Neurology

Tremor

This video presented by Dr Fiona McKevitt, Consultant Neurologist and CASES Mentor aims to:
• Show how to assess tremor and in particular distinguish between Essential Tremor (ET) and the tremor of Parkinson’s Disease
• Highlight signs and symptoms that should prompt referral to secondary care
• And, to discuss how ET can be treated in Primary Care

Webinar Session with Dr Tom McAnea 2022: How to approach the management of headaches

Q&A from the session PDF download here

Webinar Session with Dr Tom McAnea 2023: Taking the Headache out of the headache

Advice for Sheffield GPs Press portal (primary care CASES)

http://www.primarycaresheffield.org.uk/cases/gp-resources/

1. Tremor: The two most common causes of tremor are essential tremor (ET) and Parkinson’s disease (PD). ET is frequently present for many years before patient seeks medical attention. It is typically symmetrical and present on action such as drinking a cup of tea. Parkinson’s tremor is asymmetrical, frequently present at rest only and typically associated with other motor symptoms such as impairment of fine finger movements. If a further opinion is required please refer to the Neurology movement disorder clinic. If the patient is 75 or older please refer to the Care of the Elderly movement disorder clinic.

2. Migraine: If there is no diagnostic uncertainty then patients do not necessarily require referral to neurology. If a migraine referral is made it is expected that NICE guidelines have been followed before the referral is made. NICE and BASH offer useful treatment guidelines for management of migraine and headache.

1. If a patient greater than 50 presents with a headache it is advisable that inflammatory markers are checked.
2. If a patient with previous cancer presents with headache have a low threshold for brain imaging/referral

3. Peripheral neuropathy: Consider checking random glucose, Hb1AC, B12, folate. If no cause is identified then can refer to the neurology clinic.

Please note that sensory symptoms are very common in the general population. Most people with fleeting, intermittent or whole-body sensory disturbance will not have an identifiable underlying neurological cause. If symptoms come and go, they are likely to be benign sensory symptoms. Addressing any sleep, pain or mood issues could be helpful.

Paraesthesia related to peripheral neuropathy is usually persistent (although variable). If related to MS, symptoms develop over a few days, plateau for several weeks before then improving.

4. Carpal tunnel Syndrome: If suspicious of carpal tunnel please follow the carpal tunnel management pathway (https://sites.google.com/site/sheffieldccgportal/pathways/carpal-tunnel-clinical-pathway)

5. Cognitive impairment: Patients aged over 70 with cognitive impairment can be referred to the old age psychiatry memory clinic at Longley centre, Northern General Hospital. If younger than 70 then consider referral to the neurology memory clinic. Prior to referral consider checking TFTs, B12 and folate. Consider mood disorders or high alcohol intake as a possible cause especially in the younger patient. If related to high alcohol intake these should be referred to the drug and alcohol service.

6. Epilepsy: if a patient with epilepsy is known to the epilepsy specialist nurses, then advice on their management can be sought by phoning the health professional helpline number (via Royal Hallamshire Hospital switchboard).

7. First seizure: Refer suspected first seizures to the epilepsy service. Do an ECG before referral, and consider arranging an MRI brain scan.

N.B. Patients with seizures caused by alcohol dependence or use of recreational drugs with a well-recognised associated with seizures, such as synthetic cannabis and cocaine should be referred to the drug and alcohol service rather than the epilepsy service.

8. Syncope: In cases of loss of consciousness does the patient fulfil the 3Ps? Upright Position/

Prodrome (visual clouding, hearing muffled, lightheadedness) /Provoking factors.

If yes then the most likely diagnosis is vasovagal syncope and this does not impact the ability to drive. If further opinion is required but the most likely diagnosis is syncope please refer to the Transient Loss of Consciousness (TLOC) clinic via the cardiology department at the Northern General Hospital.

9. Sodium Valproate: Sodium valproate must not be started in any new patients (male or female) younger than 55 years, unless two specialists independently consider that there is no other effective or tolerated treatment, or there are compelling reasons that the reproductive risks do not apply. This decision must be documented, and a Risk Acknowledgement Form completed.

For existing patients on sodium valproate, it is a requirement that all women of childbearing age (up to age 55) comply with the conditions of the Pregnancy Prevention Programme. They need to be assessed annually by a neurologist with the completion of an Annual Risk Acknowledgement Form.

Male patients only require a Risk Acknowledgement form at initiation, NOT annually. Male patients established on valproate prior to January 2024 should be informed about a possible increased risk of neurodevelopmental disorders in children born to men treated with valproate in the 3 months prior to conception. As a precaution, they should be advised to use effective contraception throughout the valproate treatment period and for 3 months after stopping valproate. Patients only require referral to the specialist if they are planning a family in the next 12 months or if they wish to discuss alternative treatment options.

10. Space occupying lesion found on brain imaging: If brain imaging done in the community has identified a space occupying lesion refer directly to the neuro-oncology MDT for urgent discussion (Sht-tr.Cancer-NeuroOncology@nhs.net Tel: 0114  2268721). These do not need to be referred to the 2 week wait suspicion of brain cancer clinic.

11. Small vessel ischaemia found on brain imaging: Incidental small vessel ischaemia (white matter hyperintensities) is a common finding on MR imaging especially in older individuals. The mainstay of treatment is treatment of modifiable risk factors (hypertension, hypercholesterolaemia, smoking and diabetes mellitus) and the promotion of a healthy lifestyle. At present there is no evidence for anti-platelet treatment.

12. Sleep: The Sheffield neurology sleep service is able to see patients who have a sleep disturbance thought to be secondary to a primary neurological disorder (eg parasomnia, narcolepsy). If you suspect that a patient has obstructive sleep apnoea please arrange pulse oximetry or refer to the respiratory service. Psychosocial causes of sleep disturbance are common and at present are not referable to this service. The self help guide ‘Overcoming insomnia and sleep problems’by Professor Colin Espie is a useful aid.

13. Topiramate: There is a Pregnancy Prevention Programme for Topiramate. All women of childbearing potential must use highly effective contraception throughout topiramate treatment and take a pregnancy test prior to initiation. Healthcare professionals should make patients aware of the risks of the use of this medication during pregnancy and complete an annual risk awareness form.

The Topiramate Annual Risk Awareness Form – Prophylaxis of Migraine can be completed by healthcare professionals in primary care.

NOTE: Topiramate can potentially reduce the efficacy of hormonal contraception. Acceptable forms of contraception include an intrauterine method (Cu-ICD or LNG-IUS), or the medroxyprogesterone acetate depot (MDPA) injection PLUS a barrier method.

Useful Links

NICE migraine

https://cks.nice.org.uk/migraine

BASH website

http://headache.org.uk/wp-content/uploads/2023/02/bash-guideline-2019.pdf

NICE Parkinsons Disease

https://cks.nice.org.uk/parkinsons-disease

How to differentiate between essential tremor and Parkinson’s Disease Video

https://primarycaresheffield.org.uk/cases/neurology