Neurology

Headache

Headache is a common presenting symptom in both primary and secondary care. It is estimated that about 3% of patients presenting to the Emergency Department have a headache as their main complaint (Morgenstern et al, 2001).

The vast majority of patients complaining of headache will not have a serious medical problem. However, it is of vital importance to be aware of the small minority who will have life-threatening or serious organic disease.The task of diagnosing the cause of a patient’s headache is complicated due to the range of differential diagnoses.

There are many hundreds of different causes of headache. These range from the inconvenient to some of the most deadly diseases known to man (International Headache Society, 2004). Headache as a presenting complaint is a true test of a doctor’s clinical skills. It is by taking a comprehensive history and performing a thorough clinical examination that the diagnosis can often be made. A barrage of clinical tests is no substitute for listening and looking.

Seizures

Epilepsy is common, with an estimated prevalence in the developed world of 5-10 per 1000 people, and an annual incidence of 50 per 100 000 people. About 3% of people will be given a diagnosis of epilepsy at some time in their lives. For most patients epilepsy is a lifelong disorder and they will have to take medications for the rest of their lives. For these reasons it is vital to manage patients with epilepsy correctly. It is equally important that patients with epilepsy receive the information that they need.

Following evidence-based, validated treatment algorithms can significantly improve outcomes. Presentations may vary from clinically obvious tonic-clonic convulsions, to subtle focal seizures, to seemingly bizarre sensory alterations associated with partial seizures. An awareness of the existence and presentations of these different forms is required.

TIA & Stroke

Every year approximately 130,000 people in England and Wales have a stroke, ie someone has a stroke roughly every 5 minutes. 70% are new strokes, with 30% being recurrent. The risk of recurrent stroke is 30-43% within 5 years, and 10% in the first year. 20-30% of people who have had a stroke die within a month and it is the third largest cause of death in England (after ischaemic heart disease and cancer). Ultimately, 11% of all deaths are due to stroke. (The Stroke Association, 2006)

In the UK and the United States, stroke is the leading cause of disability. This does not just include physical disability, but also loss of cognitive and communication skills and mental health problems including depression.

Despite this, however, a MORI poll commissioned by The Stroke Association in 2005 showed that only half those surveyed knew what a stroke was, and only 40% could name three stroke symptoms. A quarter did not realise that treatment is available, despite stroke thrombolysis being first trialed in the early 1990s. Sixty per cent would call their GP or NHS Direct in the event of them having a stroke, however only just over half of GPs would refer a suspected stroke immediately. Only 12% of hospitals at the time of the poll had protocols with the ambulance services for acute stroke referral. This is hopefully changing since the introduction of the F.A.S.T advertising campaign in February 2009, the aim of which is to raise awareness of stroke in the community.

Stroke is expensive. It costs the UK economy about £7 billion per year: £2.8 billion in direct costs to the NHS, £2.4 billion on care within the family and £1.8 billion from lost income (Department of Health (DH), 2005). Each stroke costs around £15,000 to treat over 5 years. The US economy is $43.3 billion poorer per year as a result of stroke treatment.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

• Distinguish between TIA, stroke and stroke mimics.

• Propose a management plan for TIA's presenting to the Emergency Department

• Compose a differential diagnosis of headache presenting to the Emergency Department

• Propose a management plan for seizures and status epilepticus presenting to the Emergency Department

• Compose a differential diagnosis for a patient with coma presenting to the Emergency Department

Tasks

Complete the following before the face-to-face session:

#EM3 Content

LIGHTNING LEARNING

Blog:

• Suspected SAH – Do we still need the needle?

• Ruling out SAH in the ED – Is it more headache than a help?

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

NICE guidelines:

• Diagnosis and initial management of acute stroke and transient ischaemic attack - CG68

• Transient loss of consciousness in adults and young people - CG109

e-LfH Emergency Medicine (EMD) modules:

• Management of Coma

• Management of Transient Ischaemic Attacks

COURSE FEEDBACK