1. Headache

A common disease with benign & serious causes:

  • Brain Hemorrhage: A sudden severe first time headache associated with vomiting, loss consciousness / paralysis.
  • Infections : (Meningitis/ Encephalitis),Fever with headache, vomiting, loss of conscious/ paralysis.
  • Brain tumor : Progressive Persistent Headache associated with altered sensorium / paralysis, vomiting
  • Head Injury
  • Eyes: Refractive error, Astigmatism, Glaucoma.
  • ENT: Sinusitis
  • Trigeminal Neuralgia: Sharp current like pain lasting for few seconds associated with trigger zones on face in trigeminal nerve distribution.

When to consult a neurologist:

  • Persistent Headache
  • Disabling Headache
  • Headache associated with vomiting / fever / Paralysis/ altered sensorium

2. Migraine

  • Disabling but not a life threatening disease.
  • Easy to diagnose but needs specialist’s help in treatment.
  • Migraine is episodic disease with combination of Headache, neurological, gastro intestinal or autonomic features.
  • Headache is one of the features which need not always be present – So patient may consult eye specialist or gastroenterologist.
  • Classical Patient: One or both sided headache in temple and forehead, throbbing or pulsating, associated with nausea or vomiting,aversion to light & sound, which increases  with bending / physical activity. It is relieved with vomiting & sleep.
  • Heterogeneous Disease – Patient wise & symptom wise. So treatment is individual oriented.
  • Is seen in children also.

Treatment:

  • It is a myth that there is no treatment.
  • Analgesics in emergency are not the only treatment during headache.
  • Avoid triggering factors.
  • Medication for immediate relief.
  • Medication for prevention of further attacks.

Consequences of untreated Migraine:

  • Increased irritability
  • Poor work efficiency
  • Relationship issues at home
  • Anxiety & /Depression

WHEN TO CONSULT A NEUROLOGIST

If attacks are frequent & / or are disabling affecting personal / professional life.

3. Vertigo

  • Vertigo is Spinning sensation with feeling of motion of self or surrounding.
  • Acute attack is associated with nausea, vomiting, sweating&unsteadiness.
  • In severe attack sinking feeling or feeling of impending death is there.
  • The common causes are neurological & ear related. They have to be investigated.
  • Patient may have single attack, recurrent attacks & may feel chronically unsteady (Chronic disequilibrium).

Certain diseases can be misinterpreted as Vertigo by patient:-

  • Epilepsy
  • Double vision due to any cause.
  • Unsteadiness due to brain causes.
  • Unsteadiness due to Numbness in feet – Neuropathy

4. Stroke

WHAT IS STROKE BRAIN ATTACK ?

Brain Stroke or attack causes sudden onset weakness/paralysis of a part of body. It is equivalent of heart attack. In brain attack symptoms depend on which part of brain is affected.

Types:

It is of two types.
In the first one, which is common, there is reduction in blood supply to brain damage.
In the second one there is rupture of blood vessal in brain i.e. brain hemorrhage.

Symptoms:-

  • Sudden onset of weakness/numbness of one side of part of body.
  • Sudden problem in speech.
  • Sudden and double vision.
  • Unsteadiness in gait, difficulty in swallowing.
  • Acute headache with or without paralysis.

Remember- F.A.S.T. For early detection & timely action.
F: Facial deviation.
A: Arm Weakness.
S: Speech Slurring.
T: Time to Act fast to save Brain.

Sometimes one can have mini strokes. i.e. above symptoms lasting for a short duration and patient may recover completely but in more than 50% of these patients, develop complete stroke with in 48 hrs of mini stroke, so do not ignore mini stroke.

S – Smile
T – Talk } Can also help to detect early stroke.
R – Raise Arm

Risk Factors: Old age, high Cholesterol, Blood Pressure, Diabetes mellitus, Smoking ,alcohol & oral contraceptives & family history of Stroke.
CONSULT AS EARLY AS POSSIBLE – BECAUSE.

