Natural Treatments to Help With 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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Migraine and headaches

Occasionally foods with a high content of tyramine, such as cheese, coffee, red wine and yeast extract, are responsible for migrainous headaches.19 In some patients the association is obvious and these patients usually avoid these foods. In other cases of chronic headache, once other treatable causes have been excluded, a diet excluding foods with high tyramine content may be tried. However, double-blind challenges are often unsuccessful in confirming a relationship of foods with headaches.

M Tension and Migraine Headaches

There is a wealth of outcome research demonstrating that these two disorders can be effectively treated with biofeedback techniques. For tension headaches, BFRT, with placements of the EMG sensors in the frontal location, combined with general relaxation techniques, such as PMR has been shown to be effective. Utilization of specific muscle feedback of the muscles of the face, neck, and cervical area has also proven effective. This author recommends the combination of frontal EMG feedback, PMR, and specific muscle feedback of the face, neck, and cervical area. The muscles selected for the feedback are determined by a dynamic EMG assessment. For biofeedback treatment of migraines the treatment of choice is finger temperature feedback combined with a relaxation technique, such as autogenic training. For those clients unresponsive to the finger temperature feedback, usually frontal EMG feedback will be effective. Based on the outcome research, biofeedback should be the treatment of choice...

Post Lumbar Puncture Headache

If a patient complains of headache following a lumbar puncture, it is probably related to a loss of CSF secondary to leakage through a dural defect. The headache is often exacerbated in the upright position and relieved with recumbency. The pain has been described as a dull ache that may become throbbing. The headache onset starts within hours to days after the procedure and may persist for 2 to 3 weeks. The symptoms usually subside spontaneously. Prevention is the key and the use of smaller needles has been recommended to decrease the incidence of these headaches. Treatment of the post-lumbar puncture headache consists of bed rest in the horizontal position. A blood patch to stop the leak may be beneficial.

Complications of Migraine

Status Migrainosus Previously, this condition was called intractable migraine or persistent (pernicious) migraine. It is distinguished as a migraine attack with the headache phase lasting more than 72 hr despite treatment. A headache-free interval of less than 4 hr may occur. Any episode of migraine, in any form of migraine, may evolve into an intractable, daily, continuous headache attack, unresponsive to standard treatments. The headache may be unilateral or global, pulsatile or pressure-like, or may have characteristics of both migraine and tension-type headaches. The headache progressively intensifies to a debilitating pain, accompanied by the usual characteristics of migraine. Typically, the associated nausea and vomiting are severe, leading to osmophobia, dehydration, refusal to eat, and prostration. The photophobia, phonophobia, and headache exacerbated by any movement forces the patient to remain in a dark and quiet room, unable to function at even a basic level. Some...

Cluster Headache Variant

These headache attacks are believed to be a form of cluster headache or CPH but do not meet their criteria. Cluster headache variant, originally described by Diamond and Medina, is a syndrome consisting of a triad of symptoms atypical cluster headaches, multiple jabs, and background continuous headache. The atypical cluster headache is irregular in location, duration, and frequency, occurring several times a day. Multiple jabs are sharp, variable, painful episodes, lasting only a few seconds and occurring several times a day. Background headaches are chronic, continuous, often unilateral, sharply localized and of variable severity, and have vascular features throbbing and exacerbated by physical exertion. The pathophysiology is unknown. The therapy consists of indomethacin or lithium.

Investigation of the ED Headache Patient

COMPUTED TOMOGRAPHY SCANNING The ED patient whose headache requires emergent investigation usually begins with a noncontrast computed tomography (CT) scan.4 The use of contrast material increases the time, expense, and risk of adverse effects (minor 10 percent, severe 0.1 percent), 5 and the noncontrast CT scan usually adequately excludes critical lesions or mass effects requiring emergent interventions. In particular, the noncontrast CT scan is the best neuro imaging test for diagnosing an acute SAH, but CT scan cannot rule it out. When there is strong suspicion of small lesions likely to be missed without contrast (e.g., in an AIDS patient suspected of cerebral toxoplasmosis or suspected small brain mass), then a CT with contrast material may be needed. 5 MAGNETIC RESONANCE IMAGING The cost and restricted availability of magnetic resonance imaging (MRI) limit its utility in the emergency investigation of headache. MRI is more sensitive than CT in evaluating brain injuries, such as...

Primary Headache Syndromes

The term primary headache includes all forms of migraine, tension-type, and cluster headaches. There is considerable clinical overlap in primary headache syndromes, and it has been suggested that they share a pathophysiology and represent different ends of a clinical spectrum. 7 MIGRAINE Epidemiology Migraine headaches are common, with onset usually in the early teens or even younger. Prevalence is estimated at approximately 5 percent for males and 15 to 17 percent for females.2 Prevalence peaks in both sexes at around 40 years of age and then gradually declines. Pathophysiology Early theories postulated abnormal vasculature as the root cause of migraine headaches, with vasoconstriction being responsible for the aura and rebound vasodilatation the cause of the pounding headache. It now seems clear that migraines are a primary response of brain tissue to some trigger, while the disordered activity of blood vessels is secondary. Pain-sensitive intracranial structures, such as blood...

TABLE 2194 Emergency Department Treatment Options for Migraine Headache

Dexamethasone has been touted as effective in reducing the rate of recurrent migraine following standard treatment. 2 In one ED-based RCT, patients received either 20 mg intravenous dexamethasone or placebo after standard migraine therapy. A significant reduction in the rate of 48- to 72-h recurrent migraine was found in the dexamethasone group as compared to the placebo group.19 Special mention is reserved for the use of opioid analgesics in migraine. Meperidine is still used as an acute migraine treatment despite several studies that have shown it to be less effective than other agents.20 The frequent use of opioids in chronic and recurrent headache conditions may lead to adverse effects, and may even exacerbate headaches.20 While some patients may require opioid analgesics, the preferred treatment is one of the numerous, more effective alternatives to opioids. 2 Pregnant Women Migraines generally improve during pregnancy, especially after the first trimester. Nonpharmacologic...

TABLE 2291 Considerations for Nonenhanced Head CT for Headache

Headache associated with unexplained fever is also an indication for neuroimaging, particularly when there is associated meningismus and photophobia. Although diagnosis is made by lumbar puncture, imaging is typically recommended to exclude hydrocephalus. Despite the absence of scientific validation, it has become the standard of care to precede lumbar puncture with nonenhanced head CT (NECT). Secondary hydrocephalus tends not to obviate performing lumbar puncture, but it will lead the physician to performing a low-volume lumbar puncture. Further, it can alert the physician to the possible need for shunt placement. Acute or recurrent hydrocephalus can present with headache as well as nausea, incontinence, and ataxia. There is generally an increase in the intraventricular volume. Hydrocephalus can be caused by a number of processes including prior subarachnoid hemorrhage, prior trauma, meningitis, masses obstructing the ventricular system, or masses external to the ventricles but...

Epidemiology And Comorbidity A Migraine Prevalence

Migraine is a highly prevalent condition affecting approximately 10 of the population. Migraine prevalence is age, gender, and race dependent. Women are more affected (lifetime prevalence, 12-17 ) than men (4-6 ). In the American Migraine Study, the 1-year prevalence of migraine increased with age among women and men, reaching the maximum at ages 35-45 and declining thereafter. Migraine prevalence decreases in older women but never decreases to prepubertal or even male prevalence. Migraine prevalence is influenced by race and geographical region. It is highest in North America and Western Europe and more prevalent among Caucasians than African or Asian Americans. The influence of environmental and genetic factors varies. Migraine without aura is influenced by a combination of genetic and environmental factors, whereas migraine with aura has a stronger genetic influence. Behavioral, emotional, and climatologic changes may trigger migraine, modify the vulnerability to migraine, or...

Comorbidity of Migraine

The term comorbidity refers to the greater than coincidental association of two conditions in the same individual. Migraine is comorbid with many disorders (Table I). This can alert clinicians to identify them. Comorbid illness impacts pharmacologic treatment of migraine headache. One drug may be useful for more than one disease (i.e., valproate and topiramate may be therapeutic for both migraine and epilepsy). On the other hand, some treatments may be contraindicated in certain comorbid illnesses. Beta-blockers should be avoided in patients with migraine and depression. Careful attention to a drug's effect on comorbid conditions optimizes health care use and may improve patient's quality of life.

