Natural Relief for Migraine

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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Ophthalmoplegic Migraine

A small number of migraine patients experience an ipsilat-eral oculomotor paresis in connection with an episode of migraine. Like the migraine attacks, this form of paresis appears during childhood as the initiating event in an episode that includes vomiting, photophobia, abdominal pain, irritability, and (less commonly) headache.

Micronutrients Migraine

Effective in women who have migraines associated May reduce frequency and intensity of migraines5 May reduce frequency and intensity of migraines6 May reduce frequency and intensity of migraines6 Cumulative methacholine dose (total dose 64 units) Fig. 5.23 Magnesium prophylaxis against migraine headache. 43 adults with chronic migraines received either 600 mg day magnesium or placebo for 2 months. The severity and incidence of migraines was significantly reduced in the magnesium group vs. placebo. (Adapted from Taubert K. Forschrit Ther. 1994 112 328)

Headache

Headache must be one of the commonest symptoms, and few specialities escape from the diagnostic problems that it can present. We must begin with the realisation that more or less everyone suffers from headache at some time or other. In fact, the majority of headaches that present have no detectable cause and are often labelled psychogenic if there seems to be a background of stress. The implication is that the sufferer is perhaps exaggerating mild symptoms in order to gain sympathy from his or her spouse, or even perhaps the doctor. One must, of course, be extremely cautious about not accepting symptoms at their face value, and certainly cerebral tumours have been overlooked for this reason. If the psychogenic headache is the commonest, then the headache caused by raised intracranial pressure and a space-occupying lesion must be the most important. Between these two,the whole spectrum of causes must be considered. It is essential, therefore, to memorise a permanent checklist in order...

Migraine

Migraine is a common and sometimes incapacitating disorder, affecting approx 20 of women and 15 of men at some time in their lives (94). Some degree of mental change is almost universal during attacks. Anxiety and irritability are common early in the attack and are often followed by drowsiness and lethargy. Cognitive impairment may occur. Cerebration is often slowed with poor concentration, and there may be marked impairment of memory (88). Detainees who claim that they suffered a migraine attack at or around the time of the alleged offense should be questioned closely about any cognitive impairment during previous attacks. However, it should be recognized that the pattern of any such impairment can change from attack to attack in the same person.

Diet Migraine

Foods are often triggers for migraine. Potential food sensitivities should try to be identified elimination diets can pinpoint the offending foods (see pp.205).1 Reactive hypo-glycemia may also trigger migraines (see pp. 185).2 Substances that may trigger migraine blood vessels and stimulate migraine)

Acquired immune deficiency syndrome dementia

A number of autoimmune neuroinflammatory disorders (see 6.09 Neuromuscular Autoimmune Disorders) affect either the central or peripheral nervous system. Many of these disorders are exceptionally rare such as Moersch-Woltman syndrome (stiff-man), Lambert-Eaton myasthenic syndrome, and myasthenia gravis (MG). While uncommon, these disorders tend to be highly debilitating as they directly alter neuromuscular transmission. The most common of these disorders is MG which affects an estimated 60 000 people in the USA. The primary pathology underlying MG appears to be the production of autoantibodies directed against the alpha subunit of the neuromuscular nicotinic acetylcholine receptor. Through direct interference and complement-mediated lysis of the postsynaptic muscle membrane, the autoantibodies cause disruption in the motor endplate that leads to a weakness in skeletal muscle throughout the body. The autoimmune disorder systemic lupus erythematosus (SLE) and the neuroinflammatory...

Chemistry for Chemical Genomics

Organic chemistry is the science of the synthesis and properties of molecules that are constructed from only a few atom types, such as carbon, hydrogen, nitrogen, oxygen, and sulfur, with carbon atoms constituting the majority of the core of these chemicals. As these atoms are also the building blocks of naturally occurring peptides or oligonucleotides, this chemistry was termed organic, as opposed to other disciplines of chemistry. Such chemicals, commonly referred to as small molecules, are valuable as medicines to treat diseases ranging from headache to cancer.

Placebos and the Placebo Effect

A well-known study of the placebo effect was reported in 1955 by Dr. Harry Beecher (1). He described the placebo effect in a variety of conditions, including the common cold, pain after surgery, headache, and seasickness. Overall, symptoms were improved in 35 percent of the people who were given the placebo. Subsequent studies of a variety of medical conditions found placebo effects that were frequently in the range of 30 to 40 percent. In some studies, placebos have been 70 percent effective.

Infusion Reactions Delayed Hypersensitivity Reactions

The highest frequency of adverse events in response to infliximab treatment are infusion reactions occurring within 2 h of the infusion. They typically consist of fever, shills, nausea, dyspnea, and headaches, and symptoms can be controlled with drug treatment (e.g., antihistamines). Infusion reactions led to discontinuation of treatment in approximately 3 of patients, and were considered serious in less than 1 of patients (St Clair et al. 2004 Sands et al. 2004 Lipsky et al. 2000 Gottlieb et al. 2004). Delayed reactions like myalgias, arthralgias, fever, rash, pruritus, facial, hand or lip edema, dysphagia, urticaria, sore throat and headache may occur within 3-12 days following the infusion (Lipsky et al. 2000).

CASE 1 Tshsecreting Pituitary Adenoma Case Description

Two weeks later, the patient presented for an evaluation. Since starting on atenolol 50 mg twice daily, her palpitations had resolved. She denied nervousness, tremor, hyper-defecation, insomnia, weakness, shortness of breath, chest pain, or symptoms of ophthal-mopathy. she had not noticed anterior neck discomfort, dysphagia, hoarseness, or neck swelling. she also denied headaches, visual changes, or a personal or family history of thyroid disease.

Long Sight Short Sight

Having observed the nature of the spectacle lenses, we have now made a small step towards diagnosing the eye condition. If the patient is middle aged and complaining of evening headaches, seeing haloes around street lights and, at the same time, blurring of vision, narrow-angle glaucoma is the wrong diagnosis if the patient is myopic. It could well be the right diagnosis if the patient is hypermetropic. If the patient in Figure 4.2 were to complain of the sudden appearance of black spots combined

Selective serotonin reuptake inhibitors SSRIs

Of the very limited comparative clinical data available, a meta-analysis of 20 short-term comparative studies of five SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline) showed no difference in efficacy between individual compounds but a slower onset of action of fluoxetine. The most common adverse reactions to the SSRIs, according to FDA and MHRA websites, were gastrointestinal (especially nausea) and neuropsychiatric (particularly headache, tremor, discontinuation reactions, and sexual dysfunction Table 7).

Fields Of Expertise Within Toxicology

In addition to the necessity of continuous energy generation, the heart must maintain rhythmic function throughout its lifetime. Substances such as cocaine and cyclopropane that decrease the reuptake of norepinephrine after its release from noradrenergic neurons are prone to cause fatal arrhythmias. Additionally drugs that modify plasma membrane ion channel function can also cause arrhythmias. More recently cardiotoxicity from drugs that prolong the QT-interval has been reported. Such drugs include several antimicrobial agents, antidepressants, and anti-migraine agents. This broadly based toxicological effect has clear implications for the drug discovery process 20 .

Studies in MS and Other Conditions

No well-conducted studies have shown that aspartame causes MS or worsens symptoms in most people with the disease. Through www.ms-cam.org, the CAM website of the Rocky Mountain Multiple Sclerosis Center, we conducted a survey of aspartame use among a large group of people with MS. We had 3,075 people with MS respond to this survey. A minority (15 percent) of those who responded experienced problems that they attributed to aspartame use. Headache was the most common complaint, which was noted by about one third (36 percent) of those who noticed symptoms related to aspartame. Among MS symptoms, those that were reported to be worsened most commonly by aspartame were fatigue, thinking problems, weakness, and numbness. Nearly two-thirds of people reported that their aspartame-related symptoms began within minutes or hours of using the sweetener. Overall, these findings indicate that the majority of people with MS do not have problems with aspartame and that the most common symptom provoked...

