2015-2016 Student Information St. Charles Neurology Clinic
General:
You will be seeing patients in a clinic setting, working in conjunction with Faculty, Residents, Staff & an Intern Rotator
Typical diagnoses treated in clinic:



Headache
Parkinson’s disease
Dementia


Multiple Sclerosis
Epilepsy

Hammer (Not a Tomahawk type)
Tools you will need:

Tuning Fork
Prior to the start of your rotation:



Review the basics of these diagnoses and be prepared to discuss and capably participate in patient visits
Review the Neurological Exam video demonstration & be prepared to actively practice the exam
Review Patient Notes & be prepared to actively practice writing notes
Schedule:




Monday – 8:30AM – 5:00PM
Tuesday & Wednesday – 8:30AM – 5:00PM
Thursday – Didactics @ 1542 Tulane (No morning clinic; Lectures begin either @ 11:30AM or 1:30PM)
Friday – 8:30AM – 5:00PM (Students alternate @ St. Charles Clinic & @ Kenner Neuromuscular Clinic w/Dr.
Gutierrez; located at the Ochsner Kenner campus Hospital/ Clinic Building 7th floor)
MDA & ALS Clinics @ St. Charles – 1st & 3rd Tuesday of each month
Contact: Resident on clinic month (in your Passport); If unavailable, Dr. Voigt avoigt@lsuhsc.edu
Location: 3700 St. Charles Avenue, 4th floor
Parking: On-street; Garage costs $6-7
Food: There is no cafeteria in our building, so you may want to bring lunch; microwave & refrigerator in lounge
Resources:
Neurology Review https://www.medschool.lsuhsc.edu/neurology/students/docs/Neurology%20Review.Final_05-01-2014.ppt
Neurology Exam http://mediasite-ent.lsuhsc.edu/Mediasite/Play/42c42814c920442cbfc895d8a9a22dd81d
Headache Management
Goal is to first diagnose headache type, then treat based on headache diagnosis
Poor response to meds is typically due to misdiagnosis
Best time to diagnose is not during an acute attack
Types - primary
Migraine: 3-72hrs, throbbing, unilateral, photo/phono, nausea, vomiting;
Tension: 1 hr -1 week, tightness, bandlike, photo or phono but no nausea
TAC -Cluster: 5 min-2hrs, stabbing, unilateral, autonomic symptoms, multiple events/day
hemicrania continua/Idiopathic stabbing/SUNA/SUNCT/paroxysmal HC – also fall into this group
Types – secondary
Medication overuse headache: 3 months >10 days triptans/fioricet, >15 days OTC; headache upon awakening, resolves with
meds, repeat
Increased Intracranial Pressure (Pseudotumor cerebri): daily/constant, worse w position, holocephalic, whooshing in ears,
peripheral field cuts; MRI may show optic nerve enhancement, empty sella,
Decreased Intracranial Pressure: daily/constant, worse with standing/moving, associated with POTS, MRI shows
thickening/enhancement of meninges, pitituary enlargement, subdural fluid collections, downward displacement
Acute/ER Management
-DDX: mass lesion, bleed, infectious process (encephalitis/meningitis), stroke, “migraine”
Red flags/reason for further workup: sudden onset of headache, onset of headache after 50 years of age, increased frequency or
severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness,
focal neurologic signs or symptoms, papilledema and headache subsequent to head trauma
Studies: labs, CT/CTA, LP
Tx: Migraine cocktail
- IVF, Toradol 30mg, Phenergan 25 or compazine 10, Benadryl 25-50, Mg 1g, VPA 500, 1-2g ativan
-Nerve blocks: lidocaine or bupivicaine
Office management
History: ask about red flags, as well as all med use
PE: neuro exam; special attention to BP and any ocular abnormalities/papilledema, neck exam
Labs: ESR/CRP for TA, otherwise CBC, CMP, TSH/T4 is sufficient (also consider perimenopause)
Imaging: based on red flags; MRI; possible MRA/MRV; possible LP
Abortive: fast, effective, limited side effects
Tx: abortive: migraine
-triptan: 60-65% responders, sumatriptan 50-100mg, rizatriptan 5-10mg are generic; nasal or SQ formulations for
quick onset HA, Contraindicated in stroke, MI, CAD, uncontrolled hypertension
-combination pills (Fioricet/Fiorinal/esgic): cheaper, fewer side effects, also work for TTH
-Cambia (branded dicolfenac solution): expensive but ok for non-triptan pts
-NSAIDs: to enhance triptan
-anti-emetic
-anti-anxiolytic/muscle relaxer
Tx: abortive TTH
-typically NSAIDS work; may add muscle relaxer (methocarbamol – cyclobenzaprine- tizanidine); also PT, stretching, trigger
points, biofeedback
Tx: abortive cluster
-O2 15-20min; versus fast acting triptan (injectable sumatriptan, nasal zomig)
-high dose steroids for cluster cycle: prednisone 80/60/40/20/10
-nerve block with kenalog
Prevention: start low, 6-8 week trial, set patient expectations
Tx: prevent: migraine
*topiramate – 25-200mg QD-BID; Trokendi XR QD: paresthesias, weight loss, cognitive, rare: glaucoma, kidney stones, Cat C
*depakote ER – 125-500mg QHS; weight gain, fatigue, liver, Cat X
*timolol 10 TID or *propranolol 20-60 BID: fatigue, worsen depression & asthma, good for anxiety
verapamil 40 QHS-80 BID: constipation at high doses
amitriptyline/nortriptyline 10-25mg QHS: fatigue/weight gain but good for insomnia
