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THE SEARCHLIGHT MESSENGER

Medical Advise

MIGRAINES IN CHILDREN

Many of you have read my article on migraines entitled
Is My Headache a Migraine. Recently I have been approached with questions from my college campus students regarding their children and the brittle headaches their kids endure. Two students in particular stated that their child’s doctor had diagnosed them as having migraines, prescribed the medicine, periactin as needed, but did not explain to them what migraines in children are really all about.

This is a little disturbing to me, as I feel the more educated my patients are, the better they are able to manage their headaches and lead normal healthy lives. This falls on the treating doctor, and unfortunately, it seems this new era of doctors is in such a hurry, it has forgotten how to teach. Osler would role in his grave!

This part of treatment is obviously more important than the "periactin". And both should be part of an overall plan. "Written down and easy to follow", by both the parents and the little one.

So, I thought this would be a good time to again discuss this very debilitating disorder. No one ever wants to see a child suffer through these. I recommend reviewing the above article in addition to this one.

When you think about someone having a headache, you probably think of an adult. But many kids have headaches too, and for many of the very same reasons that adults have them.

Children and teens can experience muscle tension or migraine headaches. Among school age children ages 5 to 17 in the United States, 20% are prone to headaches. Approximately 15% of these kids experience muscle tension headaches and 5% are dealing with migraines.

Chronic or frequent headaches can be tough to handle, and are even harder to understand when you are young, especially if you do not know anyone else who has them.
By the time they reach high school, most young people have experienced some type of headache. Fortunately, less than 5% of headaches are the result of serious disease, such as a tumor, abscess, infectious disease, or head trauma.

Most headaches are muscle tension type, the result of good and bad stress, sleep issues, or in a few instances, environmental or food triggers. About 5% of recurrent headaches will be diagnosed as migraine.

Episodic headaches are those that occur a few times a month at most. Chronic headaches occur with much more frequency, even several times in a week. If a child who has only had an occasional headache (once or twice a month) starts experiencing them more frequently (two, or three times a week), then these should be considered chronic and medical attention should be sought as soon as possible.

One of the most frustrating aspects of chronic headaches is the stress factor. Avoiding a known trigger is usually easier than avoiding stress. Young people want to do well on tests and in school, and they want to attend important events, but anticipating a math quiz or musical recital, or eagerly looking forward to a party or being in the school play, can result in anxiety or excitement. And, for some kids, this leads to a headache.

Up to 4% of children have their first headache before they reach elementary school, and they may not yet know how to describe the pain. If a young child has been crying or not eating, or has been restless or irritable, consult with your doctor about finding the source of discomfort or pain. Remember, the child has no idea what is happening and this can be very frightening.

The more knowledge (and easy to understand guide lines) school health officials, as well as parents have about children and chronic migraines, such as common triggers, symptoms, prevention, and treatments, the easier it will be to identify the child who is suffering through these headaches.

The best evidence based approach to treatment, interestingly, is the more holistic approach to little patients. It entails two things: 'chronic therapy', which addresses decreasing the frequency and intensity of the headaches, and 'acute therapy', which gives the patient and parents weapons to stave off an evolving attack.

As I have discussed in other articles, in adults, a migraine's throbbing head pain usually occurs on one side of the head, but in children it can affect both sides. The migraine is often accompanied by nausea, vomiting, dizziness, blurred vision, sensitivity to light and sound, and changes in temperament and personality. A headache's duration varies from individual to individual. But, generally, unlike adult migraine, which can continue up to four days, a child's migraine might be as short as one hour or may last for a day or so. Children also improve more rapidly to sleep. So, the best treatment for children is a nap in a quiet, and dark room.

About 15% of kids experience a migraine headache with an Aura. A typical aura is seeing colored or flashing lights, blind spots, or wavy lines or feeling a tingling in the face or an arm or leg. An aura alerts a migraine sufferer to the onset of a headache, warning the child several minutes before the pain starts. A small percentage of migraine sufferers also encounter temporary motor weakness, as they may lose their sense of coordination, stumble, or have trouble expressing themselves.

