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In pregnancy, if you have patients with migraine, late in pregnancy don’t use nonsteroidals. They may inhibit uterine contraction apparently. In early pregnancy – I looked up in some books – the chapters by the better clinicians, they say it’s okay. Just very small dose, one or two may be all right. The same thing with antidepressants and calcium channel blockers. Ideally you want to avoid them, but if you want to use lower dose for short periods of time, they say it may be okay.
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Cluster headache. If you can do 100% oxygen, 6 liters, 8 liters, for about ten minutes, go ahead and do it. Lidocaine spray is the new stuff out. Imitrex; there is evidence that it works for cluster too. Steroids, Depakote is useful – there is literature – for prevention. Lithium you can use too. Viagra online pharmacy.
Trigeminal neuralgia in older people. The pain is brief. Look for trigger points, like chewing, brushing, washing the face, shaving. Now remember, most people will have pain in number II and III branch of the 5th. The pain in the first branch is uncommon. Examination should be normal. If you have someone with trigeminal pain with numbness, it’s not trigeminal neuralgia, it’s trigeminal neuropathy. You look for a primary problem. Trigeminal neuroma or vasculitis, Sjögren’s. People with MS can have trigeminal-like pain. So if you have a younger person coming to you with facial pain, mimicking trigeminal neuralgia, think MS also. Posterior fossa decompression, some people are still doing it. Now this is the differential diagnosis for trigeminal facial pain. Tegretol doesn’t work very well, but amitriptyline works, antidepressants work. This is atypical lower facial pain, or atypical facial pain.
Chronic paroxysmal hemicrania pain is similar to cluster headache. It’s in females. The headache is brief but you have a dozen or two dozen headaches each day. It responds to indomethacin, Indocin.
Sometimes you can have migraine aura without headaches. It can happen, so it’s an important differential diagnosis for TIA in older people. Diet? Well, you talk to ten different people and you are going to have ten different opinions.

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Now the second important thing that has come up in the last several years is the role of the trigeminal nerve. Stimulate the trigeminal nerve, the trigeminal ganglion, impulses go in the wrong direction. If you look more peripherally you see blood vessel changes. You have vasodilatation, you have edema, you have CGRP, calcitonin gene-related protein, and substance P released in the blood vessel wall. Now some of these changes – I said about vasodilatation and plasma leakage – so there is a sterile inflammation taking place in the blood vessel wall simply because of stimulation of the trigeminal neurons, sensory neurons. So if you activate the trigeminal system you have blood vessel changes. This is proven repeatedly and convincingly. These kinds of changes that take place in the blood vessel can be blocked by Imitrex-like substances. Now this seems to be mediated by serotonin receptors, all these changes. There are receptors in the blood vessels, wall. There are a bunch of receptors even in the neurons in the brainstem. Some of the newer migraine drugs that are coming out, like zolmitriptan, is a more selective serotonin blocker at the brainstem neuronal level. Whereas Imitrex is a more peripheral serotonin blocker.
When the sagittal sinus is stimulated in experimental animals, producing a brain insult, what happens is ome of the brainstem neurons light up. C-phos expression means it’s an acute change. These neurons are getting ready to fight. These kind of changes you see even in the C1 and the C2 regions, all the way down from the brainstem to C2. Some kind of non-specific insult can activate brainstem C1, C2 neurons, which includes the trigeminal system. We already saw that the activation of the trigeminal system can produce blood vessel changes. We saw some of these changes taking place in the occipital cortex spreading depression, producing aura. So these are the fragments of information available to us. Now what is the primary trigger? Maybe the whole thing comes from the hypothalamus. Sometimes when you fast you get headaches. Periods, hormonal changes can trigger headaches. All these very primary insults, stress, seem to be triggered at the hypothalamic level. For some reason, from time to time, all these other neurons act up and produce aura, produce blood vessel changes. Blood vessel changes of course still are considered to produce pain. Pain then is a protective phenomenon. So this is our understanding of migraine pathophysiology in a nutshell.
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There is some evidence that migraine may actually be an ion channel-opathy. There is an entity called hemiplegic, familial hemiplegic migraine. They have migraine, they have hemiplegia and it is familial. Now the gene for that is in the 19th chromosome. Now there are some other potassium channel diseases that are linked to the similar area on the 19th chromosome. So you have migraine on one hand, on the 19th chromosome, familial hemiplegic migraine. You’ve got some potassium channel problems linking to the same region, then you have idiopathic migraine at the other extreme. People are trying to link all this together and suggest that migraine is familial. There may be some ion that has gone wrong somewhere on some chromosome. Maybe it’s the 19th chromosome. So this is the latest thinking, explanation of why migraine is familial. This is all hot off the press. There is no proof. Canadian online pharmacy news.

