Headache is a common complaint which is rarely serious but can be debilitating.
In some cases, however, it can be the first symptom of a life threatening condition such as meningitis, cerebral thrombosis or brain tumour. These sinister headaches often come on suddenly and are accompanied by other symptoms such as weakness or sensory disturbance All patients with new onset headaches should have a full neurological assessment to exclude the possibility of a serious underlying condition.
The most frequent severe headache is migraine: over 20% of the population are sufferers, in many it goes unrecognised, and is not treated appropriately. Migraine is often not diagnosed if patients do not have typical symptoms such as throbbing one sided headache with vomiting and / or visual disturbance. It is now acknowledged that migraine can present in many different ways, from severe headache to just dizziness with no headache.
Fortunately the treatment of migraine has advanced greatly in the last few years and there are many treatment options now available. This allows for effective ‘personalised’ care with the appropriate specialist knowledge. Previously the principles of treatments were lifestyle changes and strong pain relief at the onset of a headache and then preventative tablets to stop frequent migraines. The preventative medications were only partially effective and had many side effects, such as drowsiness. There are new preventative medications, such as candesartan, supplements for example Vitamin B2, but also non-tablet treatments such a Botox injections or devices such as ‘GammaCore’ vagal nerve stimulatory. The greatest development is the improved understanding of migraine biology which has identified calcitonin gene-related peptide (CGRP) as key to the migraine process. Monoclonal antibodies which block CGRP receptors can be given as monthly to three monthly injections such as erenumab (Aimovig) or galcanezumab which have been proven to be highly effective with few side effects and will become the mainstay of treatment for regular migraine sufferers. Similarly acting small molecules known as ‘gepants’ are also being developed which are likely to be in tablet form. For individual migraine attacks future drugs include serotonin 5-HT1F agonists (e.g. lasmitidan) which aim to be more effective and better tolerated than current triptans. In summary there are rapid and promising developments in the pharmacological treatment of migraine but lifestyle remains important component in the management of migraine.
Occasionally patients end up taking too many pain killers and develop what is called ‘medication overuse’ or ‘analgesia’ headache. This cause is often overlooked and needs carefully planned management. Less common, but usually severe headaches are ‘cluster headache’, ‘paroxysmal hemicranias’, ‘sex or exercise induced headache’, and very rare but dramatic is ‘low cerebrospinal fluid volume headache’. These conditions are frequently missed and require specialist management, each having different sensitivities to different therapies and do not respond to most pain-killers.
Multiple Sclerosis (MS) is the most common non-traumatic cause of disability in young adults. Occurring in around 1 in 1000 people, it is more prevalent in temperate climates such as the UK, and at least twice as common in women. It appears to be increasing in frequency, particularly among women.
The early symptoms of MS vary greatly, from mild alteration in sensation to loss of vision or difficulty walking. There is no single test for MS. The diagnosis is based on the patient’s symptoms and physical signs supported by magnetic resonance imaging (MRI) and examination of blood and cerebrospinal fluid.
In most patients after the first attack there is an improvement followed by stability for months or years before another attack, this is the relapsing remitting pattern (RRMS). Some patients, however, have a progressive pattern with a slow accumulation of disability, this is known as primary progressive MS (PPMS).
The prognosis for MS sufferers is hugely varied. For the majority, MS will be disabling, typically within 10 to 15 years from first diagnosis. However, a minority of patients experience a mild form of the disease, living full and normal lives. In the early stages, an assessment of a patient’s history, along with MRI scans and an analysis of biomarkers such as neurofilaments (NfL) will reveal how the disease is likely to develop over time.
Successful clinical research into disease modifying therapies (DMTs) has dramatically improved the outlook for MS patients in recent years. Dr Turner is actively involved in the development of these new therapies, having treated patients in clinical trials since the 1990s. The first therapies were interferons and glatiramer acetate, which needed to be injected regularly, and had limited impact on the disease process. Today, infrequent infusions of immune cell depleting treatments such as alemtuzumab (Lemtrada) and ocrelizumab (Ocrevus) have a far greater impact on the disease, and can suppress it for years at a time. As a result, ‘No Evidence of Disease Activity’ (NEDA) is now a realistic prospect: with active therapy and close monitoring we can keep patients free of detectable disease activity.
Barts MS, the clinical and research group based at Barts Health and Queen Mary’s University London, has pioneered NEDA and early aggressive immune therapy in MS, leading to improved outcome for people with MS.
