NEUROLOGIC DISORDERS
| NEURAL AND NEUROMUSCULAR COMPLAINTS —Terry Rascoe, MD, Assistant Professor of Family and
Community Medicine, Texas A&M College of Medicine and Staff Physician, Scott and White Clinic and Hospital,
Temple, Texas
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Bell’s Palsy
| Idiopathic acute facial paralysis: most common type; incidence same in men and women; occurs in all ages beyond
teenage years; red flag in patients <18 yr of age; greater in pregnancy, especially third trimester; precipitated by upper
respiratory infection; diabetics have worse outcome; affects facial muscles; decreased lacrimation in affected
eye; salivary glands affected; loss of taste; ear pain despite normal examination; 60% to 70% of facial paralysis
Bell’s palsy; look for associated findings; do not miss other types of paralysis
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| Etiology: herpes simplex virus (HSV)-1; high HSV titers; some evidence against HSV (low recurrence rate); 10% relapse
rate on same or opposite side; no skin lesions; if lesions seen, probably herpes zoster (Ramsey-Hunt presentation)
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| Key findings: unilateral paralysis; bilateral facial paralysis can occur, but extremely rare; stroke patients (with central
lesions) can raise eyebrows and wrinkle forehead; flaccid forehead key in Bell’s palsy; patient unable to lift eyebrow;
forehead sparing occurs in peripheral lesions (can be “red herring”)
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| Work-up: minimal testing for typical Bell’s palsy findings; clinical diagnosis; consider tests in younger patient with
systemic symptoms, no improvement after 6 mo; in Northeast, consider Lyme disease; facial nerve most commonly
affected; majority (94%) of patients recover in 1 yr if not diabetic; recovery low in diabetics
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| Treatment: steroids first choice, safe, and probably effective; prednisone 60 mg qd, then taper over 1 to 2 wk; acyclovir
becoming more popular in literature; used in combination with steroids; valacyclovir (Valtrate) easier to
dose; nerve decompression surgery effective only during first 2 wk; difficult to predict who benefits from surgery;
acupuncture data inconclusive; eye protection to prevent dryness, scarring, and lesions; use artificial tears during
day, ophthalmic ointment (eg, Lacrilube) at bedtime; tape eyelids down or use goggles; reassure patients
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Cyclic Vomiting Syndrome
| Criteria: recurrent bouts of vomiting (3 episodes); classic cardinal signs—periodic episodes on frequent basis (every
few weeks); usually affects younger children; 6 to 8 times/hr for several hours or few days, then spontaneously
resolves; child healthy in interim; no other positive findings on examination; incidence—1% to 2% of school-age
children; presents in morning before school starts; occurrence slightly higher in girls; stereotypic pattern; possible
familial variety; may have precipitating factor; considered migraine variant
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| Migraine variants: includes car motion sickness, ice cream headache; most patients develop migraines by 18 yr of
age; positive family history of migraines; most respond to migraine management; abdominal migraines present
with more pain, less vomiting
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| Red flags: severe headaches; focal pain; child complains of pain other than periumbilical; no response to treatment;
consider Munchausen by proxy
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| Work-up: abbreviated in classic cases; upper gastrointestinal (GI) radiography with small bowel follow-through to rule
out malrotation or volvulus; brief medication trial with close observation; in adult, computed tomography (CT) helpful
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| Treatment: awareness; supportive care for cases of short duration (few hours); identify and eliminate precipitators
(eg, irregular sleep patterns, stressors, motion sickness); for pronounced cases, use amitriptyline (Elavil); cyproheptadine
(Periactin) in younger child; with tricyclic antidepressants, keep dose low; (1 mg to 3 mg/kg in divided
doses daily); propranolol (Inderal); ondansetron (Zofran); rapid improvement with triptans (sumatriptan [Imitrex])
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Myofascial Trigger Points
| Presentation: nonprecipitated upper back and neck pain for 1 mo; sedentary job; treated with ibuprofen and cyclobenzaprine
(Flexeril); no fever or weight loss; unremarkable examination; tender spots in inferior neck and
periscapular area; significant pain and muscle twitching on deep palpation; negative Spurling test—no radicular
pain with manipulation or extension of neck
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| Definition: hyperirritable spot within tight band of skeletal muscle; can get referred pain away from trigger point;
some nausea; incidence high
