Файловый архив студентов. Файловый архив студентов.
1330 вузов, 5508 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
15.09.2026
Размер:
12 Мб
Скачать
☆
•
•
•
•
•
Table50.3AEDtherapyofchoicebyseizuretype
Seizuretype First-linetreatmentoptions
Focal Carbamazepine
Lamotrigine
Generalizedtonic–clonic Sodiumvalproate
Lamotrigine
Carbamazepine Oxcarbazepine
Absence Ethosuximide
Sodiumvalproate
Myoclonic Sodiumvalproate
Topiramate
Levetiracetam
Tonic/atonic Sodiumvalproate Lamotrigine
Monitoringandfollow-up
Allpatientsshouldbereviewedatleastannually.
Specialconsiderations
Contraception
FemalepatientswithepilepsyshouldbecounselledonthepossibleinteractionsoftheirAEDwith contraception.Emphasis should also be placed onthe importance of using barrier protection in additiontooralhormonaltherapy.
Pregnancy
High-dose folicacid(5mgOD)isrecommendedinallwomenplanning apregnancywhenusing AEDs Sodium valproateshould be avoided in women of childbearing age,unless alternatives are not available,duetothehighriskofteratogenicity Breastfeeding while taking AEDs is usuallysafe.The risk ofeachAED tothebaby should be considered and a discussion should be held with the patient regarding the specific risks and benefits. Clinicians should notforget togive additional safety advice to parentswithepilepsy regarding safetyprecautionswhencaringfortheirnewborn.
https://t.me/med1917
Furtherreading
1.InternationalLeagueAgainstEpilepsywebsite.Availableat:https://www.ilae.org/
2.EpilepsySocietywebsite.Availableat:http://www.epilepsysociety.org.uk
3.EpilepsyActionwebsite.Availableat:http://www.epilepsy.org.uk
https://t.me/med1917
Chapter51
Headache
Guideline: NICE CG150 (Headaches in over 12s: diagnosis and
management):https://www.nice.org.uk/guidance/cg150
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Headache isthe commonest neurologicalsymptom which presents to both primary and secondary care. The causes can be classified into primary (underlying aetiology unknown)andsecondary(whenattributedtoanunderlyingdiseaseordisorder).
Diagnosis
Differentialdiagnosis
https://t.me/med1917
•
•
•
•
•
• ◦
• ◦
• ◦ ◦ ◦
• ◦ ◦
• ◦ ◦
Primaryheadachedisorders
Migraine Tension-typeheadache Clusterheadacheandothertrigeminalautonomiccephalalgias
Secondaryheadachedisorders
Iatrogenic
Medicationoveruseheadache
Inflammatoryconditions
Giantcellarteritis
Raisedintracranialpressure
Tumour/metastaticdisease Abscess Benignintracranialhypertension
Centralnervoussysteminfections
Meningitis Encephalitis
Vasculardisorders
Haemorrhage:extradural/subduralhaematoma/subarachnoidhaemorrhage Thrombosis:corticalveinthrombosis,venoussinusthrombosis,stroke.
https://t.me/med1917
•
•
•
Table51.1Clinicalfeaturesofkeydifferentialdiagnosesforaheadache
Tension type
Migraine Cluster Medicationoveruse
headache
Site Bilateral Unilateralorbilateral Unilateral(around/abovethe
eye)
Variable
Character Mild–
moderate bandlike pressureor tight sensation
Moderatetosevere pulsatingpain
Severeorveryseverepainofa variablenature—maybe burning,throbbingorsharp
Variable
Duration 30minutes
­continuous
4–72hours Upto2hours,butusually30–
90minutes
Variable
Associated symptoms
Doesnot interfere withdaily activities
Sensitivitytolight/sound Nausea/vomiting Precedingaura(even withoutaheadache)— lasting5–60minutes, withreversible symptomssuchas:
Flashing lights, flickeringspots/lines,or visualloss Numbness or pins and needles Speechdisturbance
Autonomicsymptomsonthe samesideastheheadachesuch asnasalcongestionorrunny nose,redorwateringeye, swolleneyelid,forehead sweating,miosis,andptosis Patientisagitatedandrestless duetothepain
Headache developed/worsenedafter takingregularanalgesics Triptans/ergots/opioids>10 days/month NSAIDs/paracetamol/aspirin >15days/month
Subtypes Chronic:
15days permonth for>3 months