Migraine with aura or without aura. Unilateral throbbing, exertional vomiting, photophobia, phonophobia, go for migraine. A variant called ophthalmoplegic migraine will give you headaches and third nerve palsy, unilaterally. How do you know this is not due to diabetes? The onset is before the age of 20 in ophthalmoplegic migraine. That’s an important clue. So if a 40-year-old comes to you with third nerve palsy and a lot of headaches, think vascular, think diabetes. Persons before 20, even if the pupil doesn’t react, this probably comes first, ophthalmoplegic migraine. Look for family history. Cialis jelly strawberry, banana.
Childhood migraine may give headaches and vomiting, but it does one other unique thing. It gives you episodic confusion. Something like non-convulsive status epilepticus, or childhood migraine may be manifest by episodic confusion only, without headaches. Cyclical vomiting in small children is considered a variant of migraine. Status migrainosus is migraine lasting more than three days. The treatment is not working. The treatment for that is steroids, Decadron or DHE sometimes. Tension-type headaches could be episodic, two or three days a week, or it could be every day of the week. Bilateral, lacks pulsatile quality. This is the International Headache Society Criteria. Non-exertional, no vomiting, no photophobia, no phonophobia.
There is a physiological phenomenon called spreading depression. If you put potassium chloride on the brain surface, the neurons get suppressed. They don’t work for a little bit. In experimental situations, this kind of depression spreads from the central spot more anteriorally and more peripherally. Now they are vaso-physiologically measuring this kind of neuronal depression with magneto encephalogram and a whole bunch of other things, PET scan and all kinds of stuff. What seems to happen is that when you have aura the cerebral cells do exactly what would happen during spreading depression. There is a slow march of suppression of neuronal activity. It spreads. Now this has been shown to correlate fairly well with the aura, so the aura now is considered to be primary neuronal depression. So when the neuron misbehaves like that, the blood vessels change but the blood vessel changes seem to be secondary. So there’s one piece of evidence. Aura is not due to vasoconstriction, but it seems very likely due to the spreading depression phenomenon. Canadian generic viagra online.

With cluster headache, each headache episode goes on for about 5-10 minutes. Still unilateral, but the duration is brief. Muscle tension or tension-type of headache is a more continuous headache. The duration is important. Precipitating factors: cluster headache, alcohol is a very important precipitating factor. If you have headaches when you bend down, look for increased intracranial pressure. If you have headaches when you get up, what does that mean? Very serious pathology, intracranial pathology, that typically gets worse when you get up. Colloid cyst, third ventricle. So when you have headaches when getting up, think post-LP, low pressure, idiopathic low pressure, think colloid cyst. Now exertional headache is usually vascular migraine. Running, climbing stairs, etc.
Visual phenomena appear in migraine. You see colored zigzags, whorls, patterns. They typically go on for about five, six, seven, ten minutes. Focal seizures, if they start in the occipital area, the positive visual symptoms last only about 10, 15, 20 seconds. That’s the difference you need to know. Migraine, longer. Sensory seizures, brief. Seconds only. Same thing for the migraine march. If you have numbness creeping up one side of the body due to migraine, this takes time. This takes about five, six, seven minutes. Whereas if you have a focal-sensory seizure, the sensory sometimes comes up very quickly, in a matter of seconds. So those are the differences you need to remember. Nausea and vomiting; it could be meningitis, could be subarachnoid hemorrhage or it could be migraine. But you do not have nausea and vomiting in tension-type headaches. In fact, the International Headache Classification specifically talks about vomiting as an important feature. I’ll come back to that in a second. Tearing, nasal discharge, cluster. Nasal discharge only, acute, think sinusitis. Chronic sinusitis does not give you chronic headache. Sinusitis will give you headache almost always in the acute phase. Sinus headache typically gets worse as the day goes on, like in the afternoon. It gets worse when you bend down. It has some features of migraine. Soma online.
Family history; about 50% of people with migraine have positive family history of migraine. Medications can give you headaches. Indocin is one of them, although we use Indocin for treating some types of headaches. Many seizure drugs, believe it or not, can give you headaches. Psychotropic drugs can give you headaches. In fact, if you look at the textbooks there are tons of medications that are said to give headaches. So take a medication history. Human growth hormone cheap medications.
What are some of the common problems? Migraine, cluster, chronic paroxysmal hemicrania is usually in females. Unilateral, severe, sharp, five to ten minute pains, but you have many bouts. Ten, 15, 20 a day. Whereas cluster is half-hour, one-hour headache bouts, two, three, four in 24 hour cycle. So that’s the difference. Sex is difference, duration, number of attacks is different. Chronic paroxysmal hemicrania dramatically responds to Indocin. Meningitis. An obese female, menstrual irregularities, maybe on birth control pills, comes to you with a lot of headaches, early morning headaches, vomiting. Neuro-exam shows papilledema. Think benign intracranial hypertension, pseudotumor cerebri. Viagra professional articles.