16.1 Neurological Diagnosis and Management

The current FNP-BC Test Content Outline scores Neurological as one of the 13 body systems and lists neurological agents among the official drug-agent classes. Domain II asks you to name the syndrome and pick the test. Domain IV asks whether the abortive, the preventative, or the ambulance is the right implementation. This section is the primary-care neuro map: headache, brain attack, seizure, neuropathy, tremor, cognition, facial palsy, and vertigo.

Primary headache: migraine, tension, cluster

Most office headaches are primary. You still owe a 60-second screen for secondary disease before you write a triptan.

Migraine is a recurrent neurovascular attack, not a personality type. Use POUND conceptually: Pulsatile quality, duration about One day (classically 4–72 hours untreated), Unilateral location, Nausea or vomiting, and Disabling intensity that stops work or school. Photophobia and phonophobia travel with the attack. Aura — usually visual, sometimes sensory or speech — lasts minutes and fully reverses. A 34-year-old who goes to a dark room, vomits once, and cannot parent for a day has migraine even if she calls it a sinus headache. Sinus features without fever or purulent disease do not convert the diagnosis.

Tension-type headache is the common bilateral pressing or tightening band, mild to moderate, not worsened by routine activity, and usually without nausea. It responds to simple analgesia, sleep, hydration, and trigger hygiene. Daily tension that has slowly become daily migraine-like pain is often medication-overuse — too many combination analgesics or triptans — not a reason to add an opioid.

Cluster is short, excruciating unilateral orbital or temporal pain with ipsilateral tearing, nasal congestion, ptosis, or restlessness. Attacks last 15–180 minutes and cluster in seasons, often at night, more often in men who smoke. High-flow oxygen and a fast triptan (often subcutaneous or nasal) are acute tools; prevention is specialty-leaning. Do not call cluster a migraine because both are one-sided.

SNOOP and the headaches that are not primary

SNOOP is the red-flag mnemonic the exam expects you to run on every new or changing headache:

• Systemic symptoms (fever, weight loss, cancer, HIV, pregnancy) or secondary-risk disease
• Neurologic signs (focal deficit, confusion, seizure, papilledema)
• Onset that is sudden — thunderclap, peak in seconds
• Older age at onset, especially after 50 (think giant-cell arteritis, mass)
• Previous pattern change, positional pain, precipitation by Valsalva, or progressive worsening

Thunderclap is subarachnoid hemorrhage until a CT and, if needed, lumbar puncture say it is not. Send to the emergency department. Do not trial a triptan in the hallway because the neurologic exam is still nonfocal. The first bleed can look deceptively clean.

New headache after 50 with scalp tenderness, jaw claudication, or polymyalgia symptoms is giant-cell arteritis until proven otherwise: same-day ESR/CRP and steroids coordinated with specialty, not a two-week diary. Positional headache after a procedure or with papilledema is not a refill.

Acute migraine medicines and when to prevent

If the story is migraine and SNOOP is negative, treat the attack. A triptan (sumatriptan and class peers) plus an antiemetic (metoclopramide or prochlorperazine) is the high-yield acute pair. An NSAID can stand alone for milder attacks or combine with the triptan. Counsel chest tightness as a common triptan sensation, not automatically ACS — but do not give a triptan in uncontrolled hypertension, known coronary disease, prior stroke or TIA, peripheral vascular disease, or hemiplegic / basilar-type migraine. Do not stack a triptan with an ergot inside 24 hours. Avoid opioids. They worsen medication-overuse headache and do not treat the migraine mechanism.

Start prevention when attacks are frequent (a common teaching threshold is four or more headache days a month), last long enough to wreck function, or abortives fail or are contraindicated. First-line oral options the FNP should name: a beta-blocker (propranolol, metoprolol) if blood pressure and asthma allow, topiramate (counsel cognition, paresthesias, kidney stones, and teratogenicity), and amitriptyline when sleep and tension travel with the migraine. CGRP-pathway monoclonal antibodies and gepants are conceptual exam answers for people who fail or cannot use older preventives — you do not need a 2026 product-by-product algorithm, but you do need to know the class exists and is not an opioid. Valproate prevents migraine and is a teratogen; do not park a person who can become pregnant on it as first-line primary care. Reassess in 8–12 weeks before you declare failure.

TIA, stroke, seizure, and neuropathy

FAST is the public screen: Face droop, Arm weakness, Speech difficulty, Time to call emergency services. Any acute focal deficit — including isolated aphasia, sudden monocular vision loss, or sudden severe ataxia — is a stroke pathway, not a next-week carotid duplex you schedule from the lobby. Time-critical reperfusion lives in the emergency system.

