Neurology

What associated disorders should primary care clinicians be alert for in patients with Parkinson disease?

A 42-year-old woman had a "life-long" history of mild to moderate low back pain, without radiation, anesthesia, weakness, or incontinence. She denied recent trauma or an inciting event. The pain was constant and worse at the end of the day and with prolonged activity. Physical therapy, NSAIDs, tramadol, opioids, and manipulation provided minimal relief.

A 26-year-old woman at 30 weeks’ gestation presented to the emergency department with a throbbing frontal headache of 1 month’s duration. She had also had peripheral blurred vision for the past 2 weeks. Acetaminophen initially decreased her pain but was no longer effective. She had had a previous miscarriage.

Doctors, especially primary care doctors, love stories. We love hearing them from patients and telling them to one another. “Anecdotal learning” it’s called by some (somewhat derisively because it’s not science).

Several days earlier, a 69-year-old man had a mild headache, fatigue, and tingling and prickly facial sensations. Shortly afterward, this painful, “weepy” rash developed on his forehead, upper cheek, and nasolabial folds and vision in the right eye became blurry. The patient’s history included type 2 diabetes mellitus, hypertension, and childhood varicella.

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Migraine and chronic daily headache may be risk factors for the development of complex regional pain syndrome, according to the results of a study led by B. Lee Peterlin, DO, assistant professor of neurology, Drexel University College of Medicine in Philadelphia.

Results of a large survey show that many patients with cluster headaches (CH) are not receiving treatment with acute and preventive therapies.

Did Pablo Picasso suffer from migraine? And did these episodes influence his artwork? Not likely, said Joost Haan, MD, PhD, a member of the department of neurology at Leiden University Medical Centre, Leiden, the Netherlands. He discussed migraine and the works of master painters at the 14th annual International Headache Congress in Philadelphia.

Results of a landmark study showed that onabotulinumtoxinA effectively reduced headache symptoms, episodes, disability, and health-related quality of life in patients with chronic migraine.

Patients with migraine accompanied by depression or anxiety disorders had greater improvements in headache-related disability than those without a psychiatric disorder, according to results of the Treatment of Severe Migraine trial.

About 20% of soldiers returning from Iraq and Afghanistan who have a history of concussion or blast exposure experience chronic daily headache, according to a results of study presented at the 14th annual International Headache Congress in Philadelphia.

The portrayal of headache in film may contribute to patients’ misconceptions and fears about their illness, according to Bert B. Vargas, MD, clinical professor of neurology at the Mayo Clinic in Phoenix.

Tonabersat is effective in the prophylaxis of aura in patients with migraine, according to a recent study led by Jes Olesen, MD, a professor of neurology at the Danish Headache Center at Glostrup Hospital, University of Copenhagen, Glostrup, Denmark.

Patients with migraine are more likely than nonmigraineurs to have temporomandibular disorder (TMD). According to the results of a new study presented at the 14th annual International Headache Conference in Philadelphia, TMD may also be associated with increased headache frequency.

It is only within the past 40 years that the term "migraine art" was introduced; yet artists may have been creating works inspired by migraine aura since the Stone Age. Early depictions of migraine continue to influence newer artists with this illness. This is a natural progression that is common in all types of art, according to Klaus Podoll, MD, senior physician in the department of psychiatry and psychotherapy, University Hospital Aachen, RWTH Aachen University, Germany. But Dr Podoll has found that artists with migraine are often particularly attracted to the works of other artists who share their migraine experiences. These shared experiences "act like a filter," contributing to the an artist's perspective and leading to "elective affinities between migraine-inspired artists," he said.

Progressively worsening nasal congestion and headaches with diplopia and left proptosis for 2 months prompted an ophthalmology consultation for a 67-year-old woman. She had been evaluated multiple times for allergic rhinitis and recurrent sinusitis.

For a month, an obese 50-year-old woman with type 2 diabetes mellitus, hypercholesterolemia, and hypertension had blurry vision in both eyes. During this time, she also had ataxia and right-sided numbness. For the past 2 days, she had had horizontal, binocular diplopia with right gaze.

A 35-year-old woman presented to the emergency department (ED) with 2 black eyes, facial swelling, and other injuries (Figure 1). She said that she had been in an all-terrain vehicle accident the day before, in which she hit her face on the handlebar. She said she had lost consciousness for an unknown period and since the accident had experienced headache, dizziness, nausea, and pain over much of her body.

During a routine physical examination, multiple, randomly distributed, fleshcolored nodules were noted on the trunk, arms, and face of a 62-year-old man. The lesions measured 0.5 to 1.0 cm and appeared slightly pedunculated. The patient had had the lesions since he was a teenager; they were not painful. He also had hypertension, for which he was taking lisinopril (20 mg once daily).

A 37-year-old man was brought to the emergency department (ED) after he had 2 near-syncopal events. The first occurred in the morning and rapidly resolved; the second occurred later in the day at work. The night before he had a headache and neck pain. In the ED, he reported left arm and leg weakness and was noted to have left facial droop.

Losing weight can significantly reduce intracranial pressure and the complications it causes, including headache and optic nerve anomalies.

Most uncomplicated anxiety disorders can be treated in the primary care setting. Following the initial treatment, patients require ongoing care, which combines psychosocial and psychopharmacological therapies. Treatment of anxiety disorders can lead to improved interpersonal, social, and vocational functioning.

Highlights from the International Headache Congress are presented by Stephen D. Silberstein, MD, professor of neurology at Jefferson Medical College and director of the headache center at Thomas Jefferson University, Philadelphia, as well as chair of the congress organizing committee.

Randolph W. Evans, MD, chief of neurology at Park Plaza Hospital and clinical professor at Baylor College of Medicine in Houston, Texas, reviews postconcussion syndrome and post-traumatic headache.

Anxiety disorders are as prevalent and disabling as depression; they affect about 19.1 million adults in the United States at some point during their lifetimes.1-3 Because of the high suicide risk associated with depression, patients who have anxiety may attract less attention from their primary care providers. Thus, anxiety disorders often go undiagnosed and untreated.

A 51-year-old man was hospitalized for subacute alteration of mental status. The patient had a history of alcohol abuse. He had no other medical disorders. Vital signs were normal. The patient scored 15 out of 30 on the Mini-Mental State Examination. He had an ataxic gait; all other physical findings were normal. The family reported that he had been treated in the emergency department 3 days earlier for hypoglycemia. Results of a complete metabolic profile and complete blood cell count were normal.

A 22-year-old man seeks medical attention at his college’s infirmary. He had been in excellent health until 1 week earlier, when he noted onset of fever, headache, and malaise.

The patient has a small-fiber sensory neuropathy that is managed with lamotrigine. She is a physical therapy student who has frequent patient contact. She drinks alcohol occasionally but denies smoking and illicit drug use; she says she is not sexually active.

A 47-year-old Hispanic woman with severe headaches of 1 month’s duration presents to the emergency department (ED). The pain encompasses the entire head, is constant and crushing (10 on a scale of 1 to 10), and has progressively worsened.