Additional Resources Books

Lipton RB, Newman LC, Cohen JS, et al. Aspartame as a dietary trigger of headache. Headache 1989 29 90-92. Newman LC, Lipton RB. Maxalt MLT-down an unusual presentation of migraine in patients with aspartame-triggered headaches. Headache 2001 41 899-901. Van dewn Eeden SK, Koepsell TD, Longstreth WT Jr., et al. Aspartame ingestion and headaches a randomized crossover trial. Neurology 1994 44 1787-1793.

Caveats and Qualifications

A second factor that appears to influence the response to injury and pain, if not sensitization, is genetic background. Mutations in specific genes have recently been linked to two pain disorders erythmalgia (162) and hemiplegic migraine (163). More subtle changes in specific genes have also been shown to influence the response to noxious stimulation and analgesics and the likelihood of developing a pain condition. These include single-nucleotide polymorphisms in genes encoding the m-opioid receptor (164), an isoform of cytochrome P450 (165), melanocortin receptor-1 (166), and a catalytic enzyme catechol-O-methyl transferase (COMT) (167). Specific haplotype blocks of COMT correlate with both pain tolerance and threshold ratings and increased likelihood of developing a pain syndrome (168).

Multiplicity and ligand specificity

Two forms of the enzyme exist, MAO-A and MAO-B, that are encoded by separate genes.53 These enzymes are 80 similar, and possess overlapping, albeit sometimes distinctive, substrate specificities. Serotonin, norepinephrine, and epinephrine are the major endogenous substrates for MAO-A. The indoleamine nucleus of serotonin appears in a few drug classes, notably the triptan class of antimigraine drugs. These drugs are metabolized by MAO-A via pathways that ultimately generate carboxylic acid metabolites.40 The acetylenic compound, clorgyline, is a selective mechanism-based inhibitor of MAO-A, and reversible inhibitors of the enzyme are under development as antidepressant drugs. Amongst the neurotransmitters, dopamine is selectively metabolized by MAO-B. Another acetylenic compound, deprenyl, is a selective mechanism-based inhibitor of MAO-B and the levo enantiomer, selegiline, is marketed as Eldepryl and used as an adjunct to l-DOPA in Parkinsonism. The rationale here is to minimize...

Neurochemical Milieu Of Muscle Nociceptors Or Afferent Units

CGRP, considered one of the most potent cerebral vasodilitors during migraine, along with SP, is effective both in inducing vasodilation and plasma extravasation peripherally. SP also causes its vascular effects via degranulation of mast cells to liberate histamine, which is also a vasodilator. These vasoactive substances also diffuse to contiguous free nerve endings, inducing an enlargement of the area initially affected by a localized stimulus.

Living Electricity Around Us

People knew for a long time that fish can be a source of electric discharges. You can see an electric catfish on ancient Egyptian tombs, and electrotherapy with the help of this fish was recommended by an ancient Greek physician Galen (130-200 A.D.). Another ancient doctor who treated Roman emperor Claudius (first century A.D.) prescribed electrical treatment in the following way A headache, even if it is chronic and unbearable, vanishes, if a live black ray is placed on a painful spot and is kept there until the pain disappears. Gout was treated in the same way With any type of gout, when pain starts, a live black ray should be placed under the feet. Meanwhile the patient should stand on wet sand washed by seawater and remain so until his leg below the knee goes numb. At the same time people noticed that the shock of a ray could pass through iron spears or sticks moistened with seawater and thus affect people who have no immediate contact with the ray.

Spontaneous Intracerebral Hematoma

Hypertensive intracerebral hemorrhage accounts for about 10 to 12 of all strokes. The onset is abrupt. Generalized symptoms include headaches, vomiting, confusion, depressed consciousness ranging from stupor to coma and, in some patients, seizures. Focal symptoms indicate the site of the hemorrhage. Expansion of the hemorrhage and edema may continue, causing deterioration for about 24 hours. Early mortality remains high, at 30 to 40 .

Subarachnoid Hemorrhage

Prodromal symptoms with localized, often pulsating headaches and third nerve palsy may precede the aneurysmal rupture. The highly characteristic presentation of SAH is abrupt, with severe, often excruciating headaches and meningeal signs. Altered mentation, extraocular muscle palsy, subhyaloid hemorrhage, and

Disease Specific Data on Pain and Other Symptoms at End of Life

A retrospective chart review at a tertiary care hospital was conducted summarizing the end-of-life care of US patients more than 5 years old dying from cystic fibrosis (9). Of these patients, 25 had been receiving opioids for the treatment of chronic headache or chest pain for more than their last 3 months of life. When opioids were used for the treatment of breathlessness or chest pain, the proportion increased to 86 . When pain was present, it was described as serious pain, with chest, head, extremity, abdomen, and back the more common locations (10). Increasing pain for this patient population may signal advanced progressive disease (10).

Various Stroke Etiologies Stroke In The Young

Stroke in the young population accounts for 5 of all strokes the incidence of ischemic stroke is only slightly higher than that of hemorrhagic. Stroke in the pediatric age group usually presents with headaches and acute hemiplegia, often associated with seizures. Because of diverse etiologies, young stroke patients require a comprehensive cardiovascular, hematologic, and metabolic screening.

Nonarteriosclerotic Diseases of Cerebral Arteries

The diagnosis of these diseases often presents difficulties early diagnosis, however, is important because appropriate therapy may halt or even reverse the disease process. The clinical presentation varies across a broad spectrum. The disease may begin acutely as a TIA or a full blown stroke, or it may progress gradually with headaches, multifocal neurologic signs, seizures, behavioral changes, psychosis, and cognitive decline often progressing to dementia. Several diseases also affect the systemic blood vessels and produce visceral and cutaneous changes. Segmental constriction (beading) of the arterial wall, as seen on angiogram, is characteristic for some for others, the definite diagnosis may require tissue biopsy. The cerebral pathology also ranges widely Some angiopathies have a predilection for the large, and some for the small vessels infarctions and hemorrhages may be solitary or multiple, small or large.

Inflammatory Vascular Diseases

Giant cells infiltrate the vessel walls, thickening the intima and the media thus, the lumen becomes significantly reduced, and the temporal arterial wall becomes tender and pulseless. The disease commonly affects individuals over 50 years of age. Headache in the temporal region and elevated sedimentation rate are diagnostic.

Dehydrogenases and reductases

Alcohol dehydrogenase (E.C. 1.1.1) (ADH)32 toxifies ethanol to acetaldehyde, which is then (predominantly) detoxified by an aldehyde dehydrogenase (E.C. 1.2.1) to acetic acid. The second step, the aldehyde dehydrogenase-mediated oxidation to acetic acid, is inhibited by disulfiram (Antabus), which is used in the treatment of alcohol addiction. After alcohol consumption disulfiram leads to the accumulation of the toxic acetaldehyde. The resulting toxicity provokes headache and nausea, which is intended to keep the alcoholic from further alcohol consumption. Many other aldehydes, such as the a,b-unsaturated aldehydes (lipid peroxidation products), are also markedly toxic. Thus, aldehyde dehydrogenase predominantly leads to detoxification. However, as is the case with all adequately investigated drug-metabolizing enzymes, aldehyde dehydrogenase plays a dual role with respect to toxification detoxification, the nature of which depends on the substrate in question. Methanol is metabolized...

Disturbances In The Central Antinociceptive Systems

Research into the pathophysiology of tension-type headache (see Chapter 12) indicates that chronic painful states are associated with the dysmodulation of central antinociceptive neurotransmitter systems, particularly the serotonergic, noradren-ergic, endogenous opiate, and GABAnergic systems (48).

Saccular Berry Aneurysm

An unruptured aneurysm may remain clinically silent or may cause pulsating headaches, TIAs, and focal symptoms and signs through local pressure (see Fig. 4.32). In carotid territories, aneurysms produce visual deficit, visual field defect, and an isolated third nerve palsy. An aneurysm within the cavernous sinus presents with frontal and orbital headache, oculomotor and abducens palsies, Horner syndrome, and sensory deficit over the forehead and maxilla (V 1 and V 2 divisions). When it ruptures, it produces a carotid-cavernous (arte-riovenous) fistula with pulsating exophthalmos, bruit over the eye, hemorrhagic edema of the eyelid, and visual failure from retinal hemorrhage and occlusion of central retinal vein. In vertebrobasilar territories, aneu-rysms produce trigeminal, acoustic, or lower cranial nerve deficits and brainstem symptoms and signs.

