Neurology Clinic

Neurology Clinic Referral Guidelines for MAP Handbook

Please do NOT refer the following patients to Neurology clinic:

• Disability evaluations
• Patients with suspected carpal tunnel syndrome (Refer directly for EMG)
• Chronic non-specific pain, such as complex regional pain syndrome, fibromyalgia, phantom limb pain, etc.
• Pediatric patients age < 18
• Patients needing pain management, including neck and back pain
• Bell’s palsy unless recurrent. (Treat with short course of steroids as recommended)
• Brain and spinal cord tumors. (Refer to Neurosurgery)
• Patients with known neurosurgery needs (Refer to Neurosurgery)
• Lyme Disease (Refer to Infectious Disease)
• Patients with stroke after full workup and on medical management. (Continue medical management)
• Patients with confirmed pseudo-seizures/ non-epileptic seizures. (Provide reassurance and support, refer for counseling if needed)
• ADD/ADHD (Consider referral to behavioral health if PCP unable to manage)
• Patient with chronic headaches, negative imaging and on multiple analgesics and narcotics. (Patients will need to be weaned off narcotics before referral to Neurology)
• PTSD (Refer to behavioral health)

EMG REFERRALS:

• Refer EMG’s directly. We will refer on to Neurology clinic for more evaluation if needed. Appropriate EMG referrals would be for CTS, other entrapment neuropathies (e.g. ulnar neuropathy), foot drop, brachial plexopathies, lumbar plexopathies, cervical and lumbar radiculopathy (only if there is weakness), nerve injuries, and mild neuropathies.

Please check off the specific problem for which patient is being referred (check all that apply)

If the condition is in bold, then it is considered an urgent or emergent referral.

TIA and Stroke

• Acute onset of transient or persistent stroke like symptoms -> Patient should be sent to the ER
• Recent (within the past 3 days) or remote TIA/stroke like symptoms, please ensure the following have been performed:
  • CTA head and neck or MRA head and neck
  • MRI Brain without contrast
  • Transthoracic Echo (TTE)
  • Risk factor assessment: lipid panel, HBA1C, TSH

Treatment: antiplatelet agent (aspirin or clopidogrel), statin, anti-HTN medication, and risk factor modification (e.g. blood sugar control, smoking cessation, addressing drug and alcohol dependence)

NOTE: All patients with atrial fibrillation or paroxysmal atrial fibrillation should ideally have been evaluated by cardiology and be on an oral anticoagulant.

• Patients with a history of stroke and resultant spasticity, gait disturbance, urinary symptoms should be referred to PM&R (Physical Medicine and Rehabilitation)

Epilepsy and Seizures

• Epilepsy and currently pregnant
• First time seizure
• Documented epilepsy, compliant with at least 1 seizure medication with unprovoked seizure in the last 3 months
• Documented epilepsy, compliant with at least 1 seizure medication with no unprovoked seizure in past 3 months but within last year.
• Stable epilepsy (no seizures in past year) but needs evaluation of treatment regimen

Movement Disorders

• Parkinson’s disease
• Chorea and other hyperkinetic movement disorders
• Huntington’s disease
• Tics (severe and disabling)
• Myoclonus (severe and disabling)
• TremorsPostural and action tremor, often symmetric and usually present for more than a year, is suggestive of essential tremor (often family history of tremor –   i.e. familial tremor)
  Treatment:
  • gabapentin 300 mg po TID
  • propranolol LA 60 mg daily
  • topiramate 25-50 mg po BID
  • primidone start 50 mg po qhs and titrate to 50-100 mg po TID

*** Unilateral rest tremor present for only a few months is suggestive of Parkinson’s disease or Parkinsonism and so should be referred directly to neurology

(All other abnormal movements (tics, myoclonus, chorea, asterixis, etc) or those with known diagnosis of movement disorder should be referred directly to neurology without further work up.)