The stratified visual aura experienced by many migraineurs.Young children with migraine may not have head pain at all but rather experience recurrent stomach problems or dizziness. These types of migraine are called migraine variants (Migraine Variants will be addressed in a future article). Children who have migraine also are more prone to motion sickness.

What causes a migraine? This is treated at length in my original article.
For most kids, migraine is inherited from a parent. Migraine occurs because of alterations in a person’s genetic makeup.  An individual migraine attack is often triggered by a particular environmental or emotional event. In some cases, triggers can be identified. Among the most commonly recognized ones are stress (good or bad), a change in routine, a change in sleep pattern, bright lights or loud noises, or certain foods and beverages. Let’s look at these for moment.

One of the things I first have patients, especially children do regarding brittle migraines, is keep a diary of foods, sleep patterns, and other possible triggers. The best way to do this is to get the whole
family involved, and use a big wall calender with plenty of space for everyone to write down what they observe, as one person may notice something another didn't.

There are many triggers in childhood migraines that should be weeded out. Foods are huge, but other things as mentioned above, like stress level, even positive stressors like more money, new teacher, family gatherings, etc. can be big. Sleep can be a major player. I can't stress enough, the value of regular sleep patterns and at least 9 hours of sleep every day for kids.

Food is probably the biggest player, so you have to read labels closely. Here are the biggest triggers I've seen in practice:
(1), Caffeine in any form, even in medicines. Keep in mind that caffeine is also used to treat headaches, but can be a two edged sword, and, induce “rebound phenomena”. (2), Mint, it's in everything, start tossing it out. (3), Red food dyes. (4), Yellow food dyes. (5), Hard aged cheeses, like Parmesan, and cheddars, remember also, that cheeses are not naturally yellow ( they have yellow dye in them). (6), Pizza. (7), Lunch meats. (8), Hot dogs and sausages. (9), Bacon, use "fresh-side", or "sugar cured".

The above meats have nitrates in them which induce migraines.
MSG (10), chocolate in any form. (11), yogurt. (12), Chinese food (oriental).
(13), The additive, Mono-Sodium Glutamate (MSG) is a monster and must be avoided, it is in everything from snack foods, frozen foods, bullion, and ramen, to canned soups. (14), All citrus products. And watch out for sugar binges. Remember to write down every little detail that appears significant on that calendar, and let your doctor know how it's going.

After a formal diagnosis, a doctor's goal is to help reduce or eliminate the symptoms of a migraine and prevent future attacks.


In regard to treatment, sometimes children, especially young children, do not need any medication to treat a headache. Often there are non-medicinal treatments that can provide primary, or added benefit.

During a migraine attack, a child should be allowed to rest, and even sleep, in a quiet, dark and cool room. Raising the child’s head up on a pillow and providing a cool compress for the eyes or forehead can help them feel more comfortable. When at school, a child should be allowed to go to the nurse’s office and rest. Sometimes a quick nap is all it takes and they can return to the rest of the school day.

Trigger avoidance and a regular schedule are huge preventive measures that can be taken to avoid the frequency of attacks. Relaxation and stress management techniques can be helpful during an attack and to help alleviate stress before it becomes a full blown an attack. Daily physical activity is also very important in headache management and stress reduction. Two methods that have been well documented to help children with migraine include meditation and biofeedback. There is also much research that suggests hyper-hydration with plain water may prevent frequency in migraine attack.

Once a migraine has begun, several types of medication can alleviate the symptoms. Analgesics, such as acetaminophen or ibuprofen, are first-line pain relievers for treatment of headaches in children and adolescents. The Triptans can be helpful in those children who don’t find simple analgesics helpful. There are several different triptans available and two (almotriptan [Axert®] and rizatriptan [Maxalt®]) are FDA-approved for children. In addition, your doctor may also prescribe anti-emetics to stop the nausea and vomiting or a sedative to help a child rest.

Aspirin is not generally recommended for kids, as there is now, well documented evidence linking aspirin to the development of Reye's Syndrome, a rare disorder that children and teenagers can get while they are recovering from childhood infections, such as chicken pox, flu, and other viral infections. Reye's symptoms include nausea, severe vomiting, fever, lethargy, stupor, restlessness, and even delirium.