Migraine without Aura

The headache is characterized by episodes of head pain lasting 4-72 hr and having at least two of the following characteristics pulsatile quality, moderate to severe intensity, unilateral location, and worsening with physical activity. To fulfill the IHS criteria for migraine, headache must also have occurred on at least five occasions and have been accompanied Migraine with Aura Diagnostic Criteria 4. Headache follows aura with a free interval of less than 60 min

Familial Hemiplegic Migraine

Familial hemiplegic migraine is a rare autosomal-dominant migraine syndrome in which patients experience recurrent visual and somatosensory auras and prolonged hemiparesis in the context of migraine attacks. It may be associated with dysphasia, drowsiness, confusion, coma, and, in some, cerebellar symptoms, tremor and epilepsy. To establish a diagnosis, the patient must have at least one first-degree relative with identical attacks. This Headache

Migraine with and without Aura

Migraine has a strong genetic component. In a Danish population-based survey of migraine using IHS criteria, the sex- and age-standardized risk of suffering from migraine with aura and migraine without aura among first-degree relatives was 1.9 (95 CI, 1.6-2.2) and 1.4 (95 CI, 1.0-1.8), respectively. This suggests that migraine without aura is caused by a combination of genetic and environmental factors, whereas migraine with aura is more heavily influenced by genetic factors. Proposed modes of inheritance for migraine include autosomal-recessive inheritance for migraine with aura and sex-linked transmission, multifactorial, or autosomal-recessive inheritance for migraine without aura. Russell's epidemiology study, which included a segregation analysis of migraine with and without aura, found that both entities have multi-factorial inheritance. This analysis cannot detect genetic heterogeneity and therefore cannot exclude a mitochondrial or Mendelian pattern of inheritance. Migraine is...

Secondary Causes of Headache

SUBARACHNOID HEMORRHAGE Epidemiology SAH has an annual incidence of approximately 1 per 10,000 in the United States10 and represents 1 percent of all nontraumatic headaches seen in the ED.1 However, SAH accounts for up to a quarter of all sudden severe headaches.6 SAH occurs in young people, with a median age of 50 years. Mortality rates from SAH are high 50 percent of patients die within 6 months, and only 58 percent of survivors regain their premorbid neurologic state.22 Clinical Features At the time of presentation, almost half of patients with SAH have normal findings on neurologic examination, including normal vital signs, normal level of consciousness, and no neck stiffness.22 The headache of SAH is most commonly severe and of sudden onset, but it may also be more subtle. The most common location for the headache is occipitonuchal.8 Many presentations are atypical and may mislead the clinician. For example, sudden-onset intense neck pain may be mistakenly attributed to...

Headaches of Ocular Origin

Headache is rarely due to the eye, with the exception of obvious ocular pathology. Photophobia, associated with migraine, is rarely caused by diseases of the eye, eye muscles, or the optic nerves. Reading, eye strain, eye muscle imbalance, or refractive errors are rare causes of headache.

Vascular Headaches A Migraine

By definition, migraine is an idiopathic, recurring headache disorder manifesting in attacks lasting 4-72 hr (untreated or unsuccessfully treated), usually unilateral location, of pulsating quality, and of moderate to severe intensity that may inhibit or prohibit daily activities. Pain is aggravated by routine physical activity and is associated with nausea and or vomiting, photophobia, and phonophobia. History, physical, and neurological examinations do not suggest a secondary headache due to other disorders. Migraine is an inherited neurological condition. A parental history can be obtained in 50-60 of patients with migraine. The form of inheritance has not been identified, although some genetic studies suggest an autosomal-dominant type in familial hemiplegic migraine. For the more frequent types of migraine, genetic influence is less clear. Migraine has a marked impact on the economy and society. Surveys show that 8 of men and 14 of women miss all or part of a day of work or...

Other Forms of Migraine

Migraine with prolonged aura, perviously termed complicated or hemiplegic migraine, is characterized by one or more aura symptoms lasting more than 60 min and less than 1 week. Any of the various forms of aura may occur. This type of migraine is relatively rare. The headache usually starts within 1 hr of aura onset, becomes progressively more intense, and may linger for a prolonged period. Different forms of aura can be experienced at the same time. The intensity of the pain is usually less than that in the more common types of migraines. The aura persists into the headache stage and may continue after the pain subsides. The typical clinical features of the headache are the same with this complicated form of migraine. The etiology or mechanism of migraine with prolonged aura and related symptoms is unclear. It has been assumed that a neurological deficit of longer duration is caused by prolonged vasoconstriction or limited spasm of a cerebral artery occurring as a part of the migraine...

Tensiontype Headache

Tension-type headache was previously known by several terms muscle contraction headache, stress headache, ordinary headache, essential headache, psychogenic headache, or psychomyogenic headache. It is defined as recurrent episodes of headache lasting minutes to days. There are two primary forms episodic and chronic. The pain is bilateral, with pressing or tightening (nonpulsating) quality of mild-to-moderate severity. The headache is not aggravated by routine physical activity. Photophobia or phonopho-bia may be present, and nausea may occur in the chronic form. The episodic type has been experienced by almost everyone, is usually relieved by over-the-counter analgesics, and does not require a physician's intervention. The chronic type is daily or almost daily, and the victim is prone to dependency problems with analgesics, tranquilizers, or sedatives. The prevalence in the general population ranges from 30 to 80 . The 1-year prevalence of episodic tensiontype headaches is about 55 in...


This is a common syndrome of recurrent headache that is most often seen in young adults who are otherwise healthy. Even though these headaches are sometimes referred to as vascular headaches, the pathophysiol-ogy may not primarily implicate vascular mechanisms. It has been noted that migraineurs have slightly more MRI hyperintensities than do age-matched control subjects, and it is possible that episodic intracerebral vasoconstriction participates in their development. Clinical mainfestations of these changes have not been established, and no specific treatment other than migraine control is indicated.


Headsche Zone

Headache tops the list of common scourges of mankind. It is so common that everybody suffers from it at some time or another. When the problem becomes chronic and recurrent, life becomes miserable. Medicines and 'over-the-counter' pills worth millions of rupees are purchased every year by the victims of headache. However, none of them is absolutely safe, especially when consumed over a prolonged period. Common causes and features of headache have been tabulated below. Victim admits to be facing unfavourable circumstances and of possessing a worrying nature. Headache is usually mild and may be located anywhere front, top or back of the head. Mild pain in the forehead, occuringonly after the eyes have been used, for hours together, in tasks requiring a lot of concentration. Headache is relieved if eyes are rested for a while. 4 Migraine Vascular headache, usually affecting one half of the head cause is unknown but some consider it psychological. Pain is very severe and many a time...

Cluster Headache

This form of vascular headache has been known as histaminic cephalalgia, Horton's headache, migrai-nous neuralgia, sphenopalatine neuralgia, petrosal neuralgia, red migraine, Raeder's syndrome, Sluder's syndrome, erythromelalgia, and Bing's erythroproso-palgia. The defining characteristic of cluster headaches is their occurrence in cycles (clusters) that occur and disappear spontaneously. There are two forms of cluster headache episodic and chronic. The majority of patients with cluster headaches experience the episodic form, in which the headache cycles or series last for several weeks or months and then may disappear for years. For those unfortunate few with the chronic form, headache remission is briefer than 14 days, or the cycle of headaches is continuous, without any headache-free intervals.

Sinus Headache

Sinus headache is an often cited complaint of many patients, although the acute headache due to actual sinusitis occurs less frequently than the rate quoted by the advertising media. Acute sinusitis presents with fever, pain triggered by pressure or direct percussion, and headache. Fever is the cardinal sign of this infective process. The pain associated with sinus diseases is a constant, dull ache. If the patient is suffering from acute sinusitis, the headache will typically increase in intensity as the day progresses. To confirm the diagnosis, sinus X-rays or sinus CT should be performed. Treatment consists of antimicrobial therapy and decongestants.

Migraine with Aura

The migraine aura is a recurrent neurologic symptom that develops gradually (in more than 4 min) and persists for less than 1 hr. Headache, nausea, and or photophobia usually follow within 60 min after resolution of the aura but may not necessarily develop (acephalgic migraine). Visual aura is most frequently reported (99 ), followed by sensory (31 ), aphasic (18 ), and motor aura (6 ). The stereotypical visual aura is a serrated arc of scintillating, shining, crenelated shapes that begins near the point of fixation and Diagnostic Criteria for Chronic Migraine A. Daily or almost daily (> 15 days month) headache for > 1 month B. Average headache duration of > 4hr day if untreated History of episodic migraine meeting any IHS criteria History of increasing headache frequency with decreasing severity of migrainous features over at least 3 months Headache at some time meets IHS criteria for migraine 1.1-1.6 other than duration D. Does not meet criteria for new daily persistent...

