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Jaw Pain Symptoms

Symptom Checker: Symptoms & Signs Index

Terms related to Jaw Pain:

Pain in the Jaw

Temporomandibular Joint Pain

TMJ Pain

The jaw joint, medically referred to as the temporomandibular joint or TMJ, is made up of the bone below the mouth (the mandible, commonly referred to as the jawbone) and the bone just above the mouth (the maxilla). The TMJ allows the upper jaw to close on the lower jaw and is one of the most frequently used joints of the body.

The temporomandibular joints are complex structures containing muscles, tendons, and bones. Injury to or disorders of these structures can all result in pain in the jaw area. Additionally, other medical conditions not related to the TMJ may cause perceived pain in the jaw area. One of the most characteristic of these is the pain associated with coronary artery disease or heart attack, which typically occurs in the chest but can radiate (spread) to the jaw area.

REFERENCE:

Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.

Main Articles on Jaw Pain

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Causes of Jaw Pain

Abscessed Tooth

An abscessed tooth is a painful infection at the root of a tooth or between the gum and a tooth. It's most commonly caused by severe tooth decay. Other causes of tooth abscess are trauma to the tooth, such as when it is broken or chipped, and gingivitis or gum disease.

These problems can cause openings in the tooth enamel, which allows bacteria to infect the center of the tooth (called the pulp). The infection may also spread from the root of the tooth to the bones supporting the tooth.

What are the symptoms of an abscessed tooth?

A toothache that is severe and continuous and results in gnawing or throbbing pain or sharp or shooting pain are common symptoms of an abscessed tooth. Other symptoms may include:

Pain when chewing

Sensitivity of the teeth to hot or cold

Bitter taste in the mouth

Foul smell to the breath

Swollen neck glands

General discomfort, uneasiness, or ill feeling

Redness and swelling of the gums

Swollen area of the upper or lower jaw

An open, draining sore on the side of the gum

∑ <a href=How is an abscessed tooth treated? ∑ Can an abscessed tooth be prevented?Patient Discussions: Abscessed Tooth An abscessed tooth is a painful infection at the root of a tooth or between the gum and a tooth. It's most commonly caused by severe tooth deca y . Other causes of tooth abscess are trauma to the tooth, such as when it is broken or chipped, and gingivitis or gum disease . These problems can cause openings in the tooth enamel, which allows bacteria to infect the center of the tooth (called the pulp). The infection may also spread from the root of the tooth to the bones supporting the tooth. What are the symptoms of an abscessed tooth? A toothache that is severe and continuous and results in gnawing or throbbing pain or sharp or shooting pain are common symptoms of an abscessed tooth. Other symptoms may include: ∑ Fever ∑ Pain when chewing ∑ Sensitivity of the teeth to hot or cold ∑ Bitter taste in the mouth ∑ Foul smell to the breath ∑ Swollen neck glands ∑ General discomfort, uneasiness, or ill feeling ∑ Redness and swelling of the gums ∑ Swollen area of the upper or lower jaw ∑ An open, draining sore on the side of the gum What does an abscessed tooth look like? If the root of the tooth dies as a result of infection, the toothache may stop. However, this doesn't mean the infection has healed; the infection remains active and continues to spread and destroy tissue. Therefore, if you experience any of the above listed symptoms, it is important to see a dentist even if the pain subsides. How is an abscessed tooth diagnosed? Your dentist will probe your teeth with a dental instrument. If you have an abscessed tooth, you will feel pain when the tooth is tapped by your dentist's probe. Your dentist will also ask you if your pain increases when you bite down or when you close your mouth tightly. In addition, your dentist may suspect an abscessed tooth because your gums may be swollen and red. Your dentist may also take X-rays to look for erosion of the bone around the abscess. How is an abscessed tooth treated? Strategies to eliminate the infection, preserve the tooth, and prevent complications are the goals of treatment for an abscessed tooth. To eliminate infection, the abscess may need to be drained. Achieving drainage may be done through the tooth by a procedure known as a root canal . Root canal surgery may also be recommended to remove any diseased root tissue after the infection has subsided. Then, a crown may be placed over the tooth. The tooth may also be extracted, allowing drainage through the socket. Finally, a third way to drain the abscess would be by incision into the swollen gum tissue. " id="pdf-obj-1-95" src="pdf-obj-1-95.jpg">

What does an abscessed tooth look like?

If the root of the tooth dies as a result of infection, the toothache may stop. However, this doesn't mean the infection has healed; the infection remains active and continues to spread and destroy tissue. Therefore, if you experience any of the above listed symptoms, it is important to see a dentist even if the pain subsides.

How is an abscessed tooth diagnosed?

Your dentist will probe your teeth with a dental instrument. If you have an abscessed tooth, you will feel pain when the tooth is tapped by your dentist's probe. Your dentist will also ask you if your pain increases when you bite down or when you close your mouth tightly. In addition, your dentist may suspect an abscessed tooth because your gums may be swollen and red.

Your dentist may also take X-rays to look for erosion of the bone around the abscess.

How is an abscessed tooth treated?

Strategies to eliminate the infection, preserve the tooth, and prevent complications are the goals of treatment for an abscessed tooth.

To eliminate infection, the abscess may need to be drained. Achieving drainage may be done through the tooth by a procedure known as a root canal. Root canal surgery may also be recommended to remove any diseased root tissue after the infection has subsided. Then, a crown may be placed over the tooth.

The tooth may also be extracted, allowing drainage through the socket.

Finally, a third way to drain the abscess would be by incision into the swollen gum tissue.

Antibiotics are prescribed to help fight the infection. To relieve the pain and discomfort associated with an abscessed tooth, warm salt-water rinses and over-the-counter pain medication like ibuprofen (Advil or Motrin) can be used.

The inflammation and pain of abscesses may be relieved with a low-level laser, making the patient more comfortable to receive the injection in a more painless way.

Can an abscessed tooth be prevented?

Following good oral hygiene practices can reduce the risk of developing a tooth abscess. Also, if your teeth experience trauma (for example, become loosened or chipped), seek prompt dental attention.

WebMD Medical Reference

Reviewed by Elverne M. Tonn, DDS, on September 17, 2009

© 2009 WebMD, LLC. All rights reserved.

Last Editorial Review: 9/17/2009

Angina

Introduction to angina

Chest pain is a common symptom that is caused by many different conditions. Some causes require prompt medical attention, such as angina, heart attack, or tearing of the aorta. Other causes of chest pain that may not require immediate medical intervention include spasm of the esophagus, gallbladder attack, or inflammation of the chest wall. An accurate diagnosis is important in providing proper treatment to patients with chest pain.

The diagnosis and treatment of angina is discussed below, as well as the diagnosis of other causes of chest pain that can mimic angina.

What is angina, and what are the symptoms of angina?

Angina (angina pectoris - Latin for squeezing of the chest) is chest discomfort that occurs when there is a decreased blood oxygen supply to an area of the heart muscle. In most cases, the lack of blood supply is due to a narrowing of the coronary arteries as a result of arteriosclerosis.

Angina is usually felt as:

pressure,

heaviness,

tightening,

squeezing, or

aching across the chest, particularly behind the breastbone.

This pain often radiates to the neck, jaw, arms, back, or even the teeth.

Patients may also suffer:

sweating,

cramping, and

Angina usually occurs during exertion, severe emotional stress, or after a heavy meal. During these periods, the heart muscle demands more blood oxygen than the narrowed coronary arteries can deliver. Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing a nitroglycerin tablet under the tongue. Nitroglycerin relaxes the blood vessels and lowers blood pressure. Both rest and nitroglycerin decrease the heart muscles demand for oxygen, thus relieving angina.

Angina is classified in one of two types: 1) stable angina or 2) unstable angina.

Stable angina

Stable angina is the most common type of angina, and what most people mean when they refer to angina. People with stable angina have angina symptoms on a regular basis and the symptoms are somewhat predictable (for example, walking up a flight of steps causes chest pain). For most patients, symptoms occur during exertion and commonly last less than five minutes. They are relieved by rest or medication, such as nitroglycerin under the tongue.

Unstable angina

Unstable angina is less common and more serious. The symptoms are more severe and less predictable than the pattern of stable angina. Moreover, the pains are more frequent, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue (or the patient needs to use more nitroglycerin than usual). Unstable angina is not the same as a heart attack, but it warrants an immediate visit to your healthcare provider or hospital emergency department as further cardiac testing is urgently needed. Unstable angina is often a precursor to a heart attack.

What causes angina?

The most common cause of angina is coronary artery disease. A less common cause of angina is spasm of the coronary arteries.

Coronary artery disease

Coronary arteries supply oxygenated blood to the heart muscle. Coronary artery disease develops as cholesterol is deposited in the artery wall, causing the formation of a hard, thick substance called cholesterol plaque. The accumulation of cholesterol plaque over time causes narrowing of the coronary arteries, a process called arteriosclerosis. Arteriosclerosis can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. When coronary arteries become narrowed by more than 50% to 70%, they can no longer meet the increased blood oxygen demand by the heart muscle during exercise or stress. Lack of oxygen to the heart muscle causes chest pain (angina).

Coronary artery spasm

The walls of the arteries are surrounded by muscle fibers. Rapid contraction of these muscle fibers causes a sudden narrowing (spasm) of the arteries. A spasm of the coronary arteries reduces blood to the heart muscle and causes angina. Angina as a result of a coronary artery spasm is called "variant" angina or Prinzmetal angina. Prinzmetal angina typically occurs at rest, usually in the early morning hours. Spasms can occur in normal coronary arteries as well as in those narrowed by arteriosclerosis.

Coronary artery spasm can also be caused by use/abuse of cocaine. The spasm of the artery wall caused by cocaine can be so significant that it can actually cause a heart attack.

What are other causes of chest pain?

In caring for patients with chest pain, the doctor distinguishes whether the pain is related to a lack of oxygen to the heart muscle (as in angina or heart attack), or is due to another process. Many conditions are considered that can cause chest pain which is similar to that of a heart attack or angina. Examples include the following:

Pleuritis (pleurisy): Inflammation of the lining of the lungs (pleuritis) causes sharp chest pain, which is aggravated by deep breathing and coughing. Patients often notice shortness of breath, in part due to their shallow breathing to minimize chest pain. Viral infections are the most common causes of pleurisy. Other systemic inflammatory conditions, such as systemic lupus, can also cause pleurisy.

Pericarditis: Pericarditis is inflammation of the lining around the heart. Symptoms of pericarditis are similar to that of pleuritis.

Pneumonia: Pneumonia (bacterial infection of the lung) causes fever and chest pain. Chest pain in bacterial pneumonia is due to an irritation or infection of the lining of the lung (pleura).

Pulmonary embolism: blood clots travel from the veins of the pelvis or the lower extremities to the lung, the condition is called pulmonary embolism. Pulmonary embolism can cause death of lung tissue (pulmonary infarction). Pulmonary infarction can lead to irritation of the pleura, causing chest pain similar to pleurisy. Some common causes of blood clots in these veins is deep vein thrombosis (prolonged immobility, recent surgery, trauma to the legs, or pelvic infection).

Pneumothorax: Small sacs in the lung tissue (alveoli) can spontaneously burst, causing pneumothorax. Symptoms of pneumothorax include sudden, severe, sharp chest pain and shortness of breath. One common cause of pneumothorax is severe emphysema.

Mitral valve prolapse: Mitral valve prolapse is a common heart valve abnormality, affecting 5% to 10% of the population. MVP is especially common among women between 20 to 40 years of age. Chest pain with MVP is usually sharp but not severe. Unlike angina, chest pain with MVP rarely occurs during or after exercise, and usually will not respond to nitroglycerin.

Aortic dissection: The aorta is the major vessel delivering blood from the left ventricle to the rest of the body. Aortic dissection (tearing of the aorta wall) is a life-threatening emergency. Aortic dissection causes severe, unrelenting chest and back pain. Young adults with aortic dissection usually have Marfan's syndrome, an inherited disease in which an abnormal form of the structural protein called collagen causes weakness of the aortic wall. Older patients develop aortic dissection typically as a result of chronic, high blood pressure, in addition to generalized hardening of the arteries (arteriosclerosis).

Costochondritis, rib fractures, muscle strain or spasm: Pain originating from the chest wall may be due to muscle strain or spasm, costochondritis, or rib fractures. Chest wall pain is usually sharp and constant. It is usually worsened by movement, coughing, deep breathing, and direct pressure on the area. Muscle spasm and strain can result from vigorous, unusual twisting and bending. The joints between the ribs and cartilage next to the breastbone can become inflamed, a condition called costochondritis. Fractured ribs resulting from trauma or cancer involvement can cause significant chest pain.

