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The nightmare headache- a look at migrain

Copyright 1998 by Love Ministries, Inc. Excruciating and agonizing, disorienting and nightmarish: This is how those who suffer from migraine often describe their condition. And there are plenty of them; in the U.S., nearly one out of ten people, about twenty-three million, suffer from this disorder. To complicate matters, many "treatments" may often make the condition worse. Some very extreme treatments have included nasal surgery jaw reconstruction, hysterectomy, neck surgery, allergy shots, hormonal therapies,and various muscular and physical therapies. In some cases, radical approaches have led to the following serious complications: post-surgical difficulties, addictive disease, drug toxicity, or liver or gastrointestinal damage. This has resulted in despair among patients, who often feel rejected by physicians as well as by society. But there is reason, as we shall see, for hope. Often, they are dismissed by those without understanding, as suffering from a psychological problem. This only deepens their sense of alienation, since nothing could be further from the truth. For migraine is not caused by stress, personality flaws, or poor relationships with parents. It is not hypochondria. Instead, it is a complicated biochemical syndrome with genetic factors The good news is that up to ninety percent of migraine sufferers might find relief with current techniques, and there are new treatments on the way. UNDERSTANDING MIGRAINE Migraine is called "benign" by physicians simply because it is no direct threat to life. This does not mean, however that the condition is not extremely painful, for it is. It is also regularly exhausting, frustrating, and life-robbing. It is characterized by severe head-pain, accompanied by nausea and weakness. The pain is so intense that it has been said to be worse than child-birth, and it has been described by sufferers as a kind of "death." Still, ignorant people try to make migraine sufferers feel guilty and ashamed, by blaming them. They often are casually dismissed with some brilliant observation such as , "It' s all in your head." But migraine is NOT something that you do to yourself. It is a genuine biochemical imbalance or dysfunction. It is what physicians call a "primary disorder," and is not simply a symptom. Migraine has been with human beings for quite some time. References go back, in fact, to the Mesopotamian empire of about 3000 BC, and probably preceded even that. The average migraine attack comes from one to three times per month. The pain is often localized to one side of the head. An attack may last from four to seventy-two hours. Since the sufferer is not responsible, he or she should feel no guilt when his or her body reacts in this manner. Migraine is NOT due to any mental or emotional weakness. However, many misunderstand this, and their guilt and depression often result needlessly in a loss of self-esteem. Nor are migraine sufferers alone, by any means. Headache-treatment in the U.S. alone costs fifty billion dollars per year. Eleven billion dollars may be lost annually due to lost work-days. MIGRAINE MYTHS. Migraine is a biological, NOT a psychological, disorder. There is no known "migraine profile" of certain personality types. It is not caused by being uptight, perfectionist, etc. It is not due to clear, simple states such as anger, which might, however, exacerbate it, as might tension. Further, migraine can be controlled. Migraine does not usually lead to worse conditions, and is not their precursor. It is not caused by sinus problems. Migrainers are not lazy people, who seek to avoid responsibility. Migraine has nothing to do with TMJ. Migraines cannot be traced to allergies. Excessive medication does not increase relief. Migraine may begin in infancy,and does occur among children. It is not caused by stress or anxiety. Men also suffer from migraine; it is not a symptom of PMS. Migrainers are not unusually sensitive to pain. It is not a sign intelligence, or lack thereof. Migraine usually is not hard to diagnose, and Migrainers not difficult to work with. WHO GETS MIGRAINE? Migraine is a fairly democratic disease, and all kinds of people get it. Beginning with puberty, however, far more women than men experience it. (Estrogen, a female hormone, is considered to be a significant contributing factor.) Most people suffer from between ages twenty and forty-five, after which the condition begins to evaporate. Its presence decreases with age-- with men, in their thirties,and women in their forties. Most cases begin in childhood or adolescence. When they begin in childhood, they often end at adolescence. It appears to be less common among African Americans. In some cases, an attack might