CONSULT AS EARLY AS POSSIBLE – BECAUSE.

  • Treatment is different for both types of stroke i.e. ischemic (Brain Clotting) & hemorrhagic (bleeding) So early consultation with neurologist is a must for diagnosis.
  • Early treatment leads to long term better relief.
  • Longer the duration of reduction of blood supply to brain greater is the damage. Clot busters/dissolving drugs can be given within 3 hours of onset of stroke. It is very important that the patient reaches the hospital in the first three hours of the onset Of stroke. If the treatment is provided within this time frame the chances of recovery improves manifold.

Treatment:

  • Ischemic Stroke: Medicines to control B. P.,Sugar. Brain swelling
    can be reduced by medicines, ventilation & Surgery.
  • Hemorrhagic Stroke: Control B. P., Sugar. Reduce brain swelling,Surgery.
  • Specific investigations: C. T. Scan, MRI. Brain, MR Angiography of Brain & neck,Digital Subtraction Angiography

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5. Parkinson’s disease

  • Common Symptoms: Tremors, slow body movement,Stiffness of body & posture involvement.
  • In elderly, it can be missed as ageing phenomenon.
  • It is seen in young persons also.
  • All patients with tremors may not have Parkinson’s disease, so other causes to be excluded.
  • Parkinson’s Plus patients need to be differentiated as initial medication may be same but dosages, efficacy & prognosis varies.
  • Medicines give relief. Policy is slowly increase dose & keep the dose low. As disease progresses dosage has to be increased.After few years patient has relief in symptoms but develops side efforts of medicines. So dose has to be titrated between side effects & benefit.
  • Surgery for Parkinson’s Disease is not cure. All patients may not be candidates for surgery. There are specific indications of Surgery.

6. Multiple Sclerosis

  • There is involvement of Brain, Spinal cord & optic nerves by multiple plaques.
  • Commonly patient may have recurrent attacks & in each attack there is combination of paralysis ,Sensory , Visual involvement. These attacks when recurrent then it is called Relapsing & Remitting (RRMS) type of Multiple Sclerosis. Frequency & Severity of attacks may vary from patient to patient.
  • As disease progresses RRMS gets converted to secondary Progressive type of Multiple Sclerosis (SPMS)
  • Uncommonly disease may gradually progress continuously from beginning. It is called primary progressive multiple sclerosis(PPMS)
  • Whenever a patient comes with first attack we investigate. But patient may have asymptomatic involvement of brain, Spinal cord & eyes, So extensive investigations are done.
  • Investigations include, blood tests, contrast MRI of Brain & Spinal cord / optic nerves.
  • Visual evoked potentials, Auditory evoked potentials & Somato – sensory evoked potentials are done to detect asymptomatic involvement. Commonly visual evoked potential is done.
  • Lumber puncture to study CSF is also done. 

Treatment :

In Acute attack steroids are given & to prevent recurrence disease modifying drugs are advocated.
These are costly drugs with variable efficiency (35-70%.)

7. Myasthenia Gravis

  • In this disease the basic fault is at neuromuscular function. So mostly skeletal muscles of body are involved.
  • Symptoms are characterized by fluctuant / intermittent / temporary weakness of muscles of different parts of body Which is precipitated /aggravated by exercise / physical exertion & relieved by rest. So patient is better in morning after waking up from sleep. One may feel weakness after exertion. Hence it is also called Fatigue Paralysis.
  • When chest muscles are involved the patient feels breathless on exertion which may be misinterpreted as heart & lung problem. Severe involvement of chest muscles is medical emergency.
  • Different muscles of body are not involved equally so symptoms will vary depending on degree of involvement of different muscles.
  • Common Symptoms: Drooping of lids, Double Vision , Difficulty in chewing & swallowing, Change in voice (Nasal Twang) while prolonged talking. Breathlessness on exertion. Hand & legs weakness on exertion.
  • Relevant investigations done are anti acetylcholine receptor antibody in blood, CT, Scan / MRI of chest for detecting thymoma & Repetitive nerve stimulation.