Isopropanol Pharmacology and Toxicity

CNS Three times more CNS depression than EtOH, lethargy, weakness, headache, ataxia, dysarthria, confusion, apnea, respiratory depression, hypotension. Pulmonary and gastrointestinal Acetone breath, hemorrhagic gastritis and hemor-rhagic tracheobronchitis. Metabolic Exception only toxic alcohol not causing metabolic acidosis or hypoglycemia euglycemia is maintained ketonemia and ketonuria occur from acetone poisoning.

Signs and Symptoms of Nonarteritic Anterior Ischemic Optic Neuropathy

The average age of patients with acute nonarteritic anterior ischemic optic neuropathy (NAION) is about 61 years. The visual loss occurs abruptly and without a prodromal warning, usually while the patient is asleep or within a 12-h period, and there is no associated pain or headache. The initial swelling of the optic disc subsides within 2 months, leaving a pale, atrophic appearance, which is often sectoral (most commonly located in the superior half of the disc). There is for the most part no or very little recovery of function. In about 10 to 20 of cases, there is one or more additional episodes of abrupt loss, in a descending staircase pattern, within the ensuing 2- to 3-week period after the acute onset. Later recurrences of loss in the same eye are very uncommon, but involvement of the contralateral eye can generally be expected within the subsequent 5-year period. As in other ischemic disorders, several risk factors play a role in the process. Aside from the association with...

Herpes Zoster Ophthalmicus

This is caused by the varicella-zoster virus, the same virus that causes chickenpox. It is thought that the initial infection with the virus occurs with an attack of childhood chickenpox and that the virus remains in the body in a latent form, subsequently to manifest itself as herpes zoster in some individuals. The virus appears to lodge in the Gasserian ganglion. The onset of the condition is heralded by headache and the appearance of one or two vesicles on the forehead. Over the next three or four days the vesicles multiply and appear on the distribution of one or all of the branches of the fifth cranial nerve. The patient can develop a raised temperature and usually experiences malaise and considerable pain. Sometimes a chickenpox-like rash appears over the rest of the body. The eye itself is most at risk when the upper division of the fifth nerve is involved. There might be vesicles on the lids and conjunctiva and, when the cornea is affected,punctate-staining areas are seen,...

Signs and Symptoms of the Arteritic Form of AION j Note

The average age at the onset of anterior ischemic optic neuropathy in patients with temporal arteritis (AAION) is about 75 years. Arteritis can also present with branch retinal vessel occlusions, choroidal infarctions, or retinal ischemia, as indicated by the presence of numerous cottonwool spots. Ischemic pareses of the extraocular muscles may be present, and ischemia of the scalp, sufficient to cause patchy areas of hair loss, have been known to appear. Even myocardial infarctions, hemispheric strokes, and cranial nerve palsies can be caused by severe forms of arteritic disease. Temporal arteritis (also called giant cell arteritis, cranial arteritis, or Horton's cephalgia a now-obsolete term ) has the following typical signs and symptoms headache, jaw claudication, scalp pain when combing or brushing the hair, malaise, fatigue, low-grade fever, anorexia, migratory myalgias, weight loss, and thickened, cord-like enlargements of the superficial, subcutaneous arteries of the scalp (...

When the Fundus Is Normal

This important cause of visual loss with a normal fundus is considered in more detail in Chapter 14 on squint. When, for any reason, one retina fails to receive a clear and correctly orientated image for a period of months or years during the time of visual development, the sight of the eye remains impaired. The condition is treatable if caught before the visual reflexes are fully developed, that is, before the age of eight years. Young adults who present with unilateral visual loss and normal fundi could, of course, have amblyopia of disuse and the condition can be confirmed by looking for a squint or a refractive error more marked on the affected side. We must also remember that retrobulbar neuritis presents in young people as sudden loss of vision on one side with aching behind the eye and a reduced pupil reaction on the affected side. This contrasts with amblyopia of disuse, in which the pupil is normal. Migraine is another possibility to be...

Optic Atrophy after Papilledema Definition

The pathogenic mechanism is not well understood, but ischemia is thought to play an important role. The time needed to develop this complication is variable and is not predictable in individual cases. The transient obscurations of vision often associated with papilledema seem to be unrelated to the risk of atrophy. The visual impairment can begin acutely or subacutely, often with arcuate visual field defects that are very similar to those in patients with chronic open-angle glaucoma, and as is the case with glaucoma, the central-most portions of the visual field are initially spared. The process, once begun, can seem impossible to stop, resulting in total optic atrophy and blindness. Patients with chronic papilledema need to be monitored by an experienced ophthalmologist. Papillede-ma that threatens in this manner (i.e., moderate to marked levels of papilledema that last longer than a few weeks) must be brought under control, either by shunting procedures or...

Use in Prevention and Therapy

Moderate to severe iron deficiency produces clear signs of anemia. However, subclinical chronic iron deficiency (reduced iron stores), without signs of anemia, is much more subtle and common. It produces nonspecific symptoms of fatigue, lack of energy, headache, and difficulty concentrating. Supplemental iron together with vitamin C replenishes depleted iron stores and can eliminate these symptoms.

Pharmacokinetics and toxicity

IFN-a side effects can be separated into acute and chronic toxicity (35). Acute toxicity is represented by a flu-like syndrome, characterized by fever, chills, bone pain, and headache. These side effects usually appear 2 to 4 h application IFN-a after. Acute side effects can be attenuated significantly by prophylactic application of acetaminophen at a dose of 500 to 1000 mg orally (po) taken 2 h before and 2 h after subcutaneous injection of IFN. Side effects are generally dose related but tend to disappear within days due to tachyphy-laxis. A less common side effect is gastrointestinal toxicity, such as nausea, vomiting, and diarrhea. Cardiovascular toxicity, such as hypotension, angina pectoris, or tachyarrhythmia, is also rarely observed. The chronic toxicity of IFN generally manifests as fatigue, depression, polyneuropathy, and asthenia. Autoimmune phenomena, such as autoimmune hepatitis or hypothyroidism, may also be observed during prolonged IFN-a therapy. Occlusion of retinal...

Public health importance

The most common bacterial pathogen causing epidemic meningitis in most countries is the meningococcus, Neisseria meningitidis. Meningococcal meningitis is characterized by sudden onset with fever, intense headache, stiff neck, occasional vomiting and irritability. A purpuric rash is a feature of meningococcaemia. Epidemic meningitis has been recognized as serious public health problem for almost 200 years. The main source of the infection is nasopharyngeal carriers. The infection is usually transmitted from person to person in aerosols in crowded places. Rural-to-urban migration and overcrowding in poorly designed and constructed buildings in camps and slums can contribute to transmission. The disease can be treated effectively with appropriate antimicrobial and, with rapid treatment, the case-fatality in an epidemic is usually between 5 and 15 .

Pain Referred from Other Sites

Sinusitis is well recognised as a common cause of headache and the patient with headache should be questioned about recent upper respiratory tract infections or a previous history of sinus disease. Tenderness over the affected sinus is an important sign. The headache tends to begin after rising in the morning and reaches a

First Line Agents Selective Serotonin Reuptake Inhibitors

SSRIs have been studied in elderly depressed patients and have been shown to be effective and generally well tolerated and to have few side effects (New-house 1996). Some side effects, such as mild anorexia, nausea, gastrointestinal upset, jitteriness, and headache, typically diminish within the first few days to weeks of initiation of therapy others, such as sexual dysfunction (including inhibited desire, delayed ejaculation, and anorgasmia) and later-onset weight gain, may not diminish at all.

