Handbook of clinical neurology
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Insight into the molecular mechanisms involved in primary headaches is important to identify drug targets for improving treatment of patients, but essentially lacking. Genetic research is increasingly successful in pinpointing these mechanisms. Most progress has been made for Familial Hemiplegic Migraine, a rare subtype of migraine with aura. ⋯ Except for the MTHFR gene no gene variant has been identified yet. Convincingly demonstrated genetic findings in other primary headaches such as cluster headache and tension-type headache are even rarer. However, with current technical possibilities of massive genotyping and international efforts to collect large well-phenotyped patient cohorts, the first gene variants for various primary headache types are likely to be discovered in the coming decade.
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Historical Article
Chapter 8: the development of neurology and the neurological sciences in the 17th century.
Circa 1660 several favorable factors, instrumental to the invention of neurology, converged at the University of Oxford. Animals and men were believed to have a material soul whose functions throughout the nervous system were accessible to research. In 1659 inductive methods were introduced in clinical medicine by Thomas Willis, the founder of English epidemiology and biochemistry. ⋯ There was a physiological part, a textbook of neurophysiology, and a pathological part, a compendium of neurological and psychiatric syndromes, with early descriptions of myasthenia, restless legs, narcolepsy, dissociative and bipolar disease, and general paralysis of the insane. In 1667 he published a book on convulsive diseases, in which he described the blood-brain barrier, epileptic and hysterical brain disorders, and Parkinson's disease. Thus Willis recognized and presented the key themes of the future specialty.
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Bacterial meningitis is a neurological emergency. Empiric antimicrobial and adjunctive therapy should be initiated as soon as a single set of blood cultures has been obtained. ⋯ Patients with documented bacterial meningitis and those in whom the diagnosis is a strong possibility should be admitted to the intensive care unit. Timely recognition of bacterial meningitis and initiation of therapy are critical to outcome.
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In the acute setting, the primary objective is to decide whether the headache is primary, secondary but benign (for example a headache associated with a cold), or secondary to a potentially life-threatening cause (subarachnoid hemorrhage (SAH), bacterial meningitis, intracranial hypertension). The cornerstone of headache diagnosis is the interview with the patient, followed by a thorough physical examination. These two first clinical steps determine the need for investigation, immediate with inpatient care or on an outpatient basis, and the treatment to recommend, acutely and for future attacks in the case of primary headache. ⋯ Headaches can be separated into four groups: (1) recent onset and thunderclap; (2) recent onset with progressive installation: (3) well known to the patient and episodic (attacks with headache-free periods, as in episodic migraine or cluster headache); and (4) chronic daily headaches (more than 3 months, more than 15 days of headache per month). Headaches with a recent onset and judged unusual or worrisome by the patient (even one with frequent headaches) must raise the suspicion of a secondary cause and need to be investigated. Headaches that continue for months or years are more often primary, but secondary causes need to be ruled out in certain cases.