Chronic Migraine

Under the term chronic migraine, or transformed migraine, we propose to include all cases of chronic daily headache with features of a both migraine and tension-type headache that do not meet criteria for new daily persistent headache or hemicrania continua. Table V proposes criteria for chronic migraine. The typical patient is a woman with a past history of episodic migraine who develops a daily or almost daily headache that is mild to moderate in severity, with superimposed typical migraine attacks. The associated symptoms, such as phonophobia, photophobia, nausea, and vomiting, often become less severe and frequent. Many patients with chronic migraine overuse analgesics, triptans, and ergots, leading to increased frequency of headaches, some of them in the context of withdrawal from acute medication the so-called rebound headache. Rebound headache leads to the consumption of more analgesics, creating a vicious cycle. Patients benefit from a detoxification treatment, thereby...

Migraines and Cheese

Migraines, also called vascular headaches, are thought to involve blood vessels in the brain, although the exact cause is unknown. Some cheeses contain a naturally occurring compound called tyramine, which, in susceptible people, can cause an increase in blood pressure, an increase in the size of blood vessels in the brain, and headache pain. For people who take drugs called monoamine oxidase inhibitors (MAOIs), avoidance of all foods containing tyramine including aged cheeses is essential. foods, aged cheeses have the highest tyramine content. The amount of tyramine in cheeses differs greatly because of the variations in processing, fermenting, aging, degradation, or even bacterial contamination. The following types of cheeses are aged or have been reported to be high in tyramine and should be avoided if you are susceptible to migraines or if you take MAOIs


The next disorder we will focus upon involves headaches. Headache is ubiquitous and is always one of the top five reasons why people visit doctors. Headaches are classified by various schemes, but, most simply, they can be viewed as involving migraine headache, tension headache, cluster headache, and trigeminal neuralgia. Migraine headache in its various manifestations can involve unilateral or bilateral headache that is usually associated with a prodrome (preceding the headache) or codrome (occurring with the headache) of nausea, vomiting, photosensitivity-photophobia, and alterations in mood. Its etiology is not fully known, but it is now thought to involve excessive serotonergic activity due to histamine-induced release of 5HT from mast cells in the vertebrobasilar arterial system. In this model, the excessive serotonergic activity results in alternating constrictions and relaxation of vascular structures, which, with repetition, result in vasospasm. The vasospasm is thought to be...

Coparent See compadrazgo

Study such characteristics as the age-composition of populations, fertility, fecundity, and mortality. dengue fever. Like malaria, dengue causes fever, headache and chills, as well as body pain and skin rash. Unlike malaria it is not recurrent, although persons who have had dengue are at elevated risk for the more serious forms of dengue hemorrhagic fever and dengue toxic shock syndrome. dependency theory. Views underdeveloped or developing nations which have not yet had substantial economic growth as being the integral result of the processes by which other nations became developed in other words, relations of dependency arose because of colonial, usually Western, powers. depression. A mood state including feelings of sadness, hopelessness, and other negative feelings. Short-lived

Disorders Of Alertness

Fatigue is a deficit in alertness, which is a normal response following physical or mental exertion and instructs the body to rest and repair. Fatigue is a symptom of many illnesses, which reflects in part the importance of rest in recuperation from illness. However, there are occasions, such as after resting, when fatigue is inappropriate and, when alertness is required, debilitating. If such unexplained fatigue is persistent and is accompanied by other symptoms (such as sleeping problems, depression, concentration or memory problems, headache, sore throat, swelling of the lymph nodes, and muscle or joint pain) it is likely to be diagnosed as chronic fatigue syndrome.

Recommended Readings

In the early 1970s, Anxiety Management Training was developed as a behavioral alternative for treatment of Generalized Anxiety Disorder (GAD). Over the years, research documented its efficacy for GAD, phobic disorders, PTSD, and other conditions with anxiety as a primary factor, such as tension headaches, essential hypertension, dysmenor-rhea, test or mathematics anxiety, and athletic or artistic performance. In 1986, the basic AMT approach was used for anger management. Since then, numerous studies have confirmed the appropriateness of AMT for anger. Hence, AMT can be viewed as a cognitive-behavioral intervention for either anxiety or anger management.

Immunological Mechanism

The main primary mediator, histamine, activates Hj and H2 receptors. Pruritus, rhinorrhea, tachycardia, and bronchospasm are caused by the Hj receptors, whereas both Hj and H2 receptors mediate headache, flushing, and hypotension. Gastrointestinal signs and symptoms are associated with histamine more so than with tryptase levels.

Chapter References

Seim MB, March JA, Dunn KA Intravenous ketorolac versus intravenous prochlorperazine for the treatment of migraine headaches. Acad Emerg Med 5 573, 1998. 23. Capobianco DJ, Cheshire WP, Campbell JK An overview of the diagnosis and pharmacologic treatment of migraine. Mayo Clin Proc 71 1055, 1996. 24. Harden RN, Gracely RH, Carter T, Warner G The placebo effect in acute headache management Ketorolac, meperidine, and saline in the emergency department. Headache 1996 36 352, 1996. 25. Ducharme J, Beveridge RC, Lee J, Beaulieu S Emergency management of migraine Is the headache really over Acad Emerg Med 5 899, 1998.

Effects on Cardiovascular System

Caffeine produces minor, transitory increases in blood pressure. Habitual users are less prone to exhibit this effect. Its significance is not known (26). Caffeine has also been reported to cause cardiac arrhythmias, but there is conflicting evidence (26). There appears to be a caffeine-intolerant population that is susceptible to this effect. Caffeine may exacerbate an existing tendency toward arrhythmias. Low dosages may decrease heart rate slightly high dosages may cause tachycardia in sensitive subjects (27). Cerebral blood flow is decreased, and this effect is the basis for its inclusion in drug preparations for the treatment of migraine headaches (28).

Management Of Patients With Chronic Pain

Complete eradication of pain is not a reasonable end point in most cases. Rather, the goal of therapy is pain reduction and return to functional status. Chronic pain syndromes discussed in this chapter include myofascial headaches, transformed migraine headaches, fibromyalgia, myofascial chest pain, back pain, complex regional pain types I and II, postherpetic neuralgia, and phantom limb pain. Drug-seeking patients are also covered.

Clinical Features

Because of the spectrum of drug-seeking patients, the history given may be factual or fraudulent. Drug seekers may be demanding, intimidating, or flattering. In one ED study, the most common complaints of patients who were drug seeking were (in decreasing order) back pain, headache, extremity pain, and dental pain. 23 Patients may complain of panic disorder or drug withdrawal symptoms and request benzodiazepines. Additional fraudulent techniques are listed in Iab e,3.4-4 In some cases, observations of vital signs and physical examination findings will help the physician identify factitious illness, but even experienced clinicians are frequently misled.23

Effects on the Cardiovascular System

Caffeine decreases peripheral resistance by direct vasodilatation and increases blood flow to a small extent. This effect results from the relaxation of smooth muscle of blood vessels. For coronary arteries, vasodilatation is also observed in vitro, but the effects of caffeine in human coronary arteries in vivo are unknown. Different effects of caffeine on circulation can be observed in different vascular beds and, for example, the treatment of migraine headaches by caffeine is mediated through the vasoconstriction of cerebral arteries. It has also been shown that caffeine is capable of attenuating postprandial hypotension in patients with auto-nomic failure.

