DOCSLIB.ORG

The Differential Diagnosis of Headaches Richard B. Mangan, OD

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

The Differential Diagnosis of Headaches Richard B. Mangan, OD, FAAO The Eye Center of Richmond Adjunct Faculty, IU School of Optometry Kentucky Cadillac w 1 “Alice in Wonderland” Syndrome “13 year-old headache” (Val Akula) Get to the “Heart” of the Matter Headache History H = History (most important) PQRST E = Examination (both physical & ocular) P = Provocative & Palliative A = Assess the need for further testing and / Q = Quality or diagnose. R = Region R = Refer, or S = Severity T = Treat T = Temporal Aspects 2 Headache History FORD (PARTS) P = Provocative Factors F = Frequency A = Associating Factors O = Onset R = Relief R = Region T = Treatment D = Duration S = Severity 3 “Tension-Type” Headache Most Common Headache Females > Males; Age of Onset (13 – 38) Charac ter ize d by gra dua l onse t, bila tera l, non- throbbing aching pain over the frontal and temporal regions, which often spreads to the occipital. Pain often worsens as day goes on. Usually no abnormal findings on physical exam. “Knight-time” Tension Headache Tension Headache Tension Headache Management Episodic (several minutes – 7 days) Remove or Reduce Stressors -or- Relaxation Techniques Chron ic (a t leas t 15 days / month) Massage, Heat, Hot Shower, Exercise, Hobbies. Medication If Episodic => OTC Analgesics (aspirin, acetaminophen, R/O signs of depression, anxiety, or environmental ibuprofin +/- caffeine. causes. If Chronic => amitriptyline (tricyclic antidepressant) “What do you think is causing your headaches?” **Avoid narcotic pain medication** r1 4 Slide 23 r1 Incorporate video of guy going through a cluster. rbm, 6/4/2008 Cluster Headache Cluster Headache Is among the most severe pain conditions! Unilateral, penetrating, excruciating pain, affecting Vascular the retro-orbital temporal region. 8:1 Male : Female Ratio Patients prefer to be mobile, rather than lie down Onset usually > age 20 during an attack. 2-3 (usually nocturnal) attacks / day for months, Usually spontaneous, but may be provoked by then cease for months or years, only to recur. alcohol, change in barometric pressure or sleep patterns. Pain peaks at 10-15 minutes and last 45 to 180 minutes. Associated w/ conjunctival injection, lacrimation, rhinorrhea, & Horner’s syndrome. Cluster HA Management Avoid Trigger (mostly alcohol) Prophylactic Tx’s (Calcium Channel Blockers (Verapamil), Seratonin antagonist (Sansert - methysergide) Abortive TOC (Subcut. Sumatriptan) & Pure O2 Surgery (ablation of trigeminal nerve components) NSAID: Indomethacin (Indocin) Migraine Headache Migraine “Triggers” Inherited Neuronal / Vascular Disorder? Dietary (25%) Unifying Theory: Neurovascular “Ping-Pong” Chocolate 28 million Americans (1/2 being moderately to Cheeses, Dairy Products severely disabled). 3:1 female:male Alcohol (red wine) Onset +/- age 12; Peak 35-40; Subside +/- 50 Citrus fruits Nuts Accounts for 1 billion dollars in direct medical Chemical Additives costs (13 billion / indirect) Caffeine 75% self-medicate Skipping Meals Provocative (Trigger) Factors (85%) 5 Migraine “Triggers” The “Full House” Migraine Dietary (25%) Hormonal (Mensus, BC Pill) Prodrome (60%) Chocolate Environmental Aura (20%) lasting ½ to 1 hour Cheeses, Dairy Products Smells (perfume, Alcohol (red wine) aftershave lotion, cigarette “Ca lm be fore the s torm ” (15m in to 3 hours ) Citrus fruits smoke, cooking odors) Unilateral, Throbbing or Pulsing Pain of Nuts Changes in barometric pressure (worse weather) Moderate to Severe Intensity, lasting 3 to 72 Chemical Additives Stress, Excitement, Physical hours (Associated w/ nausea, vomiting, anorexia, Caffeine Activity (body movement, photophobia, phonophobia, & osmophobia) Skipping Meals sex) or disruption of Postdrome normal patterns. Migraine Prodrome Migraine Prodrome Depression or Elation “Alice in Wonderland” Polydipsia & Polyuria or Fluid Retention Syndrome Disoriented Diarrhea or Constipation Altered sense of time & Chills, Fatigue, Pallor self. Illusions: Food Cravings z Enlargement “Alice in Wonderland” Syndrome z Shrinking z Elongation Migraine “Aura” Migraine “Aura” (+) Visual Phenomena (-) Visual Phenomena Photopsias (flashes of Homonymous or ligg,pht, spots, ,p sparks, Quadrantic defects streaks of light, wavy Central Scotoma lines. Tunnel defect Scintillations Altitudinal Field defect (flickering lights) Complete Bilateral Fortification Spectra Blindness (jagged zigzag lines) 6 Unusual Auras: When to Worry Aura’s always on the same side. Aura’s of short duration (5-10 minutes). HdhHeadache s ttbftarts before or diduring thAthe Aura. Need vascular work-up to rule-out AV malformation, Intracranial neoplasm, epileptic aura, Cerebral