occur only once in a lifetime, but the frequency varies to more than once a week. A new generation of "designer drugs" has been designed for the treatment of migraine. Many of these are among the "tryptan" family. THE CAUSES. Migraine used to be thought to be caused exclusively by a increase of blood circulation to the brain. Today, however, it is believed to be the result of a cascade of biochemical events that usually are set into motion by an environmental "trigger." There seems to be a genetic predisposition to the disorder, involving the CNS (central nervous system). Common migraine-triggers include foods, beverages, chemicals, sunlight, fatigue/stress, and hormone-level fluctuations. In the brain, a structure called the "hypothalamus" creates several chemicals that communicate with a fundamental part of the brain called the "brainstem." These chemical messengers are called "neurotransmitters," and include important chemicals called "serotonin" and "noradrenaline." Migraine might often involve disturbances in the balance of serotonin in the brain. This might also account for rather fast mood-swings. Other chemicals involved in the brain-processes of migraine include dopamine, tyramine, histamine, and other chemicals from a large chemical family called the "amines." In summary, the pain-control system of the body appears to malfunction. This system works with "endorphins," naturally produced chemical opiates-- strong sedatives and pain-killers. Some migraine attacks seem to include, as a component, a chemical that is similar to wasp-venom, an irritant. It lowers the body's pain-tolerance, and makes its site of accumulation much more sensitive and painful. Estrogen might also be involved, for it produces prostaglandin, which might cause blood vessels to expand or to dilate. Migraine is an "autosomal dominant" disorder, which means that a single parent with the disorder can pass it on to his/her offspring. TYPES OF MIGRAINE. The headache of migraine is really the end-point of a cascade of biochemical events which have various effects on the body. It is highly biospecific, in that it has different symptoms in different people. But essentially there are two types: 1) Migraine with aura, which used to be called "classical migraine," and 2) migraine without aura, which used to be called "common migraine." Migraine is also commonly called a "sick headache," because it is accompanied by nausea. It usually produces throbbing pain. Migraine with aura is preceded by a series of visual and neurologic distortions; migraine without aura lacks this preceding warning signal. Migrainers are not histrionic or over-sensitive. They are responding to a disorder that creates fierce, violent pain that can be excruciating. In some people, the "aura" or visual disturbances occur, and then are followed by NO migraine. Migraine or its precursor might be accompanied by stomach pain, sudden mood-changes, dizziness, blurred vision, unexpected tiredness or fatigue, food-cravings, nausea, loss of appetite, etc. e-pick headaches" include stabbing pains that may last for only a few seconds. A pre-headache phase known as a "prodrome" might occur. It can precede an actual headache by days or hours. Its symptoms can include mood-changes, irritability, fluid retention, increased thirst, frequent urination, food-cravings, gastrointestinal symptoms, bloating, , etc. Energy-level changes can also occur; some feel very lethargic, while others become almost manic. "Aura" begins twenty to sixty minutes before the actual headache phase. The classical aura might include: a bright shape that spreads across the visual field, blocking vision, in one eye; flashes of light and color; wavy lines; geometric patterns; blurred vision partial loss of sight. Other sensory changes might include partial numbness or tingling in the face, on one side. There might also be a sense that limbs are distorted in shape or size. Other-hallucinations might appear; limbs might seem weak or heavy on one side of the body. One might have difficulty finding appropriate words, or in understanding spoken or written language. General confusion or disorientation might occur. There might be intolerance of certain foods or smells, a loss of appetite, diarrhea or constipation, pallor in skin, cold and clammy extremities, facial swelling, bloodshot or black eye, facial sweating, water-retention, frequent yawning or sighing with hyperventilation, nasal congestion, runny nose, sensitivities to light or to noise, or touch or smell, depression, anxiety, nervousness, difficulty in concentrating, changes in blood-chemistry or -pressure, temperature, and heart-rhythms. The post-headache phase or "postdrome", may occur twenty-four hours after the headache; usually, it is marked by fatigue; sometimes feelings of euphoria