*Botox: chronic migraine only; every 3 months
Butterbur 75 BID, Magnesium 500-1g, riboflavin 200 BID, feverfew
Tx: prevent: tension
None FDA approved;
Tx: prevent: cluster
verapamil 80-360 daily
lithium
valproic acid 125-1g
Epilepsy & Seizures
Seizure is a paroxysmal event generally caused by excessive and abnormally synchronized discharge of cortical nerve cells.
Epileptic seizures range from clinically undetectable “electrographic seizures” to convulsions. 1 in 10 people will suffer a seizure
in their lifetime.
Epilepsy is a disease of the brain defined by 1) either at least two unprovoked seizures occurring >24 hrs apart, or 2) one
unprovoked or reflex seizure with high probability of recurrence, or 3) diagnosis of an epilepsy syndrome. Epilepsy affects ~1% of
the population.
There are generalized epilepsy syndromes (absences and generalized convulsive seizures) and syndromes associated with partial
onset seizures (without cognitive impairment – simple partial; and with cognitive impairment – complex partial) without and with
secondary generalization
Status epilepticus is defined as a prolonged seizure state either with continuous epileptic activity or with serial seizures without
return to normal state. Convulsive status epilepticus is a life-threatening medical emergency. Non-convulsive status epilepticus
can be associated with absence and complex partial status. Epilepsia partialis continua (EPC) is manifested by persistent focal
motor manifestations.
Diagnosis of epilepsy is based on a clinical evaluation by a neurologist and may require supporting ancillary tests including an
electroencephalogram (EEG) and MRI brain or CT of the head. Intractable epilepsy merits referral to an epileptologist in an
Epilepsy Center who may order further testing including video-EEG monitoring.
Therapy for epilepsy includes pharmacotherapy (antiepileptic medications) and surgical interventions including cortical
resections and implantation of devices for epilepsy (Vagus nerve stimulator and responsive neural stimulator). Two thirds of
patients will respond to appropriately selected medications based on their epilepsy syndromes. One third will remain in
“medically intractable” category.
Parkinson’s Medications
Enzyme Inhibitors
Carbidopa (Lodosyn), 25mg – peripheral dopa-decarboxylase inhibitor
Entacapone (Comtan), 200mg – Cathecol-O-methyltransferase inhibitor (COMT);
Orange urine, diarrhea
Selegiline (Eldepryl 5mg, Zelapar ODT 1.25mg) – Monoamine oxidase type B>>A inhibitor (MAO-B);
Contraindicated with tyramine-containing foods, stimulants, etc
Rasagiline (Azilect) 0.5mg, 1mg – Selective MAO-B inhibitor
Tyramine effect not an issue, may have some disease-modifying activity
Dopamine Agonists
Pramipexole (Mirapex, Mirapex ER)
Ropinirole (Requip, Requip XL)
Rotigotine (Neupro patch)
All have relatively more nausea, orthostasis, somnolence, hallucinations than levodopa
Less risk of dyskinesias
May produce impulse control disorders, leg edema, and rarely fibrotic complications
Dopamine Precursor
Levodopa – always given with carbidopa to avoid nausea and orthostasis
Carbidopa/Levodopa (Sinemet) 10/100, 25/100, 25/250
Carbidopa/Levodopa ER (Sinemet CR) 25/100, 50/200
Carbidopa/Levodopa ODT (Parcopa) 10/100, 25/100, 25/250
Carbidopa/Levodopa/Entacapone (Stalevo) 12.5/50/200, 18.75/75/200, 25/100/200, 31.25/125/200,
37.5/150/200, 50/200/200
When using carbidopa/levodopa, avoid 10/100 formulation – rarely has adequate amount of carbidopa and
so has more nausea
Higher risk of dyskinesias with long-term use
Relatively safer than dopamine agonists in individuals over age 70yo
Carbidopa/Levodopa ER Capsules (Rytary) 23.75/95, 36.25/145, 48.75/195, 61.25/245
More reliable extended release form of CD/LD
Carbidopa/Levopdopa Intestinal Gel
Given through a PEJ tube and via infusion pump – may be useful if DBS is not indicated
Other Meds
Amantadine (Symmetrel) 100mg – stimulates dopamine release
Useful early in disease for first 6mos – helpful later to reduce dyskinesias
Trihexyphenidyl (Artane) 0.5, 1, 2mg – anticholinergic
Used in refractory tremor in younger patients
Rivastigmine (Exelon patch) 4.6, 9.5, 13.3mg – acetylcholinesterase inhibitor
Helpful for cognitive impairment and freezing of gait
Also use donepezil (Aricept) 5, 10, 23mg
Quetiapine (Seroquel) 25, 50, 100, 200, 400mg – atypical antipsychotic
Used at less than 200mg for psychosis in PD
Clozapine (Clozaril) has better evidence but harder to use (agranulocytosis)
Melatonin OTC – used for sleep and REM sleep behavior disorder
Clonazepam (Klonopin) helpful if melatonin fails
Botulinum toxin – irreversibly deactivates acetylcholine synaptic terminals
Useful for focal dystonias and sialorrhea in PD
Lasts 3-4 mos on average – time for axonal sprouting to occur and re-establish terminals
Dextromethorphan/Quinidine (Nuedexta) 20/10 – antiglutamate activity
Indicated for pseudobulbar affect in ANY disease – may be useful for dyskinesias