Management of Cyclic Antidepressant Side Effects

Most side effects caused by non-TCA agents are managed symptomatically for example, antacids for nausea and analgesics for headache are often effective. Sexual side effects of SSRIs, which have been reported in up to 50 of adults, may respond to treatment with cyproheptadine, amantadine, yohim-bine, bupropion, or central nervous system stimulants such as methylpheni-date, but controlled studies are lacking (Ashton and Rosen 1998 Woodrum and Brown 1998). No effective treatment, other than dosage reduction or switching to another class of antidepressant, has been reported for SSRI-induced weight gain.

Purulent Leptomeningitis

Purulent leptomeningitis occurs at all ages from birth through old age. The age-related preferences of common bacteria are listed in Table 6.2. The onset is sudden, with fever, headaches, photophobia, and nuchal rigidity. Severe cases are complicated by an altered state of consciousness, seizures, cranial nerve deficits, and focal neurologic symptoms and signs. The cerebrospinal fluid (CSF) shows elevated cell count, chiefly with polymorphonuclear leukocytes (PNLs), increased protein levels, and decreased glucose levels. The causative microorganisms are identified in the sediment of the CSF using Gram stain and by culturing the CSF and blood. Polymerase chain reaction (PCR) and immunologic techniques identify the bacteria within hours of onset.

CASE 2 Hypertension And Hypokalemia Case Description

A 24-h urine collection for catecholamine excretion was normal. His hypertension was attributed to obesity, and he was instructed to start a weight loss and exercise program hydrochlorothiazide was started. At age 19, his blood pressure was 170 90 mmHg while on therapy. An intravenous pyelogram (IVP) and nephrogram was performed, but no renal abnormalities were identified. He had lost 25 lbs and his blood pressure was moderately improved his medication was changed to propranolol. He continued on this medication for the next 15 yr with only moderate control of his hypertension (140-160 85-100 mmHg) he also complained of frequent headaches. His past medical history was otherwise notable for peptic ulcer disease, spastic colitis, frequent headaches, and a transient (5 min) episode of left-sided weakness at age 20 that spontaneously resolved. His family history was notable for a maternal grandmother who had hypertension and died of a cerebral hemorrhage at...

Differential Diagnosis Drug Induced Bradycardia

Angina Reduce anginal attacks and decrease post-myocardial infarction mortality. Tachydysrhythmias Used in theophylline overdose, butadenosine preferred over P-blockers. Tremor Propanolol over prescribed agitation, stage fright, and panic attacks (shakes). Migraine headaches.

Therapeutic Use of the Environment

The sixth and final reason is perhaps the hardest to define. Aspects of a specific environment afford opportunities for health care workers to use them for therapeutic ends. In this definition, a specific environment is not a therapeutic necessity but can be a therapeutic aid or tool. A good example could be the use of woodland or rivers for group tasks in team building during a recreational summer camp or the phrasing of a therapy task as homework in a school-based headache treatment. Realizing the therapeutic benefits of an environment is often dependent on the treatment philosophy, model of treatment, and the skills and experience of the therapists.

Acute Aseptic Meningitis Encephalitis and Myelitis Clinical Features

Meningitis presents with fever, general malaise, headaches, photophobia, nuchal rigidity, nausea, vomiting, and muscle aches. Altered states of consciousness, focal neurologic deficits, and seizures are common in encephalitis. Flaccid mono- or paraparesis suggests myelitis. The CSF yields a mild to moderate pleocytosis, typically with lymphocytes however, during the initial stage, PNLs may also be present. Protein is moderately elevated and glucose is normal. Viral-specific DNA and RNA are identified in the CSF and blood using PCR assay and in-situ hybridization.

Subarachnoid Damage to the Oculomotor Nerve

From the ventral midbrain, through the interpeduncular fossa and to its entry into the cavernous sinus, the third nerve lies in the subarachnoid space, where it is exposed to hemorrhages from aneurysms arising from the supracli-noid carotid artery, mostly at the exit of the posterior communicating artery. Rupture of such an aneurysm produces paralysis of the third nerve, but also the dramatic symptoms of acute subarachnoid bleeds, including abrupt headache of the worst sort, reduced levels of consciousness up to complete coma, and pronounced meningismus. The ophthalmologist will not be confronted by this syndrome in his her own office.

The Second US Trial SAAB

The next trial measured incontinence episode frequency, IQOL, stress-pad test weights, and 24-h pad weights with about 35 patients in each dose group and restricted itself to stress and mixed UI patients.35 Unexpectedly, only the 20 mg group showed statistically significant improvement in all measures, while those at dose 40 mg showed significance in only stress-pad test and IQOL, and the 30 mg dose group only showed significance in IQOL (Figures 6 and 8). In hindsight, this absence of a dose response is not surprising since the dose increments of 20, 30, and 40 mg duloxetine are proportional to increments of, for example, 1, 1.5, and 2 aspirins. One might not expect to see a dose-dependent reduction in headaches in groups of 35 patients across those doses of aspirin. When all duloxetine arms were pooled, significance was retained for all measures except 24-h pad weights, which still showed twice as much reduction as placebo. As in the first trial, the overall incidence of adverse...

Clinical Development Of Dasatinib In Chronic Myeloid Leukemia

Results from a series of open-label phase II studies of dasatinib in patients with CML in all phases who had failed or become intolerant to imatinib, have been recently reported (Table 1). In these studies, dasatinib was administered at a dose of 70 mg twice daily based on pharmacokinetic data and optimal inhibition of Bcr-Abl and Src activity (28). In one study, involving exclusively patients in CP, 387 patients resistant (75 ) or intolerant (25 ) to imatinib with a median age of 58 years (range, 21 -85 years) were treated (30). Dose escalation to 90 mg twice daily was permitted in patients achieving suboptimal response, and dose reductions down to 40 mg twice daily were allowed in those who developed intolerance. A CHR was observed in 90 of patients, and MCyR was reported in 78 of imatinib-intolerant (68 CCyR and 10 PCyR) and in 42 of imatinib-resistant (30 CCyR and 12 PCyR) patients. BCR-ABL mutations were detected in 160 (44 ) of 363 assessable patients, with G250E (n 23) being...

Oculomotor Pareses in Children

Acquired oculomotor pareses in childhood are mostly traumatic, the consequence of frequent migraine episodes, associated with tumors, or in the context of acute meningitis. Aneurysms as a cause of oculomotor paresis are a rarity in children. An acquired, nontraumatic paresis in a child requires an MRI study with contrast enhancement. If meningitis is suspected, a lumbar puncture is indicated. Depending on the child's age, evaluation to rule out or treat amblyopia in the affected eye is necessary

Tricyclic Antidepressants

Effective in diabetic neuropathy, postherpetic neuralgia, tension headache, migraine, atypical facial pain, fibromyalgia and low back pain. In neuropathic pain, TCAs relieve brief lancinating pain, constant dysesthetic pain, allodynia and spontaneous pain. The pain relief from TCAs is generally moderate in degree. Side effects such as sedation, postural hypotension, dry mouth and constipation are common. The sedative property of this class of drugs is often exploited when pain is accompanied by sleep difficulty by administering them in the evening. TCAs with a balanced inhibition of serotonin (5-hydroxytryptamine or 5-HT) and norepinephrine (NA) reuptake, such as amitriptyline, imipramine and clomipramine, as well as agents with greater NA reuptake inhibition such as desipramine and nortriptyline, appear to be effective analgesics. The mechanism of action is unknown. It is probably multi - factorial as these agents are capable of multiple actions of relevance to pain transmission 8 .

Water Excess without Salt Excess

At the other extreme, when the concentration of dissolved solids gets below a certain limiting value, we lose all interest in drinking fluids. Our brains stop producing antidiuretic hormone. In the normal subject, this causes the urine to become very dilute and to increase enormously in volume. As a result, the concentration of dissolved solids returns to a normal value. In the subject with kidney disease, by contrast, there is little increase in urine flow and the urine doesn't become as dilute. Low concentration of dissolved solids is seen more commonly in patients with kidney disease than is high concentration of dissolved solids. This condition, when severe, is called water intoxication its symptoms are variable, but often there is a severe headache.