venous malformation, CA or ICA dissection…Refer. The “Full House” Migraine The “Full House” Migraine Prodrome (60%) Prodrome (60%) Aura (20%) Aura (20%) “Ca lm be fore the s torm” (15m in to 3hours ) “Ca lm be fore the s torm” (15 mi n t o 3h ours) Unilateral, Throbbing or Pulsing Pain of Unilateral, Throbbing or Pulsing Pain of Moderate to Severe Intensity, lasting 3 to 72 Moderate to Severe Intensity, lasting 3 to 72 hours (Associated w/ nausea, vomiting, anorexia, hours (Associated w/ nausea, vomiting, anorexia, photophobia and phonophobia) photophobia and phonophobia) Postdrome Postdrome Migraine Postdrome Migraine (Classification) May persist for 24 hours following Classic (Migraine with Aura) resolution of the headache: Common (Migraine without Aura) Ocular (Aura without the Migraine) Body Aches Complicated Decreased Appetite Basilar Decreased Concentration Ophthalmoplegic Fatigue / Weakness Retinal 7 Complicated Migraine Migraine Management Basilar (bilateral visual field changes, frontal or bi-occipital headache, diplopia, Reassurance nystagmus, nausea an d vom itting) Headache Diary Ophthalmoplegic (CN 3, 4, or 6 involved Behavior Modification post headache) Abortive Treatment Retinal (monocular vision loss lasting 10 to 60 minutes followed by complete recovery) Prophylactic Treatment Migraine Management Migraine Management Headache Diary Behavioral Modification How many HA’s occurred in that month? AidTiAvoid Triggers How long each lasted? Don’t Skip Meals How severe was each one? (Scale of 1-10) What trigger factors were there? Get adequate / consistent hours of sleep What and how much medication was used? Rest in a quiet, darkened room when HA is Was the medication effective? developing. Migraine Management Abortive Treatment Prophylactic Treatment Analgesics Topomax (Topiramate) Migra ine Spec ific BtBeta-Bloc kers (In dera l) Ergotamine (Cafergot) Calcium Channel DHE (Migranol) Blockers (Procardia) Sumatriptan (Imitrex) Antidepressants (Elavil Zolmitriptan (Zomig) qhs) Rizatriptan (Maxalt) Serotonin Antagonists (Sansert) 8 Migraine Management What about Feverfew? Randomized double-blinded placebo controlled crossover study (1998) Retrospective study of 6 random placebo controlled studies (2000) City of London Migraine Clinic Study (1984) 200-250mg qd • 70% + effect • +/- 5 months “Break Time” Medication-Induced or “Rebound” Headache Analgesics + Opiate (Codeine) + Barbiturate (Butalbital) + Ergotamine + Caffeine Analgesics Alone? 9 Medication-Induced or “Rebound” Headache “Rebound” Headache Characteristics Migraine sufferers > Tension They take their meds preemptively “because I know Headaches are daily (or nearly daily) IIll’ll get a headache if I don ’t ” typically occurring between 2-5am. Prophylactic medication becomes useless and the causative abortive agent becomes less effective. HA varies in type, severity, and location Patients are depressed, experience sleep Pt uses abortive meds 20 or more disturbances, have difficulty concentrating, and are days/mos irritable. Mild physical/mental activity incites HA “Rebound” Headache Rebound Headache Management Patient counseling and support Lots of Love & Family education Support. HA diary Remember…it easier CBC, Liver (BUN, creatinine) & Kidney to prevent this, than fix (AST/SGOT) function studies. this. Abrupt d/c of responsible med(s), + / - Aleve, Feverfew, Magnesium inj. & Subcu Sumatriptan. “Fiorinal Call” – Val Akula Inflammatory Headaches Sinus Headache Sinus-related headache Sinusitis => The #1 health-care complaint in Temporal Arteritis (GCA) the US. Meningeal headaches Infectious (bacterial, viral, Affects 31.2 million people incl. HIV) Accounts for 16 million outpatient visits / Neoplasm (Carcinoma, lymphoma) year. Granulomatous (Sarcoid, TB) Chronic Sinusitis => most common chronic disease in the country. 10 Sinus Headache Sinus Headache Acute Chronic Most Common Infectious Non-infectious Typically occurs after a Symptoms have to Pathogens: Contributers: cold or bout of acute persist either: Haemophilus influenza Smoking allergic rhinitis. 2 or more months, or Strep pyogenes Habitual use of: 4+ episodes of acute Symptoms last < 3 wks Strep pneumoniae Nasal Sprays sinusitis that last Inhalers >10days within 1 year. Moraxella catarrhalis Staph (Chronic) Sinus Headache Sinus Headache Sinusitis results from infected, engorged and / or inflamed nasal structures. HA character => deepp,er, dull, aching gq quality with a heaviness & fullness. Aggravated by standing, walking, bending forward or coughing. Often interferes with sleep. Worse in AM, gets better. Rarely is there nausea & vomiting. Sinus Headache Sinus Trans-illumination Evaluation: Hx of cold, allergy, URI, or decreased sense
Recommended publications
  • Acupressure for Tension Headache

