10 steps to migraine diagnosis
A ten-step approach to the diagnosis and management of migraine has been endorsed by the European Headache Federation and the European Academy of Neurology.
The consensus statement developed by European neurologists and based on the latest evidence is aimed at providing “generally applicable recommendations for the diagnosis and management of migraine and to promote best clinical practices”. The statement includes recommendations on typical clinical features, diagnostic criteria and differential diagnoses of migraine. It also outlines best practices for acute and preventive treatment of migraine in various patient populations, including adults, children and adolescents, pregnant and breastfeeding women, and older people.
“In addition, we provide recommendations for evaluating treatment response and managing treatment failure … and discuss the management of complications and comorbidities as well as the importance of planning long-term follow-up,” the authors say in Nature Reviews Neurology
Cognitive decline linked to blood pressure variability
High blood pressure variability (BPV) in older adults, particularly in men, is associated with an increased risk of dementia and cognitive decline, according to findings from the Australian-led ASPREE (ASPirin in Reducing Events in the Elderly) study.
Data from 16,758 participants over 70 years of age showed that over two year follow up, those with the highest rates of BPV had increased risks of incident dementia and cognitive decline, which were independent of average BP and use of antihypertensive drugs, for individuals in the highest blood pressure variability tertile compared with the lowest. Being male also increased the risk significantly.
The authors said the findings support earlier results that suggested BPV may be a useful indicator of cognitive decline, including older, relatively healthy adults who had reached late life without significant cognitive impairment – a group that is not typically considered at high risk for dementia in their remaining lifespan.
“Accumulating evidence suggests BPV is associated with structural brain changes, including increased white matter hyperintensities, cerebral microbleeds, and enlarged perivascular spaces,” they wrote in the Journal of the American Heart Association.
“The basal forebrain cholinergic neuronal degeneration and associated presynaptic cholinergic denervation in Alzheimer’s disease may influence sympathetic and parasympathetic autoregulation of BP, contributing to BPV. The resultant hemodynamic instability can increase shear stress and promote microvascular damage, which may affect permeability of the blood brain barrier and accelerate neuronal injury,” they added
New CVST advice from Department of Health
The Department of Health has released guidance on the management of suspected cerebral venous sinus thrombosis (CVST) after COVID-19 AstraZeneca vaccine.
The recommendations, aimed at primary care practitioners, differ slightly from the multidisciplinary guidance issued by the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) vaccine-induced immune thrombotic thrombocytopenia (VITT) syndrome Communications Committee in May.
According to the DoH guidance, suspected cases should be referred immediately to emergency if they are acutely unwell with neurological deficits. They list possible signs of CVST as unusual headache that starts or persists at least 48 hours after vaccination, and which is severe or does not improve following simple analgesia. They also warn GPs to be alert for signs or symptoms of raised intracranial pressure (e.g. headache worse when supine or associated with nausea and vomiting), and neurological deficit (e.g. blurred vision, dysarthria, altered mental status or seizures).
Initial investigations in primary care should a full blood count and D-dimer which can reviewed within six hours and repeated within 24-48 hours for patients with normal results and persistent symptoms,.
In contrast, the THANZ multidisciplinary guidelines recommend obtaining urgent FBC, APTT, PT, fibrinogen and D-dimer within four hours.