N M OBrien and T P OConnor

Histamine toxicity can result in a wide variety of symptoms such as rash, urticaria, inflammation, nausea, vomiting, diarrhoea, abdominal cramping, hypotension, tingling sensations, flushing, palpitations and headache. In general, toxic symptoms are relatively mild and many patients may not attend a doctor. Thus, the exact prevalence worldwide of histamine toxicity is unclear. The prevalence of cheese-related toxicity is also unclear although several incidences have been reported in the literature. For most individuals, ingestion of even large concentrations of biogenic amines, such as histamine, does not elicit toxicity symptoms since they are rapidly converted to aldehydes by monoamine oxidase (MAO) and diamine oxidase (DAO) and then to carboxylic acids by oxidative deamination. These enzymes, present in the gastrointestinal tract, may prevent reduce the absorption of unmetabolised histamine into the bloodstream. However, if MAO and DAO are impaired due to a genetic defect or the...

Salt and Water Deficit

Hyponatremia (low serum sodium concentration) is much more common in patients with chronic renal failure than is hypernatremia (high serum sodium concentration). Hyponatremia in itself causes no symptoms unless it is severe. When patients drink too much water during their glomerular filtration rate (GFR) determination, they may develop very low serum sodium concentration, accompanied by severe headache and, rarely, by convulsions. This doesn't usually happen in people with normal or nearly normal kidney function because their bodies can increase their urine flow enough to get rid of the water load rapidly. They can, that is, unless they become nauseated or undergo a lot of pain during attempts at venipuncture. Both pain and nausea are powerful stimuli for the release of antidiuretic hormone, and can prevent the needed increase in urine flow. Hence, even normal people can suffer from hyponatremia during water loading for a GFR measurement, unless they are carefully instructed as to how...

Progressive Rubella Panencephalitis

Mycotic infections may present acutely or may progress insidiously and slowly over weeks or months. Headaches, visual symptoms, nuchal rigidity, cranial nerve deficits, and low-grade fever are common presenting symptoms. Depending on the location of the pathologic lesions, focal symptoms and signs develop. Confusion, disorientation, psychiatric symptoms, and cognitive impairment evolve in chronic cases and may present diagnostic difficulties. A high suspicion for fungal infection and the use of appropriate tests secures the correct diagnosis.

Historical Context

For long outside the body and enters through mucous membranes or skin, typically sexually transmitted (venereal) passed from mother to child (congenital) or spread through blood transfusions. Its four recognizable stages are primary, secondary, latent, and tertiary. Treatment should begin at first indication, usually when, in the sexually transmitted kind, a chancre or lesion appears on the genitals within four to six weeks of infection. If untreated, the secondary stage from six to 12 weeks after infection includes headache, fever, nausea, swollen lymph nodes, rashes, sore throat, and fatigue. Lesions may persist, and grayish patches with red areolae may occur on the mucous membranes of the mouth and genital region. Hair patches often fall out (alopecia areata). After three months symptoms may come and go but the whole body is now infected as bacteria invade vital organs, bone marrow, and the central nervous system. During a period of latency, from a few years to the end of life, the...

Yohimbe and Yohimbine

Limited studies have evaluated the effectiveness and safety of yohimbe for sexual disorders. Some studies indicate that yohimbe may be beneficial for erectile dysfunction in men and decreased libido in women. However, it has many serious side effects, including severely decreased blood pressure, abnormalities of heart rhythm (arrhythmias), heart failure, and death. Other side effects include insomnia, anxiety, tremor, high blood pressure, rapid heart rate, headache, nausea, and vomiting. The FDA has determined that yohimbe is not safe or effective and that it should not be available for over-the-counter use. Yohimbine, the active ingredient in yohimbe, is available by prescription in the United States.

Clinical Presentation

The signs and symptoms depend on the speed at which the pathological process progresses. Abrupt expansion of the intrasellar contents, after infarction or hemorrhage into a pituitary adenoma, causes a rapid onset of combined, often bilateral cranial neuropathies, associated with severe headache and uni- or bilateral, often profound, loss of vision. With a subarachnoid hemorrhage, the patient's condition can rapidly deteriorate to the level of a coma. Neuroradio-logical imaging will show an enlarged sella with intrasellar bleeding and or necrosis.

CASE 4 Its All In The Genes Case Description

A 56-yr-old Russian woman with a history of hypertension went to an emergency room (ER) with a severe headache that was unrelieved by over-the-counter analgesics. Ten years prior to this, while living in the Ukraine, she began experiencing intense throbbing bifrontal headaches that occurred two to three times a week. The headaches were accompanied by visual changes, pallor, and generalized weakness. Over the next 5 yr, the headaches became more severe and were accompanied by symptoms of sweating and palpitations. A few months prior to the ER visit, she sought medical attention when the headaches began to disturb her on a daily basis. Her blood pressure was noted to be elevated, and she started treatment with hydrochlorthiazide and methyldopa. Although her blood pressure apparently normalized with this therapy, she continued to experience heat intolerance. One week prior to her ER visit, she was given pseudoephedrine for a sinus headache. In the ER, the patient's blood pressure was...

Cognitive Behavioral Therapy with Bruce Dick

The majority of single studies of the efficacy of CBT in pain management are not of sufficient quality to provide evidence of the efficacy of this treatment modality for chronic pain on their own. However, in a systematic review of the efficacy of CBT on chronic pain in adults (excluding headache) 7 , data from 25 trials were evaluated. While considerable variability was identified between studies with regard to measures used and experimental design, CBT was found to provide significant benefit in terms of pain experience, positive cognitive coping and appraisal, and reduced pain behavior. CBT was not found to be associated with benefit in the domains of mood affect, negative cognitive coping, or social role functioning. Overall, it was concluded that CBT is an effective treatment modality for managing chronic pain.

Intracavernous Carotid Aneurysm

Characteristic signs and symptoms include sixth nerve palsy, frequently with Horner's syndrome, facial pain (first division of the fifth nerve), and sometimes with episodic frontotemporal headache. With large increases in size, there can be involvement of the third and fourth nerves, and even compression of the optic nerve. Confirmation of the diagnosis is provided by CT MRI scanning, followed by appropriate angiography. For loss of vision with progressive damage to ocular movements and pain, an endovascu-lar approach is indicated. If the aneurysm is well defined and saccular, it can sometimes be closed by coil emboliza-tion. In the case of an arteriosclerotic, fusiform aneurysm, permanent closure of the affected artery should be preceded by temporary balloon closure, to test the safety of the approach.

Other monoclonal antibodies

Tolerated except for mild fatigue, nausea, and headaches. Moreover, single-agent activity was approximately 15 .75 Based on preclinical data suggesting synergy, a phase I II study of the combination of galiximab and rituximab was conducted, and a response rate of 58.3 was reported.76 This combination has been evaluated as the initial therapy for patients with follicular lymphoma in a Cancer and Leukemia Group B phase II trial and results are pending.

Pfiesteria Complex Organisms PCOs

Symptoms Confusion and or memory loss and more than three (3) of the following symptoms headache, skin rash, conjunctivitis, upper respiratory tract (URT) irritation and sensitivity, muscle cramps, and any type of gastrointestinal symptoms (abdominal cramps, nausea, vomiting, usually no diarrhea). Diagnosis By history of aerosol exposure only. Treatment Supportive only. Prognosis Symptoms resolve in 1-2 weeks. Prevention Avoid swimming, skiing, fishing, and all other recreational exposures in all waters with extensive fish kills citizens should immediately report large fish kills to state environmental and public health agencies and to the CDC.

Other Pathophysiological Aspects of FMS

Similar to the ANS changes found in chronic tension-type headache (see Chapter 12), FMS is also associated with changes in ANS function. Spinal cord glial cells (microglia, astrocytes, and oligodendrocytes) may contribute to abnormal pain sensitivity in FMS via release of neuroactive substances including prostaglandins, excitatory amino acids (EAAs), NGF, and NO (126). Glia are known to play key roles in neuromodulation and neuroimmunicity of the CNS (127,128). In FMS patients, it appears that there are reduced levels of CSF glial cell line-derived neurotrophic factor (GDNF), and in chronic migraineurs (129). Finally, Gi proteins are known to be involved in the modulation of pain perception (132,133). Patients with FMS were found to have hypofunction of the Gi protein systems, but this was not found in patients with neuropathic pain, RA, or OA. FMS patients also showed a higher basal level of cAMP (adenosine monophosphate) than controls (134). Gi protein hypofunction may be looked at...