Nerve compression: Compression of the nerve roots by bone spurs as they exit the spinal cord can cause pain. Nerve compression can also cause weakness and numbness in the upper arm and chest.

Shingles (herpes zoster infection of the nerves): Shingles is nerve irritation from the infection, which can cause chest pain days before any typical rash appears.

Esophageal spasm and reflux: The esophagus is the long muscular tube connecting the mouth to the stomach. Reflux, or regurgitation of stomach contents and acid into the esophagus can cause heartburn and chest pain. Spasm of the muscle of the esophagus can also cause chest pain which can be indistinguishable from chest pain caused by angina or a heart attack. The cause of esophageal muscle spasm is not known. Pain of esophageal spasm can respond to nitroglycerin in a similar manner as angina.

Gallbladder attack (gallstones): Gallstones can block the gallbladder or bile ducts and cause severe pain of the upper abdomen, back and chest. Gallbladder attacks can mimic the pain of angina and heart attack.

Anxiety and panic attacks: Anxiety, depression, and panic attacks are frequently associated with chest pain lasting from minutes to days. The pain can be sharp or dull. It is usually accompanied by shortness of breath, or the inability to take a deep breath. Emotional stress can aggravate chest pain, but the pain is generally not related to exertion, and is not relieved by nitroglycerin. These patients often breath too fast (hyperventilate), causing lightheadedness, numbness, and tingling in the lips and fingers. Coronary artery disease risk factors are typically absent in these patients. Since there is no test for panic attacks, patients with chest pain usually undergo tests to exclude coronary artery disease and other causes of chest pain.

Why is it important to establish the diagnosis of angina?

Angina is usually a warning sign of the presence of significant coronary artery disease. Patients with angina are at risk of developing a heart attack (myocardial infarction). A heart attack is the death of heart muscle precipitated by the complete blockage of a diseased coronary artery by a blood clot.

During angina, the lack of oxygen (ischemia) to the heart muscle is temporary and reversible. The lack of oxygen to the heart muscle resolves and the chest pain disappears when the patient rests. In contrast, the muscle damage in a heart attack is permanent. The dead muscle turns into scar tissue when healed. A scarred heart cannot pump blood as efficiently as a normal heart, and can lead to heart failure.

Up to 25% of patients with significant coronary artery disease have no symptoms at all, even though they clearly lack adequate blood and oxygen supply to the heart muscle. These patients have "silent" angina. They have the same risk of heart attack as those with symptoms of angina.

How is angina diagnosed?

The electrocardiogram (EKG, ECG) is a recording of the electrical activity of the heart muscle, and can detect heart muscle which is in need of oxygen. The EKG is useful in showing changes caused by inadequate oxygenation of the heart muscle or a heart attack.

Exercise stress test

In patients with a normal resting EKG, exercise treadmill or bicycle testing can be useful screening tools for coronary artery disease. During an exercise stress test (also referred to as stress test, exercise electrocardiogram, graded exercise treadmill test, or stress ECG), EKG recordings of the heart are performed continuously as the patient walks on a treadmill or pedals on a stationary bike at increasing levels of difficulty. The occurrence of chest pain during exercise can be correlated with changes on the EKG, which demonstrates the lack of oxygen to the heart muscle. When the patient rests, the angina and the changes on the EKG which indicate lack of oxygen to the heart can both disappear. The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%. If the exercise stress test does not show signs of coronary artery disease, a nuclear agent (thallium) can be given intravenously during exercise stress test. The addition of thallium allows nuclear imaging of blood flow to different regions of the heart, using an external camera. A reduced blood flow in an area of the heart during exercise, with normal blood flow to the area at rest, signifies significant artery narrowing in that region of the heart.

Stress echocardiography

Stress echocardiography combines echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing. Like the exercise thallium test, stress echocardiography is more accurate than an exercise stress test in detecting coronary artery disease. When a coronary artery is significantly narrowed, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle during exercise. Abnormalities in muscle contraction can be detected by echocardiography. Stress echocardiography and thallium stress tests are both about 80% to 85% accurate in detecting significant coronary artery disease.

When a patient cannot undergo exercise stress test because of neurological or orthopedic difficulties, medications can be injected intravenously to simulate the stress on the heart normally brought on by exercise. Heart imaging can be performed with a nuclear camera or echocardiography.

Cardiac catheterization

Cardiac catheterization with angiography (coronary arteriography) is a technique that allows x-ray pictures to be taken of the coronary arteries. It is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the coronary arteries. Iodine contrast "dye" is injected into the arteries while an x-ray video is recorded. Coronary arteriography gives the doctor a picture of the location and severity of coronary artery disease. This information can be important in helping doctors select treatment options.

CT coronary angiogram

CT coronary angiography is procedure that uses an intravenous dye that contains iodine, and CT scanning to image the coronary arteries. While the use of catheters is not necessary (thus the term "noninvasive" test applies to this procedure), there are still some risks involved, including the following:

Patients allergic to iodine

Patients with abnormal kidney function

Radiation exposure which is similar to, if not greater than, that received with a conventional coronary angiogram.

Nonetheless, this is generally a very safe test for most people. It is a major tool in the diagnosis of coronary artery disease in patients:

at high risk for developing coronary disease (cigarette smokers, those with genetic risk, high cholesterol levels, hypertension, or diabetes),

who have unclear results with exercise stress tests or other testing, or

who have symptoms suspicious of coronary disease

What are the treatment options for angina patients?

Treatment options include:

rest,

medications (nitroglycerin, beta blockers, calcium channel blockers),

Angina medications

Nitroglycerin

Resting, nitroglycerin tablets (placed under the tongue), and nitroglycerin sprays all relieve angina by reducing the heart muscle's demand for oxygen. Nitroglycerin also relieves spasm of the coronary arteries and can redistribute coronary artery blood flow to areas that need it most. Short-acting nitroglycerin can be repeated at five minute intervals. When 3 doses of nitroglycerin fail to relieve the angina, further medical attention is recommended. Short-acting nitroglycerin can also be used prior to exertion to prevent angina.

Longer-acting nitroglycerin preparations, such as Isordil tablets, Nitro-Dur transdermal systems (patch form), and Nitrol ointment are useful in preventing and reducing the frequency and intensity of episodes in patients with chronic angina. The use of nitroglycerin preparations may cause headaches and lightheadedness due to an excess lowering of blood pressure.

Beta Blockers

Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart. Inhibiting adrenaline decreases the heart rate, lowers the blood pressure, and reduces the pumping force of the heart muscle, all of which reduce the heart muscle's demand for oxygen. Examples of beta blockers include:

acebutolol (Sectral)

atenolol (Tenormin)

bisoprolol (Zebeta)

metoprolol (Lopressor, Lopressor LA, Toprol XL)

nadolol (Corgard)

propranolol (Inderal)

timolol (Blocadren)

Side effects include of beta blockers include:

worsening of asthma,

excess lowering of the heart rate and blood pressure,

increased cholesterol levels, and

shortness of breath due to diminished heart muscle function (congestive heart failure).

Calcium Channel Blockers

Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping force of the heart muscle, thereby reducing muscle oxygen demand. Calcium channel blockers also relieve coronary artery spasm. Examples of calcium channel blockers include:

amlodipine (Norvasc)

bepridil (Vascor)

diltiazem (Cardizem)

felodipine (Plendil)

isradipine (Dynacirc)

nicardipine , (Cardene)

nifedipine (Adalat, Procardia)

nimodipine (Nimotop)

nisoldipine (Sular)

verapamil (Calan)

Side effects of calcium channel blockers include:

swelling of the legs,

excess lowering of the heart rate and blood pressure, and

depressing heart muscle function.

Other anti-anginal drugs

Ranolazine (Ranexa) is indicated for the treatment of chronic angina. Ranexa may be used with beta-blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE inhibitors, and angiotensin receptor blockers.

Angioplasty and coronary artery bypass surgery

When patients continue to have angina despite maximally tolerated combinations of nitroglycerin medications, beta blockers and calcium channel blockers, cardiac catheterization with coronary arteriography is indicated. Depending on the location and severity of the disease in the coronary arteries, patients can be referred for balloon angioplasty (percutaneous transluminal coronary angioplasty or PTCA) or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.

What are other methods are used to evaluate angina?

Computerized X-ray scan (ultrafast CT scan) is highly accurate in detecting small amounts of calcium in the plaque of coronary arteries. If an ultrafast CT scan shows no calcium in the arteries, atherosclerotic coronary

artery disease is unlikely. Ultrafast CT scanning is useful in evaluating chest pain in younger patients (men under 40 and women under 50 years old). Since young people do not normally have significant coronary artery plaque, a negative ultrafast CT scan makes the diagnosis of coronary artery disease unlikely. However, finding calcium by this method is less meaningful in older patients who are likely to have mild plaquing simply from the aging process.

Even though an ultrafast CT scan is useful in detecting calcium in plaque, it cannot determine whether the calcium-laden plaque actually causes artery narrowing and reduces blood flow. For example, a patient with a densely calcified plaque causing minimal or no artery narrowing will have a strongly positive ultrafast CT scan but a normal exercise treadmill test. In most patients who are suspected of having angina due to coronary artery disease, an exercise treadmill study is usually the first step in determining whether any plaque is clinically significant. Newer very high speed CT scanners can actually detect true coronary artery plaques and lesions similar to coronary angiography.

Magnetic resonance imaging (MRI), using magnetism and radio waves, can be used to image (produce a likeness of) the blood vessels. Currently, the larger vessels, such as the carotid arteries in the neck, can be imaged using this technique. Future software and hardware improvements may allow screening of the heart's arteries with magnetic resonance testing.

What's new in the treatment of angina and heart attacks?

Coronary arteries can close after angioplasty, causing recurrent angina or even heart attacks. One way to decrease the risk of coronary artery closure is by deploying stents to keep the arteries open. Drug-coated stents are being improved to significantly reduce the rate of artery closure.

Angina At A Glance

Angina is one of many causes of chest pain.

Angina is chest pain that is a result of inadequate oxygen supply to the heart muscle.

Angina can be caused by coronary artery disease or spasm of the coronary arteries.

EKG, exercise stress test, stress echocardiography, stress thallium, and cardiac catheterization are important in the diagnosis of angina.

Treatment of angina includes rest, medications, angioplasty, and/or coronary artery bypass surgery.

Additional resources from WebMD Boots UK on Heart Disease: Angina

REFERENCE: Reference:

UpToDate.com. Transmyocardial laser revascularization for management of refractory angina.

FDA Prescribing Information for Ranexa.

Last Editorial Review: 4/11/2008

Arthritis

What is arthritis? What causes arthritis?

Arthritis is a joint disorder featuring inflammation. A joint is an area of the body where two different bones meet. A joint functions to move the body parts connected by its bones. Arthritis literally means inflammation of one or more joints.

Arthritis is frequently accompanied by joint pain. Joint pain is referred to as arthralgia.

There are many types of arthritis (over 100 identified, and the number is growing). The types range from those related to wear and tear of cartilage (such as osteoarthritis) to those associated with inflammation resulting from an overactive immune system (such as rheumatoid arthritis). Together, the many types of arthritis make up the most common chronic illness in the United States.

The causes of arthritis depend on the form of arthritis. Causes include injury (leading to osteoarthritis), metabolic abnormalities (such as gout and pseudogout), hereditary factors, the direct and indirect effect of infections (bacterial and viral), and a misdirected immune system with autoimmunity (such as in rheumatoid arthritis and systemic lupus erythematosus).

Arthritis is classified as one of the rheumatic diseases. These are conditions that are different individual illnesses, with differing features, treatments, complications, and prognoses. They are similar in that they have a tendency to affect the joints, muscles, ligaments, cartilage, and tendons, and many have the potential to affect other internal body areas.

What are arthritis symptoms and signs?

Symptoms of arthritis include pain and limited function of joints. Inflammation of the joints from arthritis is characterized by joint stiffness, swelling, redness, and warmth. Tenderness of the inflamed joint can be present.

Many of the forms of arthritis, because they are rheumatic diseases, can cause symptoms affecting various organs of the body that do not directly involve the joints. Therefore, symptoms in some patients with certain forms of arthritis can also include fever, gland swelling (swollen lymph nodes), weight loss, fatigue, feeling unwell, and even symptoms from abnormalities of organs such as the lungs, heart, or kidneys.

Who is affected by arthritis?