Children and adolescents who experience migraine attacks more than twice a week and which interfere with school or social activities, may be prescribed a daily medicine to try to prevent headaches. There are no medications that have been specifically designed for migraine so they all come from other categories including anti-seizure, blood pressure and anti-depressant drug classes. Common preventive medicines include beta blockers, tricyclic antidepressants, topiramate, and valproate. Please note: none of these medications are approved for migraine treatment in children. However, research in this area continues with excellent progress and doctors will utilize these medications as "off label" prescriptions.

Frequent headaches, especially those that occur more than once a week, deserve treatment, with both medication and non-medicinal options.  Headaches are not good for the brain and headaches often lead to more headaches. With the right treatment regimen your child can get his or her headaches under control and prevent further progression.

Further questions can be directed below, and look for continued articles on headaches in future posts on The Searchlight Messenger.

BatmanDr. Counce

The Killer On Campus

The serial killer, Meningococcal Meningitis is upon us as students return to college campuses across North America.

Many in my readership have seen my previous articles on Meningitis, and again, it's that time of year, when every August, I write an article on this important subject. This year my article will be accompanied by a discussion regarding the state of the art in the management of this disease.  

Although there are many organisms that can induce meningitis, a crippling and often fatal disease, from parasites and bacteria, to viruses, and even fungi as was seen in the tainted steroid vials from the New England Compounding Center just this last year, the Meningococcal bacterium is relentless in its attack once it invades. A serious pathogen with weaponry that is both efficient, and nearly impossible to repel.

College students, whether returning to school or just starting this fall, should be warned, and remember that there is a killer loose on campus. Its name is Neisseria Meningitidis, also known as the Meningococcus. Yes, it causes meningitis, but this is just one of the specters of disease this killer brings. It is vicious and unwavering in its ability to take down even the most robust human. It can attack at multiple levels affecting multiple systems, taking in some cases, only hours from initial infection to coma and death. Nothing, it seems is spared. From stroke to cardiogenic shock and renal failure, it can kill before meningitis even gets a chance to set up shop.

Although rare in the United States, it has caused epidemics in the United Kingdom and New Zealand, and is obviously an organism to be reckoned with. In addition to striking small children, it likes to attack robust men and women in their upper teens and early twenties. That's right, college students. And when it strikes, you feel like you have the flu; a few hours later, you are septic; in a few more, you are in septic shock. When the inflammation of the meningeal covering around your brain and spinal cord begins (meningitis), it’s too late, and “you will find yourself alone in green pastures with the sun on your face, because you are in Elysium, and you are already dead!"

Imagine a college athlete at age 20 with everything going for him; a great school, academic success, strength and quickness, a full ride scholarship, popularity, and a life style envied by everyone. Then one October morning, he wakes up chilled, notices a mild fever, and he has a sore throat. He thinks “he’s caught a cold”, takes the usual remedies, and doesn’t tell anyone he’s “under the weather today”, because, “it’s just a cold”, and all he needs is rest. The next morning, he is found dead in his dorm room by his team mates. They notice reddish-black “splotches” all over his body.

Unfortunately, this is the rule and not the exception in a meningococcal attack. Small children are done in by this predator even more quickly. It invades through intimate contact usually, but can be acquired from casual contact as well. The really bad thing with this organism, is its deliberate swiftness. Moreover, the agonizing death of shock and accompanying meningeal “tightening” which is brutally painful, and described by survivors, as the most agonizing torture they have every been through. Many say they would rather die than go through it again.  

Survivors usually lose limbs, go blind, develop renal failure, suffer heart attacks or strokes due to ischemia and dissolved blood vessels. The Meningococcus is a deliberate killer with no apparent goal except to take down its host rapidly. Scientists are always perplexed by infectious diseases like this one, which attack, then kill their host and themselves so quickly in the process.

What’s happening? This organism secretes an endotoxin that attacks macrophages (white cells, whose job is to search and destroy invaders), creating circulating cellular debris, at the same time, eating away the intimal lining of our blood vessels, creating an immune reaction of cytokines. This is why many victims have severe petechiae and bruising almost immediately after infection, and of course, the reason the victim succumbs so swiftly.