Clinical Description

Four main symptoms are observed in CADASIL migraines with aura, ischemic attacks, mood disturbances, and cognitive decline or dementia. The clinical presentation is highly variable between and within families. The age of onset varies greatly, depending on the criterion used for the onset of the disease. 1-3 Migraine attacks may begin even before age 10 years, but more commonly during the second and third decades. The most constant finding is a history of ischemic events, transient or completed, which are present in 87 of symptomatic individuals. They are often recurrent over years, leading to gait difficulties, pseudobulbar palsy, and incontinence. All subjects older than age 66 years have developed ischemic signs and all deceased subjects had suffered from strokes. 3 Mood disturbances such as severe depression of the melancholic type are present in more than 20 of cases. Rare manic episodes and psychotic disorders were

Genotypephenotype Correlation

No correlations are found between a mutation and a clinical phenotype because a family unique presentation such as migraine or stroke is also found with several other mutations. 2,3 Additionally, we did not notice neither different clinical presentations nor different skin vessel wall lesions in CADASIL patients with mutations located either in the first or very last exons. Interestingly, a homozygous patient followed in Finland was indistinguishable when compared with an age-matched heterozygous patient with the same R133C Notch3 mutation. The double dose of gene defect does not appear to aggravate the symptoms, which indicates that either mutated Notch3 receptors retain some of their function, or other molecules can compensate for the loss. 16

The Clinical Response To Endotoxin Administration In Humans

Many controlled studies have been done involving bolus injections of endotoxin into human subjects (38-45). Typically, such studies involve administering an injection of between 2 and 4 ng kg of E. coli derived purified LPS. Within about an hour to an hour and a half most injection subjects commonly complain of influenza-like symptoms, including myalgia, headache, and nausea. Some two-thirds of a typical group develop chills and all develop fever of 1 C or 2 C above baseline accompanied by an increased heart rate. Leukocyte count initially decreases for the first hour, then abruptly begins to rise rapidly and is accompanied by neutrophilia. At about two hours post injection a lowering of the blood pressure occurs. Whereas peak endotoxin concentrations in the blood are reached within five minutes, peak body temperature is not reached until 60-90 minutes and correlates well with peak TNF and IL-6 cytokine levels. The initial and peak levels of IL-6 typically occur 15 minutes after the...

Contemporary Uses Of Biofeedback

Biofeedback is presently applied either as a means of directly addressing specific physical symptoms (primary intervention), or as an adjunct to teaching self-control skills to enhance coping with a variety of physical and emotional problems (secondary intervention). A good example of the former is migraine headaches. Thermal biofeedback, in which the peripheral temperature is the focus, has long been used to control blood flow, which has been implicated in this condition. Studies have shown that the ability to produce vasodilation is related to alleviation of migraine symptoms. An example of the latter is the use of EMG biofeedback to teach effective progressive muscle relaxation, which can be used to alleviate pain symptoms. These two modes are often used simultaneously.

Clinical Features and Diagnosis

Fever is common, as is sinus tachycardia, which is usually out of proportion with respect to the extent of temperature elevation. Signs and symptoms depend on the extent of myocardial involvement and resultant depression of myocardial systolic function. In severe cases, progressive heart failure, with its associated symptoms, may be seen. With less extensive myocardial involvement, pericarditis and the clinical manifestations of systemic illness (fever, myalgias, headache, and rigors) may overshadow clinical signs of myocardial dysfunction, and myocarditis may not be suspected. Retrosternal or precordial chest pain is a frequent presenting complaint and is most commonly secondary to associated pericardial inflammation (myopericarditis). This chest pain may mimic angina in its character. A pericardial friction rub is commonly heard in patients with myopericarditis.15

Selection Of An Antihypertensive Agent

The following section outlines therapies for hypertensive emergency and urgency. For those patients in an ambulatory setting, Table53 2. summarizes guidelines for the selection of an antihypertensive agent for patients with various coexisting conditions. 14 Diuretics should be one of the agents of first choice in patients with renal disease and congestive heart failure who are judged to be volume overloaded. Because of their greater prevalence of stage 3 hypertension (systolic pressure of 180 mmHg or more, and diastolic pressure of 110 mmHg or more), African American patients may require multidrug therapy. For treatment of patients with angina pectoris or postmyocardial infarction, b blockers are indicated. They are also indicated for those patients with a history of migraines, atrial fibrillation with rapid ventricular response, paroxysmal supraventricular tachycardia, and senile tremor. The use of b blockers is safe in the latter part of pregnancy, but their use should be avoided in...

Intravenous Nitroglycerin

SIDE EFFECTS AND CONTRAINDICATIONS The most common side effects include headache, tachycardia, nausea, vomiting, hypoxia, and hypotension. Hydralazine SIDE EFFECTS AND CONTRAINDICATIONS Hydralazine should not be used in patients with aortic dissection or a history of coronary artery disease, because it causes reflex tachycardia and increases plasma renin and catecholamines. It also causes sodium and water retention and can cause headaches, nausea, tachycardia, lethargy, and postural hypotension. A lupuslike syndrome can result from chronic oral use.

Elicit a Medical History

The patient reports no past medical history. He has not seen a doctor since he was a child and has had no hospitalizations and no history of past surgeries. He reports smoking a half of a pack of cigarettes per day, moderate alcohol use, and occasional drug use, including marijuana and cocaine. He takes no medications except for an over-the-counter multivitamin daily and ibuprofen for the occasional headache and muscle pain. He has no known drug allergies. At the same time that you have been learning the medical history, a nurse has been putting in two large bore IVs and starting intravenous fluids for resuscitation. What next

Clinical Presentation

During the neuroophthalmologic examination, the fundus of each eye should be examined for papillede-ma or hemorrhage. Although episodic anisocoria associated with headaches is usually benign, a unilateral, dilated fixed pupil (sometimes referred to as a blown pupil'') suggests damage to parasympathetic fibers of the external portion of the third cranial nerve as a result of brain herniation. In contrast, pinpoint pupils suggest compression of pontine structures. Midposition, fixed pupils indicate midbrain failure and loss of both sympathetic and parasympathetic pupillary tone, whether caused by structural or metabolic disease.

Clinical Evaluation and Management

Supratentorial lesions can be classified as either extracerebral or intracerebral. Extracerebral lesions include neoplasms, infections, and trauma-related injuries such as hematomas. Lesions such as neoplasms or abscesses impair consciousness via the mass effect that they exert. Headaches, seizures, motor sensory deficits, and cranial nerve dysfunction, rather than an altered state of consciousness, are usually the initial symptoms of neoplasms. Occassionally, a progressing frontal lobe lesion can produce behavioral changes prior to brain herniation. Subdural empyema, a process secondary to otorhinologic infection, meningitis, or intracerebral abscess, can present as an extracerebral lesion. Initial presentation includes subdued consciousness, sinusitis, headaches, focal skull tenderness, and fever. Further deterioration can lead to language dysfunction, hemiparesis, seizures, and eventual coma. sensory deficits, headache, or loss of language function. The size of the hemorrhage...

Theoretical Bases

Taking personal responsibility for events where there is insufficient evidence that you were responsible e.g., when a friend fails to phone, you interpret this as due to some personal failing (I'm boring to talk to) instead of considering the other possibilities (She didn't call because she had a migraine).

Basic Tenets And Philosophy

Therapy were found to be effective in the treatment of atten-tion-deficit hyperactivity disorder, encopresis, enuresis, obesity, obsessive-compulsive disorder, recurrent headache, and the undesirable behaviors (e.g., self-injury) associated with pervasive developmental disorders. A growing body of research is addressing the mechanisms of change in these therapies as well as questions about the applicability of these treatments to a variety of clinical settings and populations (i.e., the moderators of change).

Complications Of Immunosuppressive Agents

Cyclosporine and FK506 inhibit T-cell proliferation. Nephrotoxicity is a common and usually reversible side effect manifest by elevated serum creatinine levels, hypertension, hyperkalemia, hyperuricemia, and gout. Patients are sensitive to dehydration.12 Other side effects include headache, hirsutism, gingival hyperplasia, hyperglycemia, hypomagnesemia, hypercholesterolemia, hypertriglyceridemia, hepatotoxicity, and hemolytic uremic syndrome. Unlike those of other immunosuppressive agents, blood levels of cyclosporine and FK506 can be monitored along with serum creatinine to avoid serious toxicity however, random levels are rarely helpful and dose is adjusted based on trough levels.3

Arteriovenous Malformations

AVMs is predominantly located intraparenchymally rather than within the subarachnoid space. Neurologic improvement is often seen as the clot regresses and is resorbed, and it provides rationale for delayed surgery 1-4 weeks after hemorrhage when the clot is organized and the brain less friable. Seizures are the second most common presentation of patients with AVMs, being noted in 11-33 of cases. Seizures are thought to be related to gliosis in the adjacent brain resulting from hemosiderin deposition and inflammation. Additionally, patients may present with the new onset of headache (from stretching of the dura, elevated venous pressure, or hydrocephalus) or progressive neurological deficit or cognitive decline (from arterial steal or venous hypertension). Comprehensive management of patients harboring AVMs involves three main therapeutic modalities endovascular therapy, microsurgery, and stereotactic radiosurgery. Endovascular therapy, applying catheter-administered materials for...