Arthritis sufferers include men and women, children and adults. Approximately 350 million people worldwide have arthritis. Nearly 40 million people in the United States are affected by arthritis, including over a quarter million children!

More than 27 million Americans have osteoarthritis. Approximately 1.3 million Americans suffer from rheumatoid arthritis.

More than half of those with arthritis are under 65 years of age. Nearly 60% of Americans with arthritis are women.

How is arthritis diagnosed, and why is a diagnosis important?

The first step in the diagnosis of arthritis is a meeting between the doctor and the patient. The doctor will review the history of symptoms, examine the joints for inflammation and deformity, as well as ask questions about or

examine other parts of the body for inflammation or signs of diseases that can affect other body areas. Furthermore, certain blood, urine, joint fluid, and/or X-ray tests might be ordered. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and any blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist (see below).

Many forms of arthritis are more of an annoyance than serious. However, millions of people suffer daily with pain and disability from arthritis or its complications.

Earlier and accurate diagnosis can help to prevent irreversible damage and disability. Properly guided programs of exercise and rest, medications, physical therapy, and surgery options can idealize long-term outcomes for those with arthritis.

It should be noted that both before and especially after the diagnosis of arthritis, communication with the treating doctor is essential for optimal health. This is important from the standpoint of the doctor, so that he/she can be aware of the vagaries of the patient's symptoms as well as their tolerance of and acceptance of treatments. It is important from the standpoint of patients, so that they can be assured that they have an understanding of the diagnosis and how the condition does and might affect them. It is also crucial for the safe use of medications.

What is the treatment for arthritis?

The treatment of arthritis is very dependent on the precise type of arthritis present. An accurate diagnosis increases the chances for successful treatment. Treatments available include physical therapy, splinting, cold- pack application, paraffin wax dips, anti-inflammatory medications, immune-altering medications, and surgical operations.

What is the national financial impact of arthritis?

It has been estimated that the total cost of the arthritis bill for the United States, in terms of hospitalization, doctor visits, medications, physical therapies, nursing-home care, lost wages, early death, and family discord is over $50 billion dollars annually.

This does not include the nearly $2 billion spent each year in the United States on unproven remedies by patients addressing their symptoms on their own.

What is a rheumatologist?

A rheumatologist is a medical doctor who specializes in the nonsurgical treatment of rheumatic illnesses, especially arthritis.

Rheumatologists have special interests in unexplained rash, fever, arthritis, anemia, weakness, weight loss, fatigue, joint or muscle pain, autoimmune disease, and anorexia. They often serve as consultants, acting like medical detectives at the request of other doctors.

Rheumatologists have particular skills in the evaluation of the over 100 forms of arthritis and have special interests in rheumatoid arthritis, spondylitis, psoriatic arthritis, systemic lupus erythematosus, antiphospholipid syndrome, Still's disease, dermatomyositis, Sjogren's syndrome, vasculitis, scleroderma, mixed connective tissue disease, sarcoidosis, Lyme disease, osteomyelitis, osteoarthritis, back pain, gout, pseudogout, relapsing polychondritis, Henoch-Schonlein purpura, serum sickness, reactive arthritis, Kawasaki disease, fibromyalgia, erythromelalgia, Raynaud's disease, growing pains, iritis, osteoporosis, reflex sympathetic dystrophy, and others.

Classical adult rheumatology training includes four years of medical school, one year of internship in internal medicine, two years of internal-medicine residency, and two years of rheumatology fellowship. There is a subspecialty board for rheumatology certification, offered by the American Board of Internal Medicine, which can provide board certification to approved rheumatologists.

Pediatric rheumatologists are physicians who specialize in providing comprehensive care to children (as well as their families) with rheumatic diseases, especially arthritis.

Pediatric rheumatologists are pediatricians who have completed an additional two to three years of specialized training in pediatric rheumatology and are usually board-certified in pediatric rheumatology.

What is the Arthritis Foundation?

The Arthritis Foundation is the only national voluntary health organization whose purpose is directed solely to all forms of arthritis. The Arthritis Foundation has national and international programs involving support for scientific research, public information and education for affected patients and their families, training of specialists, public awareness, and local community assistance.

Local branch chapters of the Arthritis Foundation serve to disseminate information about arthritis and rheumatic diseases, as well as function as referral centers. Moreover, many of the various forms of arthritis have their own foundations that serve as information and referral resources for local communities.

Summary

It is the ultimate goal of scientific arthritis research that optimal treatment programs are designed for each of the many form of arthritis. This field will continue to evolve as improvements develop in the diagnosis and treatment of arthritis and related conditions.

Arthritis At A Glance

Arthritis is inflammation of one or more joints.

Symptoms of arthritis include pain and limited function of joints.

Arthritis sufferers include men and women, children and adults.

A rheumatologist is a medical arthritis expert.

Earlier and accurate diagnosis can help to prevent irreversible damage and disability.

REFERENCE:

"Arthritis Prevalence: A Nation in Pain." Arthritis Foundation. <http://www.arthritis.org>.

Last Editorial Review: 6/21/2010

Cluster Headaches

Introduction

The term "cluster headache" refers to a type of headache that recurs over a period of time. People who have cluster headaches experience an episode one to three times per day during a period of time (the cluster period), which may last from 2 weeks to 3 months. The headaches may disappear completely (go into "remission") for months or years, only to recur. A cluster headache typically awakens a person from sleep 1 to 2 hours after going to bed. These nocturnal attacks can be more severe than the daytime attacks. Attacks appear to be linked to the circadian rhythm (or "biological" clock). Most people with cluster headaches will develop cluster periods at the same time each year -- either in the spring or fall or the winter or summer.

Cluster headaches are one of the most severe types of headache. It can be 100 times more intense than a migraine attack.

Who Gets Cluster Headaches?

Cluster headaches are the least common type of headaches, affecting less than 1 in 1,000 people. Cluster headaches are a young person's disease: the headaches typically start before age 30. Cluster headaches are more common in men, but more women are starting to be diagnosed with this problem. The male to female ratio is 2-3:1.

What Causes Cluster Headaches?

The true biochemical cause of cluster headaches is unknown. However, the headaches occur when a nerve pathway in the base of the brain (the trigeminal-autonomic reflex pathway) is activated. The trigeminal nerve is the main nerve of the face responsible for sensations (such as heat or pain.)

When activated, the trigeminal nerve causes the eye pain associated with cluster headaches. The trigeminal nerve also stimulates another group of nerves that causes the eye tearing and redness, nasal congestion, and discharge associated with cluster attacks.

The activation of the trigeminal nerve appears to come from a deeper part of the brain called the hypothalamus. The hypothalamus is home to our "internal biologic clock" which regulates our sleep and wake cycles on a 24- hour schedule. Recent imaging studies have shown activation or stimulation of the hypothalamus during a cluster attack.

Cluster headaches are not caused by an underlying brain condition such as a tumor or aneurysm.

What Are the Symptoms of a Cluster Headache?

Cluster headaches generally reach their full force within five or ten minutes after onset. The attacks are usually very similar, varying only slightly from one attack to another.

Type of Pain: The pain of cluster headache is almost always one-sided, and during a

headache period, the pain remains on the same side. When a new headache period starts, it rarely occurs on the opposite side. Severity/Intensity of Pain: The pain of a cluster headache is generally very intense and

severe and is often described as having a burning or piercing quality. It may be throbbing or constant. The pain is so intense that most cluster headache sufferers cannot sit still and will often pace during an attack. Location of Pain: The pain is located behind one eye or in the eye region, without changing

sides. It may radiate to the forehead, temple, nose, cheek, or upper gum on the affected side. The scalp may be tender, and the pulsing in the arteries often can be felt. Duration of Pain: The pain of a cluster headache lasts a short time, generally 30 to 90

minutes. It may, however, last from 15 minutes to three hours. The headache will disappear only to recur later that day. Typically, in between attacks, people with cluster headaches are headache free. Frequency of Headaches: Most sufferers get one to three headaches per day during a cluster period (the time when the headache sufferer is experiencing daily attacks). They occur very regularly, generally at the same time each day, and have been called "alarm clock headaches" because they often awaken the person at the same time during the night.

Most cluster sufferers (80%-90%) have episodic cluster headaches that occur in periods lasting seven days to one year, separated by pain-free episodes lasting 14 days or more.

In about 20% of people with cluster headaches, the attacks may be chronic, meaning there are less than 14 headache-free days per year. Chronic cluster headaches vary from episodic cluster headaches, as they are continuous without remission periods.

Cluster headaches are not typically associated with nausea or vomiting. It is possible for someone with cluster headaches to also suffer from migraines.

Is There Any Way to Tell That a Cluster Headache Is Coming?

Although the pain of a cluster headache starts suddenly, there may be a few subtle signs of the oncoming headache. Some signs include:

Feeling of discomfort or a mild, one-sided burning sensation.

The eye on the side of the headache may become swollen or droop. The pupil of the eye may

get smaller and the conjunctiva (the pink tissue that lines the inside of the eyelid) will redden. Nasal discharge. There may be nasal discharge or congestion and tearing of the eye during

an attack, which occur on the same side as the pain. Excessive sweating.

Flushing of the face on the affected side.

Light sensitivity.

What Is the Treatment for Cluster Headaches?

Abortive medications. The most successful treatments are Imitrex (sumatriptan) injections and breathing oxygen through a face mask for twenty minutes. Other options include:

ergotamine drugs and intranasal lidocaine. Preventive medications. Your doctor can prescribe preventive medications to shorten the length of the cluster headache period as well as decrease the severity of the headaches. All cluster headache sufferers should take preventive medication unless their cluster periods last less than two weeks. Some medications used in the prevention of cluster headaches include:

verapamil, lithium, divalproex sodium, prednisone (only short courses), and ergotamine tartrate. Surgery. This may be an option for people with chronic cluster headaches who have not been helped with standard therapy. Most of the procedures involve blocking the trigeminal nerve.

All of these treatments should be used under the direction of a doctor familiar with treating cluster headaches. As with any medication, it is important to carefully follow the label instructions and your doctor's advice.

SOURCE:

Reviewed by Jonathan L Gelfand, MD on January 23, 2008

Edited by Lily Jung, MD on December 01, 2006

'Portions of this page © The Cleveland Clinic 2000-2004

Last Editorial Review: 1/23/2008

Cysts

What is a cyst?

A cyst is a closed, saclike structure that contains fluid, gas, or semisolid material and is not a normal part of the tissue where it is located. Cysts are common and can occur anywhere in the body in people of any age. Cysts vary in size; they may be detectable only under a microscope or they can grow so large that they displace normal organs and tissues. The outer wall of a cyst is called the capsule.

What are the causes of a cyst?

Cysts can arise through a variety of processes in the body, including

"wear and tear" or simple obstructions to the flow of fluid,

infections,

tumors,

chronic inflammatory conditions,

genetic (inherited) conditions,

defects in developing organs in the embryo.

Most cysts arise due to the types of conditions listed above and are only preventable to the extent that the underlying cause is preventable.

What are cyst symptoms and signs, and how are cysts diagnosed?

Sometimes you can feel a cyst yourself when you feel an abnormal "lump." For example, cysts of the skin or tissues beneath the skin are usually noticeable. Cysts in the mammary glands (breasts) also may be palpable (meaning that you can feel them when you examine the area with your fingers). Cysts of internal organs such as the kidneys or liver may not produce any symptoms or may not be detected by the affected individual. These cysts often are first discovered by imaging studies (X-ray, ultrasound, computerized tomography or CAT scan, and magnetic resonance imaging or MRI). Cysts may or may not produce symptoms, depending upon their size and location.

This is a picture of a skin cyst, one of hundreds of types of cysts. What( fibrocystic breast disease )Ovarian cysts , including dermoid cysts , a specific type of ovarian tumor that often contains cysts and other tissues ∑ Cysts within the thyroid gland ∑ Baker cyst (popliteal) behind the knee ∑ Ganglion cysts of the joints and tendons ∑ Cysts of the glands within the eyelid, termed chalazions " id="pdf-obj-16-2" src="pdf-obj-16-2.jpg">

This is a picture of a skin cyst, one of hundreds of types of cysts.

What are the different types of cysts?

