.

Cervical lymphadenopathy

See p. 219.

Mumps

See p. 206.

Migraine

See p. 276.

Giant cell arteritis

See p. 242.

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.

Diagnosis

Examination

• The whole of one side of the face is affected and the patient has unilateral difficulty raising the eyebrows, showing the teeth and puffing out the cheeks.
• Exclude geniculate herpes (Ramsay Hunt syndrome) by looking for vesicles in the ear and mouth.
• Make sure that the patient can close the eye on the affected side, to avoid corneal abrasion (see below).
• Examination of the other cranial nerves should be normal.

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