Neurologic Complications

It is reported that between 19 and 47 percent of all adult liver transplant patients have a neurologic complication at some time during their posttransplant course. Neurologic complications in children, however, are much less common (8 percent).14 Common presenting problems include headache, seizure, and mental status changes. The etiology is more likely to be noninfectious than infectious. Common noninfectious etiologies are hemorrhage, immunosuppressive toxicity, and metabolic derangement. Central nervous system (CNS) infection is most common in the first few months, with viral and fungal etiologies predominating. CNS CMV infection is rare and CNS herpesvirus infection is seen with the same frequency as in the general population. Bacterial etiologies include Listeria, Klebsiella, S. aureus, Nocardia, and Escherichia coli. Aspergillus, Candida, and Cryptococcus sp. are the more common fungal agents involved. Cryptococcal disease is most common between 2 and 7 months.16 Patients...

Cavernous Malformations

Seizures are the most common manifestation of supratentorial cavernous malformations. Surrounding hemosiderin and gliosis is thought to be responsible for this epileptogenicity. Symptomatic hemorrhage and headache are the next most common presentions. Cavernous malformations are also frequently found incidentally in radiographic studies performed for other indications.

Hypertensive Encephalopathy

Hypertensive encephalopathy is a neurologic emergency characterized by exceedingly elevated blood pressures with the subsequent development of focal cerebral edema. This potentially reversible condition presents with rapidly progressive neurological signs, headache, seizures, altered mental status, and visual disturbances. The clinical and neuroradiologic presentation of hypertensive encephalopathy shares similarity with the reversible posterior leukoencepha-lopathy syndrome, a clinical entity that encompasses multiple disorders with a common predisposition for the development of focal cerebral edema. The patho-genesis of edema formation is controversial but is thought to involve elevated hydrostatic forces due to excessive blood pressure, with lesser degrees of involvement attributed to vasogenic edema and secondary ischemic components. The contributions of autoregulatory dysfunction and BBB leakage compared to hydrostatic causes of plasma extravasation continue to be controversial....

Intracranial Pressure Monitoring

ICP elevation can infer the presence of cerebral edema. Symptoms of elevated ICP include headache, nausea, vomiting, and altered level of consciousness, which may be superimposed on focal neurologic deficits. When ICP reaches a critical threshold, herniation syndromes may ensue. The initial presentation of this clinical scenario demands an emergent CT scan of the head to identify the underlying process and assess the degree of parenchymal injury. Although neuroimaging methods routinely diagnose the presence of cerebral edema, ICP monitoring devices may detect the evolution of edema in patients expected to develop this complication. A diagnostic lumbar puncture may be performed safely on most patients whose imaging does not indicate a mass lesion to identify elevations of CSF pressure. ICP monitoring by ventriculostomy can be employed to permit drainage of CSF in hydrocephalic conditions. Continuous ICP monitoring is also possible with subarachnoid bolts, fiberoptic catheters, and...

TABLE 1016 Potential Complications of Tocolytic Agents

Subcutaneously and repeated hourly as needed until contractions stop, is commonly used. Common side effects include tachycardia, hypotension, palpitations, headaches, and tremor. Terbutaline should be withheld if the maternal pulse exceeds 140 beats per minute. The combination of magnesium sulfate and nifedipine is potentially dangerous, since nifedipine can enhance the toxicity of magnesium and result in neuromuscular blockade, interfering with both pulmonary and cardiac function. Careful monitoring of the mother and fetus with use of any of these agents, alone or in combination, is mandatory.

Characteristics of Manualized Interventions

Headache to childhood enuresis, sexual dysfunction to sex offenses. A detailed list of empirically supported treatment is provided by Hayes, Barlow, & Nelson-Gray in their 1999 book. Criteria have been developed for three levels of empirically supported interventions well-established treatments, probably efficacious treatments, and experimental treatments. These criteria were developed by a task force formed by Division 12 of the American Psychological Association whose mandate was to formulate both criteria for determining efficacious treatments and to identify treatments that have been established.

Large Extracranial Artery Diseases and Stroke

Extracranial carotid artery disease is an important cause of stroke. Carotid stenosis becomes more likely with advancing age and occurs in approximately 2-7 of individuals aged 50 or older. However, carotid stenosis of over 80 affects only 1 of the general population. Carotid artery dissection and giant cell arteritis may also lead to extracranial stenosis and stroke. Arterial dissection occurs most frequently in the setting of minor or major trauma but may occur spontaneously. The vessel wall develops a hemorrhage, which expands and narrows the lumen. The smooth lining within the vessel (endothelium) often becomes irregular and serves as a nidus for clot formation. The hemorrhage may grow sufficiently to cause stenosis and occlusion of blood flow through the damaged artery, or the clots that form at the site of the endothelial damage may embolize to the brain. In giant cell arteritis, inflammation within the wall of extracranial vessels, most often the carotid arteries, leads to...

Intracranial Arterial Disease and Stroke

Intracranial arterial disease may lead to ischemic and hemorrhagic strokes. Aneurysms and arteriovenous malformations (AVMs), intracranial atherosclerosis, and vasculitis are some of the major diseases of intracranial arteries producing stroke. Approximately 80 of nontraumatic subarachnoid hemorrhage is due to ruptured intracranial aneurysm. Arteriovenous malformations carry a 40-50 lifetime risk of rupture with subsequent fatal or disabling hemorrhagic stroke. Central nervous system vasculitis may occur with or without coexisting systemic vasculitis. Fibromuscular dysplasia rarely affects intracranial arteries. Cerebral amyloid angiopathy may lead to both ischemic and hemorrhagic stroke. Migraine may cause sufficient constriction of intracranial arteries to produce ischemia and infarction. Vasospasm (constriction of vessels due to contraction of vascular smooth muscle) is common following subarachnoid hemorrhage. Toxic substances such as cocaine and other stimulants may lead to...

Intracranial Venous Disease and Stroke

Within the brain, there are several large veins that drain into the venous sinuses. Sagittal sinus thrombosis is the most serious disorder of the intracranial venous pathways. This condition frequently leads to headache (80 ), swelling of the optic nerve (papilledema, 50 ), motor or sensory deficits (35 ), seizures (29 ), hemorrhage (50 ), and death (5-10 ). Contrast enhanced CT scanning allowed superior sagittal sinus thrombosis to be diagnosed by showing the empty delta'' sign. Now, MR is the preferred test, showing increased signal intensity on T1, T2, and proton density weighted images. The clot can be directly visualized using such routine MR techniques, and MRV can easily demonstrate the absence of venous blood flow caused by the thrombus. Although angiography will demonstrate the problem during the venous phase of contrast washout, MRI techniques have reduced the need for angiography for the diagnosis of sagittal sinus thrombosis.

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

Second, determine what symptoms accompany the vomiting. Is the patient febrile Fever could point toward an infectious or inflammatory source, or it could represent a toxicologic cause, such as salicylate intoxication. Is there associated abdominal pain, back pain, headache, or chest pain that may point to a specific cause Pancreatitis, cholecystitis, peptic ulcer disease, appendicitis, and pelvic inflammatory disease typically cause abdominal pain. Back pain usually accompanies aortic dissections, rupturing aortic aneurysms, pyelonephritis, and renal colic. Vomiting is one of the signs of increased intracranial or intraocular pressure and may be a foreboding sign in patients complaining of headache. Finally, the complaint of vomiting associated with chest or epigastric pain might suggest a diagnosis of myocardial ischemia. In female patients, obstetric and gynecologic causes of vomiting should always be considered. In a pregnant woman, epigastric pain and vomiting accompanying...