Menstrual:migraines2 dayspriorto,orwithin3 daysofstarting menstruationforatleast 2outof3consecutive cycles Chronic:15daysper monthfor>3months
History
Carefulhistorytakingiskeytoidentifyingtheunderlyingcause
https://t.me/med1917
•
•
•
•
•
•
•
• ◦ ◦ ◦ ◦ ◦
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Presentingcomplaint:headachefeatures(Table51.1) Pastmedicalhistory
Previousheadachedisorders Intracranialbleedsorthromboses Procoagulantriskfactors,e.g.cancer,factorVLeidendeficiency Previousintracranialsurgery
Medications
Evidenceofmedicationoveruse.Askparticularlyabout:
Paracetamol,aspirin,andNSAIDs Triptans Opioids Ergots,e.g.dihydroergotamineandergotamine
Combinationanalgesics,e.g.co-codamol Anticoagulantsorantiplateletsincreasingtheriskofbleeding Anyregularmedicationsthepatientmayusewhereheadacheisasideeffect
Familyhistory Socialhistory
Alcoholhistory(abusecanincreaseriskoftraumatichaemorrhage) Illicitdruguse(couldtheheadachebewithdrawalrelated?) Effectofheadachesonactivitiesofdailyliving
Consider asking the patient to usea headachediary(minimum of 8 weeks) tolookfor patterns whichmay pointtowards aparticular diagnosis.The diaryshoulddocumentfrequency, duration, and severity of headache, associated symptoms, possible triggers, analgesia used, and any relationshipoftheheadachestothemenstrualcycle.
Painhistory
Don’tforgettheacronym‘SOCRATES’:
Site:unilateral?Bilateral? Onset:sudden(thunderclap)?Gradual? Character:throbbing?Stabbing?Dullache? Radiation:neck?Occiput?Eye? Associatedsymptoms:symptoms?Nausea?Aura? Time:duration?Episodicorcontinuous?Frequency?Relationshiptomenstrualcycle? Exacerbatingandalleviatingfactors Severity:scoreoutof10.
Redflags
Bewareof thefollowingfeatures in the historyof anew-onset headachethatcanpoint
https://t.me/med1917
•
•
•
•
•
•
towardsasinisterunderlyingcause, for whichyoushould considerurgent investigation oronwardreferral:
Fever,rash,orneckstiffness(suggestiveofmeningitisorinfection;seeChapter52) Sudden-onset, reaching maximum intensity within 5 minutes (suggestive of subarachnoid haemorrhage) Newneurologicalorcognitivedeficit,personalitychange,or↓levelofconsciousness(suggestive ofintracranialhaemorrhage,stroke,orspace-occupyinglesion;seeChapter56) Recenttrauma(suggestiveoftraumatichaemorrhage,withinthelast3months) Headache worsening with cough, sneeze, Valsalva, or posture (suggestive of ↑ intracranial pressure) Severe eyepainor temporalarterytenderness(suggestiveofothersecondaryheadachessuchas glaucomaorgiantcellarteritis;seeChapter84) Vomiting History of immunocompromise, previous or current malignancy (increases suspicion of intracranialinfectionormalignancy).
Examination
Afullneurologicalexaminationmustbeperformedtoelicitanyfocaldeficits Assessmentofcognitivefunction Ophthalmoscopyshouldassessforpapilloedema If the history is suggestive, look for evidence of meningeal irritation(Kernig’s or Brudzinski’s signs;seeChapter52)andarash.
Investigations
Suspectedprimaryheadachedisorders
Imaging
Neuroimagingmaybeconsideredforafirstboutofclusterheadaches.
Suspectedsecondaryheadachedisorders
Bedside
Pyrexia,tachycardia,orhypotensionmaypointtowardsmeningitis.
Bloods
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
FBC,CRP—elevatedininfection ESR—elevatedintemporalarteritis U&EandLFTfunctionifprescribingantibioticsforsuspectedintracranialinfection Coagulationprofile—particularlyifapatientisonanticoagulantsandanintracranialhaemorrhage issuspected.
Imaging
CTheadshouldbeconsideredforanyonewithsymptomstoassessforintracranialpathology.
Other
LPasguidedbyspecialistsorseniorclinicians:
Send for cell count, protein, glucose, Gram stain, and viral PCR in cases of suspected intracranialinfection Measureopeningpressure Xanthochromiaifsuspectedsubarachnoidhaemorrhage.