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| Etiology: shortened bands of muscle fiber; recognized pattern; typical referred pain pattern; mapping charts very
helpful; muscle twitching with palpation; myofascial component; spasms in sternocleidomastoid muscle
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| Treatment: self-treatment; massage; tennis ball; injection (eg, saline, steroid, “dry needling”); 1% to 2% lidocaine
causes immediate numbness; acupuncture; physical therapy; use vapocoolant sprays, (eg, ethyl chloride) and stretch
muscle; osteopathic technique—press hard with thumb for 90 sec to initiate ischemic response (gets muscle to relax)
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Ketogenic Diet
| Use: treatment of patients with seizure disorders unresponsive to antiepileptic medications; various theories postulated
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| Diet: ratio of fat grams to nonfat grams 4:1; 90% of calories from fat; highly ketogenic fat preferred; medium-chain
fatty acids most ketogenic; flaxseed oil healthy; diet promoted by Johns Hopkins University; informative website
(http.www.neuro.jhmi.edu/Epilepsy/Peds/index.html); set caloric intake at 75% of what child should be receiving
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| Outcome: 50% of children on diet become seizure-free; another 25% have dramatic improvement; works better in
younger children due to compliance or blood-brain barrier changes; children can usually transition to normal diet in
few years
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| Disadvantages: difficult to maintain; requires constant compliance; does not taste good; parents and staff must be
motivated; requires significant medical support (eg, dietician)
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| Monitoring: initiated in hospital; fast child until ketones produced in urine; check ketones twice daily; periodic blood
work to include lipids and liver transaminases; every meal must be 4:1; do not use liquid medications because of
sugar content; crush tablets; vitamins
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| Side effects: fatigue, nausea; children adapt to diet; for constipation, use docusate (Surfak Liquigels); kidney stones exacerbated
by antiseizure medications (eg, zonisamide [Zonegran], topiramate [Topamax]); growth retardation not problematic
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| MIGRAINES AND OTHER HEADACHES— David E.J. Bazzo, MD, Associate Clinical Professor of Family Medicine,
and Associate Director of the PACE program at the University of California, San Diego, School of Medicine
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| Migraines: common disorder; female to male predilection 3:1; prevalence equals asthma and diabetes combined; two thirds
of migraine sufferers seek care from family physicians
|
 | Diagnosis: criteria provided by International Headache Society (IHS); based on research data; primary—intrinsic;
3 major categories (migraine, tension, and cluster); 1 in 11 people suffer from migraine; secondary—symptom
of underlying pathology (eg, meningitis, subarachnoid hemorrhage, tumor); 1 in 250,000 headaches secondary to
serious underlying pathology; ruling out secondary causes is not treating primary headache
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| Recognizing pattern of primary headache: positive family history (migraine genetic disorder); stereotypic headache
pattern over time; menstrual association; prodromes and auras; resolution with sleep; changing location of headache;
otherwise healthy individual
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| Worrisome features: onset of first headache after age 50 yr; must rule out vascular problems first; onset of new, different,
worst headache; exertional component; positive neurologic evaluation; abnormal vital signs; systemic illness;
all require further evaluation
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| Neuroimaging guidelines: from IHS; acute cases require CT to rule out bleeding; add contrast to rule out tumor or obtain
magnetic resonance imaging (MRI); does not fit defined pattern; worsening under observation; persistent neurologic
signs; any significant physician or patient concern
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| Neuroimaging not indicated: history of similar headaches; normal vital signs; alert patient with supple neck; no neurologic
signs; headache improves without analgesia; criteria determine primary headache; further diagnosis
through history and physical examination; initiate treatment
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International Headache Society Criteria
| Migraine without aura: most common type; 70% of migraines; requires 2 major criteria and 1 minor criterion;
major—unilateral pain; throbbing, pulsatile quality due to sensitization of cranial nerve V (trigeminal) innervation
in cerebral vasculature; pain moderate to severe in intensity; aggravated by routine activity; minor—photophobia;
phonophobia; nausea or vomiting