There is now evidence that therapies can also benefit those with progressive MS, bringing the prospect of treatment to patients who previously had little hope of intervention.
Dr Turner has also helped pioneer the use of ‘stem cell’ therapy in MS which works by ‘rebooting’ the immune system. Dr Turner is part of the London group actively researching the use of AHSCT in MS.
There are two types of stem cell treatments. Mesenchymal stem cell therapy – by which any basic cell in the body could be adapted and used to replace injured cells – is unfortunately still many years away, particularly for use in MS. By contrast, autologous hematopoietic stem cell transplantation (AHSCT), is already available.
The process of AHSCT, is that stem cells are harvested from the patient’s blood and then by destroying the patient’s immune cells and replacing them with the harvested stem cells, the hope is that the immune system returns ‘renewed’, preventing a recurrence of MS. The data is very encouraging with some 80% of patients remaining stable after 3 years. There is growing evidence that it can be more effective in the early stages of the disease. Further trials are planned which will establish which patients are most likely to benefit from the treatment.
Dr Turner has extensive experience of these new disease modifying therapies and first-hand knowledge of their individual risks and benefits. In addition to stem cell therapy, there are also new generic medications which are less expensive than licenced medications for MS sufferers, as well as new symptomatic therapies. Whilst the disease modifying therapies are exciting, symptom management remains an important aspect of medical intervention with MS. This includes pain management with analgesia – including cannabis based products such as Sativex – bladder control with antimuscarinics and spasticity with medication and Botox.
Dr Turner’s MS research is carried out as Honorary Senior Lecturer at Barts and The London School of Medicine and Dentistry, Queen Mary, University of London. As a member of the Barts MS and Neuroimmunology team headed by Professor Gavin Giovannoni at The Blizard Institute of Cell and Molecular Science, he is at the forefront of ground-breaking efforts to meet the challenges of this complex condition.
The sensation of ‘dizziness’ is among the most disturbing of medical symptoms and the hardest to diagnose.
Patients’ experience of dizziness varies widely from a general feeling of ‘light headedness’ faintness or weakness to a more specific sensation of vertigo.
Vertigo, most commonly experienced after disembarking from a boat or fair-ground ride, is the sensation that the world or floor continues to move. It is also known as the ‘hallucination of movement’.
Dizziness has multiple possible causes since the mechanism of balance is complex, involving parts of the body from the ear to the heart. Most commonly, it results from a problem with a part of the inner ear called the labyrinth, such as labyrinthitis or Benign Paroxysmal Positional Vertigo. But it may also be due to abnormalities in specific areas of the brain that deal with balance or integration of vision. One of these abnormalities is migraine. Accurate diagnosis relies on a thorough understanding of a patients’ medical history.
Medication may be an appropriate treatment for some patients, however many forms of dizziness can be treated with simple head manoeuvres, such as the Epley’s. Patients should avoid commonly prescribed but ineffectual treatment known as vestibular suppressants.
In some sufferers, the dizziness can become chronic. This is now recognised as Persistent Postural Perceptual Dizziness (PPPD) and may require a combination of medication and vestibular rehabilitation.
The sensory nervous system is one of the most complex functions of the human body. We normally take it for granted, so any malfunction can be particularly disturbing. Sensory disturbance can result in a sensation, for example burning, without any apparent cause.
Sensory abnormalities can arise from anywhere – from the cortex of the brain to the fine nerve endings in the tip of the toes. They may be caused by the entrapment of a nerve due to prolonged posture or tissue thickening, such as carpal tunnel, or by a medical condition such as diabetes which damages the nerve fibres, giving rise to a diminished or unpleasant sensation. Temporary sensory changes can also occur during migraine or hyperventilation.
The sensory nervous system is a complex yet a highly organised network. Most sensory abnormalities can be diagnosed, given sufficient expert knowledge of the distribution of particular sensory function and of the diseases that could afflict them.
Investigation of sensory nerve abnormalities usually involves neurophysiological tests, such as nerve conduction studies where electrical stimuli are applied to individual nerves and the amplitude and speed of conduction is then measured. Electromyography is another option, whereby small needles are inserted into particular muscles to detect alterations in electrical activity and the resulting loss of nerve supply. Whilst these tests may sound unpleasant, in the correct hands they merely feel a little uncomfortable or simply strange.
Ultimately, sensation is part of normal human experience and for many people, unusual sensations arrise not from any physical abnormality but rather from a psychological shift in perception.