Management
Primaryheadachedisorders
Patienteducation
In the managementof all patientswithheadaches, ensure thatthe patient and their relatives are informedofthediagnosis,reassuredthatotherpathologyhasbeenexcluded,andgivenoptionsfor management Trytoprovidewritteninformationaswellasdetailsofsupportorganizations Recommendtokeepaheadachediary.
Pharmacologicalmanagement
SeeTable51.2.
https://t.me/med1917
•
•
•
•
•
•
Table51.2Managementofprimaryheadachedisorders
Acute Prophylactic
Tension Aspirin/paracetamol/NSAIDs
Donotofferopioids
Acupuncture(10sessionsover5–8weeks)
Migraine Oraltriptan,e.g.zolmitriptan2.5mg+
NSAIDOR Oraltriptan+paracetamol Ifthepatientisabletotolerateonlyasingle agent,considertriptan,high-doseaspirin (900mg),NSAID,orparacetamol Iforalagentsarenottolerated,considerIM metoclopramideorprochlorperazine+/-IM NSAIDornasaltriptan Considerantiemeticsinallpatients
Firstline:topiramate(initialdose25mgODthen titrated)orpropranolol(80–240mgODindivided doses) Secondline:amitriptyline(initialdose10–25mgOD thentitrated) ±Riboflavin400mgOD—canreducemigraine severityandfrequency ±Acupuncture(10sessionsover5–8weeks) Reviewafter6monthsoftreatment
Menstrual­related migraine
Trialtheabove-listedmigrainetreatments Ifacutetreatmentsareineffective,consider
frovatriptan(2.5mgBDPO)orzolmitriptan(2.5mg BD–TDSPO)onthedaysofexpectedmigraine Ifdifficulttopredictexactdateofmigraineonset,use for2daysbeforemenstruationispredictedtostart, until3daysafterstartofmenstruation
Cluster Oxygen(100%withaflowofatleast
12L/minviaanon-rebreathemask,canbe providedathome) SC(e.g.sumatriptan6mg)ornasal(e.g. zolmitriptan5mg)triptans
Verapamil—undertheguidanceofaspecialist
Secondaryheadachedisorders
Principlesofmanagement
Stabilizethepatient using anABCDEapproach,particularlyiftheGCSscoreis reduced,dueto therisksofrespiratorycompromise.Involvehigherlevelcareifnecessary Call forhelp:manysecondaryheadachesare emergenciessoensureearlyescalationtoa senior clinicianandinvolverelevantspecialities(e.g.neurosurgery,ophthalmology)assoonaspossible Specificmanagementwilldependupontheidentifiedunderlyingcauseofthe headache,andmay includelifestyleadvice,pharmacologicalinterventions,orevensurgery.
Medicationoveruseheadache
Advisethepatienttostoptakingtheoverusedmedicationabruptlyforatleast1month Informthemthatsymptomsofheadachemayinitiallyworsenbeforetheyimprove Reviewafter4–8weeks.
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialconsiderations
Specialistreferral
Migrainewithanyofthefollowingatypicalaurasymptoms:
Motorweakness Doublevision Unilateralvisualsymptoms Poorbalance ↓GCSscore Prolongedaura(>1hour)
Formanagementofmigraineprophylaxisinpregnancy Foradviceonclusterheadacheprophylaxis Ifpatientshaveanywhichmightpointtowardsasinisterunderlyingcause Ifmedicationoveruseheadacheisduetoopioiduse Chronicmigrainerefractorytofirst-linetreatments.
Pregnancyandwomenofchildbearingage
DosageadjustmentsmaybenecessaryaspertheBNF.Keypointstorememberinclude:
Topiramate is teratogenic and may impair the effectiveness of some hormonal contraceptives. Womenshouldreceivecarefulcounsellingregardingappropriatecontraception Intheacutemanagementofmigraines,paracetamol isasafetreatmentinpregnancy,butifthisis ineffective,therisksoftriptansandNSAIDsshouldbediscussedandcanbeoffered Seekspecialistadvice in pregnancy with the useof all prophylactic agents for the treatmentof migraine Combinedhormonalcontraceptioniscontraindicatedforwomenwhohavemigrainewithaura.
Furtherreading
1. Manji H, Connolly S, Kitchen N, et al. (2014). Topics on headache. In: Oxford Handbook of Neurology, 2nd ed (Chapter 5). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199601172.003.0005_update_001
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности