Natural Migraine Treatment Systems

The Migraine And Headache Program

In this simple program you'll learn: 5 Body balancing techniques that free your diaphragm to do its actual job of pumping fresh air into your lungs. This will ensure that your body will have enough resources to do what needs to be done including healing your headaches. Simple breathing technique that boost your oxygen level. In a few minutes of practice, your blood may carry 20% more oxygen to your brain. This can immediately reduce even the worst headaches. Other breathing exercises that spread the oxygen delivered to the brain evenly. The parts of the brain that are often highly oxygen deprived will finally receive fresh oxygen on a plate. Simple head muscle exercises that remove tension from the muscles around the head such as the the jaw, the tongue, the throat, and the eyes. These exercises can quickly relieve tension from the head and eliminate headaches in just a few seconds. New revolutionary neck exercise that removes tension from the neck. Tension in the neck muscles does not only block blood flow to the brain, but will also not support the veins in pumping the blood which is their actual function. Some people experience blast of energy rushing up to their head after doing this exercise. More here...

The Migraine And Headache Program Overview

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Headache Diagnostic Approach

Headache in children All causes of adult headache (except in retrobulbar neuritis, glaucoma, temporal arteritis and cervical spondylosis) may cause headache in children. In this age group, the commonest type of headache is that accompanying any febrile illness or infection of the nasal passages or sinuses. The clinician must not take a complaint of headache lightly the younger the child, the more likely the presence of an underlying organic disease. Pyrexia may not only represent a mild 'constitutional' upset, but may result from meningitis, encephalitis or cerebral abscess. The presence of neck stiffness and or impaired conscious level indicates the need for urgent investigation. Although intracranial tumours are uncommon in childhood, when they occur they tend to lie in the midline (e.g. medulloblastoma, pineal region tumours.) As a result, obstructive hydrocephalus often develops acutely with headache as a prominent initial symptom. In a child with 'unexplained' headache, CT scan...

Headache Specific Causes

TENSION TYPE HEADACHE This is the commonest form of headache experienced by 70 of males and 90 of females at some time in their lives. Characteristics Diffuse, dull, aching, 'band-like' headache, worse on touching the scalp and aggravated by noise associated with 'tension' but not with other physical symptoms.

Box 331 Serious secondary headaches headaches to worry about

Intracranial tumours rarely produce headache until quite large, when raised intracranial pressure is apparent in the history and, in all likelihood, focal neurological signs are present. Because of the infrequency of intracranial tumours, brain scanning is not justified as a routine investigation in patients with headache (18). Meningitis, and its associated headache, occur in an obviously ill patient. The signs of fever and neck stiffness, later accompanied by nausea and disturbed consciousness, reveal the cause. The headache of subarachnoid haemorrhage, commonly but not always of sudden onset, is often described as the worst ever. Neck stiffness may take some hours to develop. Unless there is a clear history of similar uncomplicated episodes, these characteristics demand urgent investigation. New headache in any patient over 50 years of age should raise the suspicion of giant cell (temporal) arteritis. Headache can be severe. The patient, who does not feel entirely well, may...

Prophylaxis against migraine

Patients with frequent or severe migraine headaches or those refractory to symptomatic treatment may benefit from prophylaxis. Menstrual or other predictable migraine attacks may sometimes be prevented by a brief course of ergotamine or an NSAID, such as naproxen sodium, taken for several days before and during the first few days of menstruation. 3. Valproate (Depakote), an anticonvulsant, has been effective in decreasing migraine frequency. Its effectiveness was equal to that of propranolol. Adverse effects include nausea, weight gain and fatigue. Valproate taken during pregnancy can cause congenital abnormalities. 4. Tricyclic antidepressants can prevent migraine and may be given concurrently with other prophylactic agents, but they often cause weight gain. Amitriptyline (Elavil) in a dosage ranging from 10 to 150 mg day is commonly used.

Tensiontype headache

Reassurance and over-the-counter analgesics (acetylsalicylic acid or ibuprofen rather than paracetamol) (39) are sufficient for infrequent episodic tension-type headache. Most people with this condition manage themselves episodic tension-type headache is self-limiting and, though it may be temporarily disabling, it rarely raises anxieties. If medication usage is on fewer than two days per week there is little risk of escalating consumption. People consult doctors because of episodic tension-type headache when it is becoming frequent and, in all likelihood, is no longer responding to painkillers. Long-term remission is then the objective of management, as it is for chronic tension-type headache. Symptomatic medication is contraindicated for tension-type headache occurring on more than two days per week where it is already being taken at high frequency a diagnosis of chronic tension-type headache rather than medication-overuse headache cannot be made with confidence. Whichever condition...

Medicationoveruse headache

Prevention is the ideal management of medication-overuse headache, which means avoidance of acute medication for headache on more than 2-3 days per week on a regular basis. Education is the key factor many patients with medication-overuse headache are unaware of it as a medical condition (40). Once this disorder has developed, early intervention is important since the long-term prognosis depends on the duration of medication overuse (41). Treatment is withdrawal of the suspected medication(s). Although this will lead initially to worsening headache and sometimes nausea, vomiting and sleep disturbances, with forewarning and explanation it is probably most successful when done abruptly (42).

Sleep and headache syndromes

Cluster headache and chronic paroxysmal hemicrania are most often related to sleep, and migraine may occur both during sleep and wakefulness. Cluster headache is predominantly noted in men and is a severe unilateral headache which occurs more frequently during sleep at night than during the daytime. The headache is characterized by severe excruciating pain around one eye and on the same side of the temple, accompanied by increased lacrimation, conjunctival injection, nasal stuffiness, rhinorrhea, and increased sweating from the forehead on the same side of the face. Polysomnographic recording documents occurrence of cluster headache out of REM sleep. Attacks usually last a few hours. Sleep apnoea, particularly REM-related sleep apnoea, may trigger cluster headache and there may be an increased prevalence of sleep apnoea in this condition. These patients also suffer from sleep maintenance insomnia because of awakening with cluster headache.

Headache General Principles

Headache is a common symptom arising from psychological, otological, ophthalmological, neurological or systemic disease. In clinical practice psychological 'tension' headache is encountered most frequently. International classification of headache type (19SS) Tension type headache Migraine Cluster headache

Migraine

Migraine is a primary headache disorder. It almost certainly has a genetic basis (4), but environmental factors play a significant role in how the disorder affects those who suffer from it. Pathophysiological , activation of a mechanism deep in the brain causes release of pain-producing inflammatory substances around the nerves and blood vessels of the head. Why this happens periodically, and what brings the process to an end in spontaneous resolution of attacks, are uncertain. Usually starting at puberty, migraine is recurrent throughout life in many cases. Adults with migraine describe episodic disabling attacks in which headache and nausea are the most characteristic features others are vomiting and dislike or intolerance of normal levels of light and sound. Headaches are typically moderate or severe in intensity, one-sided and pulsating, aggravated by routine physical activity they usually last from several hours to 2-3 days. In children, attacks tend to be of shorter duration and...

Cluster headache

Cluster headache is one of a group of primary headache disorders (trigeminal autonomic cepha-lalgias) of uncertain mechanism that are characterized by frequently recurring, short-lasting but extremely severe headache (1). Cluster headache also has episodic and chronic forms. Episodic cluster headache occurs in bouts (clusters), typically of 6-12 weeks' duration once a year or two years and at the same time of year. Strictly one-sided intense pain develops around the eye once or more daily, mostly at night. Unable to stay in bed, the affected person agitatedly paces the room, even going outdoors, until the pain diminishes after 30-60 minutes. The eye is red and watery, the nose runs or is blocked on the affected side and the eyelid may droop. In the less common chronic cluster headache there are no remissions between clusters. The episodic form can become chronic, and vice versa. Though relatively uncommon, probably affecting no more than 3 per 1000 adults, cluster headache is clearly...

Headaches

Migraines headaches are common neurovascular-based head pain that has both genetic and environmental etiologies. Patients with this disorder may develop OSA, but the prevalence of sleep apnea in these patients is unknown. Paiva (38) showed that among individuals with frequent headache arising during the sleep period, 55 had an identifiable sleep disorder including sleep apnea. The mechanism of this relationship is unclear, but some of these individuals are vulnerable to headaches that are provoked by the sleep apnea. These patients can be routinely studied and do not require any special monitoring. Some patients on opiates may demonstrate significant effect of the medication on respiration. For these individuals carbon dioxide monitoring may be helpful. However, patients otherwise tolerate the studies well and typically can handle CPAP intervention. Therapy for these patients is the same as therapy of the general population. In the general population, CPAP therapy appears to reduce...

Migraine Headaches

Migraines are a debilitating neurovascular disorder that affects 28 million people over the age of 11. The cause of migraines is not clearly understood although research indicates the expansion of blood vessels and the release of certain chemicals such as dopamine and serotonin causes inflammation and pain. Dopamine and serotonin are found normally in the brain. A migraine can occur if an abnormal amount of these chemicals are present or if the blood vessels are unusually sensitive to them. Patients who have migraines experience intense, throbbing, headache pain which is often accompanied by nausea, photophobia (sensitivity to light), phono-phobia (sensitivity to sound), and temporary disability. Migraines are sometimes preceded by an aura such as a breeze, odor, a beam of light, or a spectrum of colors. Migraines can occur on one side of the head (unilateral) and the pain is frequently reported as pulsating or throbbing. Treatment of migraine is divided into prevention and...

Headache

Most headaches, characterized by a dull pain, are tension or stress related. Other sources may be a musculoskeletal problem in the upper back and neck that can be helped with craniosacral therapy by an osteopath or pressure from the sinuses. A headache on awakening may be an indication of high blood pressure. About 10 of headaches are called migraines throbbing in nature, genetic in origin, they are the result of constriction and dilation of blood vessels in the brain. Severe headaches that appear suddenly or that increase in severity may be caused by an underlying condition and should be checked by a physician. Allergies, especially to certain foods, and food sensitivies are suspected of being the major causes of migraines, in children as well as adults. The effect from the allergen may not be felt for days following ingestion. Hormonal fluctuations and stress can also be factors in the illness. Migraines will usually appear when there are simultaneous triggers or when there is an...

Migraine Management

Can be managed with symptomatic medication use (ie, when headache occurs, take an analgesic medication). These medications include acetaminophen, aspirin, NSAIDs, and a variety of combination medications (containing butalbital, caffeine, and codeine), such as Midrin and Fioricet. Triptans (eg, sumatriptan, rizatriptan, zolmitriptan, and naratriptan) can be used for infrequent headaches occurring less than once per week. Triptan medications are effective in treating migraine headache along with accompanying symptoms of nausea and vomiting. Dose can usually be repeated in 2 hours. 2. Prophylactic treatment. Various agents from many medication classes have been used to treat headaches prophylacti-cally. Choose medications based on efficacy in various headache types. Symptomatic medications are used to treat rare or occasional headaches. Most patients will not start a prophylactic headache medicine until they regularly have at least three or four headaches per month...

Headache IN PD

Headache is an important symptom that may occur in PD, but its relationship to the disease is uncertain. It does not fit into the pain categories described above but instead represents a painful symptom that often requires its own specific evaluation and treatment. In a survey of 71 patients with PD, headache was described in 25 individuals (35 ).58 Headaches were generally located in the nuchal region but did not correlate with a clinical assessment of nuchal rigidity. The character of the headaches ranged from dull, aching discomfort to sharp, squeezing or pulsatile pain. In a subsequent report, a specific early morning headache was described in three individuals, relieved within two hours of the first levodopa dose.58 In another report, PD patients with headache scored significantly higher on measures of depression and anxiety than those without headache.63 It is always important to note whether a headache in a patient with PD may represent an adverse effect of a medication,...

Headache Disorders

International Headache Society A worldwide professional society, the mission of IHS is to work with others to reduce the world burden of headache. The web site includes all published guidelines and recommendations of the IHS, and professional educational pages are planned. World Headache Alliance (WHA) A worldwide lay alliance, WHA exists to relieve the suffering of people affected by headache throughout the world, in particular by sharing information among headache organizations and by increasing the awareness and understanding of headache as a public health concern with profound social and economic impact. The web site includes a regularly updated source of detailed and quality-controlled information on headache for the general public, with many useful links. European Headache Federation (EHF) A European professional federation, EHF dedicates its efforts to improving awareness among governments, health-care providers and consumers across Europe of headache disorders and their...

Drug Control And Development

The 1906 law defined drug broadly and governed the labeling but not the advertising of any substance used to affect disease. This law gave the Pharmacopoeia and the National Formulary equal recognition as authorities for drug specifications. In the first contested criminal prosecution under the law, action was taken against the maker of a headache mixture bearing the beguiling name of Cuforhedake-Brane-Fude. In 1912, Congress passed an amendment to the Pure Food and Drug Act that banned false and fraudulent therapeutic claims for patent medicines.

A pAdrenergic receptor blockers

P-blockers are recommended first-line agents in uncomplicated hypertension, or in hypertensive patients with angina pectoris, cardiac arrhythmias, mitral valve prolapse, a history of myocardial infarction (MI), diastolic dysfunction, or migraine headaches. p-blockers are preferred in young Caucasian hypertensive patients (younger than 40-50). African-Americans tend to respond less well to p-blockers.

The Healthillness Continuum

The individual's state of health is one of continual change. He moves back and forth from health to illness and back to health again. His condition is rarely constant. He may wake up feeling great, develop a headache mid-morning, and feel fine again by noon. The health-illness continuum (see figure 1-1) illustrates this process of change, in which the individual experiences various states of health and illness (ranging from extremely good health to death) that fluctuate throughout his life.

Vectorborne Rickettsial Diseases Typhus and spotted fever

The disease is an acute febrile illness, with sudden onset of headache and chills followed by a fever that persists for 2-3 weeks, and a characteristic rash appearing on the trunk and extremities on about the 4th day of the disease. Delirium, shock and renal failure may occur in severe cases, and despite the use of antibiotics, the case-fatality rate has remained at about 5 . The disease occurs widely throughout South, Central and North America, where it is transmitted by several genera of ixodid ticks (Derma-centor, Ixodes, Rhipicephalus and Amblyomma) depending upon the locality. The ticks serve both as reservoirs and vectors of spotted fever group rickettsiae. The infection is maintained in the tick during all stages of the developmental cycle, and most tissues are infected, including the salivary glands. Humans coming into contact with ticks become infected during the feeding process.

Classes of Variation Associated with Elevated Disease Risk

A more complex example of the relationship of genetic variation to disease is the CACNL1A4 gene. This gene encodes a protein localized in the cell membrane and has a role in the transport of calcium into the cell. In this case, three different types of DNA sequence changes in a single gene are responsible for high risk of three different neurological conditions, including a specific class of migraine headache (Ophoff et al., 1996 1998 2001). Each class of variation disrupts the protein structure differently, and thus has a different impact on the ability of the protein to transport calcium and the degree of normal cellular function. An even higher level of complexity in the relationship of genetic variation to disease is observed for Alzheimer disease, where a subset of variants in one of three different genes, b-amyloid precursor and presenilin 1 and 2, places an individual at high risk of disease (Saunders, 2001 Sorbi et al., 2001). In addition, individuals with a variant allele at...

Influence of products of the immune system on the central nervous system

The immune system affects brain and behaviour, especially via the effects of immune cytokines on the central nervous system.(42) Although cytokines are relatively large molecules, some, particularly IL-1, can cross the blood-brain barrier via active transport. IL-1 is also produced in the brain by both microglia, which are macrophages resident in the central nervous system, and astrocytes. Peripheral IL-1 can affect the brain, including its production of cytokines, via stimulation of the vagus afferent fibres. There are cytokine receptors in the brain, including those for IL-1, IL-8, and interferon, on both glial cells and neurones. Cytokines play a role in the development and regeneration of myelin-producing oligodendrocytes. Brain cytokines play a role in immune effector mechanisms as regulated by the brain, including a role in brain infection and inflammation. Cytokines are relevant to the progression of multiple sclerosis, gliomas, HIV-associated dementia, brain injury, and...

Immunosuppression And Infection

Spores enter the airways, and for rhino-orbital-cerebral mucormycosis, the infection begins in the paranasal sinuses, or nasal airway, then spreading to the orbit and cranial cavity. The organism causes isch-emic necrosis and invades blood vessels, including major arteries. The disease process is usually more fulminant than in invasive aspergillosis, with time from onset of symptoms to death often measured in days. The predisposed patient presents with pain, headache, swelling of the lids, ophthalmoplegia, and visual loss, occasionally with a central retinal artery occlusion. The classic black eschar due to tissue necrosis, which may be seen in the skin, nasal mucosa, or palate, is a late sign. Signs of intracranial involvement usually occur within a short period, with death resulting from cerebral infarction or subarachnoid and intracerebral hemorrhage. Early diagnosis is essential in mucormycosis. The tissue required for diagnostic purposes can be obtained from the sinuses or the...

Ehrlichiosis and related diseases

Seropositive to Rickettsia or Ehrlichia species, the major risk factor being tick bites (McCall et al., 2001). Dogs are susceptible to E. chaffeensis infection without showing clinical signs and may serve as a natural host (Zhang et al., 2003). White-tailed deer, Odocoileus virginianus, are also susceptible, and the tick Amblyomma americanum is an important vector in disease transmission. HGE was first described in 1994, and is caused by an agent closely related to Ehrlichia equi, which causes equine granulocytic ehrlichiosis, and Ehrlichia phagocytophila, which causes disease in ruminants in Europe. In 1999, Ehrlichia ewingii, a veterinary pathogen, was shown to cause granulocytic ehrlichiosis in humans. Patients infected with E. ewingii experience symptoms similar to those observed in other human ehrlichioses, such as fever, headache and myalgia. These ehrlichial agents are all transmitted to humans by ticks and maintained in nature in various vertebrate reservoirs.

Pediatric Brain Tumors

Tumors of the central nervous system are the second-most common group of childhood neoplasms, after leukemia and lymphoma. Children affected by brain tumors have clinical presentations that vary with patient's age and location and growth rate of the mass. Infants can present with vomiting or lethargy, cranial nerve or motor dysfunction, or an enlarging head size due to hydrocephalus. Older children can present with positional headaches, nausea and vomiting, confusion, seizures, cranial nerve or motor deficits, or ataxia. Tumors in the sellar, supra-sellar or hypo-thalamic region can lead to diabetes insipidus, growth failure, amenorrhea or precocious puberty by disrupting the hypothalamic-pituitary axis. Children with pineal region masses often present with hydrocephalus, diplopia or Parinaud's sign (impairment of upward gaze). Clinical features of pediatric brain tumors are discussed in greater detail in Chapter 4.

Estimates And Projections For Neurological Disorders

For the purpose of calculation of estimates of the global burden of disease, the neurological disorders are included from two categories neurological disorders within the neuropsychiatric category, and neurological disorders from other categories. Neurological disorders within the neuropsychiatric category refer to the cause category listed in Group II under neuropsychiatric disorders and include epilepsy, Alzheimer and other dementias, Parkinson's disease, multiple sclerosis and migraine. Neurological disorders from other categories include diseases and injuries which have neurological sequelae and are listed elsewhere in cause category Groups I, II and III (10). The complete list used for calculation of GBD estimates for neurological disorders is given in Annex 3. Among the various neurological disorders discussed in this report, please note that for headache disorders, GBD includes migraine only (see Chapter 3.3). Also, GBD does not describe separately the burden associated with...

Infectious and Inflammatory Conditions

Meningitis is the most common CNS infection affecting children. The diagnosis of meningitis is based on the analysis of CSF, obtained by lumbar puncture the absence of inflammatory changes such as leptomeningeal enhancement on CT or MRI must not be used to exclude this diagnosis. Affected children present with fever, irritability, lethargy, headaches and nuchal rigidity seizures, cranial neuropathies or stroke may develop. Imaging is performed mainly for the evaluation of children who are deteriorating neurologically despite apparently appropriate antibiotic therapy, in order to determine the cause of deterioration.

Review of Other Technologies

In two randomized clinical trials in people with intractable partial seizures, therapy with the vagus nerve stimulator was associated with a median percentage reduction in seizures of 23 . In addition, 23 to 30 of patients achieved a 50 or greater reduction in seizures leading to marketing approval, therapy with the vagus nerve stimulator reduced partial seizures Cyberonics, 2002 . Long-term uncontrolled follow-up of patients participating in the investigational trials suggests that persons continuing vagus nerve stimulation over one to two years continue to benefit. However, fewer than 5 achieve freedom from seizures. Adverse effects arise in approximately 30 of patients, including hoarseness, headache, muscle pain, throat pain, coughing, and nausea Schachter and Schmidt, 2001 .

Paraneoplastic Syndromes

Paraneoplastic syndromes such as hyponatremia due to inappropriate secretion of antidiuretic hormone such as seen in small cell lung cancers, prostate, pancreas, and other cancers, or hypercalcemia such as seen in squamous cell carcinomas of the lung, breast, or kidney, will alter nutritional and fluid and electrolyte management. Although mild hyponatremia can be associated with mild symptoms such as nausea and headaches, severe, acute hyponatremia can lead to more severe symptoms, even seizures or coma. Hypercalcemia is most often associated with bone metastasis, but it may be related to a paraneoplastic syndrome and can lead to neuro-muscular symptoms such as weakness and fatigue and gastrointestinal symptoms such as nausea, ileus, and abdominal pain. Severe hypercalcemia can disturb cardiac conductivity. Given the tendency to malnutrition and low serum albumin in cancer patients, serum calcium levels are often best determined by measuring ionized calcium.

Vectorborne Nematode Diseases Lymphatic filariasis

In filariasis caused by Wuchereria or Brugia, it may be several months before adult females in the lymph vessels produce microfilaria, and some individuals may have microfilaraemia for many years without developing disease symptoms. Eventually, attacks of filarial fever lasting 3-15 days accompanied by headache and localized pain in the lymphatic areas in the groin and armpits occur. These attacks may begin as early as 6 years of age and may continue until 25 years of age, when eventually the lymphatics become fibrosed and the nodes calcify. Elephantiasis may develop in the legs, and in males orchitis and hydrocele may occur with inguinal lymphadenopathy.

Mogensen et al 8Institute of Medicine

Complex Mixtures At the opposite end of the spectrum is exposure to complex mixtures, which can be intentional or unintentional. During the Gulf War, military personnel were intentionally exposed to vaccines and preventive agents including anthrax vaccine and the chemical warfare antidote pyridostigmines (9). Unintentional exposures included chemical biologic agents and smoke and petroleum combustion products. Potential exposures could have been through a combination of inhalation, oral, and dermal routes. Such mixed exposures were associated with symptoms such as fatigue, abdominal pain, diarrhea, headache, memory loss, skin rashes, and hair loss. Also, the exposure occurred under varying environmental conditions of temperature, humidity, and high winds. These types of complex mixture exposures pose a formidable challenge for health risk assessors. In general, the availability of information on chemical mixtures encountered in the real world varies greatly between simple and...

The Partial Seizures

Confusion and headache after an attack are common. The whole episode may last for seconds but occasionally may be prolonged and a rapid succession or cluster of attacks may occur. Attacks show an increased incidence in adolescence and early adult life. A history of birth trauma or febrile convulsions in infancy may be obtained. Lesions in the hippocampus occur as a result of anoxia or from the convulsion itself and act as a source of further epilepsy. When surgery is carried out, hippocampal sclerosis is often found. Occasionally other pathologies are identified, such as hamartomas, vascular malformations and low-grade malignant astrocytomas. 91

Vestibular Schwannomas Acoustic Neurinoma

Complications of radiosurgery can be immediate and late. In the first 24 hours, nausea and headache were seen, particularly in the early days of radiosurgery when larger radiation doses and less precise dose planning were used. The combination of conformal planning, delivering no more than 12-15 Gy peripheral dose, and perioperative steroid cover eliminated these side-effects. Late cranial neuropathies are dependent on peripheral dose and the size of the tumor. The latter is an important factor, as with larger tumor size a longer section of the nerves receives toxic dose. On the other hand, intra-canalicular tumors may also pose a challenge. They are more difficult to delineate precisely, and the relative imprecision of MRI imaging may lead to complications. In these cases fusion with CT scan is particularly helpful.

Blastic Transformation

Meningeal leukemia may rarely be the first manifestation of blastic transformation, although it more commonly occurs after systemic blast crisis.91,92 In an NCI series of 101 patients with CML in blastic phase, 7 subsequently developed meningeal leukemia.91 All seven patients had a cerebrospinal fluid (CSF) pleocytosis (including myeloblasts) and associated neurological features including headaches and cranial nerve palsies.

Complications and Side Effects

Headache following implantation is still an enigma but may be related to proximity to cerebral vessels or pia. We have seen headache in only a few patients in the operating room and have moved the electrode implant site with relief of these symptoms however, we have one patient with persistent headache that is stimulus parameter sensitive. They are usually unrelated to whether stimulation is on or off, can be seen in any implant site, and may be transient or permanent in our experience (25, 51).

Laboratory tests

Acyclovir (Zovirax) is the drug of choice for the treatment and suppression of genital herpes. It is usually well tolerated, but nausea, vomiting, rash, or headache occur rarely. Topical acyclovir is not effective. Serious or life-threatening HSV infections require intravenous acyclovir.

Presentation and Clinical Features

The three main presenting features are similar to pituitary adenomas endocrine disturbance, headache and visual impairment. In a recent large series of over 28 RCCs 1 , the mean age at presentation was 45 years. Clinically, endocrine disturbance was the most common presentation (50 ), including amenorrhea (37.5 of female patients), growth retardation, impotence and DI. Biochemically, hypopitu-itarism, hyperprolactinemia and gonadotrophin deficiencies were the common endocrine findings. Headache was a major feature in 32.1 and visual disturbance in14.3 . Patterns of visual disturbance included central field loss as well as the peripheral field loss expected in sellar region lesions. Four patients had pre-operative DI, a feature that, in the authors' opinion, excludes pituitary adenoma.

Increased Intracranial Pressure

A rise in intracranial pressure results in the appearance of a number of symptoms, including headache, vomiting, edema of the optic discs, changes in vital signs, and possibly death. Dehydrating measures, including the use of diuretics, can help lower the pressure, particularly if the elevated intracranial pressure is of a nontraumatic origin. The parenteral administration of a hypertonic solution of one of the osmotic diuretics, urea or mannitol, can relieve the pressure through its osmotic effects. The oral administration of glycerol also has been used in neurosurgical procedures when increases in intracranial pressure are anticipated.

Clinical features of raised intracranial pressure

There are no specific signs or symptoms of raised ICP. Most are produced indirectly as a result of distortion, shifts, and herniations of brain tissue. The classic triad of headache, papilledema, and vomiting is encountered in two-thirds of patients with space-occupying lesions, and at least two of these symptoms occur in the

Clinical features

Classically, patients with bacterial meningitis present with headache, fever, photophobia, vomiting, neck stiffness, and alteration of mental status. These are present at some stage in 85 per cent of patients. Cranial nerve palsy (particularly nerves III, IV, VI, and VII), focal neurological signs (10-20 per cent of cases), and seizures (up to 30 per cent of cases) may also occur. Papilledema is rarely seen (about 1 per cent of cases). With disease progression, signs of raised intracranial pressure (ICP), including coma, hypertension, bradycardia, and altered respiratory status, become more likely.

Preoperative Evaluation

Intraventricular tumors are often slow-growing and benign. These lesions frequently grow large before clinical manifestations and, ultimately, produce symptoms secondary to hydrocephalus, either by obstruction of the normal pathways of cerebrospinal fluid flow or by its overproduction. Most patients present with headaches 2 . Colloid cysts, which typically occur anteriorly and superiorly within the third ventricle, have a tendency to intermittently obstruct the foramen of Monro, resulting in acute lateral ventricular hydrocephalus with symptoms of intracranial hypertension. Visual loss, impotence and diabetes insipidus may be caused by tumors invading the floor of the third ventricle. Asymmetric bitemporal hemianopia, starting with inferior temporal field loss, may occur due to dilatation of the third ventricle with pressure on the optic chiasm from above. The extension of the tumor may cause a variety of visual field defects, including homonymous hemianopia, binasal field defects,...

Multifunctional Surfactants

The concept of multifunctionality brings to mind two separate ideas. First is the idea that a single component is able to replace many separate ingredients without sacrificing performance characteristics. Second is the concept of a single ingredient that offers varying functionality in a wide range of vastly different formulations. The latter is becoming a driving force for development, as large manufacturers are paring down their total number of inventoried raw materials. Not many single-component raw materials are able to meet this second criterion. Although there are many multifunctional ingredients, they are generally limited to specific formulations owing to their molecular functional groups, the product form of the raw material, or the functional benefit these ingredients are able to offer. To be quite simple, one would not formulate aspirin into a shampoo formulation to relieve a headache. The idea of functional availability is most important. The ingredient must function as it...

Management And Prevention

Successful management of headache disorders follows five essential steps Therefore the key to successful health care for headache is education (31), which first should create awareness that headache disorders are a medical problem requiring treatment. Education of health-care providers should encompass both the elements of good management (see Box 3.3.2) and the avoidance of mismanagement.

Side Effects And Complications

In their meta-analysis of controlled trials, Watts and Silagy compiled a list of adverse effects, including subarachnoid tap (2.5 ), transient headache (2 ), and transient increase in low back or radicular pain (2 ). One woman reported irregular menses (32). There also have been reports of transient hypotension or vasovagal response, cardiac angina, and respiratory difficulty with an inadvertent spinal block (56). In their report on 5489 consecutive fluoroscopy-guided ESIs, Johnson et al. found only four complications that required either an emergency department visit or hospitalization. These included one patient with a vasovagal reaction and another with significant hypotension, both of which resolved uneventfully a cervical epidural hematoma that required no intervention, with symptoms resolving after 18 hours and a patient who was admitted for three days of observation for tachycardia and hypertension, thought to be due to an unusual response to the steroids (75).

Postoperative hyponatremia

The incidence of postoperative hyponatremia in the United States is about 250 000 cases per year, with an overall morbidity of approximately 5 per cent ( Ay.u.s, a.D.d,., Arieff. . . 1996). In the majority of cases, patients tolerated the surgery without complications and the symptoms of encephalopathy developed between 1 and 2 days postoperatively. Initial symptoms usually include progressive headache, nausea, emesis, and weakness, which are often mistakenly believed to be routine postoperative symptoms. If the symptoms represent hyponatremic encephalopathy and are not treated, the patient may progress to seizures, obtundation, respiratory arrest, coma, and brain damage (Fraser a.D.d Arie tf,19.9.0 Ayys Dd A ieff 19.95). Thus symptomatic hyponatremia in postoperative patients is particularly dangerous, whatever the level of serum sodium, and should be treated promptly. Premenopausal women with hyponatremic encephalopathy are at particular risk of developing

Predisposing and trigger factors

Migraine, in particular, is said to be subject to certain physiological and external environmental factors. While predisposing factors increase susceptibility to attacks, trigger factors may initiate them. The two may combine. Attempts to control migraine by managing either are often disappointing. A few predisposing factors (stress, depression, anxiety, menopause, and head or neck trauma) are well recognized but not always avoidable or treatable. Trigger factors are important and their influence is real in some patients, but generally less so than is commonly supposed. Dietary triggers are rarely the cause of attacks lack of food is a more prominent trigger. Many attacks have no obvious trigger and, again, those that are identified are not always avoidable. Diaries may be useful in detecting triggers but the process is complicated as triggers appear to be cumulative, jointly overflowing the threshold above which attacks are initiated. Too much effort in seeking triggers causes...

Is this an emergency urgent or routine clinical condition

How is headache described Obtain a thorough description of the headache, related symptoms, and exacerbating and relieving factors, as well as symptoms prior to, during, and after episode(s). Obtain descriptions from child, parent, and a witness, if possible. Specific questions include 1. If a recurrent problem, what is the usual duration of headache When does it occur 2. Are there any complaints associated with headache(s) Any associated activities, such as involuntary motor movements, falling, or stiffening, with headache(s) 4. Are there any precipitants to headache(s) Any alleviating factors for headache(s)

Differential diagnosis

Symptomatic depersonalization often occurs during the course of a variety of clinical conditions, including schizophrenia and related psychotic states, mood and anxiety disorders, acute intoxication with or withdrawal from alcohol, illicit substances, or medication, and as a physiological consequence of migraine, hypoglycaemia, hyperventilation, epileptic seizures, or structural central nervous system pathology. (4,89)

Laboratory Data

Basic metabolic panel, glucose, calcium. Electrolyte abnormalities (hypernatremia, hyponatremia, hypocalcemia) and hypoglycemia or hyperglycemia can present with headache. Metabolic acidosis may be seen with underlying metabolic disorder or intoxication respiratory acidosis is seen in other intoxications (alcohol, benzodiazepines, and barbiturates). 4. Toxicology screening or drug levels. Based on patient's history blood levels of prescription medications, ingested medications, or substances of abuse may point to cause of headache.

Evaluation Of Clinical Findings

There are three clinical presentations of plague-bubonic, primary septicemic, and pneumonic. Patients with pneumonia due to Yersinia pestis present with high fever, headache, myalgia, and productive cough with bloody sputum, which progresses rapidly to sepsis58. Plague has been endemic in the western U.S. since 1900, with 5-15 cases of human disease occurring each year however, only 2 of plague has been pneumonic. Therefore pneumonic plague in the U.S. would raise the suspicion of an intentional event.

Followup And Referral

For migraine and episodic tension-type headache, attack frequency is likely to be the principal determinant. For chronic tension-type headache, follow-up provides the psychological support that is often needed while recovery is slow. In medication-overuse headache, early review is essential once withdrawal from medication has begun, in order to check that it is being achieved nothing is less helpful than discovering, three months later, that the patient ran into difficulties and gave up the attempt. During later follow-up, the underlying primary headache condition is likely to re-emerge and require re-evaluation and a new therapeutic plan. Most patients with medication-overuse headache require extended support the relapse rate is around 40 within five years (41). Urgent referral for specialist management is recommended at each onset of cluster headache. Weekly review is unlikely to be too frequent and allows dosage incrementation of potentially toxic drugs to be as rapid as possible....

Nonselective Epidural Steroid Injection

Anesthetic and steroid can be injected in a nonselective fashion via an interlaminar (transflaval) route, or through the sacral hiatus (caudal injection), with superior infiltration of medication to the lower lumbar levels. This approach results in more diffuse distribution of medication than selective injections described above however, nonselective injection can be of benefit if there is disease at multiple lumbar levels bilaterally. The main complication of interlaminar injection is intrathecal injection, with spinal anesthesia, headache, or dural leak. This risk is minimized with contrast injection and careful fluoroscopic monitoring.

Potential Complications

Inadvertent intrathecal or subarachnoid injection is a known complication of epidural injection, but is mainly a consequence of nonselective interlaminar injection (13) intrathecal injection is exceedingly rare when using a proper selective transforaminal approach or a caudal approach through the sacral hiatus. Some potential sequelae of an intrathecal injection include spinal anesthesia (if anesthetic is used), dural leakage, headache, hypotension, meningitis, and arachnoiditis (20,21). Hypotension may also occur from caudal injection if a large amount of fluid is injected in order to push the medication superiorly (21). In order to minimize these complications, many prefer the selective transforaminal approach for needle placement. Again, whatever approach is used, verification of needle position with contrast injection is essential to minimize complications. Rarely, intraneural injection can occur, which can injure the nerve. If the needle is placed within the nerve itself,...

Partnerships Within And Beyond The Health System

The elements listed above form the framework of WHO's Global Campaign to Reduce the Burden of Headache Worldwide (45). Launched in March 2004, this campaign known as Lifting the Burden is a formal partnership between WHO and the international nongovernmental organizations for headache the lay World Headache Alliance and the professional International Headache Society and European Headache Federation. The objectives of Lifting the Burden are, region by region throughout the world, to measure the burden of headache disorders raise awareness of headache disorders among local health policy-makers

Clinical Presentation

The clinical presentation of a metastasis reflects the location and size of the tumor 4 . The most frequent presenting symptoms are headache, focal deficits and behavioral or cognitive changes (Table 16.3). Headache, although non-specific, is the most common single symptom. In a patient with known cancer, new onset of headaches, especially those occurring in the early morning, warrants radiologic investigation. Behavioral changes are more common with multiple than with single metastases. They may be as subtle and non-specific as mild confusion, memory loss, depression or emotional lability. Symptoms such as headache, behavioral change and focal deficits are usually subtle in onset and slowly progress as the mass effect from the tumor increases.

B2 Adrenoceptor Polymorphism

In many ways, the -adrenergic receptor gene (b2AR) is an ideal candidate for the study of genetic variation, biological relevance, and clinical consequences of polymorphisms. The receptor is expressed on most cells, and agonists and antagonists are used in treatment of a number of diseases, such as asthma, COPD, hypertension, heart failure, preterm labor, glaucoma, and migraine. On the other hand, all these diseases are complex and multi-factorial, and most have a substantial environmental component. As such, the influence of

Neurological Disorders and Neurodegenerative Diseases

It is generally thought that local vasodilatation of intracranial extracerebral blood vessels and a consequent stimulation of surrounding trigeminal sensory nervous pain pathways is a key mechanism underlying the generation of headache pain associated with migraine. This activation of the trigeminovascular system is thought to cause the release of vasoactive sensory neuropeptides, especially CGRP, that increase the pain response. The activated trigeminal nerves convey nociceptive information to central neurons in the brain stem trigeminal sensory nuclei that in turn relay the pain signals to higher centers where headache pain is perceived. Indeed, enriched localization of CGRP in trigeminal sensory ganglia has been detected as well as CGRP has been detected in increased amounts in external jugular venous blood during migraine attacks and intravenous administration of CGRP causes headache and migraine in migraineurs. In addition, studies in patients have revealed a clear association...

Clinical signs and symptoms

The symptoms of cyanide poisoning begin with central nervous system stimulation followed by depression (faintness, headache, anxiety, and giddiness). These symptoms may mimic those of hypoxia however, cyanosis will not be present unless respiratory failure has occurred. Eventually nausea, ataxia, palpitations,

Product case study Ontak

The major clinical study underpinning product approval was a randomized, double blind study in which 71 CTCL patients were administered the product at one of two dosage levels (9 or 18 g kg-1 day-1) overall, 30 per cent of patients experienced an objective tumour response. Serious side effects potentially associated with product administration include acute hypersen-sitivity-type reactions, vascular leak syndrome and visual impairment. Additional adverse reactions include flu-like symptoms, headache, hyper- or hypo-tension, as well as digestive upset. Ontak is manufactured by Seragen Inc. and is distributed by Ligand Pharmaceuticals.

Vectors Of Viral Disease

Because viruses are lifeless particles, their spread depends on other agents. A vector is an intermediate host that transfers a pathogen or a parasite to another organism. Vectors of viral diseases include humans, animals, mosquitoes, ticks, and fleas. The West Nile virus, a virus that causes fever and headache and, in very rare cases, coma and paralysis, infects mainly birds, such as crows and jays. If a mosquito bites a bird infected with West Nile virus and then bites a human, the virus can be spread. Mosquitoes can transmit several other viruses, such as the yellow fever virus.

Prevention And Treatment

Smallpox once killed 40 percent of the people it infected, leaving survivors scarred and often blind. The smallpox virus is a DNA virus that is spread by nasal droplets from sneezing or coughing. Symptoms include fever, headache, backache, and development of a lumpy skin rash, shown in Figure 24-9. The World Health Organization (WHO) began a smallpox eradication program in 1967 through vaccination and the quarantine of sick people. The last naturally acquired smallpox case occurred in Somalia in 1977. In 1980, WHO declared that smallpox had been eradicated in nature.

Systemic Side Effects and Complications

Adrenocortical insufficiency is usually temporary but can be permanent and is directly related to high doses and lengthy therapy. Adrenal suppression may be so severe that physiologic production cannot begin quickly enough when extended therapy is discontinued. Once withdrawal of the exogenous source has occurred, the required levels for normal body functions cannot be maintained. This can be a very dangerous situation. First, with inadequate levels of corticos-teroids (physiologic or therapeutic), inflammation cannot be suppressed, and a rebound of the condition can occur. New organisms may also take advantage of the body's weakened state, and secondary problems can arise. Lastly, steroid withdrawal may cause symptoms of lethargy, weight loss, headache, fever, muscle soreness, nausea, and vomiting.

Sarin and VX terrorism in Japan

The nerve gas sarin, used by terrorists from a religious organization, injured over 500 people (seven fatalities) in Matsumoto in June 1994, and over 5000 people (11 fatalities) in Tokyo in March 1995. In slight and moderate cases, rhinorrhea, dim vision with prominent miosis, headache, or ocular pain occurred. In severe cases, coma, foamy bronchial secretion, respiratory weakness, fasciculation, convulsion, tachycardia, and hypertension were recognized. Atropine and or pralidoxime improved consciousness and respiration. Pralidoxime produced rapid recovery in serum and red cell cholinesterase. In surviving patients, extubation could be conducted on the first or second day. Complete recovery was obtained when patients received advanced life support before cardiac arrest developed. The same terrorist group also used VX in three serial incidents between 1994 and 1995 three people were injured, of whom one died. Dermal exposure or intramuscular injections were suspected.

Summary of Research and Conclusions3

Man anticancer trials have not yet been conducted, other than one in which selenium was used in the symptomatic treatment of brain tumor patients.12 In that trial, selenium, in combination with several other therapeutic agents, produced general improvements such as reductions in nausea and headaches. Still other studies have reported that selenium reduced the side effects of chemotherapy drugs these are discussed in Chapter 23.

Nasopharyngeal Angiofibroma

Nasopharyngeal angiofibromas (or juvenile nasopharyngeal angiofibromas) are rare benign tumours with an incidence of 0.5 of all head and neck tumours. They occur exclusively in adolescent males and become clinically evident between 10 and 25 years of age with nose bleeds, respiratory distress, headaches or sometimes visual disturbances. Nasopharyngeal angiofibromas arise from the posterior lateral wall of the nasal cavity near the pterygo-palatine fossa at the superior margin of the foramen sphenopalatinum and extend into adjacent structures such as maxillary, sphenoid or ethmoid sinuses and the nasal cavity. The most advanced cases show intracranial extension 153, 203 . The blood supply of nasopharyngeal angiofibromas comes from the external carotid artery with the internal maxillary artery as feeding branch. In a minority of cases, the feeding vessels are the sphenopalatine artery and the ascending pharyngeal artery 75, 153 . Diagnosis of a nasopha-ryngeal angiofibroma is based on...

Treatment of iron deficiency anemia

Injectable iron dextran, containing 50 mg of iron per mL, is supplied in a 2-mL single-dose vial. Adverse reactions include headache, dyspnea, flushing, nausea and vomiting, fever, hypotension, seizures, urticaria, anaphylaxis and chest, abdominal or back pain. A small test dose (0.5 mL) should be given to determine whether an anaphylactic reaction will occur. If the patient tolerates the test dose, the full-dosage may then be given at a rate of 50 mg per minute, up to a total daily dosage of 100 mg.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder representing up to 25 of outpatient visits in gastrointestinal practices.1 It is twice as common in females as in males and more prevalent in young patients of high socioeconomic status. Interestingly, only one-fourth of all affected patients will seek medical attention and they seem to be those with a greater degree of somatization and psychiatric disorders. Association with other functional disorders such as migraine or fibromyal-gia is not uncommon.

Primary Glaucoma 1031 Primary Open Angle Glaucoma Definition

Symptoms The majority of patients with primary open angle glaucoma do not experience any subjective symptoms for years. However, a small number of patients experience occasional unspecific symptoms such as headache, a burning sensation in the eyes, or blurred or decreased vision that the patient may attribute to lack of eyeglasses or insufficient correction. The patient may also perceive rings of color around light sources at night, which has traditionally been regarded as a symptom of angle closure glaucoma.

Other electromagnetic stimulation light therapy see also Doris et al 1999

A simple and therefore attractive and widely researched idea is that there is an inverse relationship between short duration of the local daylight period and the incidence of depression (Young et al., 1997). This correlation has not always been replicated, and possible confounds, such as seasonal unemployment, have to be considered (Murray & Hay, 1997). There is some evidence for the effectiveness of light therapy in seasonal affective disorder. (Lee et al., 1997). However, the usual irradiation at 10000 lx is not always without side effects. About half the patients suffer from headaches and visual problems early in treatment (Kogan & Guilford, 1998). There have also been reports of emerging suicidal tendencies during light therapy (Praschak et al., 1997), so that this treatment should not be given without psychiatric supervision. Proof that seasonal depression is in any way different from major depressive illness is still lacking. Its symptoms are consistent with (atypical)...

Cerebrovascular Disease Unusual Forms

Extracranial and intracranial dissections are an underdiagnosed cause of stroke in young persons. Spontaneous dissections occur in Marian's syndrome, fibromuscular dysplasia, migraine and hypertension. Pathological examination often reveals cystic degeneration or necrosis of the media.

Sleepinduced respiratory disturbances

Clinical features include night-time and daytime symptoms. Night-time symptoms are represented by loud snoring, apnoeic episodes ending with sonorous breathing resumption, nocturia, severe fatigue upon awakening, and sometimes headache. Daytime symptoms are dominated by excessive sleepiness which varies in intensity among patients. Other symptoms include irritability, negligence, loss of concentration, loss of libido, impotence, and sometimes depression.

Anticopper Strategies

The toxic molybdenum dose in humans is uncertain, but it appears that the LOAEL dose is about 1.6 mg kg and the NOAEL dose about 0.9 mg kg in rats. The human equivalent of these is about 26 and 15 milligrams per day, respectively. A dose of 26 milligrams per day is much higher than the 0.2 to 0.5 milligram per day dose commonly prescribed in noncancerous conditions. At high doses, side effects of molybdenum can include aching joints resembling gout, headache, anemia, and adverse effects on fetal development. Anemia and fetal impacts, which were seen in rodents, may be largely caused by low plasma copper concentrations low copper concentrations can produce iron deficiency and inhibit the angiogenesis needed for fetal development.

Antiaggregating Agents

Microvascular occlusion, resulting in symptoms such as painful digits leading to gangrene, transient ischemic attacks, migraine, and erythromelalgia is definitely improved by aspirin.16 A maintenance dose of 75 mg is usually sufficient and reduces the risk of peptic ulceration associated with larger doses, although it also increases the risk of hemorrhage, particularly at platelet counts above 1,000 X 109 L. In the occasional patient who has side effects, aspirin may be replaced by dipyridamole, clopido-grel, or newer antiaggregating agents. Whether aspirin reduces the incidence of major vascular occlusion is uncertain. In younger patients who have not had a thrombotic event or other risk factors for thrombosis (hypertension, diabetes, consistently very high platelet counts) treatment of ET by aspirin alone is almost universally accepted.

Applications To Clinical Neurosurgical Practice

Presenting symptoms included the following headache incidental (169), seizure (197), hemorrhage (165), and progressive neurological deficit (20). Thirty patients had undergone prior surgery, and 49 had undergone prior embolization. Spetzler-Martin scores were as follows I, 22 II, 173 III, 204 and IV, 86. AVMs were further delineated into four nidus volume categories A, < 1 mL B 1-4 mL C 4-10 mL and D > 10 mL.

Nonfood Uses Of Plants

The ancient Greeks treated headaches with the bark of the white willow tree, which contains the chemical salicin. This use gave scientists the idea to test the chemical acetylsalicylic (uh-SEET-uhl-SAL-uh-SIL-ik) acid. The willow is in the genus Salix, hence the names salicin and salicylic. Acetylsalicylic acid is aspirin, the world's most widely used medicine. Besides pain relief, aspirin is used to thin blood and thereby prevent heart attacks and strokes. Plants were our first medicines, and early plant biologists, like Linnaeus, were often doctors.

Treatment for Alcoholism

One pharmacological approach is aversion therapy using drugs such as disulfiram to associate drinking ethanol with unpleasant consequences. If ethanol is taken after disulfiram administration, blood acetalde-hyde concentrations increase 5 to 10 times, resulting in vasodilation, pulsating headache, nausea, vomiting, severe thirst, respiratory difficulties, chest pains, orthosta-tic hypotension, syncope, and blurred vision. In certain cases, marked respiratory depression, cardiac arrhythmias, cardiovascular collapse, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, and sudden death have been reported. Despite these potentially severe consequences, disulfiram is prescribed for some alcoholic patients.

And a few more visitors

Whilst the mice have now been eradicated, I am by no means on top of the fact that it is even more imperative than usual for the children to pick up after themselves. I suppose time will tell. I was told that for every one mouse that is seen, another fifteen are lurking elsewhere in the house. Mice also 'leak' urine continually as they scurry around and this can eventually cause tiredness and headaches in humans - not a pleasant thought at all but not one that seems to bother the children one iota One thing these little additions to the family have taught us is that it is never too late to learn new habits. We now have new waste bins in every room and linen bins in each of the children's bedrooms (I caused quite a stir buying fourteen waste bins and ten linen bins ) and all I can do is to press on with our chore rotas and reward schemes in the hope that at some point the children will become accustomed to picking up after themselves .roll on that day

Immediate Questions

Does patient have any symptoms Headache is rarely caused by moderate hypertension (ie, < 99th percentile). Hypertensive urgency may be indicated if headache is present and BP is > 99th percentile. Patients with symptoms (nausea, vomiting, dyspnea, mental changes, visual changes, or seizure) must be treated as a hypertensive emergency.

Calcium Channelopathies Involving PQType Calcium Channel ai Subunits

Mutations in the a1 subunits of voltage gated calcium channels have been linked to a number of disorders. These include hypokalemic periodic paralysis (Cav1.1) (Lapie et al. 1997), Timothy syndrome (Cav1.2 and Cav3.2) (Splawski et al. 2005 Splawski et al. 2004 Splawski et al. 2006), congenital stationary night blindness (Cav 1.4) (Bech-Hansen et al. 1998 Hoda et al. 2005), and various forms of absence epilepsy (Cav3.2) (Khosravani and Zamponi 2006), none of which we will elaborate on further. Mutations in P Q-type calcium channels of both mice and humans are also associated with a number of pathological conditions. As mentioned earlier, point mutations in Cav2.1 have been associated with episodic ataxia type 2, as well as with familial hemiplegic migraine (FHM) in humans (Ophoff et al. 1996). When introduced into recombinant channels and expressed in either transient expression systems or neurons, FHM mutations tend to result in decreased channel function (Pietrobon and Striessnig...

Endovascular Embolization

Endovascular embolization of AVMs is a rapidly evolving technique. This treatment modality is used primarily as an adjunct to surgery or radio-surgery to reduce blood flow and eliminate surgically inaccessible arterial feeders pre-operatively or to incrementally reduce the size of a large AVM nidus, making it amenable to surgical or radiosurgical treatment. The optimal time between embolization and surgery is not defined. Most surgeons, however, operate within 5-7 days after the last embolization to prevent recruitment of new vessels. In some patients, endovascular embolization may be used as a palliative measure to treat headaches or reverse neurologic deficit, whereas, in a small number of select patients, AVM embolization may be curative (Table 20.4). The long-term

Assessment of pain Clinical assessment

The psychiatric assessment of pain requires a full psychiatric history and mental state examination, with particular attention to those additional features relevant to the somatoform disorders. The history of pain should include total duration (often underestimated by the patient), a detailed inquiry about the location and distribution of pain, including direct questions aimed at a total body survey, and the timing of first onset, subsequent periods of relapses and remissions, and their relationship to life events and difficulties. Patients who somatize will tend to deny concurrent psychosocial events and their significance. For example, a patient of the author was consistently unable to recall any distressing events in the year prior to the onset of severe, persistent, and disabling headache. His wife gave an account of the deaths of his father, brother, and closest friend during that year, and moreover described him as so distressed by these bereavements that he felt unable to...

Psychosocial contributions to the development of pain

The concept of gain helps to illustrate some of the processes that are involved. Primary gain may be evident where pain serves to remove the patient from a situation that evokes conflict and helps to maintain self-esteem, for instance where there is little hope of finding a new job following redundancy owing to inadequate skills (the term 'primary gain' is used here in a sense different to that in psychoanalytical writings). Secondary gain includes the concern of others and enhanced financial benefits, particularly where there is the opportunity for compensation. Tertiary gain is the benefit to others, such as the impotent husband who gains from his wife's headaches.

Cotton and Other Textile Dusts James A Merchant MD

Two febrile syndromes characterized by fever, cough, and other constitutional symptoms including headache and malaise are also associated with byssinosis and textile manufacturing. These occur most frequently with exposure to low-grade, spotted cotton. Mattress-maker's fever and weaver's cough may be considered together because of their characteristically high attack rate and probable similar etiology. Mill fever, which is characterized by fever, malaise, myalgia, fatigue, and often cough, was a common complaint among workers first exposed to high levels of these vegetable dusts, with the prevailing cotton dust levels in the Western world it now rarely occurs. These febrile syndromes are similar to other febrile syndromes described among agricultural workers exposed to high levels of contaminated vegetable dusts. It is now also clear that symptoms typical of byssinosis are observed among others occupationally exposed to vegetable dusts. Many of those exposed are employed in...

Cardiovascular System

A slow intravenous injection of histamine produces marked vasodilation of the arterioles, capillaries, and venules. This causes a fall in blood pressure whose magnitude depends on the concentration of histamine injected, the degree of baroreceptor reflex compensation, and the extent of histamine-induced release of adrenal catecholamines.Vasodilation of cutaneous blood vessels reddens the skin of the face, while a throbbing headache can result from vasodilation of brain arterioles. Vasodilation is mediated through both H1- and H2-receptors on vascular smooth muscle. Stimulation of H1-receptors produces a rapid and short-lived response, whereas stimulation of H2-receptors produces a more sustained response that is slower in onset. Stimulation of H3-receptors on sympathetic nerve terminals inhibits the release of norepinephrine and its associated vasoconstriction.

Other central nervous infections in HIVrelated illness

One of the most frequent neurological complications encountered in HIV-infected patients, cerebral toxoplasmosis, is linked to the reactivation of a latent cerebral infection by Toxoplasma gondii, an opportunistic intracellular protozoan. The clinical presentation can vary greatly, but it is characterized by the rapid development of a marked alteration in the mental state. The focal involvement can produce headache and lateralized neurological effects. The lesions tend to be located in basal ganglia. Diagnosis is based on structural neuroimaging tests, and treatment is with pyrimethamine and sulphadiazine. This form of meningitis, caused by infestation with the yeast-like fungus Cryptococcus neoformans, is characterized by headache, meningism (although it sometimes courses without this symptom), photophobia, nausea, fever, and delirium. The diagnosis is made after a lumbar puncture, and analysis of the culture and antibodies.

Sellarsuprasellar tumours pituitary adenoma

This is an uncommon complication of pituitary tumours due to the occurrence of haemorrhage into the tumour substance. Severe headache of sudden onset simulating subarachnoid haemorrhage, rapidly progressive visual failure and extraocular nerve palsies accompany acute pituitary insufficiency. Death may follow unless urgent steroid treatment 330 is instituted.

HT3 Receptor Antagonists

Ondansetron (Zofran) and granisetron (Kytril) are potent antagonists of 5-HT3 receptors, which are found peripherally on vagal nerve terminals and centrally in the CTZ. During chemotherapy that induces vomiting, mucosal enterochromaffin cells in the GI tract release serotonin, which stimulates 5-HT3 receptors. This causes va-gal afferent discharge, inducing vomiting. In binding to 5-HT3 receptors, ondansetron and granisetron block serotonin stimulation, hence vomiting, after emetogenic stimuli such as cisplatin. Headache is the most frequently reported adverse effect of these medications.

Proton Pump Inhibitors

The prodrugs are unstable in the presence of acid and therefore must be administered as an enteric-coated preparation or as a buffered suspension. Pantoprazole is also available in an intravenous formulation. The most commonly reported side effects are diarrhea and headache. Hypergastrinemia has been noted as a reaction to the marked reduction in acid secretion. Gastric carcinoid tumors have developed in rats but not in mice or in human volunteers, even after long-term use.

Supplemental Reading

JK is a 32-year-old white woman who works as the administrative assistant to the chief executive officer of a large firm. She has two small children and describes her life as stressful. She smokes 1 pack of cigarettes per day. She frequently takes naproxen for headaches. For the past 5 weeks she has noticed significant epigastric discomfort. This morning she went to the emergency department complaining of hematemesis. She was admitted, and the gastroenterologist performed an upper en-doscopy that revealed a 1-cm ulcer. Is further evaluation necessary, and what recommendations would you make to this patient

Conclusions And Potential Clinical Relevance

Given the current use of melatonin as a popular over-the-counter jet lag and sleeping aid, it is important to understand the potential for cardiovascular effects in people self-administering melatonin. Possible interactions with estrogen are additional considerations for women taking melatonin during puberty, childbearing years and hormone replacement therapy after menopause. In addition, defining the role of mela-tonin in vascular regulation may lead to novel approaches for treating migraine, stroke and cardiovascular disease.

Scrub typhus tsutsugamushi fever

A few days after the infection, in about 40 of cases, a small nodule can be seen at the site of the mite bite. The nodule will become necrotic and suppurate. About a week after the appearance of disease symptoms (general malaise, headache, fever, regional lymphadenitis, etc.) a spotted fever exanthema usually appears on the trunk, on the extremities and in the face. There is often bronchitis and encephalitis. Pneumonia, encephalitis, and heart failure are serious complications and may indicate fatal cases. During serious epidemics the mortality rate of untreated cases can exceed 60 . Scrub typhus has been, and may continue to be, of great importance in military medicine.

Tickborne encephalitides

Signs and symptoms of meningoencephalomyelitis may develop, including fever, neck rigidity, and headache, sometimes with paralyses of one or more extremities. The second phase of the disease usually lasts for 2-3 weeks. Fatigue and remaining signs of paralysis may persist for a year or more. The RSSE type is, in general, more severe than the TBE type. Also, the symptoms are more severe in the elderly than in children. Effective vaccines are available.

Nonaneurysmal subarachnoid haemorrhage

The management goals in spontaneous SAH are similar to those in patients with head trauma, namely diagnose the condition and minimise the potential for further injury. The treatment of SAH of unknown aetiology is aimed at preventing secondary injury and providing relief of symptoms. Patients are initially placed on bedrest under close observation. Blood pressure is controlled with antihypertensives and the patients are well hydrated. Headache and cervical pain are treated with analgesics as needed and prophylactic anticonvulsants are administered. Corticosteroids, in the form of dexamethasone 4 mg every six hours, are used to alleviate symptomatically signs of blood induced meningitis. While symptomatic vasospasm occurs in a small percentage of patients who present with SAH of undetermined aetiology, we administer an oral calcium channel blocking agent, nimodipine, 60 mg every four hours, to reduce the effects of cerebral vasospasm, should it occur. The incidence of vasospasm is less...

Ticktransmitted rickettsioses

Rickettsia sibirica is distributed in northern Asia from the Far East westwards to Armenia. Dermacentor marginatus, D. silvarum, Hyalomma concinna, and R. sanguineus are the main vectors. The symptoms of R. sibirica infection resemble those of mild Rocky Mountain spotted fever with a rash, fever, and headache.

General considerations

Most proximal, irregularly shaped, and largest will be the most likely source of SAH.117 Aneurysms with small secondary outpouchings are thought to be particularly prone to rupture and these outpouchings may actually be false sacs from previous haemorrhages.118 DuBoulay has hypothesised that secondary aneurysm bulges are regions where the aneurysm wall is most unstable. Asymptomatic aneurysms rarely had secondary protuberances. He also found the mortality rate of such aneurysms to be twice that of smooth walled lesions.119 To help determine which of multiple aneurysms is the most likely source of SAH, one must correlate the history of the ictal event, clinical examination, CT scan, angiogram, and MRI study. The patient may lateralise the initial headache when bilateral aneurysms are present and the clinical exam may demonstrate unilateral weakness or cranial nerve palsy. When multiple aneurysms are diagnosed, CT localisation of subarachnoid blood, ventricular shift, and the site of an...

Clinical Presentation of Hydrocephalus

In older children and adults, the classical symptom complex of raised intracranial pressure, headache, vomiting and drowsiness is more likely to herald an underlying diagnosis of hydrocephalus. Where hydrocephalus has developed insidiously, cognitive impairment, poor concentration and behavioural changes occur. Visual obscurations and papilloedema are more common than in the younger age group.

Indications and contraindications

Controlled trials confirm that valproate is effective in the treatment of multiple seizure types, including complex partial, simple and complex absence, generalized tonic-clonic, and myoclonic seizures.(3) Valproate is also effective in the prophylaxis of migraine headaches. At least seven controlled studies indicate efficacy in the treatment of the manic phase of bipolar disorder. Ml 1 and 12 No controlled studies have been conducted in patients with bipolar depression. Other conditions for which valproate may sometimes be useful include pain syndromes, schizoaffective disorder, anxiety disorders, eating disorders, alcohol and sedative withdrawal syndrome, impulse control disorders, personality disorders, and behavioural and affective disturbances associated with mental retardation and dementia. (2)

Validation Of Signals

The evaluation of 50 reports coded as tolerance with sumatriptan was facilitated by having a longitudinal record of prescription data with the numbers of tablets or injections dispensed recorded for many patients over a period of several years. The reports described patients who claimed that over a period of months or years the drug did not work as well as it did initially and they required higher or more doses to relieve an attack of migraine, or the drug did not work at all. In the natural history of the disease there are fluctuations in frequency and severity of attacks and so these reports were difficult to interpret. It was felt that if there was any general trend to tolerance, then mean usage per patient over time would increase.

ATP and Blood Vessels

Arteries and veins receive a rich sensory innervation.42 Sensory nerves innervating blood vessels have been implicated in the pain associated with angina, embolism, myocardial infection, and migraine, although local acidification43 44 and released ATP have also been expected to cause nociception through the activation of ionotropic and metabotropic receptors innervating cardiac myocytes in those situations. Some reports have suggested that vasosensory nerves may be involved in reflex regulation of the cardiovascular system.45'46 ATP, ADP, UTP, and adenosine are released from endothelial cells and platelets to act on smooth muscle P2X1 receptors and on P2X2 and P2X4 receptors in some vessels, resulting in vasoconstriction.47'48 They also act on smooth muscle P2Y receptors, resulting in vasodilatation.47 Anandamide, a candidate for endogenous ligand for TRPV1, induced vasodilatation by activating TRPV1 on perivascular sensory nerves followed by release of calcitonin-gene-related peptide...

Sulfur compounds in wine are responsible for defects and virtues alike depending on the molecule

Is the presence of sulfur always a defect in wine In the 1960s the undue interest of some growers in preserving their wines as long as possible gave sulfur a bad reputation. Sulfur dioxide added in excessive quantities during the fumigation of casks and the sulfiting of harvested grapes causes painful headaches, it is true. But recent biochemical studies show that the use of sulfur is not to be rejected altogether. Chemists at the Facult d'Gnologie de Bordeaux have discovered that sulfur is capable of both the best and the worst Although some sulfur molecules are the source of indisputable flaws, others contribute pleasing notes of boxwood, broom, passion fruit, and grapefruit in both white and red wines.

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