Tetrodotoxic Fish Poisoning

Vectors All pufferfish (balloonfish, blowfish, fugu fish, globefish, swellfish, toadfish), porcupine fish, marine sunfish xanthid crabs, marine worms blue-ringed octopus bites skin secretions of some newts, frogs, and toads. Incubation 10-20 minutes. Symptoms Initial paresthesias, perioral burning, then salivation, headache, nausea and vomiting (diarrhea rare), sweating, glove and stocking paresthesias then numbness, tremor, ataxia, dysarthria, dysphagia, respiratory depression then paralysis, cardiovascular instability, stupor, and coma. Diagnosis Mouse bioassay, TLC, HPLC, gas chromatography mass spectrometry. Treatment Supportive protect airway, gastric lavage then AC-MDAC, IV fluids, vasopressors, and mechanical ventilation. Prognosis CFR 62 survivors will recover within 1 week of ICU care (not universally available, especially in developing world).

Cervical and Lumbar Epidural Injections

In a literature review, completed in 1995, of randomized trials of epidural steroid injections in the treatment of low back pain and or sciatica 3 twelve trials were identified, all with flaws in their study design. Six studies showed benefit and six showed either no benefit or worse outcomes after epidural steroid injection. The best quality studies showed inconsistent results and any benefits appeared to be only short term. Therefore the efficacy of epidural steroids was not established. A significant number of side effects and complications, including headache, backache, water retention, fever, bacterial meningitis and epidural abscess, were noted. A further issue is that successful placement of a needle into the epidural space can be challenging, even with the use of X-ray guidance 5, 11, 12 and there are a number of serious published complications 13 , some of which are life threatening. Overall side effects and complication rates are high (0.5 to 2.5 ). Most of these are minor...

Miscellaneous Saltwater Fish Poisoning

Shark poisoning Consumption of cooked shark meat from large bull and tiger sharks has caused an initial ciguatera-like illness with perioral paresthesias, ataxia, and pruritus, then coma and death (increased CFR 30 ). Structure of two toxins (carchatoxins A and B) is unknown. Mackerel poisoning Mild, self-limited diarrhea after consumption of cooked mackerel species due to a castor oil-like toxin. Mackerel liver consumption has also caused a hypervitamin-osis-A-like syndrome with headache, nausea, vomiting, diarrhea, and a macular rash that later desquamates. A similar hypervitamin-osis-A-like syndrome occurs after polar bear liver consumption and may cause pseudotumor cerebri.

Variants of Multiple Sclerosis

Neuromyelitis optica or Devic's disease. A 30-year-old woman presented with a history of headaches and rapidly progressing loss of vision in the left eye that began about 5 weeks following a difficult labor and a short febrile episode. Shortly after the onset of visual impairment, she developed paresthesias and weakness in all four extremities and urinary retention. After a short period of improvement, her condition deteriorated she became quadriplegic and experienced respiratory difficulties. Six months after the onset of symptoms, she died. A. Extensive demyelination in left optic nerve. B. Extensive demyelination in the swollen cervical and thoracic cord (Weil stain). C. Massive perivascular lymphocytic infiltration (HE). Neuromyelitis optica or Devic's disease. A 30-year-old woman presented with a history of headaches and rapidly progressing loss of vision in the left eye that began about 5 weeks following a difficult labor and a short febrile episode. Shortly after the onset of...

Acute Disseminated Postinfectious and Postvaccination Encephalomyelitis

The onset is acute with headaches, fever, meningeal signs, focal neurologic deficits, and often seizures. The disease resolves within several weeks, and the course is monophasic. The outcome varies from full recovery through variable residual neurologic impairment to death, which occurs in about 20 to 30 of cases. Acute hemorrhagic leukoencephalitis. A 42-year-old man, with a 3-week history of muscle and stomach aches and cough, suddenly developed headaches, neck pain, fever, and left hemiparesis. Four days later, he became hemiplegic and comatose. Six days after the headaches began, he died. Grossly, the hemispheric white matter displayed multiple petechial hemorrhages. Histologic section shows fibrinoid necrosis of a small vessel, dense perivascular and diffuse parenchymal infiltrations with neutrophils and lymphocytes, and small hemorrhages (HE). Acute hemorrhagic leukoencephalitis. A 42-year-old man, with a 3-week history of muscle and stomach aches and cough, suddenly developed...

Experimental Disease Models

However, there are model of parts of the pathophysiology in animals and in humans.40 The essential issue is what is one trying to do If the question is to screen or evaluate new chemical entities (NCEs) for migraine, then basic animal studies are used. For exploration of identified questions in humans, there are now models of trigeminal function in humans that can allow, for example, dose selection for further clinical trials. A list of models is shown in Table 2. A case history example would be the development to proof-of-principle of the potential for adenosine A1 receptor agonists in the acute treatment of migraine (see Section 6.16.7.4).

Clinical Trial Issues

The methods for doing clinical trials in migraine have been largely set out. The International Headache Society (IHS) has provided guidelines41 that evolved with the sumatriptan development program.42 In general terms, for acute attack treatments, since patients seek rapid, quick, and prolonged relief of pain, the primary endpoint of the 2 h painfree Table 2 Models of aspects of migraine pathophysiology experimental animal or human headache Measurement of nociceptive-specific blink reflex Allows classic pharmacology and receptor characterization but will not address unmet needs in primary headache such needs include nonvascular treatments Screen for pharmacology of peripheral trigeminal transmission with a high false-positive rate48 Useful for identifying neuronal targets for inhibiting trigeminal nociceptive

Current Treatment

The management of migraine may be divided into three parts. First, the diagnosis, which rests on a careful clinical history and neurological examination.4 Second, after an explanation of what can and cannot be done, and particularly advice about lifestyle in the context of migraine as an episodic, probably ionopathic disorder. Third, physicians can offer preventive treatment to reduce the attack frequency and severity, or acute attack treatment for individual attacks. 6.16.5.1 Preventive Treatments for Migraine A simple rule for frequency might be that for 1-2 headaches a month there is usually no need to start a preventive, for 3-4 it may be needed but not necessarily, and for 5 or more a month, prevention should definitely be on the agenda for discussion. Options available for treatment4 vary somewhat by country in the European Union and again compared to North America. The largest problem with preventives is not that there are none, but that they have fallen into migraine from...

Stellate Ganglion Block

Stellate ganglion blocks have been used for the treatment of many conditions, from hay fever, angina, headache, deafness and vasospasm in peripheral vessels to persistent pain in the upper limb. There is no evidence to support the long- term use of stellate ganglion block with local anesthetics in upper limb pain In skilled hands it is a safe procedure, but the side effects can be significant and the patient should be warned regarding the potential for rare but serious or catastrophic consequences 32 .

Unmet Medical Needs

The greatest unmet need in migraine is a broader recognition of the biological basis of the problem. It remains true after the decade of the triptans, 1995-2005, that the majority of migraine sufferers in the western world, and certainly the developing world, still do not access best-practice care. If diagnostic rates in most of the world reflect those of the US, where nearly 50 of migraine sufferers do not have the diagnosis made,65 and only a minority are treated with migraine-specific treatments, the opportunity to do good is huge. Any medicine development needs to bear this in mind. Having said that, the obvious need in acute treatment is a purely neuronally acting treatment that has no vascular side effects this would be a major opportunity given the perceived cardiac safety issues with triptans.66 A drug with less recurrence, i.e., a greater 24-h sustained painfree response, would also be most welcome by the fully one-third of migraineurs who suffer headache recurrence the...