Treatment :

  • Tab. Pyridostigmine / Neostigmine for symptomatic relief.
  • Disease modifying medicines
  • Thymus Surgery.
  • Plasmapheresis

8. ALZHEIMERS’ DISEASE

Dementia:

  • Memory Disturbance
  • Behavioral Problems
  • Language Disturbances
  • Neurological Symptoms
  • Type of Dementia – Affecting Elderly
  • 10% of patients – Early Age
  • Incurable

Diagnosis:

  • Exclude Treatable Causes-20%
  • Clinical Psychologist
  • Pre Clinical Diagnosis-
  • Medical issues
  • Psychological issues
  • Legal issues

Treatment:

  • Medicines – Mild and moderate disease
  • Behavioral Therapy

Prevention of Alzheimers’ disease:

  • Protect your brain – from head injury, drug abuse and take adequate sleep
  • Feed your brain – Balanced diet, Vitamins and Omega -3 fatty acids
  • Work your brain – Crossword Puzzle, Mental math, Socialize, Learn new and difficult things, Aerobics and coordination exercises, Educational activity, learn new languages.

Tips for Care Givers:

  • Know about the disease
  • No two patients are alike
  • Fluctuating symptoms-day to day basis
  • Modify therapy accordingly
  • Have patience- Do not rush in conversation/action
  • Stick to a daily fixed routine
  • Don’t make changes in geography of the house
  • Don’t change residence to a new place
  • Take time out for yourself
  • Take deep breaths and relax

9. Epilepsy

Q.1- What is Epilepsy?

Ans- Whenever a patient has two or more seizures, then he is diagnosed to be suffering from epilepsy. After a first seizure, he is not labeled as a case of epilepsy. However he is investigated for the cause of the seizure and if seizure recurs, he is labeled as a case of epilepsy.

Q.2- What are the main symptoms which help in the diagnosis of Epilepsy?

Ans- The main symptom which helps in the diagnosis is the description of the fit/seizure. The most important thing is that the patient himself is not aware of the details of the event. Hence the practitioner has to elicit all the details of the event from the witness of the seizure/attack. However patient may say that he became unconscious and when he regained consciousness, he was disoriented/confused for sometime and suffered from headache/bodyache and vomiting.

Q.3- What are different types of Epilepsy?

Ans- Epilepsy is of many types. However there are four main types of epileptic attacks seen in practice.

A. The first and the commonest of all is called Generalized Tonic –clonic Seizure (GTC). In this seizure, the patient becomes unconscious and his body becomes stiff which is followed by jerky movements of the body. His neck may turn to one side and the eyes may roll upwards. He may have frothing from the mouth, tongue bite, urine/stool incontinence. This phase may last for few minutes. When the jerks subside, patient may remain unconscious or in confused state for sometime and recovers gradually. After regaining consciousness, patient may complain of headache, body ache or vomiting.

B. The second type of epilepsy is called Complex Partial Seizures. In this seizure, the patient becomes blank, has a staring look which is associated with lip Smacking, abnormal tongue and hand movements. This may last for 2-3 minutes. This may occur repeatedly in a day. He has loss of contact with the surroundings.

C. The third type of epilepsy is called Absence Seizures. This is commonly seen in children. The child becomes blank for few seconds. At times the parents and teachers may complain about his absent mindedness and inattentiveness. If these episodes are frequent, these may affect the performance of the child in the school.

D. The fourth type of epilepsy is called Myoclonic Seizures. In this seizure, the patient is conscious and has single/ multiple jerks. If jerks involve hands, the patient may complain of dropping of objects like tooth-brush, pen and tea-cup etc.If it involves legs, then the patient may fall. Commonly these jerks occur before the onset of sleep or soon after getting up from bed in the morning (awakening).

Q.4- Are there any diseases which can mimic epilepsy?

