Neurology for MRCGP AKT

A 26-year-old woman with epilepsy takes sodium valproate 800 mg daily. She has had no seizures for 4 years. She has just found out she is 6 weeks pregnant and asks what to do about her medicine. Which is the most appropriate action?

1. Stop valproate today and start lamotrigine Wrong. Stopping suddenly risks seizures, and switching drugs needs specialist supervision.
2. Continue valproate unchanged and review after the birth Wrong. This ignores a known cause of birth defects and misses the chance for specialist advice, scans and counselling.
3. Advise termination of the pregnancy Wrong. That is not the doctor's choice to push. The risk to the baby is real but far from certain. She needs accurate information and specialist advice.
4. Halve the dose straight away Wrong. Cutting the dose without specialist advice risks seizures, and the baby has already been exposed in early pregnancy.
5. Do not stop valproate suddenly; refer urgently to the epilepsy team and start folic acid 5 mg correct Correct. Valproate can harm the baby's development, but stopping it suddenly risks severe seizures, which are dangerous for her and the baby. The epilepsy specialist must decide quickly what to do.

The point: Valproate should not be used in anyone who could become pregnant unless the pregnancy prevention programme is in place. If a woman on valproate is already pregnant, do not stop it yourself. Refer urgently to the epilepsy service and start folic acid 5 mg daily.

Source: NICE NG217: Epilepsies in children, young people and adults NICE · tier 1, national regulator or guidance

A 38-year-old man has had severe pain behind his right eye for 3 days. Each attack lasts about 45 minutes and comes 3 or 4 times a day, often at night. During an attack his right eye is red and watery, his right nostril runs and he paces the room. He is pain free between attacks. His neurological examination is normal. He had a similar bout last year. According to current national guidance, which is the most appropriate treatment for an attack?

1. Co-codamol 30/500 Wrong. Opioids and paracetamol are not advised for cluster headache. Regular use also risks a second headache from painkiller overuse.
2. 100% oxygen at 12 litres per minute by non-rebreather mask correct Correct. His pain, red watery eye, runny nostril and restlessness fit cluster headache. NICE offers oxygen and/or a subcutaneous or nasal triptan for each attack.
3. Verapamil Wrong. Verapamil is a preventer used during a bout, usually with ECG monitoring. It does not stop a single attack.
4. Oral sumatriptan 50 mg Wrong. The pain peaks within minutes and each attack is short. A tablet is too slow, and NICE says not to use oral triptans for cluster headache.
5. Naproxen 500 mg Wrong. Anti-inflammatory painkillers do not act fast enough for attacks like his, and NICE advises against them for cluster headache.

The point: Cluster headache gives short, severe pain around one eye, with a red watery eye, a runny nostril and restlessness. For an attack, NICE says offer 100% oxygen at 12 litres per minute or more by non-rebreather mask, and/or a subcutaneous or nasal triptan. Do not offer paracetamol, NSAIDs, opioids, ergots or oral triptans. Verapamil can prevent attacks during a bout. Discuss imaging for a first bout with a specialist.

Source: NICE CG150: Headaches in over 12s: diagnosis and management NICE · tier 1, national regulator or guidance

A 41-year-old woman has had a headache on most days for 6 months. It is often there when she wakes. She took migraine tablets in her twenties. For the past 6 months she has taken co-codamol 30/500 on about 20 days each month. Her examination, including her optic discs, is normal. She has no red flag features. According to current national guidance, which is the most appropriate management?

1. Reduce the co-codamol slowly over 3 months Wrong. NICE advises stopping the overused medicine abruptly. A slow taper keeps the cycle going.
2. Refer for an MRI brain scan Wrong. She has no red flags. NICE says not to send people with a known headache disorder for scans only for reassurance.
3. Start propranolol and carry on with co-codamol Wrong. A preventer may be added, but only alongside withdrawing the overused painkiller. On its own it will not work while she keeps taking it.
4. Admit for inpatient withdrawal of co-codamol Wrong. NICE does not routinely offer this. It is kept for strong opioid use, serious illness or repeated failed attempts. None apply to her.
5. Stop all the overused painkillers at once for at least 1 month correct Correct. Co-codamol on 10 or more days a month for over 3 months can cause medication overuse headache. The treatment is to stop it, with close follow-up, and expect a short-term worsening.

The point: Think of medication overuse headache when a headache starts or worsens after 3 months or more of overuse. Triptans, opioids, ergots and combination painkillers count at 10 or more days a month. Paracetamol, aspirin or an NSAID count at 15 or more days a month. NICE says stop all overused acute medicines abruptly for at least 1 month, warn that headaches get worse first, consider a preventer, and review at 4 to 8 weeks.

Source: NICE CG150: Headaches in over 12s: diagnosis and management NICE · tier 1, national regulator or guidance