Neurology - Review Note (Winkel)

Neurology - Review Note (Winkel) Date: 1 November 2024 History: * Patient presents for follow-up regarding persistent migraines with aura, specifically visual scotomas and unilateral throbbing headache, occurring approximately 3-4 times per month. Since the last review, the patient reports a slight decrease in migraine frequency from 5-6 episodes per month to 3-4, which they attribute to better adherence to their prophylactic medication. However, the intensity of the headaches during an episode remains severe (8/10 on a pain scale), and the duration has not significantly shortened. The patient has been compliant with taking their prescribed topiramate 50mg BID, and has used sumatriptan 100mg for acute attacks, reporting moderate relief within 2 hours of administration. They have noted no new neurological symptoms or significant side effects from the medication. Examination: * **Vital Signs:** * Blood Pressure: 120/78 mmHg * Heart Rate: 72 bpm * Respiratory Rate: 16 breaths/min * Temperature: 36.7°C * Oxygen Saturation: 99% on room air * **Physical Examination Findings:** * **General:** Alert and oriented, well-nourished, no acute distress. * **Mental Status:** Fully conscious, cooperative, speech fluent and coherent. Intact memory for recent and remote events. Calculation and abstraction within normal limits. * **Cranial Nerves:** * CN I (Olfactory): Intact to coffee and peppermint. * CN II (Optic): Visual acuity 6/6 OU with corrective lenses. Fundoscopy unremarkable; optic discs sharp. Visual fields full to confrontation. * CN III, IV, VI (Oculomotor, Trochlear, Abducens): Pupils equal, round, and reactive to light (PERRLA), 3mm bilaterally. Extraocular movements full without nystagmus or diplopia. * CN V (Trigeminal): Sensation intact to light touch and pinprick in all three divisions bilaterally. Corneal reflexes present bilaterally. Masseter strength 5/5 bilaterally. * CN VII (Facial): Symmetrical facial movements, no facial droop. * CN VIII (Vestibulocochlear): Hearing intact to whispered voice bilaterally. Rinne and Weber tests normal. * CN IX, X (Glossopharyngeal, Vagus): Symmetrical palatal elevation, gag reflex present. Clear speech, no dysphagia. * CN XI (Accessory): Shoulder shrug and head turn against resistance 5/5 bilaterally. * CN XII (Hypoglossal): Tongue midline with good range of motion, no fasciculations. * **Motor System:** * Strength: 5/5 throughout all four extremities (deltoids, biceps, triceps, wrist extensors/flexors, interossei, hip flexors, quadriceps, hamstrings, dorsiflexors, plantarflexors). * Tone: Normal tone in all limbs, no spasticity or rigidity. * Bulk: Symmetrical, no atrophy. * **Sensory System:** Intact to light touch, pinprick, vibration, and proprioception in all four extremities. * **Reflexes:** 2+ and symmetrical throughout (biceps, triceps, brachioradialis, patellar, Achilles). Plantar responses flexor bilaterally. * **Coordination:** Finger-to-nose and heel-to-shin movements smooth and accurate. Rapid alternating movements performed without dysdiadochokinesia. * **Gait:** Normal tandem gait, no ataxia. Romberg test negative. * **Investigation Results:** * **MRI Brain (performed 2 weeks prior):** No acute intracranial pathology, no evidence of structural lesions or vascular malformations that could account for migraine symptoms. * **Blood tests (recent):** Full blood count, electrolytes, renal and liver function tests all within normal limits. Plan: * **Investigations Planned:** * Consider MRA Head if symptoms escalate or become atypical, to rule out other vascular causes. * **Medical Treatment Planned:** * Increase Topiramate dosage to 75mg BID. Patient counselled on potential side effects including paresthesia, fatigue, and cognitive slowing. Informed about the importance of adequate hydration to prevent kidney stone formation. * Continue Sumatriptan 100mg for acute attacks, not to exceed 2 doses in 24 hours or 10 doses per month. * Discussed potential for CGRP inhibitors if current regimen proves insufficient. * **Lifestyle Modifications Discussed:** * Reinforced importance of maintaining a regular sleep schedule, aiming for 7-9 hours per night. * Advised on stress management techniques including mindfulness and regular, moderate exercise (e.g., walking, swimming). * Reviewed dietary triggers such as caffeine, alcohol, aged cheeses, and processed meats. Encouraged a migraine-friendly diet, focusing on fresh, whole foods. * **Referrals to Specialties or Services:** * Consider referral to a headache specialist if current adjustments do not yield significant improvement within 3 months. * **Follow-up Appointments:** * Return for review in 6-8 weeks to assess response to increased Topiramate dosage and overall migraine control. Monitoring for side effects will be key. Additional Notes: - Patient education was provided regarding the chronic nature of migraines, explaining that while there is no cure, effective management strategies can significantly improve quality of life. The impact of migraines on daily activities, work, and social life was discussed, and coping mechanisms were explored. The importance of adherence to both pharmacological and non-pharmacological treatments was emphasised. - Instructions were given for monitoring and managing symptoms, particularly concerning acute attacks. The patient was advised to keep a headache diary to track frequency, intensity, duration, and potential triggers. They were also informed about warning signs indicating a need for urgent care, such as the sudden onset of the worst headache of their life, new focal neurological deficits, or changes in consciousness. - The patient expressed concern about the long-term use of medication and its potential side effects. This was addressed by explaining the risk-benefit profile of Topiramate and Sumatriptan, and reassuring them that medication dosages would be regularly reviewed and adjusted as appropriate. Their spouse also raised questions about genetic predisposition, to which it was explained that migraines often have a hereditary component, but environmental factors also play a significant role.