or well-being also mark this period. Three common migraines are : 1) menstrual, 2) week-end, and 3) let-down. The first, as indicated, ties in with the flow and changes in hormones, and is related to the onset of menstruation. The "let down" variety occurs after the accomplishment of a major task, when it is all over, stress-levels plummet, and you begin to relax. MIGRAINE TRIGGERS include the following: sleep-cycle disorders, large amounts of coffee, cigarette smoke, red wine; chocolate, and perfumes. Alcohol (including beer), aged cheeses, pickled herring, dried and smoked fish, sour cream, yogurt, and yeast-products food additives such as monosodium glutamate, sodium nitrite, aspartame, excessive caffeine, dairy products, onions, beans, nuts, citrus fruits, light, flickering lights, bright sunlight, camera flashes, overhead lighting, strong industrial odors, changes in weather-conditions, high altitude, dry air, motion, patterns such as checks or wavy lines, stress, skipping meals, eating at irregular or unaccustomed intervals, junk food, smoking, various medications (especially vasodilators and nitroglycerine, and high blood-pressure drugs such as reserpine)diuretics, anti-asthma compounds birth-control pills, the too-frequent use of pain-medication, over-use of ergotamine head-trauma (including minor injuries), invasive medical procedures , sudden exertion, some sports, hormonal factors, the on-set of menstruation, pregnancy delivery, hormone supplementation, hysterectomy, and neck disorders, etc. Triggers are not actual causes, and a person with no genetic predisposition to migraine can be exposed to any number of triggers with absolutely no ill effects. MIGRAINE AND OTHER HEADACHES. Tension headache are marked by dull, tight, squeezing pain around the head, and are about ninety percent of all headaches. They do not throb, and nausea is absent. They last from fifteen minutes to about three hours. Usually, they occur in or around the eyes or temples. These often occur to smokers, and can be quite intense; also, over-medication is a common cause. However, if ANY of the following symptoms occur, seek MEDICAL EMERGENCY-ROOM TREATMENT IMMEDIATELY: sudden, severe head-pain; head-pain accompanied by fever; progressively worsening headache, especially after injury; head-pain accompanied by confusion, seizures, mood-swings; headache that begins after exertion strain, coughing, or sexual activity; a first-headache problem beginning after age fifty-five; any headache that occurs daily, or that interferes with the quality of life. TREATMENT. You have a right to treatment by a physician that is both caring and knowledgeably informed about your condition. Avoid those who are judgmental or who make careless snap-decisions. Never blindly follow what the physician says; find out reasons for, and effect of, treatment. You have aright to be taken seriously. You must develop a positive interactive relationship with your physician.(This is called a "treatment partnership.") Ask your doctor: Have you treated many migraines? What do you feel causes migraines? You might find help also in areas other than your private physician. Usually, it is not appropriate to be referred to a specialist, unless your history indicates otherwise; so, beware of a physician that tries to "pass along" your problem to others. Further, if you are taking pain-killers more than THREE TIMES PER WEEK, you probably need help in either breaking a drug-habit, or in seeking non-drug pain-control methods. CAUTION: Do not attempt self-diagnosis and self-medication, without practical professional guidance. Remember, you are part of the treatment. Do not expect a doctor to solve your problems, repair or fix you, or take responsibility for your condition. Instead, learn to cooperate in taking care of yourself. For you know yourself better than anyone else. It might help to keep a "headache journal," listing the times, occurrences, durations, and symptoms of headache-episodes. Pay special attention to environments and exposure to potential triggers, and note the results of any treatments. A migraine "profile" prepared for a physician, should include the following: age at which the first migraine was experienced; frequency and duration; known triggers; recent changes; typical symptoms pain-rating on a number-scale;dietary triggers; family history; treatments attempted; questions to which you need answers.A common number-rating scale is the following: level one-- head pain, but still functional; depressed. Level two-- moderately bad pain with stomach symptoms, including nausea, vomiting, or diarrhea; functional with only the basics thinking becoming muddled. Level three-- terrible head-pain; pronounced stomach upset; light, sounds and smells worsen headache; cannot think clearly. Level