NEUROLOGY + NEUROSURGERY

ResponseMigraine

• Hx of migraines, classic visual aura, unilateral, throbbing, gradual onset, nausea, phono/photophobia
• 1st episode CTB +/- LP
• Tx:
• First line:Aspirin 900mg, Paracetamol, prochlorperazine, others.
• Intractable migraine (Failed first line tx): Ketorolac, chlorpromazine, tryptans (sumatriptan 6mg SC, Ryzatriptan 10mg wafer), prednisone controversial but is 2nd line in pregnancy (pred 50mg)
• Prevention: Amitriptyline, propranolol, valproate, topiramate, verapamil

GCA

• Temporal tenderness, jaw claudication, elderly patient. Papilloedema, decreased VA, decreased temporal pulse, Diplopia
• ESR >50, Temporal artery biopsy
• Rx: Steroids

Acute closed angle glaucoma

• Acute severe pain with red eye, orbital or unilateral head pain, blurred vision + haloes
• Raised IOP >20mm.HG (?more like 30-40?)
• Rx: Acetazolemide, Pilocarpine, timolol, analgesia, antiemetics, ophthal

Cavernous sinus thrombosis

• Persistent non severe pain, chemosis, proptosis
• CT venogram/MRI venogram
• Rx: anticoagulation, maintain CPP

Space occupying lesion

• Morning headaches, B symptoms
• CTB + Contrast
• chemo/radio/surgery - Referral basically

Stroke

ResponseCTB
LP
CT angiogram

ResponseOpioids
Pro - dosing titratable, good general analgesia
Con - respiratory depressant, limited efficacy in headache, dependence

Anti emetics - prochlorperazine (Stemetil)
Pro - effective in migraine and tension headaches, additional antiemetic effect
Con - High incidence of akasthesia, technically should only be administered IM not IV

Antiemetic - Droperidol, Chlorpromazine (Largactil)
Pro -Proven efficacy in headache management for migraine and tension, no resp depression, lowers BP
Con - Hypotension, sedation, akasthesia

Paracetamol
Pro: additive effect with other avenues of analgesia, minimum side effect profile
Con - Limited potency of analgesia

NSAID’s
Pro: additive effect with other analgesia, Efficacy in majority of migraine headaches
Con: Limited potency, potential antiplatelet effect