Ans- Sometimes patient’s relatives may give history of fits similar to an epileptic fit. However, the limbs movements during the episode are bizarre and not stereo typed. The patient is conscious during the episode. These episodes are commonly stress related and are called Pseudo seizures. In some heart and blood pressure related ailments, patients may become unconscious due to reduction in blood supply to the brain and the body may become stiff for short duration. Apart from these two main causes, there are other conditions which can mimic epilepsy and these can be diagnosed by a neurologist by detailed investigations and follow up of the patients.

Q.5- What all investigations are done in a patient of epilepsy?

Ans- Certain tests need to be done to find the cause of epilepsy.

Some tests done are routine tests like blood tests, X ray chest and ECG.

Some tests done are specific like EEG, CT Scan and MRI.

CT Scan and MRI help to detect the structural abnormality of the brain.

Q.6- What is EEG test?

Ans- EEG detects an abnormal electrical discharge of the brain and in certain specific types of epilepsy we get specific abnormality in EEG.

It not only helps in diagnosis but helps in treatment by choosing specific medicine for the same.

Q.7- Is EEG test of different types?

Ans- Yes, EEG is of many types. However three types of EEG are commonly done.

The first is the Routine EEG.

The second one is called “Sleep Deprived EEG.” This EEG is done when routine EEG is normal but there is a strong suspicion of epilepsy in the patient. The patient is asked to remain awake throughout the night and EEG is recorded next morning. In a sleep deprived state, the chances of recording abnormal electrical discharges are more compared to routine EEG. The third one is called the “Video EEG”In this, the video and the EEG of the patient is recorded simultaneously. This is done in those patients in whom there is a diagnostic dilemma or in patients who have to undergo surgery for epilepsy(as a pre-surgery evaluation)

Q.8- What are the causes of epilepsy?

Ans- There are many causes of epilepsy-

In infants and children, the epilepsy is mainly due to the birth related issues.

Apart from this, other causes in children and adults could be due to brain TB, cysticercosis, head injury or brain tumor etc.

If CT scan/ MRI are normal, then the main cause is abnormal electrical discharge in the brain.

Q.9- What action should be taken by the witness during the epileptic attack of the patient?

Ans- The first and the foremost thing is not to panic as in majority of patients the attack subsides on its own.

Do not crowd around the patient.

Loosen out the clothes around his neck and belt area.

Do not try to put anything in the mouth during the fits.

Do not try to forcibly stop the jerky movements as these are involuntary. But do keep a watch that patient does not injure himself during these movements. When these movements subside, turn the patient on one side and remove the froth and sputum from the mouth so that it does not enter and block the respiratory passage. After this attack, patient will be confused/unconscious for sometime, so do not leave him alone till he is fully conscious.

Q.10- What is the treatment of epilepsy?

Ans- Treatment of Epilepsy is mainly based on Two principles.

Medicines are given for prevention of further episodes of fits.

If a particular cause of epilepsy is found, it is also treated accordingly by medicines or surgically.

Q.11- Are there any side effects of these medicines?

Ans- No medicine is free from side effects. However side effects are seen in only a small percentage of patients. So if a patient notices any specific change, then he should definitely share this with his doctor and if that change needs to be observed/monitored, doctor will advise him accordingly.

Q.12- What precautions should be taken while taking medicines of epilepsy?

Ans- Take medicines regularly without missing a single dose so as to maintain the proper drug level in the blood.

Always take the same brand of medicines.

Have proper sleep.

Do not skip meals.

Alcohol and other intoxicants are to be avoided.

Never stop the medication abruptly on your own.

Q.13- Should the patient be prevented from watching TV or working on computers while on medication?

Ans- “Photo-sensitive Epilepsy” is a type of epilepsy in which not only TV but other things like video games, DJ lights, flickering lights, or sun rays penetrating through the trees on highway can trigger epileptic attacks. Patients diagnosed with this epilepsy should definitely avoid above mentioned factors. However in few patients of other types of epilepsy these factors can also trigger seizures, so this kind of attack should be told to the physician. About 10% of all epileptics suffer from these attacks so it is not justifiable to put a blanket ban on all epileptics for watching TV.

