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Dr Estelle McFadden
MBChB, MRCP, MRCGP
GPwSI, Bradford
Headaches
www.mipca.org.uk
Why is this important?
Psychogenic
Red Flags
If history inadequate
Presume cardiovascular till proven otherwise
ECG, cardiac enzymes, cardiac monitor, ECHO, tilt table,
carotid sinus massage
If cardiac symptoms present before, during or
after arrange cardiac tests especially while
symptomatic
Altered consciousness, behavioural change
Exclude epilepsy
Exclude cardiac/cardiovascular causes
The Blackouts Checklist (refs)
Vomiting
Vertigo and the neck
Compression of vertebral arteries
expect multiple neurological symptoms;
tinnitus & hearing loss
very rare cause of recurrent vertigo
Carotid sinus hypersensitivity
Relatively common, but causes falls NOT vertigo
Cervicogenic vertigo
proprioceptive dysfunction
desensitization to neck stimuli
vestibular failure
Not common
Nystagmus
Curative manoeuvres
Epley
Barrel
Epley manoeuvre and Barrel
manoeuvre
3 4
5 6
The best policy: A team approach
2 Unilateral 60 mins
weakness
Risk of stroke following TIA
Antiplatelet
Aspirin 75mg 300mg plus dipyridamole MR
200mg bd for 2 years following event then
aspirin alone
Clopidogrel alone if aspirin intolerance or
sensitivity
Anticoagulation
Anticoagulant if arrhythmia unless
contraindication (high risk of falls, recent GI
bleed)
Secondary prevention
Hypertension
Risk of stroke halves with every 10mmHg fall
in diastolic blood pressure even in
normotensive patients
Cholesterol
Equal benefit of simvastatin 40mg across all
those who had had a stroke or TIA down to
baseline 3.5mmol/l total cholesterol
Lifestyle advice
Smoking cessation
Alcohol intake
Binge drinking associated with increase in
blood pressure
Exercise
Obesity