    Acupressure for Tension Headache

    MANUAL THERAPY Malissa Martin, EdD, ATC, CSCS, Report Editor Acupressure for Tension Headache Sandra Hendrich, PT, DPT; Leamor Kahanov, EdD, LAT, ATC; and Lindsey E. Eberman, PhD, LAT, ATC • Indiana State University Tension headache (TH) or “stress head- milder severity and longer duration and is ache” is the most common type of headache generally described as a feeling of tightness occurring among adults, occurring twice as or a band-like pressure felt around the back often in women as in men, and a leading of the neck or the head or in the forehead health complaint.1,2,3 Exercise-related head- region.1-4 The pain associated with TH is usu- aches are one of the ally dull in nature and generally occurs on most common medical both sides of the head. Tight muscles in the Key PPointsoints problems affecting ath- neck, shoulders, upper back, and temporal Addressing three key acupressure points letes, with up to 50% regions, often accompanied by stress, may (temporal, base of the skull, first dorsal reporting headache as be an indication that myofacial trigger points 1-4 interossi) may reduce or eliminate tension a regular consequence (MTPs) are a cause of TH. headache symptoms. of athletic participa- Treatment may include psychological tion.4 A majority (72%) counseling, manual therapy, physiologic Accupressure points (i.e., Joining of the of these athletes report intervention, and pharmaceutical treat- Valleys, LI4; Gates of Consciousness, that neither trauma or ment.1,3 An association between MTPs and GB20; and the temporal region) may be concussion is the cause, TH has been identified, with treatment ame- specific to tension headaches but may also and therefore, such liorating or eliminating symptoms.2,3 MTPs be hypersensitive muscles delineated by a headaches can be cat- in the upper trapezius, sternocleidomastoid taut band of tissues.
  • Bronson Healthcare Midwest Epic Review of Systems 10.3

