Specialist care from a leading London neurologist

Headaches are very common. Many people worry that their headaches indicate a serious problem with the brain, but in the vast majority of cases the problem is simply migraine or tension-type headaches. Neurologists can diagnose most headaches from a simple history and examination, though sometimes an MRI scan can be useful. Occasionally, further tests might be necessary although this is very unusual. 

There are many treatments which can be helpful for headaches, from simple adjustments in lifestyle, to medications, nerve blocks, or even injections of Botox. A sudden, severe headache that is not normal for you is a worrying symptom and you should go to hospital straight away.

Mark is often interviewed by the media and here he is talking about migraine on BBC Radio 4.

By far the most common cause of recurrent debilitating headaches is migraine. More than eight million Britons – three quarters of them women – suffer migraines. Migraine headaches are often severe enough to stop us doing what we want to do, and are typically accompanied by other features such as nausea, or sensitivity to lights, noises, smells, or movement. About a quarter of people with migraine experience an aura – typically flashing lights or blind spots in their vision, lasting up to 30 minutes – usually before the headache comes, but sometimes on its own without any other symptoms at all.

The condition affects more people than diabetes, asthma and epilepsy combined and is the sixth most common cause of disability in the world. Patients make lifestyle changes, take painkillers, and are prescribed drugs including beta blockers, antidepressants and anticonvulsant drugs. Tablets called triptans relieve symptoms but over time these can cause headaches themselves.

If chronic migraine does not respond to at least three drug treatments, patients may be offered jabs of the muscle-freezing drug Botox, because of its nerve-blocking effects, but this can involve 31 separate injections per treatment and has to be done in a specialist clinic.

Fremanezumab is among a new wave of drugs which targets a certain protein – in this case, calcitonin gene-related peptide (CGRP), which is responsible for the pain and nausea associated with a migraine. CGRP causes blood vessels intertwined with nerve endings in the head to swell up. Fremanezumab, which must be given by injection either every month or three months, depending on dose, contains an antibody that blocks that process.

Many of us will lose consciousness during our lifetime. Most of the time this is a faint, causing nothing more than temporary blackout. If you pass out regularly, and with no explanation, you should see a neurologist. The good news is that this is very commonly a blood pressure problem, but sometimes it can be the result of problems with your heart rate or rhythm (rare in the young, but common in older people) or with the electrical activity of your brain (epilepsy, which is comparatively rare). 

It is important that you keep a note of your blackout history not only as you experience it, but as witnessed by others around you, as this will prove useful information for your neurologist.

Tremor, shaking of your limbs during movement, at rest or in other circumstances such as writing, is common. Most tremors are benign and no more than an irritation or an embarrassment, but certain tremors can be caused by medical problems such as an overactive thyroid gland or vitamin deficiencies. Simple blood tests can often help uncover these problems and lead to treatment. A different type of tremor is seen in conditions such as Parkinson's disease. Luckily, there are effective treatments for most tremors and for most cases of Parkinson’s disease.

If you experience sudden weakness of the face or limbs, you should take this as a serious symptom that could indicate a possible stroke. It is important that you go to hospital as soon as possible for immediate investigation. 

Weakness coming on more gradually can be a problem with your brain, spine, nerves or muscles. Again, it is important to make a detailed history available to your neurologist, and examination will usually suggest an answer.

The nerve circuits that control movement are complex, and specific systems ensure that muscle movements are smooth and co-ordinated. However, there are multiple ways in which these systems can go wrong, and this can lead to slowness and stiffness when you move. If you visit a neurologist, your medical history and a thorough assessment and examination will provide pointers towards the underlying problem, or problems. 

For example, slowing down of movement caused by Parkinson’s disease and related conditions is usually easy to spot. 

Imaging of the brain and spine can be helpful in establishing, for example, whether there are any changes that suggest inflammation, a mini-stroke, or wear and tear in the neck or lower back. Occasionally, movement problems of this nature are due more to problems with the joints than the nervous control of movement. In these cases, you might be referred to a rheumatologist. 

Most of us experience occasional disturbances in sensation. This is normal, but if you experience persistent numbness, tingling, burning discomfort in your face, arms or legs, then you should get these symptoms checked out by a doctor. 

It is common to find trapped nerves in your wrist (carpal tunnel), elbow and knee. These usually settle down by themselves if you take simple precautions to prevent pressure on the nerves. In rarer circumstances, you might need a minor operation to solve the problem. 

It is also common to experience trapped nerves in your neck, or lower back, again causing pain, numbness and even weakness in your limbs. A simple clinical examination, backed up by electrical tests of the nerves and sometimes a neck or lower back scan can usually resolve these problems and help guide your neurologist to the appropriate treatment.

If you experience persistent burning or itching pain, this will usually be caused by problems with nerves, and is called neuropathic pain. It is often associated with loss of sensation related to the causes mentioned in the section above, around numbness or tingling sensations. 

Neuralgia is a persistent stabbing pain that follows the path of a nerve, and occurs when nerves fire off by themselves. The pain can feel similar to an electric shock. If you’ve experienced this, we’ll look at the history of your symptoms, and where you feel the pain, as this will often lead to a diagnosis for the type of neuralgia you have. 

For example, excruciating stabbing pains in your cheeks and/or jaw brought on by chewing, speaking, brushing your teeth, or even by exposure to the cold is seen commonly in trigeminal neuralgia (neuralgia of the face). 

In most cases, you can start treatment immediately, even if you need further investigations to pinpoint the exact nature or cause of the pain.

Dizziness and vertigo can mean many different things, such as light-headedness due to low blood pressure. It can also mean a sense of the world moving around you, or you moving when you know you are not. This is vertigo, most commonly due to a problem with the inner ear, but occasionally because of a neurological problem, such as migraine. A neurologist will be able to do a thorough assessment of your symptoms, followed by an examination, so they can find out the most likely cause of your symptoms, and which tests you may need. 

Some causes of dizziness, such as benign paroxysmal positional vertigo ((BPPV)), can often be cured by a doctor with experience of specific repositioning manoeuvres (movements that encourage loose calcium crystals out of the inner-ear canals, where they cause vertigo).

Insomnia and other problems with sleep are very common. Something as simple as keeping a sleep diary will often help you to see if there is a pattern to your sleep issues. You might not need professional help, but learning about – and implementing – good sleep hygiene can be very effective. If you need expert help, sleep-specific cognitive behavioural therapy and appropriate medications can be effective. 

Unusual experiences that occur while falling asleep, or whilst asleep (such as restlessness, muscle jerks, falling sensations, or periodic leg movements) can also often be diagnosed and treated without the need for further investigations. In more complex cases, you might find an onward referral to a sleep clinic that can be arranged.

We are all forgetful from time to time particularly if stressed, tired, depressed, anxious or short of sleep, but significant memory problems are extremely rare in people under 50. In-clinic tests can often give a clear idea of whether memory problems are part of what you might expect in everyday life, or whether there is a more serious problem which needs further investigation. 

An experienced neurologist can diagnose and manage many conditions. Some, like migraine, are common and usually simple to manage. Other more chronic conditions such as multiple sclerosis and Parkinson's disease are far more rare, but there are ways that your neurologist can help. 

Whatever your concern, getting an accurate, early diagnosis is very important because there are many new and potentially effective treatments available, as well as new treatments emerging.