Clinical Characteristics

While listeriosis during pregnancy usually presents with flu-like symptoms which can lead to infection of the fetus causing abortion, premature birth or stillbirth, in non-pregnancy associated cases it mainly manifests as meningoencephalitis and or septicemia. The onset of meningoencephalitis (which is rare in pregnant women) can be sudden, with fever, intense headache, nausea, vomiting, and signs of meningeal irritation, or may be subacute, particularly in an immunocompromised or an elderly host (13). Rhomben-cephalitis is an unusual form of listeriosis, which involves the brain stem and is similar to circling disease in sheep. L. monocytogenes can produce a wide variety of focal infections conjunctivitis, skin infection, lymphadenitis, hepatic abscess, cholecystitis,

Neurological and musculoskeletal disease

Migraine is a very difficult symptom to describe and has many causes. It is familial and many people describe migraine that is related to foods. Whether it is due to direct effects of molecules that are in the food or an immunological reaction to the food is difficult to establish. The same is true for arthralgia. I am not aware of any double-blind studies that have shown an association between arthralgia and food. The association of foods with symptoms such as ME (myalgic encephalomyelitis) is very difficult to prove or disprove.

Clinical Significance

Frequently, Balantidium infections can be asymptomatic however, severe dysentery similar to those with amoebiasis may be present. Symptoms include diarrhea or dysentery, tenesmus, nausea, vomiting, anorexia, and headache. Insomnia, muscular weakness, and weight loss have also been reported. Diarrhea may persist for weeks or months prior to development of dysentery. Fluid loss is similar to that observed in cholera or cryptosporidiosis. Symptomatic infections can occur, resulting in bouts of dysentery similar to amebiasis. Colitis caused by Balantidium is often indistinguishable from E. histolytica (Castro et al, 1983). Diarrhea, nausea, vomiting, headache, and anorexia are characteristic of balantidiasis.

Streptococcal Pharyngitis

DIAGNOSIS No set of symptoms or signs is completely specific for GABHS. Nonetheless, there are findings that are typically, but not exclusively, associated with GABHS. Generally, the infected child experiences sudden onset of sore throat and fever. The tonsils and pharynx appear markedly red and have a moderate-to-large amount of exudate. The soft palate and uvula are also red and may have petechiae. The anterior cervical lymph nodes are enlarged and tender. The presence of a scarlatiniform rash and pharyngitis is virtually diagnostic of GABHS. Headache, vomiting, abdominal pain, meningismus, and torticollis can occur as well. These are of little diagnostic importance but must be recognized as possibly attributable to GABHS. The presence of significant coughing, rhinorrhea, or both suggests an alternative diagnosis. Diagnostic accuracy on the basis of clinical findings alone is reported at about 50 to 75 percent for children thought to have GABHS and 75 to 85 percent for children...

TABLE 1175 Signs and Symptoms in Children with Sinusitis

Acute, severe infections of the sinuses are infrequent during childhood. Such patients often have a history of headache and an elevated temperature. Findings include fever, localized swelling and or erythema, and facial tenderness. A mucopurulent discharge usually accompanies severe sinusitis but may also indicate a nasal foreign body when unilateral.

Case presentation 1

A 30-year-old male presents to the emergency department with a 24-hour history of fever and headache. The patient's symptoms began abruptly and have worsened steadily over the last day. His wife reports that in the last 6 hours he has become somewhat confused. He has no significant past medical or surgical history. He takes no medications and denies alcohol, tobacco, and drug use. His family history is likewise non-contributory.

NonST Segment Elevation Myocardial Infarction Nstemi and Unstable Angina

-Morphine sulfate 2-4 mg IV push prn chest pain. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Ondansetron (Zofran) 2-4 mg IV q4h prn N V. -Famotidine (Pepcid) 20 mg IV PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

Biological effects in vivo

The biosynthesis of recombinant GM-CSF protein has permitted a wide number of studies to be undertaken on the efficacy of GM-CSF as a therapeutic agent. As predicted from in vitro studies, GM-CSF has proved to be a potent stimulator of hematopoiesis when administered in vivo. Administration is generally well tolerated but may be associated with bone pain and influenza-like symptoms, including fever, flushing, malaise, myalgia, arthralgia, anorexia and headache. These effects are usually mild, are alleviated by antipyretics and resolve with continued administration. At higher doses, GM-CSF has been associated with a capillary leak syndrome.

Clinical features of a major haemolytic reaction

Haemolytic shock phase - this may start within minutes after a few millilitres of blood have been transfused or may take 1-2 h after the end of the transfusion to develop. Symptoms include urticaria, lower backache, flushing, headache, shortness of breath, precordial pain and hypotension. These symptoms may be difficult to identify in the anaesthetized patient or the unconscious intensive therapy unit (ITU) patient. Laboratory examinations will reveal evidence of blood cell destruction, jaundice and disseminated intravascular coagulation. Urinalysis will demonstrate haemoglobinuria.

Neurodegenerative diseases

Dyspnoea usually occurs as a direct result of respiratory muscle weakness, although other indirect symptoms such as thick mucous secretions and chronic hypoventilation also contribute. Any or all of the three muscle groups involved in normal breathing maybe involved. As already described, it is this respiratory muscle weakness itself (and the subsequent afferent mismatch) that produces the sensation of dyspnoea. Infrequently, MND ALS may present with respiratory failure, but for most patients, when the disease presents, there is usually reduced inspiratory, expiratory and upper airway muscle strength. Breathless-ness is often the most severe symptom18 and commonly presents as part of the complex of symptoms related to chronic nocturnal hypoventilation. This complex of symptoms includes daytime fatigue and sleepiness, poor concentration, difficulty sleeping and nightmares, morning headache, autonomic symptoms, depression and anxiety, reduced appetite and weight loss, recurrent or...

Intracerebral Vascular Disorders

Subarachnoid hemorrhage may occur following trauma or spontaneous rupture of a berry aneurysm or arteriovenous malformation. Nuchal rigidity is an inconstant finding. Venous thrombosis may follow severe dehydration or a pyogenic infection of the paranasal sinuses, mastoid, or middle ear. Periorbital edema with cranial nerve abnormalities is a clue. Arterial thrombosis is uncommon in children, except in those with homocystinuria. Children with homocystinuria have a marfanoid appearance, dislocated lenses, and mental retardation. Intracerebral and intraventricular hemorrhages may follow birth asphyxia or trauma in neonates, but in older children they may signify a congenital or acquired coagulopathy. Signs of subacute bacterial endocarditis include splinter hemorrhages, splenomegaly, microscopic hematuria, and AMS caused by cerebral emboli. Acute infantile hemiplegia presents with an acute seizure followed by hemiparesis and coma. Acute confusional migraine may be associated with...

Approach to food avoidance

If the symptoms are largely subjective, such as headaches or behaviour changes, and an improvement is observed with the exclusion diet, DBPCFC is essential. If the diagnosis is confirmed, food should be excluded for a longer period. Again, reintroduction or challenge should be done at regular intervals, especially in children who often grow to tolerate the food. When more than one food is suspected the dietitian should carefully monitor the exclusion diet and suggest appropriate replacement foods.

Hormonal contraceptive methods other than oral contraceptives

In a multicenter study, including 2322 women, the Pearl Index of efficacy in compliant patients was 0.8. Irregular bleeding was uncommon (5.5 of cycles), and withdrawal bleeding occurred in 98.5 of cycles. Compliance was 86 , with 15 of women discontinuing treatment because of an adverse event, most commonly device-related discomfort, headache, or vaginal discharge vaginitis. Only 2.5 of discontinuations were device related.

Transdermal contraceptive patch

Amenorrhea, irregular bleeding, and weight gain (typically 1 to 3 kg) are the most common adverse effects of DMPA. Adverse effects also include acne, headache, and depression. Fifty percent of women report amenorrhea by one year. Persistent bleeding may be treated with 50 g of ethinyl estradiol for 14 days. 2. Weight gain, hypertension, headache, mastalgia, or other nonmenstrual complaints are common.

Mycoplasma Infections

Mycoplasma pneumoniae infections are a common cause of pneumonia, upper respiratory infections, and bronchitis in children between 5 and 19 years of age. The most frequent presenting clinical findings in children and adults are fever, cough, sore throat, malaise, headache, chills, and rash. An erythematous maculopapular rash, the most frequent presentation, is located on the trunk and may be discrete or confluent. However, the most frequently reported exanthem is consistent with erythema multiforme and Stevens-Johnson syndrome, with lesions occurring primarily on the trunk, legs, and arms. The rash occurs most commonly during the febrile period. An enanthem of generalized ulcerative stomatitis or pharyngitis-tonsillitis associated with the exanthem is common. The diagnosis can be confirmed by the use of either serum cold agglutinins or several specific antibody tests.