four-- excruciating; impaired reasoning; extreme sensitivity to light, sounds, etc.; incapable of functioning. In a headache diary or journal, note the time each headache begins, its duration, and its number from the above scale; note any stomach distress or sensitivities; note any medications taken within forty-eight hours, including time, dosage, and results; note possible triggers encountered within forty-eight hours; note any unusual post-headache symptoms. DIAGNOSIS. Although there is no single test for migraine, diagnosis is relatively easy for a knowledgeable physician. Diagnosis should include a fairly thorough headache-history, and a personal headache-profile. A complete physical exam is recommended, including blood-tests to rule out any other causes. Imaging techniques and an electroencephalograph might be used as well. Certain exotic tests are not generally recommended; if they are, ask why. You might also, under certain circumstances, be referred to a specialist; but if so, ask why. These might include orthopedists, ophthalmologists, endocrinologists, allergistsotolaryngologists, gynecologists, rheumatologists, dentists, or oral surgeons. Be cautious, and always ask for a complete, thorough, satisfying explanation that answers all your questions. Never simply assume that "the doctor knows best." You have every right to know; after all, it is your body. The doctor works for you; you do not work for him/her. Discuss completely any fears with your physician. MEDICATIONS. Some migrainers suffer enormously and needlessly because they fear medications that might bring them comfort an d relief. There are two types of medication that are currently used: those for acute attacks, and those that help prevent attacks. If you find that a medication is ineffective, you might need to change the medication, not simply to increase the dosage. Those available for acute stomach distress include Reglan, Compozine, chlorpromazine, dramamine. PAIN RELIEVERS: Most regimens begin with a simple analgesic, and then progress to a combination-drug or an ergot-derivative. Two drugs found to be effective even when the pain is at full force are sumatryptan and DHE (dihydroergotamine). In some cases, caffeine might also serve as an analgesic agent. (Caution: More than 500 mg. daily for more than three days might actually cause or worsen a headache.) Besides non-prescription drugs such as aspirin, acetaminophen, and ibu prophen, prescription preparations include but are not limited to the following: neproxin, talfein, endomethycin. The first line of attack might be aspirin, but CAUTION: Aspiring should be completely avoided by those with ulcers or those who are taking anti-coagulants. Further, it is NOT to be administered to children. Acetaminophen comes in various preparations, including Percacet (prescription). Percadan (prescription) contains aspirin. Other pain-relieving prescription agents include Roxacet and Vicadan. Other pain-killing formulas include barbiturate, muscle-relaxant, or narcotic compounds. These include all oxycodon (Percaset) and hydrocodon (Vicadan) preparations. Caution: a potential for addiction exists with most pain-killing compounds, so use with conservative care. Also, frequent over-use may result in "rebound headaches." Further, narcotic compounds can sometimes lead to depression. A specific anti-migraine drug is ergotamine tartrate, and dihydroergotamine. Although side-effects might include increased pain, this usually passes within thirty minutes. NOTE: Patients with heart-problems should avoid sumatryptan. CAUTION: Do not take DHE or any ergotamine compound within forty-five minutes (before or after) of sumatryptan. Also, sumatryptan should not be used more than three times a week. Phenylthiozines are also used, although they might cause drowsiness or restlessness. SUMMARY. While migraines can and should be treated, do so with caution and extreme care. Migraines need not control or ruin your life; and new discoveries are being made every day. Migraines can serve to teach us to deeply appreciate every pain-free moment of our existence, and should be seen not as curses but as learning tools. For more information, see the book Migraine: the Complete Guide, by the American Council for Headache Education, with Lynn M. Constantine and Suzanne Scott (City; company, 1994)

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A N T O N I O A V E R S A C U R R I C U L U M V I T A E INFORMAZIONI PERSONALI ANTONIO AVERSA 03.11.1964 Consulente Dipartimento Medicina Sperimentale, Sapienza Università di Roma 06/45421411 335/6642900 antonio.aversa@uniroma1.it ANTONIO AVERSA ISTRUZIONE E FORMAZIONE Laurea in Medicina e Chirurgia 1990 Università “Sapienza”, Roma - Abilitazione al a p

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