    Bronson Healthcare Midwest Epic Review of Systems 10.3

    Bronson HealthCare Midwest Epic Review of Systems 10.3 Constitution Endocrine Activity Change Y N Cold intolerance Y N Appetite Change Y N Heat intolerance Y N Chills Y N Polydipsia Y N Diaphoresis Y N Polyuria Y N Fatigue Y N GU Fever Y N Difficulty urinating Y N Unexpctd wt chnge Y N Dyspareunia Y N HENT Dysuria Y N Facial Swelling Y N Enuresis Y N Neck pain Y N Flank pain Y N Neck stiffness Y N Frequency Y N Ear Discharge Y N Genital Sore Y N Hearing loss Y N Hematuria Y N Ear pain Y N Menstrual problem Y N Tinnitus Y N Pelvic pain Y N Nosebleeds Y N Urgency Y N Congestion Y N Urine decreased Y N Rhinorrhea Y N Vaginal bleeding Y N Postnasal drip Y N Vaginal discharge Y N Sneezing Y N Vaginal pain Y N Sinus Pressure Y N Musc Dental problem Y N Arthralgias Y N Drooling Y N Back pain Y N Mouth sores Y N Gait problem Y N Sore throat Y N Joint swelling Y N Trouble swallowing Y N Myalgias Y N Voice Change Y N Skin Eyes Color change Y N Eye Discharge Y N Pallor Y N Eye itching Y N Rash Y N Eye pain Y N Wound Y N Last Name: ___________________________________ First Name: ______________________________________ Date of Birth: _____________________________ Today’s Date: __________________________________________ Bronson HealthCare Midwest Epic Review of Systems 10.3 Eye redness Y N Allergy/Immuno Photophobia Y N Env allergies Y N Visual disturbance Y N Food Allergies Y N Respiratory Immunocompromised Y N Apnea Y N Neurological Chest tightness Y N Dizziness Y N Choking Y N Facial asymmetry Y N Cough Y N Headaches Y N Shortness of breath Y N Light-headedness
  • Migraine; Cluster Headache; Tension Headache Order Set Requirements: Allergies Risk Assessment / Scoring Tools / Screening: See Clinical Decision Support Section

    Migraine; Cluster Headache; Tension Headache Order Set Requirements: Allergies Risk Assessment / Scoring Tools / Screening: See Clinical Decision Support Section

    Provincial Clinical Knowledge Topic Primary Headaches, Adult – Emergency V 1.0 © 2017, Alberta Health Services. This work is licensed under the Creative Commons Attribution-Non-Commercial-No Derivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Disclaimer: This material is intended for use by clinicians only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. Revision History Version Date of Revision Description of Revision Revised By 1.0 March 2017 Topic completed and disseminated See Acknowledgements Primary Headaches, Adult – Emergency V 1.0 Page 1 of 16 Important Information Before You Begin The recommendations contained in this knowledge topic have been provincially adjudicated and are based on best practice and available evidence. Clinicians applying these recommendations should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as best practice evidence and practice change. The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements such as the Required Organizational Practices.
  • W10: Causes and Co-Morbidities of Nocturia Workshop Chair: An-Sofie Goessaert, Belgium 12 September 2017 09:00 - 10:30

    W10: Causes and Co-Morbidities of Nocturia Workshop Chair: An-Sofie Goessaert, Belgium 12 September 2017 09:00 - 10:30

    W10: Causes and Co-morbidities of Nocturia Workshop Chair: An-Sofie Goessaert, Belgium 12 September 2017 09:00 - 10:30 Start End Topic Speakers 09:00 09:20 Phenotyping Nocturia – Judge a Book by its Cover? An-Sofie Goessaert 09:20 09:40 Sleep and Nocturia – Central Mechanisms into Business? Karlien Dhondt 09:40 10:00 Bladder and Kidney – Making the Bladder Gladder or Lowering Philip Van Kerrebroeck the Water Levels? 10:00 10:20 Questionnaire on Nocturia – to TANGO or Not to TANGO? Wendy Bower 10:20 10:30 Questions All Speaker Powerpoint Slides Please note that where authorised by the speaker all PowerPoint slides presented at the workshop will be made available after the meeting via the ICS website www.ics.org/2017/programme Please do not film or photograph the slides during the workshop as this is distracting for the speakers. Aims of Workshop Nocturia is a highly prevalent condition affecting both men and women of all ages. It is no longer a problem merely attributed to overactive bladder or benign prostate hyperplasia. There can be an impairment in one or more factors of the triad brain-kidney- bladder but also other factors such as obesity, hypertension, peripheral edema, sleep disturbance, depression, medication, etc can play a role. The objective of this workshop is to provide an overview on causes and co-morbidities of nocturia and how to identify them. Learning Objectives This workshop should allow the attendant to know the answers to following questions: 1. What physical features can help you to identify possible causes or co-morbidities of nocturia? 2.
  • Headache in Primary Care *