There are hundreds of different types of cysts that can arise in the body. Here are some of the more well-known types of cysts:

Cysts in the breast which are part of benign proliferative ("fibrocystic") disease (fibrocystic breast disease)

Ovarian cysts , including dermoid cysts, a specific type of ovarian tumor that often contains cysts and other tissues

Cysts within the thyroid gland

Baker cyst (popliteal) behind the knee

Ganglion cysts of the joints and tendons

Cysts of the glands within the eyelid, termed chalazions

Sebaceous cysts of the small glands in the skin

Epidermal cysts of the skin, sometimes known as epidermal inclusion cysts, that are frequently found on the face, scalp, neck, and trunk

Bartholin cysts, enlargement of small glands near the vaginal opening

Pineal cysts, cysts within the pineal gland of the brain

Pancreatic cysts are collections of fluid within the pancreas. Some pancreatic cysts are true cysts that are lined by cells that secrete fluid. Other pancreatic cysts are pseudocysts and do not contain specialized lining cells.

Polycystic kidney disease , an inherited condition in which the kidneys contain multiple cysts

Tarlov cysts, also known as meningeal or perineural cysts, are located in the sacrum, the fused bones at the base of the spine.

Infections and inflammation, such as abscesses and boils on the skin, can also be causes of cysts.

Arachnoid cysts are located between the brain or spinal cord and the arachnoid membrane, one of the three membranes that cover the brain and spinal cord.

The majority of cysts are benign, but some may produce symptoms due to their size and/or location. Rarely, cysts can be associated with malignant tumors (cancers) or serious infections. If you're concerned about any abnormal swelling or lump, talk to your doctor. He or she can recommend appropriate diagnostic tests to determine whether a cyst is present and the cause of the cyst.

What is the treatment for a cyst?

The treatment for a cyst depends upon the cause of the cyst along with its location. Cysts that are very large and result in symptoms due to their size may be surgically removed. Sometimes the fluid contained within a cyst can be drained, or aspirated, by inserting a needle or catheter into the cyst cavity, resulting in collapse of the cyst. Radiologic imaging may be used for guidance in draining (aspirating) cyst contents if the cyst is not easily accessible. Drainage or removal of a cyst at home is not advised.

Surgical removal of a cyst is sometimes necessary. If there is any suspicion that a cyst is cancerous, the cyst is generally removed by surgery or a biopsy is taken of the cyst wall (capsule) to rule out malignancy. In certain

cases, aspirated fluid from a cyst is examined under a microscope to determine if cancer cells are present in the cyst.

If a cyst arises as part of a chronic medical condition (for example, in polycystic ovary syndrome or fibrocystic breast disease), treatment is generally directed at the underlying medical condition.

Is prevention of cysts possible?

Prevention of cyst formation is only possible to the extent to which prevention of the underlying cause of the cyst is possible. Most kinds of cysts are not preventable.

What is the prognosis of cysts?

The majority of cysts are benign conditions and do not result in long-term or serious complications. However, cysts that are associated with malignancy or serious infections can have a poor prognosis.

Cysts At A Glance

Cysts are common, closed saclike structures that contains fluid, gas, or semisolid material.

There are hundreds of different types of cysts.

Cysts can be located in all areas of the body.

Superficial cysts may be felt as an abnormal "lump" on the skin. Cysts of internal organs, such

as the liver, kidneys, or pancreas, may not be noticed and may or may not produce symptoms. Cysts of internal organs may not be noticed and may or may not produce symptoms. A number of different processes can result in cyst formation, including blockage of the flow of

fluids, infection, trauma, tumors, congenital defects, and chronic inflammatory conditions. The majority of cysts are benign, but certain cases can be associated with malignant tumors.

Additional resources from WebMD Boots UK on Cysts, Lumps and Bumps

REFERENCES:

Hanson, Linda J., and Nathalie C. Zeitouni. "Epidermal Inclusion Cysts." eMedicine.com. May 6, 2010.

<http://emedicine.medscape.com/article/1061582-overview>.

Kumar, Vinay, Abul K. Abbas, Nelson Fausto, and Jon Aster. Robbins & Cotran Pathologic Basis of Disease. 8th ed. Philadelphia: Saunders, 2009.

Last Editorial Review: 2/17/2011

Fracture

Introduction to fracture

Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and the bone marrow is the production center for blood products.

Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been lost and the bone structure fails.

Broken bones hurt for a variety of reasons including:

The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the bone is broken or bruised.

Broken bones bleed, and the blood and associated swelling (edema) causes pain.

Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the bone may determine what type of injury that occurs. Descriptions of fractures can be confusing. They are based on:

where in the bone the break has occurred,

how the bone fragments are aligned, and

whether any complications exist.

The first step in describing a fracture is whether it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively.

Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or inibuprofen . These fractures can take six to eight weeks to heal (as long as the fracture can be seen on x-ray). Trying to return too quickly can cause re- injury, and may also allow the stress fracture to extend through the entire bone. Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to inflammation of the lining of the bone, called the periosteum . Shin splints are caused by overuse, especially in runners , walkers , dancers, including those who do aerobics . Muscles that run through the periosteum and the bone itself may also become inflamed. Treatment is similar to a stress fracture and physical therapy can be helpful. Compression fracture As people age, there is a potential for the bones to develop osteoporosis , a condition where bones lose their calcium content. This makes bone more susceptible to breaking. One such type of injury is a compression fracture to the spine, most often the thoracic or lumbar spine. Since we are an upright animal, if the bones of the back are weaker than the force of gravity these bones can crumple. Pain is the major complaint, especially with movement. " id="pdf-obj-20-2" src="pdf-obj-20-2.jpg">

Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their normal alignment.

What are common types of fractures?

Stress fracture

A stress fracture is an overuse injury. Because of repeated micro-trauma, the bone can fail to absorb the shock that is being put upon it and become weakened. Most often it is seen in the lower leg, the shin bone (tibia), or foot. Athletes are at risk the most, because they have repeated footfalls on hard surfaces. Tennis players, basketball players, jumpers, and gymnasts are typically at risk. A March fracture is the name given to a stress fracture of the metatarsal or long bones of the foot. (It is named because it often occurs in soldiers who are required to march long distances.)

Diagnosis is made by history and physical exam, though on occasion a bone scan may be done to confirm the diagnosis.

Treatment is conservative, rest, ice, and anti-inflammatory medication like ibuprofen. These fractures can take six to eight weeks to heal (as long as the fracture can be seen on x-ray). Trying to return too quickly can cause re- injury, and may also allow the stress fracture to extend through the entire bone.

Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to inflammation of the lining of the bone, called the periosteum. Shin splints are caused by overuse, especially in runners, walkers, dancers, including those who do aerobics. Muscles that run through the periosteum and the bone itself may also become inflamed.

Treatment is similar to a stress fracture and physical therapy can be helpful.

Compression fracture

As people age, there is a potential for the bones to develop osteoporosis, a condition where bones lose their calcium content. This makes bone more susceptible to breaking. One such type of injury is a compression fracture to the spine, most often the thoracic or lumbar spine. Since we are an upright animal, if the bones of the back are weaker than the force of gravity these bones can crumple. Pain is the major complaint, especially with movement.

Compression injuries of the back may or may not be associated with nerve or spinal cord injury. An x-ray of the back can reveal the bone injury, however, sometimes a CT scan or MRI will be used to insure that no damage is done to the spinal cord.

Treatment includes pain medication and often a back brace. Some compression fractures can also be treated with vertebroplasty. Vertebroplasty involves inserting a glue-like material into the center of the collapsed spinal vertebra in order to stabilize and strengthen the crushed bone. The glue (methylmethacrylate) is inserted with a needle and syringe through anesthetized skin into the midportion of the vertebra under the guidance of specialized x-ray equipment. Once inserted, the glue soon hardens, forming a cast-like structure with the locally broken bone.

Rib fracture

The ribs are especially vulnerable to injury and are prone to breaking due to a direct blow. Rib x-rays are rarely taken as it doesn't matter if the rib is broken or just bruised. A chest x-ray is usually taken to make certain there is no collapse or bruising of the lung.

When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and the diaphragm moves down. When a person has a rib injury, the pain associated with it makes breathing difficult, and the person has a tendency to not take deep breaths. If the lung underlying the injury does not expand, it is at risk for infection. The person is then susceptible to pneumonia (lung infection),which is characterized by fever, cough, and shortness of breath.

As opposed to other parts of the body that can rest when they are injured, it is very important to take deep breaths to prevent pneumonia when rib fractures are present. The treatment for bruised and broken ribs is the same: ice to the chest wall, ibuprofen as an anti-inflammatory, deep breaths and pain medication. Even if all goes well, there will be significant pain for four to six weeks.

With lower rib fractures, there may be concern about organs in the abdomen that the ribs protect. The liver is located under the ribs on the right side of the chest, and the spleen under the ribs on the left side of the chest. Many times your doctor may be more worried about abdominal injury than about the broken rib itself. Ultrasound or CT scan may help diagnosis intra-abdominal injuries.

Skull fracture

With the wide availability of CT scans, skull x-rays are rarely taken to diagnose head injury. If a head injury exists, the physician will feel or palpate the scalp and skull to determine if there may be a skull fracture. He will also look into the ears to see if there is blood behind the ear drumm and he will also complete a neurologic examination.

The skull is a flat, compact bone and it takes significant force to break it. If a skull fracture exists, there is an increased likelihood of bleeding in the brain, especially in children. There are guidelines that are available to decide whether a CT scan is indicated (needed).

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in patients with a GCS (Glasgow Coma Score) score of 13-15. With minor head injury, the following risk groups are considered when evaluating need for CT brain scan:

High risk for potential neurosurgical operation

Abnormal neurologic exam within two hours after injury

Suspected open or depressed skull fracture

Any sign of basal skull fracture (blood behind the ear drum, blackened eyes, clear fluid running from the ears, or bruising behind the ear)

Vomiting - two episodes

65 years of age or older

Medium risk (for brain injury on CT)

Amnesia before impact - more than 30 minutes

Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height greater than 3 feet or five stairs)

Fracture in children

Children can break bones and yet have normal x-rays. Fractures appear as clear lines through the bone on an x- ray through the bone. If calcium hasn't yet accumulated in the repairing bone, the break may not be apparent. This lack of calcification happens in two ways.

  • 1. Bones mature at different times in a child's development and while the bony structure is there, it may have more cartilage than calcium.

  • 2. The second situation is associated with growth plates. Each bone has an area where cell activity is maximal and where the bone grows. These areas appear as lucent lines on x-ray. It may be one of the weaker points in the bone as well, and a fracture through the growth plate may not be seen.

The doctor needs to match the history and physical exam with what is seen on x-ray to make to a diagnosis. Sometimes, the child is placed in a cast for a period of time to protect the broken limb. As fractures heal, the body lays down extra calcium as building material and then remodels it to normal shape. After 7-10 days, there may be evidence on x-ray of the healing calcium to confirm the fracture.

Growth plate fractures are classified by Salter-Harris category. When a break occurs through the growth plate, it can involve different parts of the bone on each side of the plate. It is important that these fractures are aligned properly so that the bone grows properly as the child ages. For more, please read the Growth Plate Fractures in Children article.

Children are more flexible than adults until the calcium completely solidifies their bone. If you think of an arm or leg bone as tubular, sometimes only one side of the bone breaks, just like an immature branch on a tree. This is referred to as a greenstick fracture, and may need to be "set" so that it heals properly. Sometimes the bones can bend but not break because they are so pliable. This is called a plastic deformity and again will need to be set or aligned to allow proper healing.

How is a fracture diagnosed?

When you arrive for medical care, the doctor will take a history of the injury. Where, when, and why did the injury occur? Did the person trip and fall, or did they pass out before the fall? Are there other injuries that take precedence over the fracture? For example, a person who falls and hurts their wrist because they had a stroke or heart attack will have their fracture care delayed to allow care for the life threatening illness. The injured area will be examined and a search will happen for potential associated injuries. These include damage to skin, arteries and nerves.

Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the doctor believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remain empty for potential anesthesia.

A decision will be made whether x-rays are required, and which type of x-ray should be taken to make the diagnosis and better assess the injury. There are guidelines in place to help doctors decide if an x-ray is necessary. Some include the Ottawa ankle and knee x-ray rules.

The body is three dimensional, and plain film x-rays are only two dimensional. Therefore, two or three x-rays of the injured areas may be taken in different positions and planes to give a true picture of the injury. Sometimes the fracture will not be seen in one position, but is easily seen in another.

There are areas of the body where one bone fracture is associated with another fracture at a more distant part. For example, the bones of the forearm make a circle and it is difficult to break just one bone in that circle. Think of trying to break a pretzel in just one place, it is difficult to do. Therefore broken bones at the wrist may be associated with an elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The doctor may x-ray areas of the body that don't initially appear to be injured.