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| Migraine with aura: criteria similar, except requires aura (neurologic phenomenon); variety of visual and auditory
signs; hypernosmic changes; paresthesias; difference between transient ischemic attack (TIA) and stroke—migraine
aura lasts 1 hr; in majority of cases, headache follows aura within 1 hr of intermittent symptoms; TIAs not followed by
headaches; stroke symptoms last >1 hr
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| Episodic tension headache: most common headache; patients self-treat; major criteria—pressing, tightening, nonpulsatile
quality; mild or moderate in intensity; may inhibit, but does not prohibit activity; bilateral; minor
criteria—no nausea or vomiting; slight photo- or phonophobia, but not both
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| Chronic tension headache: same symptoms, but lasts longer; ongoing, ie, at least 15 days/mo for at least 6 mo; major
criteria same as for episodic; might have some minor criteria (eg, nausea)
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| Cluster headache: low prevalence; severe for patient; different from migraine or tension headache; pain originates
behind or around eye, radiating into temple, jaw, nose, teeth, or chin; eyelid droops, eye may tear; face flushes; no
nausea or vomiting; patient restless and agitated
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Migraine
| Treatment: patient education; acute, prophylactic, and non-pharmacologic strategies; follow-up; ongoing relationship
between patient and doctor for long-term care
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| Risk factors: hormonal fluctuations; chronobiologic (eg, circadian rhythm changes); vasodilators; other drugs; sensory
input; emotional stress; trauma
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| Protective factors: regular sleep, meals, and exercise; biofeedback; healthy lifestyle
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| Therapeutic phases: 5 phases; prodrome—different from aura; patient feels headache starting; educate patients to use
anti-inflammatory drugs and nonnarcotic analgesics immediately; do not give triptans (5-HT1B/1D-agonist vasoconstrictors);
wait until aura has passed (phase II); might mimic TIA or beginning stroke; do not give vasoconstrictor to
someone who might be having stroke; early—treat patient quickly and early with 5-HT1B/1D-agonist and dihydroergotamine
(DHE); step therapy not useful; rescue or rescue combination—migraine-specific medication not effective
(only 70% successful); use narcotics, combination analgesics or antiseizure medications; postdrome—
nonsteroidal anti-inflammatory drugs
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| Medications: choose triptans based on patient response and specific drug half-life; intranasal DHE works well but has
complex delivery system (not first-line choice); rescue drugs to relieve pain (eg, phenothiazines); commonly used—
antihypertensives (eg, β-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors); antiseizure
medications (eg, topiramate) can cause drowsiness); tricyclic antidepressants and selective serotonin reuptake
inhibitors (SSRIs); nonpharmacologic strategies—injections and blocks (eg, occipital nerve, sphenopalatine
ganglion, trigger point, botulinum toxin type A [Botox]) effective but underutilized; biofeedback; physical therapy;
osteopathic manipulation; alternative therapies used with varied effectiveness
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| Questions and answers: is migraine over- or underdiagnosed? dramatically underdiagnosed, especially in men; can
riboflavin be used for treating migraines? anecdotally, feverfew (Chrysanthemum parthenium, Tanacetum parthenium)
data “okay,” magnesium “not okay”; riboflavin better than magnesium, but not as good as feverfew; speaker
treats with these; what are contraindications of triptans? must screen patients for cardiovascular disease (black-box
warning); 5-HT1B-receptors in coronary arteries; might cause spasm and chest tightness; no reported case of myocardial
infarction; triptans contraindicated for basilar migraine
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Educational Objectives
| The purpose of this program is to provide the listener with information on the nature and management of neuromuscular
complaints and migraine and other headaches. After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Review the key findings and treatment of Bell’s palsy.
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| 2. Discuss the evaluation and treatment of cyclic vomiting syndrome.
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| 3. Summarize the presentation, etiology, and treatment of myofascial trigger points.
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| 4. List the advantages and disadvantages of using the ketogenic diet to treat epilepsy.
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| 5. Describe the examination and treatment of the patient with migraine and other headaches.