Serotonin Receptor Signaling

Serotonin (5-hydroxytryptamine 5-HT) receptors are a family of G-protein-coupled receptors (GPCRs) and one ligand-gated ion channel that transduce an extracellular signal by the neurotransmitter serotonin to an intracellular response. 5-HT receptors are involved in multiple physiological functions such as cognition, sleep, mood, eating, sexual behavior, neuroendocrine function, and gastrointestinal (GI) motility. Since many physiological processes are influenced by 5-HT receptors, it is not surprising that dysfunction and regulation of 5-HT receptors are implicated in numerous disorders and disease states including migraine, depression, anxiety, schizophrenia, obesity, and irritable bowel syndrome. Therefore, understanding 5-HT receptor second messenger systems, their effector linkage, the multiplicity of coupling pathways, and how these pathways are regulated is critical to disease etiology and therapeutic discovery.

Chiari II Malformation

Chiari II malformation is present in the majority of children with meningomyelocele. Chiari II malformation consists of malformation of the cerebellum, hindbrain, and brainstem. Aqueductal stenosis is commonly associated. Symptomatic Chiari malformation is characterized by apnea, vocal cord paralysis, stridor, oral motor dysfunction, visual dysfunction, and upper limb weakness and incoordination in the infant. In older children it presents with visual dysfunction, motor incoordination, headache, and hand weakness.11 Even mild cervical hyperflexion-extension injuries may result in symptoms. Of greatest concern is the young child or infant who presents to the ED with stridor and meningomyelocele. Suspicion of a Chiari malformation should be present, and evaluation should be ordered on an expedited basis. Stridor may be associated with vocal cord paralysis and may proceed to complete airway obstruction in a small number of patients. Evaluation is by MRI of the craniocervical junction....

Susceptibility gene identification

To test whether or not high-density single nucleotide polymorphism (SNP) mapping could detect a susceptibility locus within a large region, GlaxoWellcome scientists constructed a SNP map of 2 megabases (mb) on either side of APOE (Lai et al 1998). We asked the question whether a SNP map analysis could detect the location of the APOE locus for AD, if we did not know it was there. The locus was narrowed to less than 100 kilobases (kb), which included the APOE locus, in a very short time frame. This process has since been employed within GlaxoWellcome for other disease susceptibility gene searches through large linkage regions, including psoriasis, diabetes mellitus, migraine, chromosome 12-linked AD and others. These experiments will define the practical density of SNP maps useful for narrowing the large linkage areas to 50 200 kb, containing far fewer candidate genes that could then be tested for disease association (Martin et al 2000).

Potential drawbacks

Eighty-three per cent of patients receiving laser light and 76 of those receiving broadband halogen light PDT reported some discomfort during and after illumination. Sixty-eight per cent of the patients who received laser light and 74 of patients who received broadband halogen light reported some degree of discomfort (stinging, itching, pain, headache, sensation of warmth or blushing) during the first week of treatment. No serious adverse events were reported during the 6-month follow up.

Clarifying Access To The Test Report And Raw Data

A seventeen-year-old boy comes to your office and asks for a comprehensive psychological evaluation. He has been experiencing some headaches, anxiety and depression. A high school dropout, he has been married for a year and has a one-year-old baby but has left his wife and child and returned to live with his parents. He works full time as an auto mechanic and has insurance that covers the testing procedures. You complete the testing. During the following year, you receive requests for information about the testing from a number of people

TABLE 1414 Natural History of Clinical Rabies in Humans

During the prodromal period, the symptoms and signs of rabies are often nonspecific. They include fever, sore throat, chills, malaise, anorexia, headache, nausea, vomiting, dyspnea, cough, and weakness. Early in the course some patients may report symptoms suggestive of rabies such as limb pain, limb weakness, and paresthesias at or near the presumed exposure site. Nonspecific neurologic symptoms may be reported including apprehension, anxiety, agitation, irritability, depression, and psychiatric disturbances.

Central Nervous System

Toxoplasma, an intracellular parasite carried by cats and other intermediate hosts, can cause significant disease in immunocompromised patients. Infection can come from the ingestion of oocysts or undercooked meat, by placental transfer, following organ transplant, or during a blood transfusion. Acquired toxoplasmosis is usually asymptomatic. During acute infection, transient lymphadenopathy and splenomegaly may be present. Reactivation can result in encephalitis, chorioretinitis, myocarditis, and pneumonia. Symptoms of cerebral toxoplasmosis can include severe headache, seizures, confusion, and lethargy. Focal deficits may appear, and cerebellar, brainstem, and cranial nerve lesions may be seen. Making the diagnosis may be difficult. Ventricular fluid, brain tissue, or the buffy coat from a blood sample may be inoculated into test animals. The Sabin-Feldman dye test is fairly specific. An ELISA test for IgG and IgM antibodies to Toxoplasma is available. CT scanning may reveal...

Gastrointestinal Zoonotic Infections

Zoonotic gastroenteritis often presents with fever, headache, and abdominal pain often localizing to the right lower quadrant. Patients may have diarrhea or constipation. Laboratory findings may consist of electrolyte and acid-base abnormalities if diarrhea is severe. Leukocytosis may be seen if an interstitial invasion has occurred, and eosinophilia is often a finding with intestinal parasitic infestation. Most cases of zoonotic gastroenteritis are self-limiting and require only fluid hydration. However, specific pathogens may require specific therapy (Table 145-6).

TABLE 1458 Pet Associated Zoonotic Infections

Bacterial zoonoses from household pets include, but are not limited to, brucellosis, leptospirosis, salmonellosis, and campylobacteriosis. Brucellosis ( Brucella canis) is an uncommon infection in humans and is most often acquired from dogs. Pigs, cattle, and goats are less frequent transmitters. The typical human course for brucellosis is self-limited, with fever, headache, myalgias, and nonspecific laboratory findings. Tetracycline is the standard therapy in treating human brucellosis, with streptomycin added to tetracycline in the treatment of severe cases.30,34 Leptospirosis (Leptospira canicola) infects almost all mammals, but dogs are the principal vector for humans. Humans become infected through exposure to body fluids, particularly urine, of an infected animal. The acute phase of leptospirosis is characterized by headache, malaise, myalgias, and fever. Nonspecific rash, meningitis, uveitis, myositis, and leptospiruria follow the acute phase. Doxycycline (100 mg PO bid for 10...

Psychosomatic Medicine

The increase in recognition of the mind-body connection, and the physical manifestations of psychological processes led to the study of psychosomatic medicine in the early 1900s. The contributions of Freud and Pavlov to this field were first recognized during this time. Psychosomatic medicine is a term that evolved from psychodynamic theory and the biomedical sciences. The focus of psychosomatic medicine was on the mind-body relationship as it pertained to illness (rather than health), and physiological disorders that were thought to be activated by intrapsychic repressions (Millon, 1982). In keeping with the medical and illness models, psychosomatic medicine emphasized the pathogenesis of physical disease. Shorter (1991) documented that in the 1940s in a clinic in Boston, 400 out of 1000 patients were documented as having neuropsychiatric problems, of which the great majority were a mixture of nervous exhaustion, nervous digestive problems, and tension headaches (p. 149). Thus,...

Encephalitis Arboviral

Arboviral encephalitis is characterized by a febrile illness associated with any of the following neurologic signs and symptoms headache, confusion, altered sensorium, nausea and vomiting, meningismus, cranial nerve palsy, paresis or paralysis, sensory deficit, altered reflexes, seizures, abnormal movements, or coma. The illness may be of varying severity and cannot be distinguished clinically from other central nervous system infections.

Hantavirus Pulmonary Syndrome

Hantavirus pulmonary syndrome is a febrile illness characterized by bilateral interstitial pulmonary infiltrates and respiratory compromise resembling adult respiratory distress syndrome. There is typically a prodrome of fever, chills, myalgias, headache, and gastrointestinal distress. Common laboratory findings include one or more of the following hemoconcentration, left shift in white blood cell count, neutrophilic leukocytosis, thrombocytopenia, or circulating immunoblasts.

Rocky Mountain Spotted Fever

This is a tick-borne illness of acute onset and characterized by headache, myalgia, fever, and petechial rash that appears on the palms and soles in two-thirds of patients. Laboratory diagnosis may be made by one of several methods (1) a fourfold or greater rise in antibody titer to Rickettsia rickettsi. antigen by immunofluorescence antibody, complement fixation, latex agglutination, microagglutination, or indirect hemagglutination antibody test in acute and convalescent specimens taken 4 weeks apart, (2) positive polymerase chain reaction to R. rickettsii, (3) positive immunofluorescence of skin lesion (biopsy) or organ tissue (autopsy), or (4) isolation of R. rickettsii from a clinical specimen.