We can kill this organism with antibiotics. He has never been one to show resistance to our antibiotic weaponry. The problem is that when the organism breaks down from penicillin or any other antibiotic we use, huge quantities of this endotoxin are released, the condition of the patient is exacerbated exponentially, and we gain nothing. The victims die outright or they are left crippled. There is no real treatment for an acute attack, but there is a vaccine! It is our only true and effective weapon right now, and yes, it works very well. Do yourself and others a favor and get the meningococcal vaccine. Realize that most schools require it now, before you start college.

Keep in mind that this is a stealthy organism. Fifteen to twenty percent of Americans are carriers. That means two out of every ten people you brush by, are harboring this organism without it causing illness to them, but they can infect you. It can be transmitted by sharing a cup or straw. Yes you can catch it from a casual kiss as well as sexual activity. Use your head, and keep your hands clean.

Remember, meningitis in general, can be caused by a host of different organisms and viruses, and although the meningococcus has a scary reputation, it is a smaller player in this regard. For example, the organism we worry about the most, and the number one cause of meningitis in children under two years of age in North America, is Haemophilus Influenza (H. Flu.). Also a well known killer, we can take it down with antibiotics if caught in time. Unfortunately, survivors are usually left deaf. This is why we vaccinate against H. Flu. Also known as the HIB vaccine, it is required by all fifty of the United States. The recent Listeria scare is also a concern. Listeria Monocytogenes, although a well known food poisoner and one of the reasons we pasteurize all of our dairy products in the U.S., it is also known for causing meningitis in little ones, especially infants.

Do yourself a big favor, and get the vaccine before heading back to school this fall, it’s never too late. Get it now! If your doctor doesn't offer it, any county health department will have it. Do the right thing. Make sure all of your vaccines are up to date, including the meningococcal vaccine. And don’t forget to keep your hands clean.

Just this month (August, 2013), the US Food and Drug Administration (FDA) broadened the indication for the quadrivalent meningococcal vaccine (Menveo; Novartis Pharmaceuticals, Inc) to include infants and toddlers aged 2 months and older. The vaccine, which protects against the common N meningitidis serogroups: A, C, Y, and W-135, was already approved for use in adolescents and adults aged 11-55 years and in children aged 2-10 years.

Below, is my discussion regarding Neisseria Meningitidis Meningitis and our latest in the standard of patient care in the specialties of Internal Medicine and Pediatrics here in North America and Great Britain.




Dr. Counce


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Discussion and Management of Meningitis

By Dr. C. M. Counce

Signs and symptoms of Meningitis

Meningococcal meningitis is characterized by acute onset of the following:

  • Intense headache
  • Fever
  • Nausea
  • Vomiting
  • Photophobia
  • Stiff neck

Don’t forget the general presentation of catarrhal symptoms alone, prior to the presentation of meningeal irritation as noted above. Lethargy or drowsiness in patients frequently is reported. Stupor or coma is less common. If coma is present, the prognosis is obviously poor.

Patients also may complain of skin rash, which usually points to disease progression, and an indication that the cytokine storm has begun.

Elderly patients are prone to have an altered mental state and a protracted course with fever.

Meningococcal septicemia, which is characterized by rapid circulatory collapse and hemorrhagic rash, is a more severe, but less common, form of meningococcal disease as patients are now presenting sooner to our emergency departments.

Young children

In young children, subacute infection can progress over several days. Meningococcal meningitis can manifest as follows:

  • Irritability
  • Projectile vomiting
  • Seizures, usually with a focal onset - Typically during the first few days
  • Waterhouse-Friderichsen syndrome - Characterized by large petechial hemorrhages in the skin and mucous membranes, fever, septic shock, and disseminated intravascular coagulation (DIC) which is always an ominous specter
  • Insidious onset can be a feature in infants; nuchal ridgitity may be absent.

In children, even when the combination of status epilepticus and fever exists, the classic signs and symptoms of acute bacterial meningitis may not be present.  

