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Approach to Neurology Problems in Clinic

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E-Consult Basics

E-consults in neurology are useful when a SPECIFIC question is asked, especially around management decisions. They are not as useful when asking about evaluation questions for new complaints.

Examples of good E-consult questions:
A) New onset migraine headaches this past year -- do I need to obtain imaging?
B) Patient has history of cluster headaches and want to taper medications -- can you recommend a taper?
C) Patient has history of alcohol withdrawal seizures, on Dilantin. No seizures in many years -- do I need to continue dilantin? For how long?

Examples of inappropriate E-consult questions:
A) Patient with sciatica, fatigue, generalized weakness (no question asked)
B) Please evaluate patient with new neuropathy (E-consults not appropriate for evaluation, as need more information than what can be found in chart)

Headaches

Tension Headaches

1) Often bilateral, can be described as “squeezing” or “vice-like”, not associated with more than one migraine symptom
2) If <8 days per month, can treat symptomatically with Tylenol, NSAIDs
3) If 8+ days per month, should start on daily, preventative medication (can use e-consult to address appropriate medication)

Uncomplicated Migraines

1) Associated with migraine symptoms (e.g. unilateral, pulsating, avoidance of routine activity, light/sound sensitivity, nausea/vomiting)
2) If < 6-8 days per month, can treat symptomatically with triptan (avoid if history of CAD, stroke/MI, or uncontrolled hypertension) Tylenol, NSAIDs, anti-emetics, muscle relaxants if prominent neck pain (can use e-consult to address appropriate medication)
3) If 8+ days per month, should start on daily, preventative medication (can use e-consult to address appropriate medication)
4) Treatment of status migrainosus (migraine lasting longer than 72 hours) – can use BID NSAID’s for 3-5 days or short course of steroids, can use econsult to address appropriate medication or need for further workup
5) Treatment of medication overuse headache (use of acute medications more than 10 days a month for >3 months) -wean offending agent, can use econsult to address appropriate medication use.

Neuroimaging / Further Testing in Headaches

In general, imaging of the head is not indicated in chronic headache syndromes that do not have any red-flag symptoms (see appropriate section). However, if headache is refractory to treatment, no longer responding to treatment, or changing in quality/pattern, imaging may be needed. Can use e-consult to address this question.

Red Flag Signs for Headaches (Refer to neurology for in-person visit)

Refer for any of the following:
1) Acute/Severe onset ("worst headache of my life")
2) Any new onset headache in someone over the age of 50
3) Complicated headaches (e.g. neurologic deficits such as vision loss, double vision, motor weakness)
4) Headaches in immunocompromised patient or those with cancer
5) Headaches associated with autonomic symptoms (e.g. unilateral eye lacrimation, ptosis, injection, unilateral congestion)
6) New onset headache in pregnancy or immediately post-partum

Neuropathy / Neuropathic Pain

Red Flag Symptoms

Rapidly progressive symptoms or neuropathy with associated motor weakness should prompt a referral to in-person or video neurology visit

Distal Sensory Neuropathy

1) "Stocking Glove Distribution", should be fairly symmetric and beginning in the feet, but over time if progresses can occur in hands as well. If symptoms start in hands first, other etiologies should be considered (e-consult or neurology referral for guidance).
2) Described as numbness, tingling "pins and needles", and/or burning (e.g. paresthesias)
3) Basic workup in IMA: A1c, TSH, Vitamin B12, SPEP / IFE
4) Treatment: Treat underlying condition. Symptom management with gabapentin, pregabalin, TCAs. Symptom management does not help numbness but can be helpful for "positive" symptoms such as tingling or burning.
5) Can place E-consult if questions regarding further work-up if initial/basic work-up is negative OR for symptom management questions.