Occasionally, the broken bone isn't easily seen, but there may be other signs that a fracture exists. In elbow injuries, fluid seen in the joint on x-ray is an indicator of a subtle fracture. And in wrist injuries, fractures of the scaphoid or navicular bone may not show up on x-ray for one to two weeks, and diagnosis is made solely on physical examination with swelling and tenderness over the snuffbox at the base of the thumb.

In children, bones may have numerous growth plates that can cause confusion when reading an x-ray. Sometimes, the doctor will choose to x-ray the opposite arm or leg to determine what normal is for the child before deciding whether a fracture exists.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders or paramedics may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury.

Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial splint does not go completely around the limb. After a few days, the splint is removed and replaced by a circumferential cast. Circumferential casting does not occur initially because fractures swell (edema). This swelling would cause a build up of pressure under the cast, yielding increased pain and the potential for damage to the tissues under the cast.

Surgery

Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk (for staying where it is) once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery.

Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time.

References: Stiell IG, et al. The Canadian CT head rule for patients with minor head injury. Lancet May 5, 2001;357:1391-6. Stiell IG, et al. The Canadian CT head rule for patients with minor head injury. Lancet May 5,

2001;357:1391-6.

Additional resources from WebMD Boots UK on Fractures

Last Editorial Review: 8/7/2007

Heart Attack (Myocardial Infarction)

What is a heart attack?

A heart attack (also known as a myocardial infarction) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen. Blockage of a coronary artery deprives the heart muscle of blood and oxygen,causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue.

Approximately one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack.

What causes a heart attack?

Atherosclerosis

Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery. Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain normal function of the parts of the body they supply. For example, atherosclerosis of the arteries in the legs causes reduced blood flow to the legs. Reduced blood flow to the legs can lead to pain in the legs while walking or exercising, leg ulcers, or a delay in the healing of wounds to the legs. Atherosclerosis of the arteries that furnish blood to the brain can lead to vascular dementia (mental deterioration due to gradual death of brain tissue over many years) or stroke (sudden death of brain tissue).

In many people, atherosclerosis can remain silent (causing no symptoms or health problems) for years or decades. Atherosclerosis can begin as early as the teenage years, but symptoms or health problems usually do not arise until later in adulthood when the arterial narrowing becomes severe. Smoking cigarettes, high blood pressure, elevated cholesterol, and diabetes mellitus can accelerate atherosclerosis and lead to the earlier onset of symptoms and complications, particularly in those people who have a family history of early atherosclerosis.

Coronary atherosclerosis (or coronary artery disease) refers to the atherosclerosis that causes hardening and narrowing of the coronary arteries. Diseases caused by the reduced blood supply to the heart muscle from coronary atherosclerosis are called coronary heart diseases (CHD). Coronary heart diseases include heart attacks, sudden unexpected death, chest pain (angina), abnormal heart rhythms, and heart failure due to weakening of the heart muscle.

Atherosclerosis and angina pectoris

Angina pectoris (also referred to as angina) is chest pain or pressure that occurs when the blood and oxygen supply to the heart muscle cannot keep up with the needs of the muscle. When coronary arteries are narrowed by more than 50 to 70 percent, the arteries may not be able to increase the supply of blood to the heart muscle during exercise or other periods of high demand for oxygen. An insufficient supply of oxygen to the heart muscle causes angina. Angina that occurs with exercise or exertion is called exertional angina. In some patients,

especially diabetics, the progressive decrease in blood flow to the heart may occur without any pain or with just shortness of breath or unusually early fatigue.

Exertional angina usually feels like a pressure, heaviness, squeezing, or aching across the chest. This pain may travel to the neck, jaw, arms, back, or even the teeth, and may be accompanied by shortness of breath, nausea, or a cold sweat. Exertional angina typically lasts from one to 15 minutes and is relieved by rest or by taking nitroglycerin by placing a tablet under the tongue. Both resting and nitroglycerin decrease the heart muscle's demand for oxygen, thus relieving angina. Exertional angina may be the first warning sign of advanced coronary artery disease. Chest pains that just last a few seconds rarely are due to coronary artery disease.

Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery has narrowed to such a critical degree that the heart is not receiving enough oxygen even at rest. Angina at rest infrequently may be due to spasm of a coronary artery (a condition called Prinzmetal's or variant angina). Unlike a heart attack, there is no permanent muscle damage with either exertional or rest angina.

Atherosclerosis and heart attack

Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack (see picture below). The cause of rupture that leads to the formation of a clot is largely unknown, but contributing factors may include cigarette smoking or other nicotine exposure, elevated LDL cholesterol, elevated levels of blood catecholamines (adrenaline), high blood pressure, and other mechanical and biochemical forces.

Unlike exertional or rest angina, heart muscle dies during a heart attack and loss of the muscle is permanent, unless blood flow can be promptly restored, usually within one to six hours.

especially diabetics, the progressive decrease in blood flow to the heart may occur without any painnitroglycerin by placing a tablet under the tongue. Both resting and nitroglycerin decrease the heart muscle's demand for oxygen, thus relieving angina. Exertional angina may be the first warning sign of advanced coronary artery disease. Chest pains that just last a few seconds rarely are due to coronary artery disease. Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery has narrowed to such a critical degree that the heart is not receiving enough oxygen even at rest. Angina at rest infrequently may be due to spasm of a coronary artery (a condition called Prinzmetal's or variant angina). Unlike a heart attack, there is no permanent muscle damage with either exertional or rest angina. Atherosclerosis and heart attack Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack (see picture below). The cause of rupture that leads to the formation of a clot is largely unknown, but contributing factors may include cigarette smoking or other nicotine exposure , elevated LDL cholesterol, elevated levels of blood catecholamines (adrenaline), high blood pressure, and other mechanical and biochemical forces. Unlike exertional or rest angina, heart muscle dies during a heart attack and loss of the muscle is permanent, unless blood flow can be promptly restored, usually within one to six hours. While heart attacks can occur at any time, more heart attacks occur between 4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to rupture of cholesterol plaques. " id="pdf-obj-25-20" src="pdf-obj-25-20.jpg">

While heart attacks can occur at any time, more heart attacks occur between 4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to rupture of cholesterol plaques.

Approximately 50% of patients who develop heart attacks have warning symptoms such as exertional angina or rest angina prior to their heart attacks, but these symptoms may be mild and discounted.

What are the symptoms of a heart attack?

Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a variety of symptoms including:

Pain, fullness, and/or squeezing sensation of the chest

Jaw pain, toothache, headache

Nausea, vomiting , and/or general epigastric (upper middle abdomen) discomfort

Sweating

Heartburn and/or indigestion

Arm pain (more commonly the left arm, but may be either arm)

Upper back pain

General malaise (vague feeling of illness)

No symptoms (Approximately one quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus.)

Even though the symptoms of a heart attack at times can be vague and mild, it is important to remember that heart attacks producing no symptoms or only mild symptoms can be just as serious and life-threatening as heart attacks that cause severe chest pain. Too often patients attribute heart attack symptoms to "indigestion," "fatigue," or "stress," and consequently delay seeking prompt medical attention. One cannot overemphasize the importance of seeking prompt medical attention in the presence of symptoms that suggest a heart attack. Early diagnosis and treatment saves lives, and delays in reaching medical assistance can be fatal. A delay in treatment can lead to permanently reduced function of the heart due to more extensive damage to the heart muscle. Death also may occur as a result of the sudden onset of arrhythmias such as ventricular fibrillation.

What are the complications of a heart attack?

Heart failure

When a large amount of heart muscle dies, the ability of the heart to pump blood to the rest of the body is diminished, and this can result in heart failure. The body retains fluid, and organs, for example, the kidneys, begin to fail.

Ventricular fibrillation

Injury to heart muscle also can lead to ventricular fibrillation. Ventricular fibrillation occurs when the normal, regular, electrical activation of heart muscle contraction is replaced by chaotic electrical activity that causes the heart to stop beating and pumping blood to the brain and other parts of the body. Permanent brain damage and death can occur unless the flow of blood to the brain is restored within five minutes.

Most of the deaths from heart attacks are caused by ventricular fibrillation of the heart that occurs before the victim of the heart attack can reach an emergency room. Those who reach the emergency room have an excellent prognosis; survival from a heart attack with modern treatment should exceed 90%. The 1% to 10% of

heart attack victims who later die frequently had suffered major damage to the heart muscle initially or additional damage at a later time.

Deaths from ventricular fibrillation can be avoided by cardiopulmonary resuscitation (CPR) started within five minutes of the onset of ventricular fibrillation. CPR requires breathing for the victim and applying external compression to the chest to squeeze the heart and force it to pump blood. In 2008, the American Heart Association modified the mouth-to-mouth instruction of CPR, and recommends that chest compressions alone are effective if a bystander is reluctant to do mouth-to-mouth. When paramedics arrive, medications and/or an electrical shock (cardioversion) can be administered to convert ventricular fibrillation back to a normal heart rhythm and allow the heart to pump blood normally. Therefore, prompt CPR and a rapid response by paramedics can improve the chances of survival from a heart attack. In addition, many public venues now have automatic external defibrillators (AEDs) that provide the electrical shock needed to restore a normal heart rhythm even before the paramedics arrive. This greatly improves the chances of survival.

What are the risk factors for atherosclerosis and heart attack?

Factors that increase the risk of developing atherosclerosis and heart attacks include increased blood cholesterol, high blood pressure, use of tobacco, diabetes mellitus, male gender, and a family history of coronary heart disease. While family history and male gender are genetically determined, the other risk factors can be modified through changes in lifestyle and medications.

High Blood Cholesterol (Hyperlipidemia). A high level of cholesterol in the blood is associated with an increased risk of heart attack because cholesterol is the major component of the plaques deposited in arterial walls. Cholesterol, like oil, cannot dissolve in the blood unless it is combined with special proteins called lipoproteins. (Without combining with lipoproteins, cholesterol in the blood would turn into a solid substance.) The cholesterol in blood is either combined with lipoproteins as very low-density lipoproteins (VLDL), low-density lipoproteins (LDL) or high-density lipoproteins (HDL).

The cholesterol that is combined with low-density lipoproteins (LDL cholesterol) is the "bad" cholesterol that deposits cholesterol in arterial plaques. Thus, elevated levels of LDL cholesterol are associated with an increased risk of heart attack.

The cholesterol that is combined with HDL (HDL cholesterol) is the "good" cholesterol that removes cholesterol from arterial plaques. Thus, low levels of HDL cholesterol are associated with an increased risk of heart attacks.

Measures that lower LDL cholesterol and/or increase HDL cholesterol (losing excess weight, diets low in saturated fats, regular exercise, and medications) have been shown to lower the risk of heart attack. One important class of medications for treating elevated cholesterol levels (the statins) have actions in addition to lowering LDL cholesterol which also protect against heart attack. Most patients at "high risk" for a heart attack should be on a statin no matter what the levels of their cholesterol.

High Blood Pressure (Hypertension). High blood pressure is a risk factor for developing atherosclerosis and heart attack. Both high systolic pressure (when the heart beats) and high diastolic pressure (when the heart is at rest) increase the risk of heart attack. It has been shown that controlling hypertension with medications can reduce the risk of heart attack.

Tobacco Use (Smoking). Tobacco and tobacco smoke contain chemicals that cause damage to blood vessel walls, accelerate the development of atherosclerosis, and increase the risk of heart attack.

Diabetes (Diabetes Mellitus). Both insulin dependent and non-insulin dependent diabetes mellitus (type 1 and 2, respectively) are associated with accelerated atherosclerosis throughout the body. Therefore, patients with diabetes mellitus are at risk for reduced blood flow to the legs, coronary heart disease, erectile dysfunction, and strokes at an earlier age than non-diabetic subjects. Patients with diabetes can lower their risk through rigorous control of their blood sugar levels, regular exercise, weight control, and proper diets.

Male Gender. At all ages, men are more likely than women to develop atherosclerosis and coronary heart disease. Some scientists believe that this difference is partly due to the higher blood levels of HDL cholesterol in women than in men. However, this gender difference narrows as men and women grow older.

Family History of Heart Disease. Individuals with a family history of coronary heart diseases have an increased risk of heart attack. Specifically, the risk is higher if there is a family history of early coronary heart disease, including a heart attack or sudden death before age 55 in the father or other first-degree male relative, or before age 65 in the mother or other female first- degree female relative.

How is a heart attack diagnosed?