Multiple Sclerosis and other neurological autoimmune disorders

• New or existing diagnosis of multiple sclerosis
• MRI brain report highly suggestive of demyelinating disease

(If patient has not had MRI brain and cervical spine w/w/o contrast in the past one year, please obtain prior to referral.)

Headaches

• Work Up: CT brain or MRI Brain not necessary unless red flags such as:
  • marked increase in frequency
  • change in headache type or quality
  • associated focal symptoms of numbness, visual loss, weakness or seizure
  • NOTE: Some red flag symptoms may be indication for ER referral

(Note: If patient is obese, on antibiotics or Retinol for acne, and there is suspicion for increased intracranial pressure (pseudotumor cerebrii) – refer also to ophthalmology for dilated fundoscopic examination and visual field assessment)

Treatment of chronic headaches or migraine:
Abortive: If < 1 migraine/week or 6 headache days/month
Choices: NSAIDs, Excedrin migraine, Fioricet/Fiornal (only allow less than 15 tablets per month of these), triptans (sumatriptan 50-100mg , rizatriptan 10mg , zolmitriptan 5mg, etc).

Triptans are very effective and generally safe. Avoid use in patients with severe arterial disease. Prescribe one dose at the onset of HA plus a dose of NSAID. Repeat a second dose in 2 hours if needed. No more than 2 doses per day, and usually 6 doses per week.

Prophylaxis: If > 1 migraine/week or 6 headache days/month

• Amitriptyline 25-50 mg po qhs/nortriptyline 20-75 mg po qhs (Common side effects: dry mouth and drowsiness)
• Propranolol LA 60 mg daily (Common side effects: light headedness/dizziness and relative contraindication in asthmatics and diabetics)
• Topiramate 25 mg po BID and titrate p to 50 mg po BID (Common side effects: acral paresthesias, alteration of taste sensation, 5-7 lb weight loss; relative contraindication if history of nephrolithiasis) Avoid in women of childbearing potential.
• Verapamil LA 120-240 mg day (Common side effects, light headedness/dizziness, hypotension)
• SNRI if concomitant anxiety or depression (Venlafaxine ER is most commonly used. 37.5-75mg qD, Duloxetine 30-60 mg can also be effective)

If patient fails or is intolerant of two or more of the aforementioned agents, refer to neurology for possible Botox injections or other treatments.

Neuromuscular Disorders

• Myasthenia gravis (Check Acetylcholine Receptor binding Ab). If positive, order a chest CT on the way to neurology referral to look for a thymoma)
• ALS
• Muscle diseases; Myotonic muscular dystrophy, FSH Dystrophy, Polymyositis
• Periodic paralysis
• Dystonia
• Peripheral neuropathy with severe or rapidly progressive distal/ proximal weakness (Check HbA1C, B12, Serum immunoelectrophoresis, Serum free light chains).
• Hereditary neuropathies
• Painful peripheral neuropathy with unclear diagnosis (not secondary to diabetes) or has failed at least two chronic medications

Dementia and Cognitive Disorders

• Rapidly progressive dementia. Document MOCA or MMSE. Please check TSH, RPR, and vitamin B12 prior to referral
• Dementia and cognitive impairment patients with completed workup including TSH, RPR, B12 and brain imaging (MRI or CT)

Other Neurological Disorders

• Untreated Narcolepsy
• New diagnosis of binocular diplopia and gaze abnormalities
• Ataxia and Gait abnormalities not secondary to pain and negative workup
• Acute and sub-acute spinal cord disease/myelopathy (compressive or trauma spinal cord injuries should be referred to neurosurgery)
• Syncope only if cardiac workup done and normal
• Refractory trigeminal neuralgia.
• Dizziness/vertigo referrals only accepted from ENT
• CNS vasculitis managed by Rheumatology, one-time consult.

Documentation required for scheduling an appointment:

• Completed Referral form
• Past Medical History (PMH)
• Current medication list
• Most recent progress note describing condition for which patient is being referred
• Recent pertinent lab results
• Recent pertinent imaging reports