Physical Examination 

Neurologic signs of meningococcal meningitis include nuchal rigidity (eg, Kernig sign, Brudzinski sign), lethargy, delirium, coma, and seizures. Irritability is a common presenting feature in children. However, in a 2008 published cohort study from Netherlands (the Meningitis Cohort Study), conducted in adult patients with meningococcal meningitis, only 70% of the patients had the classic triad of fever, neck stiffness, and change in mental status. If the presence of rash was added, 89% of the patients had 2 of the 4 features. Patients older than 30 years were noted to have petechiae (62%) less frequently than younger patients (81%).














A petechial or purpuric rash usually is found on the trunk, legs, mucous membranes, and conjunctivae. Occasionally, it is on the palms and soles. The rash may progress to purpura fulminans, when it usually is associated with multiorgan failure (ie, Waterhouse-Friderichsen syndrome). The petechial rash may be difficult to recognize in dark-skinned patients.  

Ancillary Studies

Laboratory studies

Laboratory examination of the cerebrospinal fluid (CSF) usually confirms the presence of meningitis. Typical CSF abnormalities in meningitis include the following:

  • Increased opening pressure (>180 mm water)
  • Pleocytosis of polymorphonuclear leukocytes (white blood cell [WBC] counts between 10 and 10,000 cells/µL, predominantly neutrophils)
  • Decreased glucose concentration (< 45 mg/dL)
  • Increased protein concentration (>45 mg/dL)

Other laboratory tests can include the following:

  • Culture of CSF and blood specimens to identify N meningitidis and the serogroup of meningococci, as well as to determine the bacterium’s susceptibility to antibiotics.
  • Polymerase chain reaction (PCR) assay for confirmation of the diagnosis.

Imaging studies

  • Computed tomography (CT) scanning - Indications for performing CT scanning prior to lumbar puncture include an altered level of consciousness, papilledema, focal neurologic deficits, and focal or generalized seizure activity
  • Magnetic resonance imaging (MRI)  with contrast is preferred to CT scanning, because MRI better demonstrates meningeal lesions, cerebral edema, and cerebral ischemia.

Electroencephalography

An electroencephalogram (EEG) study is sometimes useful to document irritable electrical patterns that may predispose the patient to seizures.  

Management

To prevent serious neurologic morbidity and death, prompt institution of antibiotic therapy is essential when the diagnosis of bacterial meningitis is suspected. Antimicrobial treatment should be administered as soon as possible after a lumbar puncture is performed.

Empiric pharmacologic therapy

Initial empiric therapy until the etiology of the meningitis is established should include the following agents:

  • Dexamethasone
  • A third-generation cephalosporin, ceftriaxone or cefotaxime
  • Vancomycin
  • Acyclovir - Should be considered according to the results of the initial CSF evaluation
  • Doxycycline - Should also be added during tick season in endemic areas

Postdiagnosis pharmacologic therapy

  • Penicillin - The drug of choice for the treatment of meningococcal meningitis and septicemia
  • Ampicillin - Also an option
  • Ceftriaxone (or cefotaxime) - If the isolate is resistant to penicillin
  • Dexamethasone - Controversial in the management of bacterial meningitis in adults

Prophylaxis

Deterrence and prevention of meningococcal meningitis can be achieved by either immunoprophylaxis or chemoprophylaxis. Rifampin, quinolones, and ceftriaxone are the antimicrobials that are used to eradicate meningococci from the nasopharynx.

Currently, vaccinations against meningococcus A, C, W, and Y are available. No effective vaccine exists to protect individuals from meningococcal meningitis caused by serogroup B. Interesting, in that serogroup B is the mainstream killer in countries with higher prevalence of this disease (The United Kingdom and New Zealand).

Dr. Counce









Is My Headache a Migraine?

I have to tell you, one of the occupational hazards of being a physician, is the formal dinner table. This is the traditional “non-doctor place” where doctors are hit-up by guests for medical advice. I'm not sure how conversations drift to "headaches". I mean, a lot of people get them. So when you're a doctor, people are going to ask.

So, one question will lead to another because somebody had a stressful day, and they're glad to be winding the day down with a pleasant dinner, and wondering, "Why am I getting a headache now?"

I am often asked by family, and friends, “What is a migraine headache, and are my headaches migraines?” This is sometimes difficult to answer when brought up as dinner conversation. So you ask why? Because we're talking about pain. Yeah, food and pain are just not good partners. I've been to a lot of dinners.