When there is severe chest pain, suspicion that a heart attack is occurring usually is high, and tests can be performed quickly that will confirm the heart attack. A problem arises, however, when the symptoms of a heart attack do not include chest pain. A heart attack may not be suspected, and the appropriate tests may not be performed. Therefore, the initial step in diagnosing a heart attack is to be suspicious that one has occurred.

Electrocardiogram. An electrocardiogram (ECG) is a recording of the electrical activity of the heart. Abnormalities in the electrical activity usually occur with heart attacks and can identify the areas of heart muscle that are deprived of oxygen and/or areas of muscle that have died. In a patient with typical symptoms of heart attack (such as crushing chest pain) and characteristic changes of heart attack on the ECG, a secure diagnosis of heart attack can be made quickly in the emergency room and treatment can be started immediately. If a patient's symptoms are vague or atypical and if there are pre-existing ECG abnormalities, for example, from old heart attacks or abnormal electrical patterns that make interpretation of the ECG difficult, the diagnosis of a heart attack may be less secure. In these patients, the diagnosis can be made only hours later through detection of elevated cardiac enzymes in the blood.

Blood tests. Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK), special sub-fractions of CPK (specifically, the MB fraction of CPK), and troponin, and their levels can be measured in blood. These cardiac enzymes typically are elevated in the blood several hours after the onset of a heart attack. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlates with the amount of heart muscle that has died.

The most important factor in diagnosing and treating a heart attack is prompt medical attention. Rapid evaluation allows early treatment of potentially life-threatening abnormal rhythms such as ventricular fibrillation and allows early reperfusion (return of blood flow to the heart muscle) by procedures that unclog the blocked coronary arteries. The more rapidly blood flow is reestablished, the more heart muscle that is saved.

Large and active medical centers often have a "chest pain unit" where patients suspected of having heart attacks are rapidly evaluated. If a heart attack is diagnosed, prompt therapy is initiated. If the diagnosis of heart attack is initially unclear, the patient is placed under continuous monitoring until the results of further testing are available.

What about heart attacks in women?

What are the risk factors for heart attack in women?

Coronary artery disease (CAD) and heart attacks are erroneously believed to occur primarily in men. Although it is true that the prevalence of CAD among women is lower before menopause, the risk of CAD rises in women after menopause. At age 75, a woman's risk for CAD is equal to that of a man's. CAD is the leading cause of death and disability in women after menopause. In fact, a 50-year-old woman faces a 46% risk of developing CAD and a 31% risk of dying from coronary artery disease. In contrast, her probability of contracting and dying from breast cancer is 10% and 3%, respectively.

The risk factors for developing CAD in women are the same as in men and include:

increased blood cholesterol,

smoking cigarettes,

diabetes mellitus, and a

family history of coronary heart disease at a young age.

Smoking cigarettes

Even "light" smoking raises the risk of CAD. In one study, middle-aged women who smoked one to 14 cigarettes per day had a twofold increase in strokes (caused by atherosclerosis of the arteries to the brain) whereas those who smoked more than 25 cigarettes per day had a risk of stroke 3.7 fold higher than that of nonsmoking women. Furthermore, the combination of smoking and the use of birth control pills increase the risk of heart attacks even further, especially in women over 35.

Quitting smoking immediately begins to reduce the risk of heart attacks. The risk gradually returns to the same risk of nonsmoking women after several years of not smoking.

Cholesterol treatment guidelines in women

Current NCEP (National Cholesterol Education Program) treatment guidelines for undesirable cholesterol levels are the same for women as for men.

What are the symptoms of heart attack in women and how is heart attack diagnosed?

Women are more likely to encounter delays in establishing the diagnosis of heart attack than men. This is in part because women tend to seek medical care later than men, and in part because diagnosing heart attacks in women can sometimes be more difficult than diagnosing heart attacks in men. The reasons include:

1.

Women are more likely than men to have atypical heart attack symptoms such as:

neck and shoulder pain,

fatigue , and

1.

Silent heart attacks (heart attacks with little or no symptoms) are more common among women than among men.

  • 2. Women have a higher occurrence than men of chest pain that is not caused by heart disease, for example chest pain from spasm of the esophagus.

  • 3. Women are less likely than men to have the typical findings on the ECG that are necessary to diagnose a heart attack quickly.

  • 4. Women are more likely than men to have angina (chest pain due to lack of blood supply to the heart muscle) that is caused by spasm of the coronary arteries or caused by disease of the smallest blood vessels (microvasculature disease). Cardiac catheterization with coronary angiograms (x-ray studies of the coronary arteries that are considered the most reliable tests for CAD) will reveal normal coronary arteries and therefore cannot be used to diagnose either of these two conditions.

5.

Women are more likely to have misleading, or "false positive" noninvasive tests for CAD then men.

Because of the atypical nature of symptoms and the occasional difficulties in diagnosing heart attacks in women, women are less likely to receive aggressive thrombolytic therapy or coronary angioplasty, and are more likely to receive it later than men. Women also are less likely to be admitted to a coronary care unit.

What is the treatment for heart attack in women?

Thrombolytic (fibrinolytic or clot dissolving) therapy has been shown to reduce death from heart attacks similarly in men and women; however, the complication of strokes from the thrombolytic therapy may be slightly higher in women than in men.

Emergency percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting for acute heart attack is as effective in women as in men; however women may have a slightly higher rate of procedure-related complications in their blood vessels (such as bleeding or clotting at the point of insertion of the PTCA catheter in the groin) and death. This higher rate of complications has been attributed to women's older age, smaller artery size, and greater severity of angina. The long-term outcome of angioplasty or stenting however, is similar in men and women, and should not be withheld due to gender.

The immediate mortality from coronary artery bypass graft surgery (CABG) in women is higher than that for men. The higher immediate mortality rate has been attributed to women's older age, smaller artery size, and greater severity of angina (the same as for PTCA). Long term survival, rate of recurrent heart attack and/or need for reoperation, however, are similar in men and women after CABG.

What about hormone therapy and heart attack in women?

After menopause, the production of estrogen by the ovaries gradually diminishes over several years. Along with this reduction, there is an increase in LDL ("bad" cholesterol) and a small decrease in HDL ("good" cholesterol). These changes in lipid levels are believed to be one of the reasons for the increased risks of developing CAD after menopause. Women who have had their ovaries surgically removed (oophorectomy) or experience an early menopause, also have an accelerated risk of CAD.

Since treatment with estrogen hormone results in higher HDL and lower LDL cholesterol levels, doctors thought for many years that estrogen would protect women against CAD (as well protect against dementia and stroke). Many studies have found that postmenopausal women who take estrogen have lower CAD rates than women who do not. Unfortunately many of the studies were observational studies (studies in which women are followed over time but decide on their own whether or not they wish to take estrogen). Observational studies have serious shortcomings because they are subject to selection bias; for example, women who choose to take estrogen hormones may be healthier and have a lower risk of heart attacks than those who do not. In other words, something else in the daily habits of women who take estrogen (such as exercise or healthier diet) may make them less likely to develop heart attacks. Therefore, only a randomized trial (a study in which women agree to be assigned to estrogen or a placebo or sugar pill at random but are not told which pills they took until the end of the study) can establish the whether hormone therapy after menopause can prevent CAD.

HERS trial results

The Heart and Estrogen/progestin Replacement Study (HERS), was a randomized placebo-controlled trial of the effect of the daily use of estrogens plus medroxyprogesterone (progestin) on the rate of heart attacks in postmenopausal women who already had CAD. The HERS trial did not find a reduction in heart attacks in women who took hormone therapy. This lack of benefit in preventing heart attacks occurred despite an 11% lower LDL and a 10% higher HDL cholesterol level in the women treated with hormones. The study also found that more women in the hormone-treated group experienced blood clots in the veins and gallbladder disease than women in the placebo-treated group. (Blood clots in the veins are dangerous because these clots can travel to the lungs and cause pulmonary embolism, a condition with chest pain, shortness of breath, and even shock and death.) However, the increase in gallbladder disease and blood clots among healthy users of estrogen who do not have heart disease is very small.

Based on the results of this study, researchers concluded that estrogen is not effective in preventing coronary artery disease and heart attacks in postmenopausal women who already have CAD. It should be noted, however, that the results of the HERS trial only apply to women who have known CAD prior to starting hormone therapy and not to women without known coronary artery disease.

WHI trial results

The Women's Health Initiative (WHI) was the first randomized controlled trial designed to determine the long-term benefits and risks of treatment with estrogens plus medroxyprogesterone (progestin) in healthy menopausal women (women without CAD). The results were reported in a series of articles in 2002, 2003, and 2004. The estrogen + progestin portion of the WHI study had to be stopped earlier than planned, after just 5.2 years, because the increase in coronary heart disease, stroke, and pulmonary embolism among women who use estrogen + progesterone outweighed the benefits of reduced bone fractures and colon cancer. The estrogen- alone portion of the WHI was stopped because women who took estrogen alone had no reduction in heart attack risk, yet there was a significant increase in stroke risk.

The increase in breast cancer became apparent after three to five years, but the increase in heart disease and pulmonary emboli occurred early on, in the first year.

Recommendations for the use of estrogens plus medroxyprogesterone (progestin) in women

Medicinenet Medical Editors believe that:

Decision regarding use of hormone therapy has to be individualized, and all women should discuss with their physicians what is best for her.

Estrogens plus medroxyprogesterone (progestin) is still the best therapy for hot flashes. Despite the WHI study, many women remain good candidates for estrogens plus medroxyprogesterone (progestin) therapy (or estrogen alone if they have had hysterectomy). This is especially true if hormone therapy is limited to the shortest duration, optimally less than five years.

Estrogens with or without medroxyprogesterone (progestin) should not be used to prevent or treat either Alzheimer's disease, heart disease, or stroke.

While estrogens plus medroxyprogesterone (progestin) are effective in preventing osteoporosis and related bone fractures, women concerned about the risk of hormone therapy should discuss with their doctors, the use of other non-hormonal alternatives to prevent and treat osteoporosis.

What is new in heart attack?

Greater public awareness about heart attacks and changes in lifestyle have contributed to a dramatic reduction in the incidence of heart attacks during the last four decades. Improved anticoagulant drugs such as hirudin and hirulog, are being tested and may complement current therapies. The role of the "super aspirins" [abciximab (Reopro) and eptifibatide (Integrilin)] is currently being investigated as well.

More effective versions of TPA are being developed. Increasingly, paramedics can do ECGs in the field, diagnose a heart attack, and take patients directly to hospitals that have the ability to do PTCA and stenting. This can save time and reduce damage to the heart. At present, the accepted best treatment for a heart attack is identification promptly of the diagnosis, and transport to a hospital that can perform prompt catheterization and PTCA or stenting within the first 90 minutes of the cardiac event.

Recent data has shown that lowering blood LDL levels even further than previously suggested may further decrease the risk of heart attacks.

Research also has shown that inflammation may play a role in the development of atherosclerosis, and this is an active area of current investigation. There also is early evidence that with genetic engineering it may be possible to develop a drug that can be administered to clear plaques from arteries (a "scavenger molecule").

Heart Attack At A Glance

A heart attack results when a blood clot completely obstructs a coronary artery supplying blood to the heart muscle and heart muscle dies.

The blood clot that causes the heart attack usually forms at the site of rupture of an atherosclerotic, cholesterol plaque on the inner wall of a coronary artery.

The most common symptom of heart attack is chest pain.

The most common complications of a heart attack are heart failure, and ventricular fibrillation.

The risk factors for atherosclerosis and heart attack include elevated cholesterol levels, increased blood pressure, tobacco use, diabetes, male gender and a family history of heart attacks at an early age.

Heart attacks are diagnosed with electrocardiograms and measurement of cardiac enzymes in blood

Early reopening of blocked coronary arteries reduces the amount of damage to the heart and improves the prognosis for a heart attack.

Medical treatment for heart attacks may include anti-platelet, anti-coagulant, and clot dissolving drugs as well as angiotensin converting enzyme (ACE) inhibitors, beta blockers and oxygen.

Interventional treatment for heart attacks may include coronary angiography with percutaneous transluminal coronary angioplasty (PTCA), coronary artery stents, and coronary artery bypass grafting (CABG).

Patients suffering a heart attack are hospitalized for several days to detect heart rhythm disturbances, shortness of breath, and chest pain.

Further heart attacks can be prevented by aspirin, beta blockers, ACE inhibitors, discontinuing smoking, weight reduction, exercise, good control of blood pressure and diabetes, following a low cholesterol and low saturated fat diet that is high in omega-3-fatty acids, taking multivitamins with an increased amount of folic acid, decreasing LDL cholesterol, and increasing HDL cholesterol.