TIA is a brief episode of focal ischemia that resolves. Resolution is not reassurance. Short-term stroke risk is front-loaded. ABCD2 conceptually adds points for Age ≥60, Blood pressure ≥140/90, Clinical features (unilateral weakness scores higher than speech alone), Duration (longer spells score higher), and Diabetes. You do not need to recite every point value. You do need the implication: a resolved spell in a hypertensive older adult with diabetes is same-day emergency evaluation, not a three-week outpatient MRI and a handshake. Do not invent a clinic tPA protocol and do not send that patient home on aspirin alone because the arm works now.

A first unprovoked seizure needs emergency or same-day evaluation: glucose, sodium, and a workup you will not finish with a reflex hammer. Do not start a lifelong antiepileptic from the hallway after a single seizure. Known epilepsy with a typical breakthrough is an adherence, sleep-deprivation, alcohol, illness, and drug-interaction visit (lowered levels from an interacting antibiotic or missed doses). Status epilepticus — a seizure at about five minutes, or repeated seizures without recovery — is EMS. Protect the airway, time the event, and do not force objects into the mouth.

Peripheral neuropathy in primary care is a short, boring, high-yield panel: glucose / A1c, vitamin B12, TSH, and a real alcohol history. Add medication review (metformin-associated B12 deficiency, chemotherapy, isoniazid). Do not order a 20-antibody neuropathy panel before those four. Painful distal symmetric polyneuropathy in diabetes is a glucose-and-foot-care problem first; gabapentinoid or SNRI pain treatment is later implementation, not a substitute for finding B12 deficiency.

Tremor, cognition, face, and vertigo

Parkinson disease starts asymmetrically: rest tremor, bradykinesia, rigidity, decreased arm swing, and a soft voice or micrographia. The tremor quiets with action. Refer to neurology to confirm and to start dopaminergic therapy; do not diagnose Parkinson because an 80-year-old has a shaky hand while writing a check.

Essential tremor is an action and postural tremor, usually bilateral, often familial, and classically improved by small amounts of alcohol. There is no bradykinesia or shuffling. Propranolol or primidone are the named treatments when function is impaired; many people need only education.

Dementia is a chronic, progressive decline in two or more cognitive domains with a preserved level of alertness. Delirium is acute and fluctuating, with inattention as the core feature, usually from infection, drugs, or metabolic insult — treat the cause, do not write a new Alzheimer label at 2 a.m. Depression (sometimes called pseudodementia in older stems) brings more insight, more “I don’t know” answers, and a PHQ-9 that is actually the diagnosis. Screen mood before you lock a dementia diagnosis. Basic reversible workup is B12, TSH, depression screen, and medication review; imaging belongs when the course is atypical, rapid, or focal.

Bell palsy is a peripheral CN7 lesion: the patient cannot wrinkle the forehead, cannot close the eye, and has a drooping mouth on one side. A typical cortical stroke spares the forehead because of bilateral upper-face innervation and usually adds arm, leg, or language findings. Forehead involvement is not a free pass if there are other deficits, vesicles (Ramsay Hunt), or a slow progressive course — those are not simple Bell. For typical Bell, start corticosteroids within 72 hours, protect the cornea, and follow recovery. Antivirals are optional adjuncts, not the headline.

Vertigo splits peripheral from central. BPPV is brief spinning lasting seconds, triggered by rolling in bed or looking up. Diagnose with Dix-Hallpike (latent, fatigable, torsional-upbeat nystagmus toward the down ear) and treat with the Epley canalith-repositioning maneuver — not a 14-day meclizine vacation. Central vertigo is persistent, often with dysarthria, diplopia, ataxia, or vertical nystagmus that does not fatigue. That patient is a stroke workup, not a home Epley video. HINTS testing is only for skilled clinicians in an acute vestibular syndrome; if you are not trained or the exam is mixed, send to the emergency department.

FNP traps: calling thunderclap a migraine because the patient has a migraine history; giving a triptan in uncontrolled hypertension or hemiplegic migraine; sending a resolved TIA home because ABCD2 “is only 2”; starting carbidopa-levodopa for essential tremor; labeling delirium as new dementia; treating forehead-sparing facial weakness as Bell palsy; and treating continuous vertigo with meclizine while a posterior-circulation stroke declares itself in the parking lot.