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Five-minute Practitioner May 2008

Only got five minutes? Then just read these key points on: epilepsy, migraine and restless legs syndrome

Only got five minutes? Then just read these key points on: epilepsy, migraine and restless legs syndrome

Epilepsy

Epilepsy is the most common serious neurological disorder and affects about 0.7% of the population. Patients are usually diagnosed after a generalised seizure, or following recurrent stereotyped attacks, which may or may not disturb consciousness. Diagnosis is clinical and a careful history is essential.

If a diagnosis of seizure is suspected, the patient should be referred to the local neurology service. In the interim, patients should be instructed to avoid heights and deep water, stop driving and operating dangerous machinery until further notice, and bring a witness to their neurology appointment. Any advice should be recorded clearly in the patient's notes.

It is important to distinguish between idiopathic generalised epilepsy and focal epilepsies. All patients with focal epilepsy should undergo MRI or CT.

After any seizure, including epileptic ‘auras' or partial events and myoclonic seizures, holders of a group 1 licence must stop driving for one year and inform the DVLA and their motor insurance provider.

Before any treatment is started, the diagnosis must have been established beyond reasonable doubt.

Every patient with epilepsy should have an annual review covering seizures, treatment, lifestyle and work factors, driving status, contraception and pregnancy. Patients with inadequate seizure control should be referred back to specialist services for review.

Migraine

Migraine is a neurovascular disorder that occurs in genetically susceptible individuals. The primary event is neural. Vascular changes are thought to be secondary to neural activation and a response to pain.

Triggers probably involve a combination of genetic factors and external triggers such as psychosocial stress, alcohol, menstruation, dehydration and missing meals.

Aura is a fully reversible focal neurological syndrome, which develops over five minutes and lasts for 5-60 minutes. It is typically followed, or accompanied, by headache.

Aura may be visual, sensory, dysphasic speech disturbance or combinations of all three. Symptoms tend to develop slowly, involving the whole or part of the face and limbs in succession. This is in contrast to vascular events such as TIA and stroke, where the neurological deficit is abrupt and maximum at onset.

Management of migraine consists of patient education, addressing trigger factors, acute treatments and preventative therapies. The key is to treat very early in the headache phase before scalp sensitivity sets in and the attack becomes established. First-line treatments include simple analgesics such as paracetamol, aspirin, NSAIDs and combination analgesics. Triptans are the gold standard in severe migraine.

Restless legs syndrome

Restless legs syndrome is a common movement disorder and is underdiagnosed and undertreated. It has an estimated prevalence of 10-15% in the general population.

The key feature of restless legs syndrome is an uncontrollable urge to move the legs. It may be accompanied by deep pain, perceived as throbbing, bubbling, a ‘creepy crawly' sensation, or an itch, with no evidence of a rash or other skin disorder, that is relieved by scratching. Symptoms are worse at rest, particularly in bed, and relieved by movement.

The diagnostic criteria are urge to move; rest brings it on; ‘get up and go' helps; evenings are worse. Sleep quality is often poor.

Exercise should be recommended as it ameliorates symptoms. Rubbing the legs and hot or cold bathing (depending on symptoms) may also be useful. Drug therapy is required in only 20-25% of more severe cases. Dopamine agonists are the mainstay of treatment and show benefit in nearly all patients.

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