    Headache in Primary Care *

    HeadacHe IN PRIMARY CARE * Dr Neil Whittaker - GP, Nelson Key Advisers: Dr Alistair Dunn - GP, Whangarei Dr Alan Wright - Neurologist, Dunedin Expert Reviewer: Every headache presentation is unique and challenging, requiring a flexible and individualised approach to headache management. - Most headaches are benign primary headaches - A few headaches are secondary to underlying pathology, which may be life threatening Primary headaches can be difficult to diagnose and manage. People, who experience severe or recurrent primary headache, can be subject to significant social, financial and disability burden. We cannot cover all the issues associated with headache presentation in primary care; instead, our focus is on assisting clinicians to: - Recognise presentations of secondary headaches - Effectively diagnose primary headaches - Manage primary headaches, in particular tension-type headache, migraine and cluster headache - Avoid, recognise and manage medication overuse headache 10 I BPJ I Issue 7 www.bpac.org.nz keyword: “Headache” DIAGNOSIS OF HEADACHE IN PRIMARY CARE The keys to headache diagnosis in primary care are: - Ensuring occasional presentations of secondary headache do not escape notice - Differentiating between the causes of primary headache - Addressing patient concerns about serious pathology RECOGNISE SERIOUS SECONDARY HEADACHES BY BEING ALERT FOR RED FLAGS AND PERFORMING FUNDOSCOPY Although primary care clinicians worry about Red Flags in headache presentation missing serious secondary headaches, most Red Flags in headache presentation include: people presenting with secondary headache will have alerting clinical features. These Age clinical features, red flags, are not highly - Over 50 years at onset of new headache specific but do alert clinicians to the need for - Under 10 years at onset particular care in the history, examination and Characteristics investigation.
  • Headache: a Patient's Guide (Pdf)

    Headache: a Patient's Guide (Pdf)

    Headache A Patient’s Guide Kathleen Digre, MD • Susan Baggaley, APRN • K.C. Brennan, MD • Seniha Ozudogru, MD 729 Arapeen Drive Salt Lake City, Utah 84108 801.585.7575 headache.uofuhealth.org Headache: A Patient’s Guide eadache is an extremely common problem. It is estimated that 10-20% of all people have migraine. Headache is one of the most common reasons H people visit the doctor’s office. Headache can be the symptom of a serious problem, or it can be recurrent, annoying and disabling, without any underlying structural cause. WHAT CAUSES HEAD PAIN? Pain in the head is carried by certain nerves that supply the head and neck. The trigeminal system impacts the face as well as the cervical (neck) 1 and 2 nerves in the back of the head. Although pain can indicate that something is pushing on the brain or nerves, most of the time nothing is pushing on anything. We think that in migraine there may be a generator of headache in the brain which can be triggered by many things. Some people’s generators are more sensitive to stimuli such as light, noise, odor, and stress than others, causing a person to have more frequent headaches. THERE ARE MANY TYPES OF HEADACHES! Most people have more than one type of headache. The most common type of headache seen in a doctor's office is migraine (the most common type of headache in the general population is tension headache). Some people do not believe that migraine and tension headaches are different headaches, but rather two ends of a headache continuum.
  • A Characteristic Ganglioside Antibody Pattern in the CSF of Patients With

    A Characteristic Ganglioside Antibody Pattern in the CSF of Patients With

    Journal ofNeurology, Neurosurgery, and Psychiatry 1993;56:361-364 361 A characteristic ganglioside antibody pattern in J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.4.361 on 1 April 1993. Downloaded from the CSF of patients with amyotrophic lateral sclerosis Andreas Stevens, Michael Weller, Horst Wietholter Abstract Materials and methods Paired cerebrospinal fluid and serum Thirty five patients with amyotrophic lateral samples of patients with amyotrophic sclerosis, 16 men and 19 women, mean age lateral sclerosis (n = 35) revealed no con- 53-5 (2 4) years, range 25-79 years at diag- sistent abnormalities of CSF cell count, nosis, without a family history of the illness, CSF albumin, CSF IgG, CSF IgM, IgG were included in this study. The diagnosis or IgM index, or oligoclonal immuno- was clinical and based on the presence of globulin band formation in the CSF. both upper and lower motor neuron symp- Determination of IgG and IgM CSF and toms and signs. Eight patients had prominent serum antibodies to gangliosides GM1, bulbar signs, 31 had definite spasticity. For GM2, GM3, AGMI, GDla, GDlb, and inclusion in this study, the onset of symptoms GTlb showed a characteristic pattern had to be insidious and not started before the which allowed the differentiation of age of 20. The clinical course had to be amyotrophic lateral sclerosis from con- progressive. Specific attention was given to trols and from patients with other neuro- alternative diagnoses of cervical spondylosis, logical disorders including multiple neoplastic lesions of cervical spinal cord sclerosis. Specifically, patients with the and brain stem, polymyositis, peripheral disease had elevated CSF IgM antibodies neuropathy, progressive muscle atrophy, to all gangliosides except AGMI.
  • Tension-Type Headache CQ III-1