Understand, many things can cause headaches. From brain tumors to eye fatigue, many conditions can present with severe to mild headaches. Besides, this subject gets so deep, unless you’re ready for a long conversation, you don’t dare get started. But that's not going to happen. Many questions come up. So, this is the discussion which usually ensues, and it always gets interesting.
 
Barring serious conditions such as brain tumors, severe head and neck pathology, trauma, eye and vision disorders, serious metabolic conditions and infectious diseases, this article is meant to discuss non-pathogenic and non traumatic induced headaches, moreover, the difference between muscle tension headaches and migraines.

Yeah the ones we all get. It can't be helped. It's where we are at the paces we run. We process more information in a day, most of which is negative, than my Grandparents did in their entire lifetime. And you wonder why we get headaches.
 
Generally, the "regular joe" thinks of a migraine as a very severe headache. So, when they get a “bad” headache, they usually refer to it as a “migraine”, but this is not the case at all. There are many types of benign headaches which are severe enough to ruin one’s day or even their week. The classification of headaches, and more importantly, migraines, has been written and rewritten by doctors for centuries.

Although doctors have been practicing neurology since there were doctors, It wasn’t until the twentieth century that the specialty of neurology was well etched in stone, which gave way to modern clinical research protocols, and methods to evaluate headaches scientifically. Interestingly, even during the  twentieth century, the classification of different types of migraines has changed substantially.
 
We live in a fast paced society. We run around dehydrated, drinking coffee, stare at LCD screens whether tiny or large. Drive to work or school, drive back, go do things, watch the news, most of it bad, and don't forget this is the stuff that didn't happen at work. Yeah, we worked today too.

Most of us manifest our stress physically, so we either get upset stomachs, aching necks, or we get headaches, and for some, all three. In America, particularly, two types of headaches are generally seen in this regard, muscle tension types, and vascular migraine types. Here’s “the quick and dirty” on both. and keep in mind that there is no purity in these classifications, and that most headaches are mixed.
 
Muscle tension headaches tend to come on as the day progresses, while the stressors one is dealing with are ongoing and building. So by the end of the day, your headache progressively worsens, your neck and scalp muscles increase their tone and now you have a full blown “head-knocker” at the end of the day.

Migraines on the other hand are vascular in nature, are brought on by chemical changes reacting to stress loads and dietary triggers. You generally awaken with the headache as they come on after the stress is gone. You guessed it, the following day, after the stressful event or events are over, you’re in pain.

It is the classic euphoric phase of “the general alarm reaction to stress”. So you wake up with a “banger” which is hugely painful and stays with you all day. This is also why a migraineur (pronounced, “mi-gren-yurr”) tends to have his headache on Saturday mornings, or say, the day after that big speech he had been preparing for weeks.
 
Muscle tension headaches, also known as “tension” headaches or “contraction” headaches, are direct results of increased tone and muscular irritation in the back, shoulders, neck, and scalp. As a result, they usually respond to anti-inflammatory drugs like ibuprofen or aspirin; massage; muscle relaxants; or just lying down for a while.

Migraines are more brittle. Since they involve vascular changes in the coverings and meningeal septa of the brain, anti-inflammatory drugs and muscle relaxation are usually ineffective treatments, moreover, they can even make a headache worse. Increased blood vessel caliber is the problem and needs to be turned off and re-set. This is why caffeine, decongestants, and other vasoconstricting agents help.
 
A test I have many patients, as well as friends and family try, is the “Beer Test”. It’s not one hundred percent, but fairly reliable, and if you want to know if that headache you have had all day is a migraine or tension headache, when you get home, drink a beer, preferably "a dark".

If the headache goes away, it’s a tension headache, if it gets worse, it’s a migraine. The practice of medicine, as cutting edge as it is, we seasoned craftsmen, can still shoot from the hip.
 
So, tension headaches are a direct result of stress insult, like someone turning up the volume on your neck muscles throughout the day.  This type of headache is obviously exacerbated by posture, compensatory changes after an injury, arthritis, chronic musculoskeletal conditions, and of course,  stress load. 
 
