Contemporary Neurology

M.J.G. Harrison

• Publisher: Butterworth-Heinemann
• Year: 2013
• Print ISBN: 9780407003088
• eBook ISBN: 9781483182612
• Topic: Medicine
• Subtopic: Diseases & Allergies

Contemporary Neurology compiles a large series of papers on the commonest neurological problems. This book discusses the management of epilepsy, involuntary movements, nerve and muscle diseases, and multiple sclerosis. The areas on infections, cerebrovascular disease, trauma, intracranial pressure, and vertebral column are also elaborated. This text likewise describes medical procedures on how to do a lumbar and cisternal puncture. Other topics include headache in children, hyperventilation, dizziness, funny turns—neurological, dysarthria, facial pain, and nystagmus. The weakness of the legs, loss of memory, coma, brain death, complications of alcoholism, and stupor and akinetic mutism are also covered. This publication is valuable to clinicians and examination candidates preparing for the DPM, MRCP (UK) and Neurology/Psychiatry "Boards.

Chapter 1

Headache

James W Lance, The Prince Henry and Prince of Wales Hospitals and the University of New South Wales, Sydney, Australia

Publisher Summary

This chapter discusses the diagnosis of headache, which is a clinical problem usually solved by taking a careful medical history. Diagnosis depends on the recognition of the pattern of headache, the time and mode of onset, the nature of the associated symptoms, and the factors that precipitate, aggravate, or relieve it. The classification of headache that has the greatest practical application is one based on the length of time the headache has been troubling the patient and the pattern of recurrence. The headache that follows concussion must be distinguished from that of cerebral compression caused by an extradural or a subdural hematoma. The vascular headache associated with the exanthems of childhood or other generalized infections, or with acute sinusitis or a hangover, does not usually present any diagnostic difficulty. The first episode of migraine that is experienced in the life of a patient may give rise to unnecessary alarm, particularly if it is accompanied by focal neurological symptoms such as aphasia or unilateral paraesthesiae. As a general rule, any headache that has been present for more than 5 years is a muscular-contraction headache or migraine.

The diagnosis of headache is a clinical problem that is usually solved by taking a careful medical history. It does not depend upon the availability of electroencephalography, isotope brain scanning, or computerized axial tomography (CAT) except in the small number of cases where a brain tumour or similar lesion is suspected. In general, the shorter the history of headache the greater the reason for concern.

Diagnosis depends on recognition of the pattern of headache (its site, quality, frequency, and duration), the time and mode of onset and the nature of the associated symptoms, and the factors that precipitate, aggravate, or relieve it. For example, any headache that is made worse by coughing, sneezing or straining is associated with dilatation or displacement of intracranial vessels. The response to alcohol is useful in the differential diagnosis between chronic vascular headaches and those caused by muscular contraction (tension headaches). The latter are commonly improved by taking alcohol whereas the former are almost always made worse.

The classification of headache that has the greatest practical application is one based on the length of time the headache has been troubling the patient and the pattern of recurrence.

Acute single episodes of headache

This group includes the serious intracranial causes of headache such as subarachnoid haemorrhage, encephalitis, and meningitis, in which the headache is usually bilateral, of rapid onset, and associated with photophobia, impaired consciousness, and neck rigidity. It is for this group that hospital admission is usually urgently required and lumbar puncture is an important diagnostic test.

The headache that follows concussion must be distinguished from that of cerebral compression caused by an extradural or a subdural haematoma. Any patient who becomes drowsy after a head injury should be investigated. If one pupil starts to dilate or any other component of a third nerve palsy appears, investigation is a matter of urgency because this sign indicates that the brain is being forced downwards through the tentorial opening by an expanding lesion and is thus compressing the third cranial nerve. Immediate action must be taken by a neurosurgeon under these circumstances. Hours or even minutes may be of importance. Such a patient should not be subjected to lumbar puncture because the removal of CSF usually increases pressure on the midbrain from above and may cause death. CAT as an emergency procedure is helpful in this post-traumatic group.

The vascular headache associated with the exanthems of childhood or other generalized infections, or with acute sinusitis or a hangover, does not usually present any diagnostic difficulty. Sinusitis is sometimes not suspected when there is no obvious blockage of the nostrils. A constant unilateral frontal pain or a boring pain in the centre of the forehead should suggest infection of one frontal sinus or of the ethmoidal and sphenoidal sinuses, respectively. The onset of closed-angle glaucoma may also be neglected if a misting of the vision in one eye with unilateral ocular or frontal headache is dismissed as migrainous. A severe loss of central vision with retro-ocular pain suggests acute retrobulbar neuritis. Occasionally, pain may be referred to the eye and forehead from an acute compression of one of the upper four cervical roots as a result of cervical spondylosis.

The first episode of migraine that is experienced in the life of a patient may give rise to unnecessary alarm. particularly if it is accompanied by focal neurological symptoms such as aphasia or unilateral paraesthesiae. If the headache is on the side of the head consistent with the symptoms (for example a left-sided headache with right-sided paraesthesiae and aphasia), investigations are usually indicated even if the subsequent history shows that they were unnecessary. If the headache is on the inappropriate side (the right side in the above example), the chances are higher that the episode is migrainous and not caused by any intracranial lesion.

