Evidence-Based Neurology: Management Of Neurolo... Extra Quality

Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.

Evidence-Based Neurology: Management of Neurolo...

The scarce evidence base on how guidelines should be implemented must not weaken international efforts to develop and evaluate implementation plans [17]. As part of the WHO implementation strategy, mhGAP recommendations have been incorporated into an integrated package of interventions called mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings [18]. The mhGAP-IG translates the evidence-based recommendations into simple clinical protocols and algorithms to facilitate decision making for assessment and management. It is aimed at non-specialist health care providers working at first- and second-level facilities. It is important that they are trained and then supervised and supported by the specialists.

Although medications are available for treatment, evidence-based guidelines for management of status migrainosus are lacking with no international consensus guidelines and no randomized trials. A study showed the average duration of status migrainosus to be 4.8 weeks, raising the question if resolution was from medical management or the attack self-abating with time.6 Ideally, a cost-effective, easily administered, stepwise home treatment approach is devised in the outpatient setting before progression into status migrainosus. It is also important to balance some acute treatments with the potential for causing medication-overuse headache, further emphasizing the need for studies to provide clear treatment guidelines. This review provides a practical approach to mananging status migrainosus in the outpatient setting including intravenous (IV) options to consider, when available.

Treatment of status migrainosus poses a significant challenge for even the most experienced neurologist. Having a plan in place is imperative to avoid unnecessary ED visits. Knowledge of various combination treatments, including those with migraine-specific targeted therapies, as well as multiple routes of administration can better equip a clinician when faced with unremitting migraine. Although various pharmacologic and nonpharmacologic agents are available, quality evidence-based research is lacking, and it would be useful to develop consensus guidelines on how to conduct trials and define outcomes to improve the management of status migrainosus. 041b061a72