Migraineurs suffer as they do because the headache waits, then sneaks up on them when they’re resting. The other important thing to remember is that in all these headache types, physical examination, metabolic workups, and imaging, are always negative for “lesion” or organic pathology. What I’m saying is that, “migraine”, is a diagnosis of exclusion. Other organic conditions must be ruled out first.
 
“Migraine” is a very old term derived from the Greek, meaning “semi-cranium” or “half skull”. Yes, generally a migraine headache is usually, but not always, unilateral, affecting one side of the head. The problem is they come in so many different manifestations that it has been difficult to classify them, even in modern medicine.

Several versions have been published since the early 1920s, however, after World War II, neurologists in America started to find some consistencies which allowed at least for neurologists, an ability to observe, diagnose, and treat with a standard of care. It also allowed doctors to communicate the type of headache a patient was experiencing.
 
This so-called classification remained in place for nearly sixty years, but in 1995, The National Headache Foundation along with The American Academy of Neurology, published straight forward guidelines that have allowed all physicians to more easily navigate the presentation of headache patients, diagnosis them accurately, and treat them appropriately and effectively.

Stratified Visual Scotoma of MigraineThe older “traditional classification” which is still used by many older doctors, uses excellent descriptors and relies on 5 major presentations, and thus, the patient is labeled as such.

They are: Classical Migraine; Common Migraine; Complex Migraine; Mixed Headache; and Migraine Equivalent (also known as Retinal Migraine). I don’t need to remind you that there are many variations on each one of these.
 
Classical Migraines are the brittle ones you hear about, and the type that causes a great many to present to the emergency department of their local hospital.

Here’s a typical presentation. Usually a woman, as 75% of migraineurs are women; she awoke with a one sided throbbing headache that wouldn’t respond to any medication. It started with a visual aura of sparkles in the upper left visual field (what we call a stratified visual scotoma). She can’t stand to have any light in the room, noises make the pain worse, and she’s nauseous and vomiting, in addition, just moving around makes it much worse.

It should be noted that auras can present in many fashions, including ringing in the ears, a tingling sensation anywhere, a deja vu, or a lot of yawning during the day. Yeah! I know!

The patient generally requires narcotic pain management, and neurovascular control with a triptan drug (see below) and an-anti emetic like phenergan.

It is this sufferer, the U.S. Department of Labor has stated, “costs our nation nearly 33 billion dollars in lost man hours a year"! That’s not including the tab to her health insurance company. Oh, and don't forget, if she’s on Medicaid insurance, your tax dollars.
 
Common Migraines, are much less intense and disabling, they still throb, are usually one sided, the patient can have nausea, but generally no vomiting. The lights and sounds are still bothersome but not as overwhelming. Most apparent in their history, is no aura or scotoma. These are self limited, usually responding to aspirin, Tylenol and caffeine in combination, and of course, rest.
 
Complex Migraines can be terrifying. Also referred to as Hemiplegic Migraines, they will generally have features of either a classical or common type, but in addition, present with neurologic deficit. Many are mistaken for Cerebral Vascular Accidents (stroke), or Transient Ischemic Attack, and require hospital observation and treatment. Ancillary studies are usually negative, and the event resolves spontaneously. Obviously, this patient requires an exhaustive evaluation before being given this diagnosis.
 
Mixed Type are just that. They are also the most common headache generally seen. They are more migraine than muscle tension, however, they are usually a common migraine with muscle tension overlay or muscle tension headache with migraine overlay. Again, aspirin, Tylenol, and caffeine are helpful; also mild muscle relaxants are effective. Usually if one component is treated, the other falls away. Interestingly, these respond very nicely to Botox injection which can keep the patient headache free for months.
 
Stratified Visual Scotoma. This is a Left Superior Quadrantanopsia.Migraine Equivalent types are very interesting. Generally seen in college aged “type A” personalities, their hallmark is the scintillating visual scotoma, but there is no pain. That’s right! There is no headache. These patients are obviously afraid they have something serious when they first see their doctors, but after a negative work up and reassurance they do fine.