    Tension-Type Headache CQ III-1

    III Tension-type headache CQ III-1 How is tension-type headache classified? Recommendation Since 1962, various classifications for tension-type headache have been proposed. Currently, classification according to the International Classification of Headache Disorders 3rd Edition (beta version) (ICHD-3beta) published in 2013 is recommended. Grade A Background and Objective Diagnostic classification that forms the basis of guidelines is certainly important for formulating clinical care and treatment policies. The ICHD-3beta is not simply a document based on classification, it also addresses diagnosis and treatment scientifically and practically from all aspects. Comments and Evidence The classification of tension-type headache (TTH) is provided by the International Classification of Headache Disorders 3rd edition beta version (ICHD-3beta).1)2) The division of tension-type headache into episodic and chronic types adopted by the first edition of the International Classification of Headache Disorders (1988)3) is extremely useful. The International Classification of Headache Disorders 2nd edition (ICHD-II) further subdivides the episodic type according to frequency, and states that this is based on the difference in pathophysiology. The former episodic tension-type headache (ETTH) is further classified into 2.1 infrequent episodic tension-type headache (IETTH) with headache episodes less than once per month (<12 days/year), and 2.2 frequent episodic tension-type headache (FETTH) with higher frequency and longer duration (<15 days/month). The infrequent subtype has little impact on the individual, and to a certain extent, is understood to be within the range of physiological response to stress in daily life. However, frequent episodes may cause disability that sometimes requires expensive drugs and prophylactic medication.
  • Biochemistry of Blood and Cerebrospinal Fluid in Tension-Type Headaches

    Biochemistry of Blood and Cerebrospinal Fluid in Tension-Type Headaches

    P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-75 Olesen- 2057G GRBT050-Olesen-v6.cls August 5, 2005 20:30 ••Chapter 75 ◗ Biochemistry of Blood and Cerebrospinal Fluid in Tension-Type Headaches Flemming W. Bach and Michel D. Ferrari The literature on biochemistry in tension-type headache tors, were reported to be reduced in patients with TTH (TTH) is characterized by the pursuit of a large variety of in headache-free periods and further lowered during ideas about pathophysiology, and it may therefore appear headache in analogy with what was seen in migraine (59). somewhat dispersed and confusing. Indeed, in many cases Schoenen et al., on the other hand, found similar magne- similar studies have been performed that yielded contra- sium concentrations in chronic TTH and control subjects dictory results, and there may be many reasons for this. (60). Lactic and pyruvic acid levels are normal in TTH (55). First, many different designations, including chronic daily headache, (chronic) muscle contraction headache, tension headache, and chronic migraine; definitions; and Peptides criteria have been used in the past to describe clinically pa- Several peptides have been studied in TTH, and the en- tients suffering from unspecified headaches. This severely dogenous opioid peptides β-endorphin and methionine- hampers straightforward comparison of the results. Only enkephalin (met-enkephalin) received much attention in recent years have most investigators used the 1988 crite- for a period. The idea was that headache was a ria (38). Second, exclusion criteria also vary markedly, the hypoendorphin-syndrome (66). It appears from Table 75-1 most important being the use of medication at the time of that the data are inconsistent with regard to this idea.
  • A 27-Month-Old Boy with Polyuria and Polydipsia

