Symptoms

Headache

• Headache is the most common neurological symptom and may be either primary or secondary to other pathology. 

  • Primary (idiopathic) causes include:

    • • Migraine

      • Tension-type headache

      • Trigeminal autonomic cephalalgias (including cluster headache)

      • Primary stabbing, cough, exertional or sex headache

      • Primary thunderclap headache

      • New daily persistent headache.

  • Secondary (or symptomatic) headaches are less common, but include potentially life-threatening or disabling causes such as subarachnoid haemorrhage or temporal arteritis.

Transient Loss of Consciousness

• Syncope is loss of consciousness due to inadequate cerebral perfusion and is the most common cause of transient loss of consciousness (TLOC). 

• Vasovagal (or reflex) syncope (fainting) is the most common type and precipitated by stimulation of the parasympathetic nervous system, as with pain or intercurrent illness. 

• Exercise-related syncope, or syncope with no warning or trigger, suggests a possible cardiac cause. 

  • TLOC on standing is suggestive of orthostatic (postural) hypotension and may be caused by drugs (antihypertensives or levodopa) or associated with autonomic neuropathies, which may complicate conditions such as diabetes.

Seizure

• An epileptic seizure is caused by paroxysmal electrical discharges from either the whole brain (generalised seizure) or part of the brain (focal seizure). 

• A tonic–clonic seizure (convulsion) is the most common form of generalised seizure, and typically follows a stereotyped pattern with early loss of consciousness associated with body stiffening.

  •  (Tonic phase) succeeded by rhythmical jerking crescendoing and subsiding over 30–120 seconds

  • (Clonic phase); this is followed by a period of unresponsiveness (often with heavy breathing, the patient appearing to be deeply asleep) and 

  • Finally confusion as the patient reorientates (postictal phase).

• Focal seizures may or may not involve loss of awareness (complete loss of consciousness is less typical) and are characterised by whichever part of the brain is involved:

  • For example, a focal motor seizure arising from the motor cortex, or temporal lobe seizures characterised by autonomic and/or psychic symptoms, often associated with automatisms such as lip smacking or swallowing. 

• Functional dissociative attacks (also known as non-epileptic or psychogenic attacks, or pseudoseizures) are common, and may be difficult to distinguish from epileptic seizures. 

  • These attacks are often more frequent than epilepsy, sometimes occurring multiple times in a day, and may last considerably longer, with symptoms waxing and waning. 

  • Other features may include asynchronous movements, pelvic thrusts, side-to-side rather than flexion/extension movements and absence of postictal confusion.

Stroke and transient ischaemic attack

• A stroke is a focal neurological deficit of rapid onset that is due to a vascular cause. 

• A transient ischaemic attack (TIA) is the same but symptoms resolve within 24 hours.