Single Nucleotide Polymorphisms Occur in the Serotonin Receptor Family

Normal genetic variations (single-nucleotide polymorphism, SNP) have been identified in almost all 5-HT receptors. Polymorphisms in the coding region of the gene have the potential to alter the receptor's ability to bind ligand, to activate signal-transduction pathways, or to adapt to environmental influences. For example, a polymorphism in the amino terminus of the human 5-HT1A receptor attenuates the down-regulation and desensitization produced by the agonist 8-OH-DPAT. A polymorphic variant in the 5-HT1B receptor in the putative third transmembrane domain alters the binding of the antimigraine drug, suma-triptan. In addition, a polymorphism in the carboxy terminus of 5-HT2A receptor reduces the receptor's ability to mobilize internal Ca2+. Currently, efforts are being made to link the occurrence of 5-HT receptor polymorphisms with various pathological disorders. Future progress in pharmacogenomics (using genetic information to predict drug response) may potentially lead to better...

Herpes simplex type

The onset of HSV-1 encephalitis (HSE) is usually abrupt, although a subacute prodrome of frontal headache and malaise may occur less commonly. Fever is present in 90 of cases, headache is prominent early in the course of disease, and the majority of patients have signs suggesting a localized lesion involving one or both temporal lobes.56,71 These findings often include dramatic personality changes, which may be the first clinical manifestation. Following these behavioural changes, patients may develop aphasia, anosmia, temporal lobe seizures, and hemiparesis. Unlike with HSV-2 meningitis, mucocutaneous herpetic lesions are rarely seen with HSV-1 encephalitis.61

If a normal vagina or uterus are not obviously present

A low or normal serum FSH concentration suggests functional hypothalamic amenorrhea, congenital GnRH deficiency, or other disorders of the hypothalamic-pituitary axis. Cranial MR imaging is indicated in most cases of hypogonadotropic hypogonadism to evaluate hypothalamic or pituitary disease. Cranial MRI is recommended for all women with primary hypogonadotropic hypogonadism, visual field defects, or headaches.

Normal or low serum gonadotropin concentrations and all other tests normal

This result is one of the most common outcomes of laboratory testing in women with amenorrhea. Women with hypothalamic amenorrhea (caused by marked exercise or weight loss to more than 10 percent below the expected weight) have normal to low serum FSH values. Cranial MRl is indicated in all women without an a clear explanation for hypogonadotropic hypogonadism and in most women who have visual field defects or headaches. No further testing is required if the onset of amenorrhea is recent or is easily explained (eg, weight loss, excessive exercise) and there are no symptoms suggestive of other disease.

Disease of nerve and muscle

Prevents the patient exercising to a level where the diaphragm weakness would cause symptoms. Thus breathlessness during wakefulness and while erect is an unusual presenting feature of respiratory muscle involvement in these conditions. More usually the patient presents with features suggestive of nocturnal hypoventilation - these being morning headache or a sensation of fuzziness or being 'hungover' coupled with unwanted daytime somnolence. However the patient may complain of orthopnea or, more rarely, dyspnoea on immersion in water. In both these cases the mechanism is a reduction in vital capacity27,28 consequent on the diaphragm's inability to defend itself against the weight of the abdominal organs and hydrostatic pressure respectively. Patients are often offered non-invasive ventilation (NIV) at this point and available data confirm the clinical impression that this therapy improves symptoms and quality of life.29 NIV is not a treatment for the underlying condition and so...

Clinical Symptoms

Many varieties of animal- or plant-based foods are sources of biogenic amines. Dopamine and tyramine are natural components of banana, cheese, and avocado, and bacterial action on the amino acids (see previously) found in meats and fish can produce putrescine and cadaverine. Also, histamine and b-phenylethylamine have been implicated as etiological agents in several outbreaks of food poisoning. These amines can affect the vascular system, resulting in vessel constriction and subsequently increased blood pressure (pressor amine effects). Norepinephrine and dopamine or catecholamines are pressor amines important as neutrotransmitters in adrenergic nerve cells. They cause diet-induced migraine headaches, and, in some cases, hypertensive crisis.

Clinical Significance Of Legionella

Legionella causes two different manifestations of pulmonary disease a mild, flulike illness, called Pontiac fever, and pneumonia. Pontiac fever has an incubation period of 1-2 days and is characterized by malaise, myalgias, fever, headache, and, sometimes, nonproductive cough. Only symptomatic therapy is required, and complete recovery within 1 week can be expected. Pneumonia, on the other hand, is the predominant manifestation of the more severe form of legionellosis, Legionnaires' disease. This pneumonia can be associated with multiorgan failure. The incubation period of legionnaires' disease ranges from 2 to 10 days, and antimicrobial chemotherapy is necessary for complete recovery of the patients. Nevertheless, in elderly or pulmonary-compromised patients, Legionnaires' disease has a mortality rate of up to 50 . 5,8

Pharmacologic Therapy

Fluoxetine (Sarafem) and sertraline (Zoloft) have been approved for the treatment of PMDD. SSRIs are recommended as initial drug therapy in women with PMS and PMDD. Common side effects of SSRIs include insomnia, drowsiness, fatigue, nausea, nervousness, headache, mild tremor, and sexual dysfunction. Insomnia, drowsiness, fatigue, nausea, nervousness, headache, mild

Disorders of Higher Brain Regions Associated with Hallucinations

Hallucinations are also associated with primary pathology at higher levels of the brain. Most prominent in this category are those that occur in migraine, epilepsy, and schizophrenia. Investigation of cerebral activity associated with hallucinations in these settings has been aided in recent years by the development of techniques such as electroencephalography (EEG), evoked potentials, single photon emission computed tomography (SPECT), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). Combined with data from other avenues of investigation, studies employing these tools have implicated a number of higher brain regions in the generation of hallucinations, corresponding to their form, content, and setting. hallucinations described previously may be described as complex or formed. Noncomplex hallucinations are referred to interchangeably as simple, unformed, or crude. In the visual system, these are known as photopsias, and they occur frequently with...

Chronic Paroxysmal Hemicrania

Chronic paroxysmal hemicrania (CPH) is a rare disorder. It has the same characteristics as cluster headache, including similar associated symptoms. These episodes are briefer, more frequent, occur mostly in females, and responsive to indomethacin. The patient with CPH will characteristically complain of 10-20 brief, intense focal episodes of head pain, localized mostly in the temporal, ocular, frontal, and upper jaw area. The pain has the same quality as cluster headache pain, but of even shorter duration (an average of 10-20 min). CPH attacks are associated with autonomic symptoms and signs that are characteristic for cluster headache. In some patients, head movement or pressure on certain points in the neck can trigger attacks. About 70 of diagnosed patients are female and the mean age of onset is 34 years. The pathogenesis is unknown, but it is considered to be a cluster variant. One of the diagnostic criteria for CPH is absolute responsiveness to indomethacin, an

Alcohol and Drugs in Suicidal Drownings

The presence of toxic or lethal concentrations of medications can assist in the determination of suicide (see Table 1 Fig. 2 and refs. 4 and 5). The finding of psychiatric drugs in a deceased person does not necessarily indicate suicide (5). This observation can verify a history of depression but not suicidal intent (5). Such medications are used for treatment of other illnesses (e.g., migraine, epilepsy 5 ).

Acute Subdural Hematoma

Chronic subdural hematoma is usually precipitated by minor head injury, which is often forgotten by the patient, and the trauma may have occurred several months previously. This form of hematoma occurs more commonly in the elderly and in patients receiving anticoagulant therapy. In addition to the headache, the patient may have decreased mentation, confusion, and drowsiness. The headache is considered secondary to the stretching of the tributary veins that drain the vessels of the cerebral hemispheres into the sagittal sinuses. Neuroimaging will establish the diagnosis, although angiography may be required. Treatment consists of surgical burr holes and evacuation of the clot.

The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

Are Constant Headaches Making Your Life Stressful? Discover Proven Methods For Eliminating Even The Most Powerful Of Headaches, It’s Easier Than You Think… Stop Chronic Migraine Pain and Tension Headaches From Destroying Your Life… Proven steps anyone can take to overcome even the worst chronic head pain…

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