    A 27-Month-Old Boy with Polyuria and Polydipsia

    UC Davis UC Davis Previously Published Works Title A 27-Month-Old Boy with Polyuria and Polydipsia. Permalink https://escholarship.org/uc/item/8x24x4p2 Authors Lee, Yvonne Winnicki, Erica Butani, Lavjay et al. Publication Date 2018 DOI 10.1155/2018/4281217 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Hindawi Case Reports in Pediatrics Volume 2018, Article ID 4281217, 4 pages https://doi.org/10.1155/2018/4281217 Case Report A 27-Month-Old Boy with Polyuria and Polydipsia Yvonne Lee,1 Erica Winnicki,2 Lavjay Butani ,3 and Stephanie Nguyen 3 1Department of Pediatrics, Section of Endocrinology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA 2Department of Pediatrics, Section of Nephrology, University of California, San Francisco, San Francisco, CA, USA 3Department of Pediatrics, Section of Nephrology, University of California, Davis, Sacramento, CA, USA Correspondence should be addressed to Stephanie Nguyen; [email protected] Received 16 May 2018; Accepted 1 August 2018; Published 23 August 2018 Academic Editor: Anselm Chi-wai Lee Copyright © 2018 Yvonne Lee et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Psychogenic polydipsia is a well-described phenomenon in those with a diagnosed psychiatric disorder such as schizophrenia and anxiety disorders. Primary polydipsia is differentiated from psychogenic polydipsia by the lack of a clear psychotic disturbance. We present a case of a 27-month-old boy who presented with polyuria and polydipsia. Laboratory studies, imaging, and an observed water deprivation test were consistent with primary polydipsia.
  • Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE

    Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE

    Novel Psychoactive Treatment UK Network NEPTUNE Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE This publication of the Novel Psychoactive Treatment UK Network (NEPTUNE) is protected by copyright. The reproduction of NEPTUNE guidance is authorised, provided the source is acknowledged. © 2015 NEPTUNE (Novel Psychoactive Treatment UK Network) 2015 Club Drug Clinic/CAPS Central and North West London NHS Foundation Trust (CNWL) 69 Warwick Road Earls Court SW5 9HB http://www.Neptune-clinical-guidance.com http://www.Neptune-clinical-guidance.co.uk The guidance is based on a combination of literature review and expert clinical con sensus and is based on information available up to March 2015. We accept no responsi bility or liability for any consequences arising from the use of the information contained in this document. The recommended citation of this document is: Abdulrahim D & Bowden-Jones O, on behalf of the NEPTUNE Expert Group. Guidance on the Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances. Novel Psychoactive Treatment UK Network (NEPTUNE). London, 2015. NEPTUNE is funded by the Health Foundation, an independent charity working to improve the quality of health care in the UK. Editorial production and page design by Ralph Footring Ltd, http://www.footring.co.uk NEPTUNE NEPTUNE (Novel Psychoactive Treatment UK Network): Expert Group members NEPTUNE Expert Group Dr Owen Bowden-Jones Neptune Chair Clinical and programme lead Consultant
  • Chronic Daily Headache Financial Disclosures

    Chronic Daily Headache Financial Disclosures

    Chronic Daily Headache Bassel F. Shneker, MD, MBA Associate Professor Vice Chair, OSU Neurology The Ohio State University Wexner Medical Center Financial Disclosures • None related to the presentation • Grants to conduct clinical trials from: UCB Pharma, GSK, Eisai, Upsher-smith, Vertex,,, Sunovion, Pfizer • Speaker bureau: Supernus 1 Outline • A case of a pati en t wi th chronic headache • Chronic Daily headache • Focus on Migraine Clinical Presentation (1) • 30 Y/O woman with history of depression • 5 year his tory o f a lmos t 24/7 h ead ach e • Reported holocephalic pressure (band-like) headache • Intensity 5/10 but can get up to 10/10 • Reported nausea a nd p hotop hob ia sometimes • No other associated neurological symptoms • Reported using acetaminophen daily 2 Clinical Presentation (2) • Tried many OTCs, prescribed analgesics, a triptan, 2 antidepressants, a beta blocker, 2 AEDs, 2 muscle relaxants • Reported many headache related ED visits annually • Normal neurological exam (no papilledema) • Normal brain MRI • 2 women in family have headaches Diagnosis & Treatment ? • Simple – Chronic daily headache (tension headache) ! – Start a pharmacological treatment she has not tried! • Is that it? 3 Clues to a Detailed History • Fluctuation of pain severity • AitdtAssociated symptoms • ED visits • Daily use of analgesics • How the headache started? History upon Detailed Questioning • Two types of headache – Constant pressure – Can have “Spikes” of severe pain lasting for hours • Constant headache – Mild to moderate intensity – Acetaminophen