Focal Numbness or Paresthesia

E-Consult is often appropriate
1) Often in an extremity, may be from a peripheral nerve issue or a radiculopathy
2) Can place E-consult if any questions regarding work-up or management. Helpful information to include in E-consult include: Specific location of symptoms, any associated pain (focal or radiating), any exacerbating factors.

Neuropathic Pain Medications Review

If there are questions about what is the best medication to use, an e-consult is a great option. In general, medications are chosen based on what is most compatible with patient comorbidities and concurrent medications, as well as the most "tolerable" side effect profile.

Gabapentin
1) Dosing: Start with 100mg or 300mg QHS to ensure no issues with sedation. Increase as needed to control pain. Dosage should be TID and taken regularly (not used PRN). Maximum daily dose = 3000mg.
2) Side Effects: Sedation, respiratory depression (avoid if on opiates), dizziness, lower extremity edema, weight gain
3) Contraindications: Renal disease (dose renally), concurrent CNS depressant use (excessive alcohol, opioids, other sedating medications)

Pregabalin
1) Dosing: Start with low dose at bedtime (50-75mg) to ensure no issues with sedation. Can increase as needed to control pain. Dosing should be TID and taken regularly (not used PRN). Maximum daily dose = 600mg, although if no response with 300mg/day then low likelihood increase will help and should likely switch medications.
2) Side Effects: Sedation, respiratory depression (do not give if on opioids), dizziness, lower extremity swelling, weight gain)
3) Contraindications: Renal disease (dose renally), concurrent CNS depressant use (excessive alcohol, opioids, other sedating medications)

TCAs
Amitriptyline and Nortriptyline are both okay to use, although nortriptyline may have fewer side effects due to pharmacokinetics
1) Dosing: Typically start low (10 or 25 mg) QHS and titrate up to control pain. Maximum daily dose = 75mg. Dosed once per day.
2) Side Effects: Sedation (but given at bedtime), dry mouth, constipation, dizziness, hallucinations or psychosis (be cautious in elderly), arrhythmias (use cautiously in those with cardiac disease, monitor EKG), urinary retention (caution in BPH or those with urinary issues)
3) Contraindications: Avoid in those on antidepressants already (SSRI or SNRI) due to risk of serotonin syndrome, those with cardiac disease. Cautious use in the elderly.

SNRIs (Duloxetine)
1) Dosing: Typically start 30mg daytime and increase to 60mg as tolerated. Maximum daily dose = 120mg.
2) Side Effects: Nausea. Activating (so should be taken during daytime). Urinary issues. Depression or Mania. Glaucoma (angle closure).
3) Contraindications: Renal disease. Mania or Bipolar Disorder. Glaucoma. Seizure History.

Back Pain

Acute low back or neck pain

E-Consult is often appropriate
1) Can be for focal or radicular back pain
2) Can treat symptomatically with NSAID, muscle relaxants, rest
3) Can use e-consult for specific questions around medications

Chronic low back or neck pain

E-consult is often appropriate
1) Can be for focal or radicular back pain
2) Management considerations include daily gabapentin, pregabalin (Lyrica), TCAs (nortriptyline, amitriptyline), muscle relaxants (See discussion of meds in Neuropathy section).
3) Refer patients to physical therapy!
4) Can use e-consult for specific questions around medications or management

Neuroimaging in Back Pain

If there is a question whether neuroimaging is needed, can place e-consult. In general, pain (focal or radiating) without any neurological deficits, such as motor weakness, can be treated symptomatically. If pain is worsening despite treatment, or any red flag symptoms present, further workup may be needed and referral to neurology should be placed.

Red Flag Symptoms

Should prompt referral to in-person or video neurology visit.
1) Motor weakness
2) Bowel or bladder issues (incontinence or retention)
3) Patients with cancer or immunosuppression

Cognitive and Behavioral Symptoms

1) Before referral to neurology, please check Vitamin B12, TSH, RPR, and HIV (if patient consents).
2) If using an e-consult, please ask a specific question (e.g. deciding on what imaging study to order).