Click here to read the Heart Attack Treatment article.

Last Editorial Review: 6/26/2008

Migraine Headache

Medical Author: Melissa Conrad Stöppler, MD Medical Editors: Jay W. Marks, MD

What is a migraine headache?

A migraine headache is a form of vascular headache. Migraine headache is caused by vasodilatation (enlargement of blood vessels) that causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. Enlargement of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries magnifies the pain.

Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called "fight or flight" response, and this activation causes many of the symptoms associated with migraine attacks; for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.

Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed.

The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.

The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet.

The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.

Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely underdiagnosed and undertreated. Less than half of individuals with migraine are diagnosed by their doctors.

What are the symptoms of migraine headaches?

Migraine is a chronic condition with recurrent attacks. Most (but not all) migraine attacks are associated with headaches.

Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain is located in the forehead, around the eye, or at the back of the head).

The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral (on both sides of the head).

The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor).

A migraine headache usually is aggravated by daily activities such as walking upstairs.

Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.

An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include:

sleepiness,

irritability,

fatigue,

depression or euphoria,

yawning, and

cravings for sweet or salty foods.

Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.

Migraine aura

An estimated 20% of migraine headaches are associated with an aura. Usually, the aura precedes the headache, although occasionally it may occur simultaneously with the headache. The most common auras are:

  • 1. flashing, brightly colored lights in a zigzag pattern (referred to as fortification spectra), usually starting in the middle of the visual field and progressing outward; and

  • 2. a hole (scotoma) in the visual field, also known as a blind spot.

Some elderly migraine sufferers may experience only the visual aura without the headache. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side of the body or pins-and-needles sensations around the mouth and the nose on the same side. Other auras include auditory (hearing) hallucinations and abnormal tastes and smells.

For approximately 24 hours after a migraine attack, the migraine sufferer may feel drained of energy and may experience a low-grade headache along with sensitivity to light and sound. Unfortunately, some sufferers may have recurrences of the headache during this period.

What are some variants of migraine headaches?

Complicated migraines are migraines that are accompanied by neurological dysfunction. The part of the body that is affected by the dysfunction is determined by the part of the brain that is responsible for the headache.

Vertebrobasilar migraines are characterized by dysfunction of the brainstem (the lower part of the brain that is responsible for automatic activities like consciousness and balance).

The symptoms of vertebrobasilar migraines include:

fainting as an aura,

vertigo (dizziness in which the environment seems to be spinning), and

double vision.

Hemiplegic migraines are characterized by:

paralysis or weakness of one side of the body,

mimicking a stroke.

The paralysis or weakness is usually temporary, but sometimes it can last for days.

Retinal, or ocular, migraines are rare attacks characterized by repeated instances of scotomata (blind spots) or blindness on one side, lasting less than an hour, that can be associated with headache. Irreversible vision loss can be a complication of this rare form of migraine.

How is a migraine headache diagnosed?

Migraine headaches are usually diagnosed when the symptoms described previously are present. Migraine generally begins in childhood to early adulthood. While migraines can first occur in an individual beyond the age of fifty, advancing age makes other types of headaches more likely. A family history usually is present, suggesting a genetic predisposition in migraine sufferers. The examination of individuals with migraine attacks usually is normal.

Patients with the first headache ever, worst headache ever, a significant change in the characteristics of headache or an association of the headache with nervous system symptoms, like visual or hearing or sensory loss, may require additional tests to exclude diseases other than migraine. The tests may include blood testing, brain scanning (either CT or MRI), and a spinal tap.

.

How are migraine headaches treated?

Treatment includes therapies that may or may not involve medications.

Non-medication therapies for migraine

Therapy that does not involve medications can provide symptomatic and preventative therapy.

Using ice, biofeedback, and relaxation techniques may be helpful in stopping an attack once it has started.

Sleep may be the best medicine if it is possible.

Preventing migraine takes motivation for the patient to make some life changes. Patients are educated as to triggering factors that can be avoided. These triggers include:

smoking , and

avoiding certain foods especially those high in tyramine such as sharp cheeses or those containing sulphites (wines) or nitrates (nuts, pressed meats).

Generally, leading a healthy life-style with good nutrition, an adequate intake of fluids, sufficient sleep and exercise may be useful. Acupuncture has been suggested to be a useful therapy.

Medication for migraine

Individuals with occasional mild migraine headaches that do not interfere with daily activities usually medicate themselves with over-the-counter (OTC or non-prescription) pain relievers (analgesics). Many OTC analgesics are available. OTC analgesics have been shown to be safe and effective for short-term relief of headache (as well as muscle aches, pains, menstrual cramps , and fever) when used according to the instructions on their labels.

There are two major classes of OTC analgesics:

acetaminophen (Tylenol), and

Acetaminophen

Acetaminophen reduces pain and fever by acting on pain centers in the brain. Acetaminophen is well tolerated and generally is considered easier on the stomach than NSAIDs. However, acetaminophen can cause severe liver damage in high (toxic) doses or if used on a regular basis over extended periods of time. In individuals who regularly consume moderate or large amounts of alcohol, acetaminophen can cause serious damage to the liver in lower doses that usually are not toxic. Acetaminophen also can damage the kidneys when taken in large doses. Therefore, acetaminophen should not be taken more frequently or in larger doses than recommended on the package label.

NSAIDS

The two types of NSAIDs are 1) aspirin and 2) non-aspirin.

Examples of non-aspirin NSAIDs are ibuprofen (Advil, Nuprin, Motrin IB, and Medipren) and naproxen (Aleve). Some NSAIDs are available by prescription only. Prescription NSAIDs are usually prescribed to treat arthritis and other inflammatory conditions such as bursitis, tendonitis, etc. The difference between OTC and prescription NSAIDs usually is the amount of the active ingredient contained in each pill. For example, OTC naproxen (Aleve) contains 220 mg of naproxen per pill, whereas prescription naproxen (Naprosyn) contains 375 or 500 mg of naproxen per pill.

NSAIDs relieve pain by reducing the inflammation that causes the pain (they are called nonsteroidal antiinflammatory drugs or NSAIDs because they are different from corticosteroids such as prednisone, prednisolone, and cortisone which also reduce inflammation). Corticosteroids, though valuable in reducing inflammation, have predictable and potentially serious side effects, especially when used long-term. Their full effects also require hours or days. NSAIDs do not have the same side effects that corticosteroids have and their onset of action is faster.

Aspirin, Aleve, Motrin, and Advil all are NSAIDs and are similarly effective in relieving pain and fever. The main difference between aspirin and non-aspirin NSAIDs is their effect on platelets, the small particles in blood that cause blood clots to form. Aspirin prevents the platelets from forming blood clots. Therefore, aspirin can increase bleeding by preventing blood from clotting though it also can be used therapeutically to prevent clots from causing heart attacks and strokes. The non-aspirin NSAIDs also have antiplatelet effects, but their antiplatelet action does not last as long as aspirin, i.e. hours rather than days.

Aspirin, acetaminophen, and caffeine also are available combined in OTC analgesics for the treatment of headaches including migraine. Examples of such combination analgesics are Pain-aid, Excedrin, Fioricet, and Fiorinal.

Finding an effective analgesic or analgesic combination often is a process of trial and error because individuals respond differently to different analgesics. In general, a person should use the analgesic that has worked in the past. This will increase the likelihood that an analgesic will be effective and decrease the risk of side effects.

There are several precautions that should be observed with OTC analgesics:

Children and teenagers should not use aspirin for the treatment of headaches, other pain, or fever, because of the risk of developing Reye's Syndrome, a life-threatening neurological disease that can lead to coma and even death.

People with balance disorders or hearing difficulties should avoid using aspirin because aspirin may aggravate these conditions.

People taking blood thinners such as warfarin (Coumadin) should not take aspirin and non- aspirin NSAIDs without a doctor's supervision because they add further to the risk of bleeding that is caused by the blood thinner.

People with active ulcers of the stomach and duodenum should not take aspirin and non- aspirin NSAIDs because they can increase the risk of bleeding from the ulcer and impair healing of the ulcer.

People with advanced liver disease should not take aspirin and non-aspirin NSAIDs because they may impair kidney function. Deterioration of kidney function in these patients can lead to failure of the kidneys.

OTC or prescription analgesics should not be overused. Overuse of analgesics can lead to the development of tolerance (increasing ineffectiveness of the analgesic) and rebound headaches (return of the headache as soon as the effect of the analgesic wears off, usually in the early morning hours). Thus, overuse of analgesics can lead to a vicious cycle of more and more analgesics for headaches that respond less and less to treatment.

What is the treatment for moderate to severe migraine headaches?

Migraine-specific abortive medications usually are necessary for moderate to severe migraine headaches. The abortive medications for moderate or severe migraine headaches are different than OTC analgesics. Instead of relieving pain, they abort headaches by counteracting the cause of the headache, dilation of the temporal arteries. In fact, they cause narrowing of the arteries. Examples of migraine-specific abortive medications are the triptans and ergot preparations.

Triptans

The triptans attach to serotonin receptors on the blood vessels and nerves that surround them, constrict the blood vessels, and reduce the inflammation. This stops the headache. The triptan with the longest history of use is sumatriptan (Imitrex). Sumatriptan is available in the US as an injection, oral tablet, and nasal inhaler. Zolmitriptan (Zomig) and rizatriptan (Maxalt) are newer triptans that are available as oral tablets and as tablets that melt in the mouth. Naratriptan (Amerge), almotriptan (Axert) and frovatriptan (Frovalan) are available only as oral tablets.

Traditionally, triptans were prescribed for moderate or severe migraines after OTC analgesics and other simple measures failed. Newer studies suggest that triptans can be used as the first treatment for patients with migraines that are causing disability. (Significant disability is defined as more than 10 days of at least 50% disability during a three-month period.). Triptans should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within two hours.

The U.S. Food and Drug Administration (FDA) has issued a warning about taking triptans together with medications of the SSRI (selective serotonin reuptake inhibitor) or SNRI (selective serotonin/norepinephrine reuptake inhibitor) classes. Taking these medicines together can cause a serious condition called serotonin syndrome.

Side effects of triptans

The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue, and dizziness. These side effects are short-lived and are not considered serious.

The most serious side effects of triptans are heart attacks and strokes. Triptans are effective in migraine headaches because they narrow arteries in the head; however, they also can narrow arteries in the heart. In individuals without existing carotid or coronary artery disease, the narrowing caused by triptans usually does not cause problems. However, persons whose carotid and coronary arteries are narrowed by atherosclerosis or who suffer from intermittent spasm of the coronary arteries (a condition called Prinzmetal's or variant angina), the narrowing caused by triptans can further reduce the flow of blood through the arteries and have been reported to cause heart attacks and strokes. Therefore, triptans should not be used by those who have had heart attacks and strokes, or those who have symptoms of atherosclerosis such as angina, transient ischemic attack (TIAs), and intermittent claudication.

Healthy adults may have atherosclerosis and narrowing of the coronary arteries that are "silent", that is, without past strokes, transient ischemic attacks, heart attacks, or angina. Therefore, before prescribing a triptan, a doctor should evaluate patients for possible atherosclerosis if they have one or more risk factors for developing atherosclerosis. These risk factors include cigarette smoking, diabetes mellitus, high blood pressure, high levels of LDL ("bad") cholesterol in the blood, obesity, male and over 40 years of age, female and postmenopausal, or a family member(s) who has had heart attacks at an early age. Some patients who are at risk should receive their first dose of a triptan in the doctor's office while being monitored with an electrocardiogram (EKG).

Triptans can interact with other drugs. For example, there have been rare reports of triptans causing a "serotonin syndrome" when given together with a selective serotonin reuptake inhibitor. Selective serotonin reuptake inhibitors (SSRIs) are a class of medications widely used to treat depression. The symptoms of serotonin syndrome include confusion, fever, tremor, high blood pressure, diarrhea, and sweating. Certain triptans such as sumatriptan, zolmitriptan, and rizatriptan can interact with monoamine oxidase inhibitors. Propranolol (Inderal) can raise rizatriptan blood levels. Cimetidine (Tagamet) can increase zolmitriptan blood levels.

Triptans should not be used in pregnant women and are not generally used in young children.

Ergots

Ergots, like triptans, are medications that abort migraine headaches. These may be combined with caffeine and/or other pain relief medications in combination products. Examples of ergots include ergotamine preparations (Ergomar, Wigraine, and Cafergot) and dihydroergotamine preparations (Migranal, DHE-45). Ergots, like triptans, cause constriction of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and their effects on the heart are more prolonged than those of the triptans. Therefore, they are not as safe as the triptans. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.