New Research Areas

Serotonin 5HT1B 1D receptor agonists, the triptans 7, and related 5HT receptor agonists, 9, 10, provided the most important advance in migraine therapeutics in the four millennia that the condition has been recognized. Simultaneously the development of triptans, with their vasoconstrictor action, produced a small clinical penalty in terms of coronary vasoconstriction and an enormous intellectual question the extent to which migraine is a vascular problem. Functional neuroimaging and neurophysiological studies have consistently developed the theme of migraine as a brain disorder and thus demand that the search for neurally acting antimigraine drugs should be undertaken. CGRP receptor blockade is an effective acute antimigraine strategy and is nonvasconstrictor terms of the mechanism of action. It is likely that direct blockade of CGRP release by inhibition of trigeminal nerves would be similarly effective. Options for such an action based on preclinical work include serotonin 5HT1F and...

Ocular Muscle Imbalance

Mild latent squints can sometimes go undetected until a period of stress or perhaps excessive reading precipitates symptoms of eyestrain and headache. The effort to maintain both eyes in line causes the symptoms. The latent deviation could be inward or outward but because most people's eyes tend to assume a slightly divergent position when completely at rest, a degree of latent divergence (exophoria) is almost the rule and of no significance. Vertical muscle imbalance is less well tolerated and even a slight deviation can cause symptoms. Small but significant degrees of vertical muscle imbalance

Clinical Presentation And Differential Diagnosis

The commonest causes of cerebral mass lesions in HIV-seropositive patients are toxoplasmosis and primary cerebral lymphoma and the differential diagnosis often proves difficult. Both diagnoses occur in patients with advanced immunodeficiency (CD4 cell counts < 50 X 106 L) and present with headaches and focal neurologic deficits. Clinical features that favor PCL include a more gradual onset over 2-8 weeks and the absence of a fever. CT and MRI scanning usually reveal solitary or multiple ring enhancing lesions with prominent mass effect and edema. Again, these features occur in both diagnoses, although PCL lesions are usually periventricular while toxoplasmosis more often affects the basal ganglia. Thus, the combination of clinical findings and standard radiologic investigations rarely provide a definitive diagnosis. Moreover, toxoplasma serology (IgG) is falsely negative in 10-15 of patients with cerebral toxoplasmosis. More than 85 patients with cerebral toxoplasmosis will respond...

Various Behavioral and Cognitive Behavioral Treatments

A review 22 of controlled trials concerning cognitive behavioral therapy and behavior therapy for chronic pain in adults, excluding headache, found that CBT resulted in significantly greater improvements in pain experience, positive cognitive coping and appraisal, and reduced behavioral pain expression. There was no significant change in measures of mood, catastrophizing, and social functioning.

The sensory phenomenality plot

What characterizes pain is its particularly large amount of alerting capacity. Here it is virtually impossible to prevent oneself from attentively focusing on the noxious stimulation. Pain also has corporality, but to a lesser extent. Moving one's body can generally modify the pain (one can remove one's finger from the fire rub the aching limb and change the incoming sensations), but there are cases like headaches or toothaches, which are more problematic. Headaches and toothaches are characterized by the fact that associated sensory input changes only moderately as a function of things that one can do such as press on the head or chew with one's teeth. This lack of an ability to easily modulate the sensory stimulation by body motions, i.e., a reduced corporality, could possibly correspond to a particular aspect of pain, such as headaches, which distinguishes them from vision, touch, hearing, and smell, namely that they have an interior quality, often not clearly localized.

Endocrine Abnormalities and Cytokines

The clinical symptoms of anorexia, nausea, fever, asthenia, fatigue, lethargy, myalgia, sickness, diarrhoea, anaemia, leucocytopaenia, tachycardia, headache, neurovegetative disturbances, etc., can be attributed to the release of cytokines by macrophages and activated inflammatory cells.

Miscellaneous Venomous Hydroids and Jellyfish

Mauve stinger Pelagia noctiluca yellow-to-luminescent pink jellyfish contact causes initial blisters that heal slowly with hyperpigmenta-tion. Systemic toxicity with weakness, headache, nausea, vomiting possible. Topical-like anesthetics more effective for pain than topical antihistamines and corticosteroids.

Based ori the History and i

13 Holroyd, K.A. and Penzien, D.B. (1990) Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache a meta-analytic review of clinical trials. Pain, 42, 1-13. 14 Holroyd, K.A. and Penzien, D.B. (1986) Client variables and the behavioral treatment of recurrent tension headache a meta-analytic review. Journal of Behavioral Medicine, 9, 515-36. 15 Campbell, J.K., Penzien, D.B. and Wall, E.M. (2002) Evidence-based guidelines for migraine headache behavioral and physical treatments. The US Headache Consortium, 2002, accessed June 30, 2008 (http www.aan.com professionals practice pdfs g10089.pdf). 16 Nestoriuc, Y. and Martin, A. (2007) Efficacy of biofeedback for migraine a meta-analysis. Pain, 128, 111-27. 22 Morley, S., Eccleston, C. and Williams, A. (1999) Systematic review and meta-analysis of randomized controlled trials of cognitive behavior and behavior therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.

CASE 2 Amenorrhea And Pituitary Neoplasm Case Description

The patient was started on 0.3 mg d of conjugated equine estrogens (CEE) and 5 mg of medroxyprogesterone acetate days 1-12 of the calendar month. The CEE was increased to 0.6 mg day and then 1.25 mg d in 6 mo intervals. There was no progression of the tumor over 10 yr of observation. During that time period, the patient developed frontal headaches diagnosed as migraines. She was tried on variety of therapies without relief. These headaches increased in severity and became disabling. Despite stable radiologic findings, the neurologist, neurosurgeon, and a radiotherapist made the decision to treat her with 3-D conformational radiotherapy and she received 5040 cGy. No significant change in symptoms has yet been noted.

Typical Signs and Symptoms of Brain Tumors

Typical signs and symptoms of a brain tumor include headache, neurological deficits, psychic changes (the patient and his her relatives are usually unaware of these changes or misjudge them as trivial, especially when they have developed gradually) epileptic attacks, and visual symptoms ( Table 12.3).

Does theophylline have a role in COPD management

Side effects have been the main problem in the clinical use of theophylline in COPD patients. Side effects, particularly nausea, vomiting and headaches, occur increasingly as plasma concentrations rise from 10 to 20mg L and may be commoner in elderly patients. Benefit may be obtained at concentrations

Mitochondrial Encephalomyopathy with Lactic Acidosis and Strokelike Episodes

Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) of children and young adults is defined by retinitis pigmentosa, recurrent attacks of focal neurologic deficits, seizures, migrainous headaches, progressive external ophthalmoplegia, intellectual deterioration, and myopathy. The disease is maternally inherited and is associated with point mutations in transfer RNA (tRNA) genes.

Clinical Manifestations Of Dengue Infection

Dengue fever is characterized by sudden onset of fever, frontal headache, retro-orbital pain, general malaise, generalized myalgias and arthralgias, nausea, vomiting, and rash. One characteristic feature of dengue fever is the severity of body pain, which can be incapacitating and explains why the disease is sometimes called breakbone fever. Other nonspecific symptoms may be present, such as anorexia, mild conjunctival injection, diarrhea, pruritus, and changes in taste sensation. Leukopenia and thrombocytopenia are frequent, and liver enzymes may be mildly elevated. The febrile period lasts 5-7 days, but the patient may remain symptomatic for several more days. The disappearance of fever correlates with the disappearance of viremia. Convalescence may be marked by a period of lassitude. There have been reports of severe depression after the acute period of illness (4,5).

Clinical features

In the early stages, a painful chancre (rare in T. b. gambiense infection), which originates as a papule and evolves into a nodule, may be found at the primary site of a tsetse fly bite. There may be fever, intense headache, insomnia, painless lymphadenopathy, anaemia, local oedema and rash. In the later stage there is cachexia, sleep disturbance and signs of central nervous system impairment. The disease may run a protracted course of several years in the case of T. b. gambiense. In the case of T. b. rhodesiense, the disease has a rapid and acute evolution. Both diseases are always fatal in the absence of treatment.