Q.14- For how long the medicines guarantee no recurrence in future?

Ans- Once the medicines are started, epileptic seizures stop. If a patient does not get Seizure for three consecutive years, an EEG is repeated. If EEG is normal, medicines are gradually reduced by the doctor and finally stopped.

Q.15- Does this full course of medicines cure the epilepsy forever?

Ans- In 70-80% of the patients, seizures do not recur after a full course of treatment. In rest of 20-30% of the patients, seizures may recur and these patients are put on second course of treatment.

Q.16- What is the role of surgery in patients of epilepsy?

Ans- In patients with uncontrolled seizures on medication, we do some advanced investigations and try to localize the area in the brain from where seizures start. Surgically that area is removed to control fits.

Q.17- Can a woman, diagnosed with epilepsy ,be allowed to become pregnant?

Ans- Yes, a woman who has completed the course of medicines as well as a woman who is presently on treatment- both can become pregnant.

However, these women should share about their disease and medicines with their Gynecologist and Neurologist. Throughout her pregnancy she should follow the advice of her Gynecologist and Neurologist. I would like to mention that women who do not want to conceive and are taking oral contraceptives should inform their neurologist about the same since some anti-convulsants reduce the efficacy of oral contraceptives.

Q.18- Should the woman be allowed to continue Anti-epileptic medication during pregnancy?

Ans- Yes, she should continue medication throughout the pregnancy because the risk to the baby due to a convulsion is much higher than the risk by the medications. The dosage of medicines needs to be adjusted so she has to follow up with her neurologist throughout the pregnancy.

Q.19- Do these anti epileptic medicines have some effect on the baby?

Ans- In epileptic women on medication the chance of giving birth to a baby with some abnormality is 3-6%. However I would like to emphasize that even a healthy woman who is not on any kind of medication throughout her pregnancy also has a 2-3% chance of giving birth to a baby with some abnormality. Statistics also reveal that 90% of epileptic women have a normal delivery and a normal baby.

Q.20- Is breast feeding contra indicated in epileptic mothers?

Ans- Breast feeding is not contra indicated if a woman is on anti epileptics. A small amount of medicine is excreted in the milk which usually does not harm the baby. However if baby seems drowsy/lazy, breast feed should be alternatively be given with bottle feed and the pediatrician should be consulted.

Q.21- Can an epileptic patient allowed to drive?

Ans- Under the Motor Vehicle Act of India, Epileptic patients whether they are still on medication or have completed the course, are not eligible to obtain a driving license. However, laws vary in different countries. In some countries, an epileptic patient on medicines but is seizure free for last 6months to 2 years can obtain a driving license.

Q.22- Is there a restriction on the sports activities of the patient?

Ans- Swimming and adventurous sports are forbidden for epileptic patients. But he can participate in all other sports activities.

Q.23- Can an epileptic lead a normal married life

Ans- Yes, he/she can lead a normal married life but continue taking the medicines. This condition should be shared with the spouse for a healthy relationship between husband and wife.

Q.24- What is the legal status of epilepsy and marriage in India

Ans- As per marriage laws Amendment Act 1976, Epilepsy was equated to insanity and was a ground for divorce.

Indian Epilepsy Association, in 1996 filed a PIL against Union of India on the basis of which , a bill was passed in Rajya Sabha on 30/11/99 and in Lok Sabha on 12/12/99, as a result of which, now epilepsy is not a ground for divorce.

Q.25- What are the superstitions associated with epilepsy?

Ans-

  • It is caused by supernatural power so patients are being taken to Baba’s & Tantriks.
  • It is a mental illness
  • It is a curse bestowed by God
  • Marriage can cure Epilepsy
  • It is an infectious disease