Midrin

Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). It is most effective if used early during a headache; however, because of its potent blood vessel constricting effect, it should not be used in persons with high blood pressure, kidney disease, glaucoma, atherosclerosis, liver disease, or taking monoamine oxidase inhibitors.

What other medications are used for treating migraine headaches?

Narcotics and butalbital-containing medications sometimes are used to treat migraine headaches; however, these medications are potentially addicting and are not used as initial treatment. They are sometimes used for individuals whose headaches fail to respond to OTC medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke.

In migraine sufferers with severe nausea, a combination of a triptan and an antinausea medication, for example, prochlorperazine (Compazine) or metoclopramide (Reglan) may be used. When nausea is severe enough that oral medications are impractical, intravenous medications such as DHE-45 (dihydroergotamine), prochlorperazine (Compazine), and valproate (Depacon) are useful.

How are migraine headaches prevented?

There are two ways to prevent migraine headaches: 1) by avoiding factors ("triggers") that cause the headaches, and 2) by preventing headaches with medications (prophylactic medications). Neither of these preventive strategies is 100% effective. The best one can hope for is to reduce the frequency of headaches.

What are migraine triggers?

A migraine trigger is any environmental or physiological factor that leads to a headache in individuals who are prone to develop headaches. Only a small proportion of migraine sufferers, however, clearly can identify triggers. Examples of triggers include:

stress,

hormones,

bright or flickering lights,

odors,

cigarette smoke,

alcohol,

aged cheeses,

chocolate,

monosodium glutamate,

nitrites,

aspartame , and

For some women, the decline in the blood level of estrogen during the onset of menstruation is a trigger for migraine headaches (sometimes referred to as menstrual migraines).

The interval between exposure to a trigger and the onset of headache varies from hours to two days. Exposure to a trigger does not always lead to a headache. Conversely, avoidance of triggers cannot completely prevent headaches. Different migraine sufferers respond to different triggers, and any one trigger will not induce a headache in every person who has migraine headaches.

Sleep and migraine

Disturbances such as sleep deprivation, too much sleep, poor quality of sleep, and frequent awakening at night are associated with both migraine and tension headaches, whereas improved sleep habits have been shown to reduce the frequency of migraine headaches. Sleep also has been reported to shorten the duration of migraine headaches.

Fasting and migraine

Fasting possibly may precipitate migraine headaches by causing the release of stress-related hormones and lowering blood sugar. Therefore, migraine sufferers should avoid prolonged fasting.

Bright lights and migraine

Bright lights and other high intensity visual stimuli can cause headaches in healthy subjects as well as patients with migraine headaches, but migraine people who suffer from migraines seem to have a lower than normal threshold for light-induced headache pain. Sunlight, television, and flashing lights all have been reported to precipitate migraine headaches.

Caffeine and migraine

Caffeine is contained in many food products (cola, tea, chocolates, coffee) and OTC analgesics. Caffeine in low doses can increase alertness and energy, but caffeine in high doses can cause insomnia, irritability, anxiety, and headaches. The over-use of caffeine-containing analgesics causes rebound headaches. Furthermore, individuals who consume high levels of caffeine regularly are more prone to develop withdrawal headaches when caffeine is stopped abruptly.

Chocolate, wine, tyramine, MSG, nitrites, aspartame and migraine

Chocolate has been reported to cause migraine headaches, but scientific studies have not consistently demonstrated an association between chocolate consumption and headaches. Red wine has been shown to cause migraine headaches in some migraine sufferers, but it is not clear whether white wine also will cause migraine headaches.

Tyramine (a chemical found in cheese, wine, beer, dry sausage, and sauerkraut) can precipitate migraine headaches, but there is no evidence that consuming a low-tyramine diet can reduce migraine frequency.

Monosodium glutamate (MSG) has been reported to cause headaches, facial flushing, sweating, and palpitations when consumed in high doses on an empty stomach. This phenomenon has been called Chinese restaurant syndrome.

Nitrates and nitrites (chemicals found in hot dogs, ham, frankfurters, bacon and sausages) have been reported to cause migraine headaches.

Aspartame, a sugar-substitute sweetener found in diet drinks and snacks, has been reported to trigger headaches when used in high doses for prolonged periods.

Female hormones and migraine

Some women who suffer from migraine headaches experience more headaches around the time of their menstrual periods. Other women experience migraine headaches only during the menstrual period. The term "menstrual migraine" is used mainly to describe migraines that occur in women who have almost all of their headaches from two days before to one day after their menstrual periods. Declining levels of estrogen at the onset of menses is likely to be the cause of menstrual migraines. Decreasing levels of estrogen also may be the cause of migraine headaches that develop among users of birth control pills during the week that estrogens are not taken.

What should migraine sufferers do?

Individuals with mild and infrequent migraine headaches that do not cause disability may require only OTC analgesics. Individuals who experience several moderate or severe migraine headaches per month or whose headaches do not respond readily to medications should avoid triggers and consider modifications of their lifestyle. Lifestyle modifications for migraine sufferers include:

Go to sleep and wake up at the same time each day.

Exercise regularly (daily if possible). Make a commitment to exercise even when traveling or during busy periods at work. Exercise can improve the quality of sleep and reduce the frequency and severity of migraine headaches. Build up your exercise level gradually. Over- exertion, especially for someone who is out of shape, can lead to migraine headaches.

Do not skip meals, and avoid prolonged fasting.

Limit stress through regular exercise and relaxation techniques.

Limit caffeine consumption to less than two caffeine-containing beverages a day.

Avoid bright or flashing lights and wear sunglasses if sunlight is a trigger.

Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers; however, it is reasonable to avoid foods that consistently trigger migraine headaches.

What are prophylactic medications for migraine headaches?

Prophylactic medications are medications taken daily to reduce the frequency and duration of migraine headaches. They are not taken once a headache has begun. There are several classes of prophylactic medications:

beta blockers,

calcium-channel blockers,

antiserotonin agents, and

anticonvulsants.

Medications with the longest history of use are propranolol (Inderal), a beta blocker, and amitriptyline (Elavil, Endep), an antidepressant. When choosing a prophylactic medication for a patient the doctor must take into account side effects of the drug, drug-drug interactions, and co-existing conditions such as diabetes, heart disease, and high blood pressure.

Beta blockers

Beta-blockers are a class of drugs that block the effects of beta-adrenergic substances produced by the body, specifically the nerves and the adrenal gland, such as adrenaline (epinephrine). By blocking the effects of adrenaline, beta-blockers relieve stress on the heart by slowing the rate at which the heart beats. Beta-blockers have been used to treat high blood pressure, angina, certain types or tremors, stage fright, and abnormally fast heart beats (palpitations). They also have become important drugs for improving survival after heart attacks. Beta- blockers have been used for many years to prevent migraine headaches.

It is not known how beta-blockers prevent migraine headaches. It may be by decreasing prostaglandin production, though it also may be through their effect on serotonin or a direct effect on arteries. The beta-blockers used in preventing migraine headaches include propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor, Lopressor LA, Toprol XL), nadolol (Corgard), and timolol (Blocadren).

Beta-blockers generally are well-tolerated. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis, or emphysema. In patients who already have slow heart rates (bradycardias) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta- blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue, decrease in endurance, insomnia, nausea, depression, dreaming, memory loss, impotence.

Tricyclic antidepressants

Tricyclic antidepressants (TCAs) prevent migraine headaches by altering the neurotransmitters, norepinephrine and serotonin, that the nerves of the brain use to communicate with one another. The tricyclic antidepressants that have been used in preventing migraine headaches include amitriptyline (Elavil, Endep), nortriptyline (Pamelor, Aventyl), doxepin (Sinequan), imipramine (Tofranil), and protriptyline.

The most commonly encountered side effects associated with TCAs are fast heart rate, blurred vision, difficulty urinating, dry mouth, constipation, weight gain or loss, and low blood pressure when standing (orthostatic hypotension).

TCAs should not be used with drugs that inhibit monoamine oxidase such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and procarbazine (Matulane), since high fever, convulsions and even death

may occur. TCAs are used with caution in peole with seizures, since they can increase the risk of seizures. TCAs also are used with caution in men with enlargement of the prostate because they can make urination difficult. TCAs can cause elevated pressure in the eyes in some glaucoma sufferers. TCAs can cause excessive sedation when used with other medications that slow the brain's processes, such as alcohol, barbiturates, narcotics, and benzodiazepines, for example, lorazepam (Ativan), diazepam (Valium), temazepam (Restoril), oxazepam (Serax), clonazepam (Klonopin), and zolpidem (Ambien). Epinephrine should not be used with amitriptyline, since the combination can cause severe high blood pressure

Antiserotonin medications

Methysergide (Sansert) prevents migraine headaches by constricting blood vessels and reducing inflammation of the blood vessels. Methylergonovine is related chemically to methysergide and has a similar mechanism of action. They are not widely used because of their side effects. The most serious side effect of methysergide is retroperitoneal fibrosis (scarring of tissue around the ureters that carry urine from the kidneys to the bladder). Retroperitoneal fibrosis, though rare, can block the ureters and cause backup of urine into the kidneys. Backup of urine into the kidneys can cause back and flank (the side of the body between the ribs and hips) pain and ultimately can lead to kidney failure. Methysergide also has been reported to cause scarring around the lungs that can lead to chest pain, shortness of breath, as well as scarring of the heart valves.

Calcium channel blockers

Calcium channel blockers (CCBs) are a class of drugs that block the entry of calcium into the muscle cells of the heart and the arteries. By blocking the entry of calcium, CCBs reduce contraction of the heart muscle, decrease heart rate, and lower blood pressure. CCBs are used for treating high blood pressure, angina, and abnormal heart rhythms (for example, atrial fibrillation). CCBs also appear to block the effects of a chemical within nerves, called serotonin, and have been used occasionally to prevent migraine headaches. The CCBs used in preventing migraine headaches are diltiazem (Cardizem, Dilacor, Tiazac), verapamil (Calan, Verelan, Isoptin), and nimodipine.

The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. When diltiazem or verapamil are given to individuals with heart failure, symptoms of heart failure may worsen because these drugs reduce the ability of the heart to pump blood. Verapamil and diltiazem may reduce the elimination and increase the blood levels of carbamazepine (Tegretol), simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can lead to toxicity from these drugs.

Anticonvulsants

Anticonvulsants (antiseizure medications) also have been used to prevent migraine headaches. Examples of anticonvulsants that have been used are valproic acid, phenobarbital, gabapentin, and topiramate. It is not known how anticonvulsants work to prevent migraine headaches.

Who should consider prophylactic medications to prevent migraine headaches?

Not all migraine sufferers need prophylactic medications; individuals with mild or infrequent headaches that respond readily to abortive medications do not need prophylactic medications. Individuals who should consider prophylactic medications are those who:

  • 1. Require abortive medications for migraine headaches more frequently than twice weekly.

  • 2. Have two or more migraine headaches a month that do not respond readily to abortive medications.

  • 3. Have migraine headaches that are interfering substantially with their quality of life and work.

  • 4. Cannot take abortive medications because of heart disease, stroke, or pregnancy, or cannot tolerate abortive medications because of side effects.

How effective are prophylactic medications?

Prophylactic medications can reduce the frequency and duration of migraine headaches but cannot be expected to eliminate migraine headaches completely. The success rate of most prophylactic medications is approximately 50%. Success in preventing migraine headaches is defined as more than a 50% reduction in the frequency of headaches. Prophylactic medications usually are begun at a low dose that is increased slowly in order to minimize side effects. Individuals may not notice a reduction in the frequency, severity, or duration of their headaches for 2 to 3 months after starting treatment.

What is the proper way to use preventive medications?

Doctors familiar with the treatment of migraine headaches should prescribe preventive medications.

Decisions about which preventive medication to use are based on the side effects of the medication and the presence of any medical conditions.

Propranolol (Inderal) often is used first, provided that the individual does not have asthma, COPD, or heart disease. Amitriptyline (Elavil, Endep) also is used commonly.

Preventive medications are begun at low doses and gradually increased to higher doses if needed. This minimizes side effects from the medications. Preventive medications are to be taken daily for months to years. When they are stopped, the dose needs to be gradually reduced rather than abruptly stopped. Abruptly stopping preventive medications can lead to headaches.

In some instances, more than one drug may be needed. Non-medication and behavioral therapies also may be needed.