CAM Approaches for Pediatric Pain 21 Acupuncture

In adults, acupuncture is among the most frequently used CAM treatments for chronic medical conditions (15-17), and its effectiveness has been supported for several specific pain problems, such as headaches (18) and chronic back pain (19). Reports of serious adverse effects are rare (20,21). Although the exact mechanisms by which acupuncture exerts analgesic effects have not been specified, numerous investigations have demonstrated that the nervous system, neurotransmitters, endogenous substances, and Jingluo (meridians) may respond to needling stimulation and electroacupuncture (EA) (22), in which an acupuncture needle is attached to a low-voltage electricity source. Kemper and colleagues (23), however, found that 67 of children referred to an acupuncturist for chronic pain problems (most commonly migraine headaches, endometriosis, and reflex sympathetic dystrophy) and 60 of their parents thought that acupuncture was a positive experience 70 of the children and 59 of the parents...

Central Sensitivity Syndromes

The terminology central sensitivity syndromes (CSS) has been used most particularly by Yunus (1-3). It reflects that FMS is only one of a group, or spectrum, of similar syndromes. This spectrum is thought to include FMS, chronic fatigue syndrome, irritable bowel syndrome (IBS), female urethral syndrome, MPS, temporomandibular pain and dysfunction syndrome, restless legs syndrome, periodic limb movement disorder, multiple chemical sensitivities, tension-type headaches, migraine, and primary dysmenorrhea (3). Yunus and Inanici (3) note that these syndromes are most likely associated with each other, although the specific physiological associations are not all known. However, they are felt to share overlapping features and common pathoetiological mechanisms of neuroendocrine dysfunction and central sensitivity. Furthermore, they note that FMS has been shown to be associated with a number of other CSS including IBS, tension-type headaches, chronic fatigue syndrome, primary dysmenorrhea,...

Finding Your Glomerular Filtration Rate

Too much water loading can lead to a severe headache, nausea, vomiting, and even convulsions. This problem tends to be self-perpetuating, because nausea and pain are powerful stimuli for the secretion of antidiuretic hormone. Thus the patient's discomfort, brought on by too much water loading and or by painful attempts to draw blood, may in itself make it difficult to urinate. Eventually, though, the water load is excreted and all symptoms disappear.

Hypoglycemic Encephalopathy

The clinical presentation varies with the severity and duration of hypoglycemia. It ranges from headaches, perspiration, nervousness, and tremulousness through confusion, myoclonic jerks, and seizures, to decerebrate rigidity and coma leading ultimately to death. Those who survive a severe and prolonged hypo-glycemic episode usually are left with variable cognitive deficits and various neurologic symptoms and signs.

Transient Visual Loss

Amaurosis fugax is often used as a synonym for transient visual loss, but this is not completely correct. The problem is seldom expressed as periods of true amaurosis. Indeed, there are instances in which an excess of visual images obliterates portions of the visual field, such as in the scintillating scotomas of migraine. These pathogenic mechanisms can in turn have multiple different sources, requiring a variety of different diagnostic considerations. A dilatative cardiomyopathy in a patient on the waiting list for a heart transplant can, in principle, cause the same visual disturbance as can a bout of faulty circulatory regulation in a competitive athlete. Patients often suffer from multiple disorders, e.g., cardiac arrhythmia combined with carotid stenosis, or migraine and erythrocytosis. The cause of the problem in a particular case can be reliably determined only by adhering to a disciplined approach during the diagnostic workup. When a young patient describes a scintillating...

Medical Complications Direct Results of Cocaine

CNS manifestations of cocaine exposure include seizures, status epilep-ticus, cerebral hemorrhage, and transient ischemic attacks. Cocaine may produce hyperpyrexia through direct effects on thermoregulatory centers. Depression of the medullary centers may result in respiratory paralysis, and sudden death may be caused by respiratory arrest, myocardial infarction or arrhythmia, or status epilepticus (Cregler & Mark, 1986). Migraine-like headaches have been associated with cocaine withdrawal and may be linked to serotonin dys-regulation (Satel & Gawin, 1989). Rhabdomyolysis is a complication of cocaine use. When it is accompanied by acute renal failure, severe liver dysfunction, and disseminated intravascular coagulation, the fatality rate is high (Roth, Alarcon, Fernandez, Preston, & Bourgoignie, 1988).

Obstetric And Developmental Effects

Indirect effects of maternal cocaine use include negative health consequences for mothers, which then impact their pregnancies. Women using cocaine are more likely to suffer arrhythmias, cardiac ischemias, and hemor-rhagic strokes. In addition, they may develop pregnancy complications similar to preeclampsia, including hypertension, headaches, blurred vision, and placen-tal abruption, as well as vascular damage and uterine vasoconstriction, leading to problems such as spontaneous abortion and premature delivery (Church & Subramanian, 1997). Poor maternal weight gain and increased energy demands are another common effect of cocaine use in pregnant women, often leading to decreased birthweights and poorer prenatal nutrition (Church et al., 1991).

Meningeal Involvement

Meningeal myelomatosis occurs rarely. Limited reports have recently been reviewed.60 Patients may experience headache, mentation changes, multiple cranial nerve palsies, and speech and gait disturbances.61 IgD and IgA myelomas appear to be overrepresented in these cases. Advanced stage with high tumor-labeling index, and, in particular, plasma cell leukemia (19 ) are common causes of central nervous system (CNS) disease. Specific laboratory findings include the presence of myeloma cells62 and paraprotein in the cerebrospinal fluid (CSF).63

Ie Parent Provider or caregiver

Reliance on parental proxy assessments of an adolescent's internal and external functioning is somewhat questionable 4, 54 , as the parents' own anxieties and uncertainties about the future may influence their HRQL reports for their offspring 58 . Studies have consistently shown imperfect concordance rates between self-report and parental proxy ratings for children and adolescents with asthma, cystic fibrosis, chronic headache, limb deficiencies, and cancer 1, 14, 59 . This lack of agreement between proxy and self-

Medulloblastoma Grade

Medulloblastoma manifests with truncal ataxia and broad-based gait. Being fast-growing in the posterior fossa, it produces increased ICP, with headache, vomiting, and papilledema early in its clinical course. The tumor is inhomogeneously hyperintense on T2-weighted images and enhances with gadolinium on Tl-weighted images. Postoperative survival averages 5 years.

Overview Review of the Literature

Recurrent pain problems are a common complaint in children 10 and tend to increase in prevalence with age 11 . Estimates of the occurrence of some common chronic pain problems have been found to be as high as 10-19 of children reporting recurrent abdominal pain 12 and as many as 28 of adolescents reporting chronic headaches 13 . Chronic pain in children and adolescents tends to be more common in females than in males 14 .

Nonsteroidal Antiinflammatory Drugs

These drugs are so called because, like adrenocortical steroids (see below), they reduce inflammation, especially in joints, but also in other tissues. NSAIDs include aspirin (also present in many over-the-counter drugs), acetaminophen (also sold as Tylenol and present in many other combination drugs), celecoxib (sold as Celebrex), ibuprofen (sold under many names, including Advil, Nuprin, and Motrin), and rofecoxib (sold as Vioxx). These are probably the most widely used drugs on the market. NSAIDs are taken for arthritic pain and for headache, among many other indications. Avoiding these pain relievers is out of the question for most people. If you do find yourself in need of a pain reliever, do not take any of these drugs for more than a few days at a time.

Tumors of the Adenohypophysis

Adenomas arising in the anterior lobe of the pituitary gland constitute 10 to 15 of all intracranial tumors. Approximately two-thirds of pituitary adenomas secrete hormones, and the remaining one-third are hormonally inactive (null-cell adenomas). The tumors grow slowly, occur chiefly in adults between 30 and 60 years of age, and are more common in women than men. Endocrine symptoms due to hormonal overproduction stand in the foreground of the clinical picture and provide the basis for classification. The endocrine activities of the various adenomas and their corresponding clinical manifestations are listed in Table 11.7. Additional characteristic symptoms and signs result from compression or invasion of the adjacent structures and include headaches, bitemporal hemianopsia, hypothalamic dysfunction, cavernous sinus syndrome, hydrocephalus, and pituitary hypofunction. Enzyme assays and MRI make possible the early diagnosis of these tumors before they reach a size large enough to erode...

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