Acute headaches without neck stiffness may also be of intracranial vascular origin. Blood pressure may increase rapidly in acute nephritis, toxaemia of pregnancy, malignant hypertension, and the crises caused by phaeochromocytoma or by a patient on monoamine oxidase inhibitors taking sympathomimetic drugs or tyramine-containing foods. The blood pressure is usually secondarily elevated in patients with subarachnoid or intracerebral haemorrhage. Obstruction to the CSF pathways may also present as acute bilateral headache.

Acute recurrent episodes of headache

Some of the conditions mentioned above, such as sinusitis, pressor reactions, and acute internal hydrocephalus, may recur periodically. Repeated episodes of meningitis suggest the possibility of CSF rhinorrhoea. If clear fluid drips from the nostril when the head is bent forward, the fact that it is CSF rather than a nasal secretion can be determined rapidly by using a Clinistix to detect glucose in the fluid. The repeated recurrence of subarachnoid haemorrhage is most commonly caused by an intracranial (or occasionally intraspinal) angioma rather than an aneurysm because the bleeding is from the venous side of the angioma and hence the prognosis of each episode is better.

The headache resulting from cerebral vascular insufficiency is usually mild and the clinical picture is dominated by focal neurological symptoms of transient ischaemic attacks. The headache of internal carotid artery insufficiency is unilateral while an occipital headache accompanies vertebrobasilar insufficiency.

Intermittent hydrocephalus is a rare cause of recurrent headache but should be considered if the headaches are precipitated by bending forwards or are associated with obscured vision, impaired consciousness, myoclonic jerks, or weakness of the legs. The occurrence of headache only on physical exertion or coughing leads to the suspicion of an intracranial tumour, but some patients slowly improve and lose their headaches over a period of about 10 years without any intracranial lesion becoming apparent.

Migraine is the commonest of the acute recurrent headaches. There is often a reluctance to diagnose migraine unless the headache is unilateral, associated with nausea, vomiting and photophobia, and preceded by fortification spectra or other symptoms of neurological disturbance. This is the case in classic migraine but there are many more patients with common or nonclassic migraine in whom the headaches may be bilateral and severe but unaccompanied by any of the classic symptoms other than mild nausea. There are variations of migraine which may present difficulties, such as facial migraine, hemiplegic migraine, and vertebrobasilar migraine. In the last of these, brainstem symptoms such as vertigo and ataxia are associated with visual disturbance and a tendency to faint at the time of migraine headache.

The pattern of cluster headache is quite distinctive. This condition has been called migrainous neuralgia because of the unilateral distribution of pain, radiating upwards or downwards from one eye. It affects males more often than females, and occurs in bouts or clusters each lasting 2–8 weeks and recurring after weeks, months, or even years of freedom from headache. The severe pain appears once, twice, or more often during each 24-hour period and lasts between 15 minutes and 2 hours. It is characterized by watering of the eye and blockage of the nostril on the affected side.

Investigations are required in migraine or cluster headache only when the clinical history is atypical and it becomes necessary to exclude the presence of an aneurysm or other intracranial disorder.

Headaches of subacute onset

The development and progression in severity of headache in a patient who has never before been subject to headaches is always a cause for concern. If the pattern of headache is not typical of migraine or tension headache, the possibility of an intracranial lesion such as cerebral abscess or tumour or subdural haematoma must be considered. If the patient is drowsy, if the headache is aggravated by coughing or head movement, or if there is any neurological deficit, the chance of an intracranial lesion is much higher. Isotope brain scanning and CAT play a very useful part in the diagnosis of this group of disorders. In patients over the age of 55 years temporal arteritis must be excluded. The scalp arteries may be thickened and tender to palpation and the erythrocyte sedimentation rate is usually greater than 40 mm/h. The uncommon syndrome of benign intracranial hypertension as the result of hormonal changes, metabolic disorders such as hypocalcaemia, or drug idiosyncrasy may require full investigation to elucidate the cause.

Chronic headache

As a general rule, any headache that has been present for more than 5 years is a muscular-contraction headache or migraine. If there is no paroxysmal quality to the headache, so that it recurs every day like a tight band or pressure sensation, the diagnosis of muscular-contraction headache is almost certain. Such patients usually have an underlying state of anxiety or depression but it is important to exclude eyestrain or imbalance of the bite as causes of frowning or jaw clenching.

Conclusion

Most of the patients seen in general practice or in hospital require nothing...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Preface
• Contributors
• Chapter 1: Headache
• Chapter 2: Headache in children
• Chapter 3: Funny turns—neurological
• Chapter 4: Funny turns—cardiac
• Chapter 5: Hyperventilation
• Chapter 6: Dizziness
• Chapter 7: Dysarthria
• Chapter 8: Facial pain
• Chapter 9: Nystagmus
• Chapter 10: Pins and needles
• Chapter 11: The wasted hand
• Chapter 12: Weakness of the legs
• Chapter 13: Loss of memory
• Chapter 14: Stupor and akinetic mutism
• Chapter 15: Coma
• Chapter 16: Brain death
• Chapter 17: Complications of alcoholism
• Management of Epilepsy
• Involuntary Movements
• Nerve and Muscle
• Multiple Sclerosis
• Infections
• Cerebrovascular Disease
• Trauma
• Intracranial Pressure
• Vertebral Column
• Procedures
• Index