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Discussed on This Program
Acyclovir [Zovirax]
Amitriptyline HCl [Elavil]
Botulinum toxin type A [Botox, Botox Cosmetic]
Chlorpromazine HCl [Thorazine]
Clomipramine HCl [Anafranil]
Cyclobenzaprine HCl [Flexeril]
Cyproheptadine HCl [Periactin]
Dihydroergotamine mesylate [D.H.E. 45, Migranal]
Docusate calcium (dioctyl calcium sulfosuccinate) [DC Softgels, Stool Softener, Surfak Liquigels]
Eletriptan HBr [Relpax]
Fluphenazine [Prolixin Decanoate]
Feverfew (Tanacetum parthenium, Chrysanthemum parthenium)
Frovatriptan succinate [Frova]
Ibuprofen [several trade names]
Imipramine HCl [Tofranil]
Lidocaine HCl [several trade names]
Mesoridazine (withdrawn from market)
Naratriptan HCL [Amerge, Naramig]
Ondansetron HCl [Zofran, Zofran ODT]
Prednisone [several trade names]
Prilocaine HCl [Citanest Plain, Citanest Forte]
Propranolol HCl [Inderal, Inderal LA, InnoPran XL]
Rizatriptan benzoate [Maxalt, Maxalt-MLT]
Sumatriptan succinate [Imitrex]
Topiramate [Topamax]
Valacyclovir HCl [Valtrate]
Vapo-coolant spray [ethyl chloride]
Zolmitriptan [Zomig, Zomig-ZMT]
Zonisamide [Zonegran]
Suggested Reading
Ahmed A: When is facial paralysis Bell palsy? Current diagnosis and treatment Cleve Clin J Med 72:398, 2005; Ashtekar
CS et al: Best evidence topic report. Do we need to give steroids in children with Bell's palsy? Emerg Med J
22:505, 2005; Benatar M, Edlow J: The spectrum of cranial neuropathy in patients with Bell's palsy Arch Intern Med
164:2383, 2004; Boles RG et al: Maternal inheritance in cyclic vomiting syndrome Am J Med Genet A 133:71, 2005;
Bulstrode NW, Harrison DH: The phenomenon of the late recovered Bell's palsy: treatment options to improve facial
symmetry Plast Reconstr Surg 115:1466, 2005; Edwards J: The importance of postural habits in perpetuating
myofascial trigger point pain Acupunct Med 23:77, 2005; Ferrante FM et al: Evidence against trigger point injection
technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A Anesthesiology 103:377,
2005; Goadsby PJ: Advances in the understanding of headache Br Med Bull 73:83, 2005; Itoh K et al: Trigger point
acupuncture treatment of chronic low back pain in elderly patients--a blinded RCT Acupunct Med 22:170, 2004;
Khasawinah TA et al: Preliminary experience with dexmedetomidine in the treatment of cyclic vomiting syndrome
Am J Ther 10:303, 2003; Kibler JL et al: Hormones, menstrual distress, and migraine across the phases of the menstrual
cycle Headache 45:1181, 2005; Kossoff EH, McGrogran: Worldwide use of the ketogenic diet Epilepsia
46:280, 2005; Linder T et al: Bell's palsy and Herpes simplex virus: fact or mystery? Otol Neurotol 26:109, 2005;
Lyczkowski DA et al: Safety and tolerability of the ketogenic diet in pediatric epilepsy: effects of valproate combination
therapy Epilepsia 46:1533, 2005; Mackay MT et al: The ketogenic diet in refractory childhood epilepsy J Paediatr
Child Health 41:353, 2005; Martin VT et al: The predictive value of abbreviated migraine diagnostic criteria
Headache 45:1102, 2005; McPartland JM: Travell trigger points--molecular and osteopathic perspectives J Am Osteopath
Assoc 104:244, 2004; Olson AD, Li BU: The diagnostic evaluation of children with cyclic vomiting: a cost-
effectiveness assessment J Pediatr 141:724, 2002; Rubenstein JE: Experience in the use of the ketogenic diet as
early therapy J Child Neurol 20:31, 2005; Silberstein SD et al: Removing barriers to appropriate migraine treatment:
formulary limitations and triptan package size Headache 45:1250, 2005; Stafstrom CE: Dietary approaches to epilepsy
treatment: old and new options on the menu Epilepsy Curr 4:215, 2004; Sticker GB: Relationship between cyclic
vomiting syndrome and migraine Clin Pediatr (Phila) 44:506, 2005; Sudel B, Li BU: Treatment Options for
Cyclic Vomiting Syndrome Curr Treat Options Gastroenterol 8:387, 2005
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lectures to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. Dr. Bazzo has
disclosed that he is a consultant for Pfizer.
Dr. Rascoe was recorded at the 21st Family Medicine Review, held April 6-9, 2005, in Austin, Texas, and sponsored
by the Scott and White Clinic and Hospital. Dr. Bazzo was recorded at Migraine Update 2005, held June 24-26,
2005, in Coronado, California, and sponsored by the San Diego Chapter of the American Academy of Family Physicians.
The Audio-Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this
program.
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