Also interesting is the phenomenon of "dissipation" with this migraine. The scotoma starts generally as a “dot”, slowly enlarges, becomes a "crescent" with a large visual field cut known as a bilateral superior, left or right, lateral homonymous quadrantanopsia, (say that 3 times, real fast),  sweeps laterally, then vanishes.
These types of migraine usually resolve as a condition by the time the individual reaches their thirties.
 
The newer guidelines have made diagnosis more accurate and streamlined for therapy using two sets: “Migraine with Aura”, and “Migraine without Aura”. Both have their specific subsets, criteria, and recommended therapies for each. Understand that The National Headache Foundation also endorses guidelines for other types of headaches that are not classified as “migraine”.
 
What we really know about migraines now, started in the 1980s, subsequently producing new knowledge and new therapies. When sumatriptan hit the medicine cabinet as migraine weaponry in 1991, much changed in the approach to headaches, including migraine classing. Since its introduction, our understanding of the migraine condition and the migraineur’s display of symptoms has been revolutionary, and produced a paradigm shift in treatment. We now know that the “migraine” is actually a cascade of events.
 
We always knew that there was an underlying driver and that migraines were vascular, hence, the pre-triptan therapies, which were designed to do two things; lyse an acute headache with narcotics and get the patient to sleep so as to break the vascular pain cycle and throbbing. The other, was to approach chronically, preventing the migraine from evolving.

We assumed that migraine headaches were vascular from the beginning, as our known therapies, mostly vaso-constricting agents, were very efficacious, right out of the bucket.

Subsequent research revealed that these headaches occurred in 2 phases. First the blood vessels of the brain would constrict during stress or dietary trigger. Then, rather than come back to their original caliber, the vessels would overshoot, engorge, ultimately causing the painful phase.
 
So, our therapies in the 1980s and 1990s were designed to keep the constricting phase from manifesting, and therefore there would be no overshoot and no pain.

This is why to this day, we continue to see migraineurs treated with blood pressure lowering medications like verapamil and propranolol, which prevent tightening of vessels. In addition to these agents, antidepressants with chronic neurovascular threshold activity like amitriptyline are added which help control chronic pain. For many patients these drugs work. That’s why they are still used in many migraineurs who suffer severe and ongoing disabling attacks.
 
Sumatriptan led to more compounds in the “triptan class”, and a host of “me too drugs” which are the mainstay for acute therapy today. This is because the research which produced these drugs revealed that deep inside the brain of a migraineur is a “migraine motor”. It is tied to an area in the midbrain called the Trigeminal Nucleus Caudalis.

When stimulated by neurotransmitters from stress loads, lack of sleep, too much sleep, medications, or food triggers, it sends pain signals along the Trigeminal Nerve (The Fifth Cranial Nerve), and the vascular bed which surrounds it.
 
The two Trigeminal Nerves (left and right) are sensory nerves innervating the scalp, forehead, face and periosteal bone of the skull. When the migraine motor is stimulated, blood vessels along these nerves are irritated, inflamed, and dilate, causing severe painful migraines.

This should not be confused with its very famous cousin, Trigeminal Neuralgia which is also extremely painful and responds to similar medical treatments.

Sumatriptan is structurally similar to serotonin (5HT), and is a 5-HT_agonist. The specific receptor subtypes it activates are present on the cranial arteries and veins. Acting as an agonist at these receptors, sumatriptan reduces the vascular inflammation and dilatation associated with migraine, countering this cascade at its source.

Even in a disabling attack, sumatriptan injection can lyse the pain of migraine within minutes, without the side effects and sedation of narcotics and anti-emetics.
 
Now we know more about migraines and tension headaches. We know what causes them, how they are different, and how we can treat them. But you’ve probably been asking yourself, what are these food triggers and how do they stimulate the “migraine motor”? Migraine triggers are all over the web. A good place to start for a thorough list is at The National Headache Foundation .
 
The real mechanism of migraine motor stimulation is not fully understood, but may involve the neurotransmitter levels of dopamine, serotonin, and nor-epinephrine, in addition, the hormones 2-hydroxy-estradiol, progesterone, and thyroxin, as well as IgG  antibodies from different food antigens. However, the triggers are well known and they themselves give us a clue.
 
Certainly there are known direct vasodilator foods such as Monosodium Glutamate (MSG), caffeine, kava based, and ephedra based herbs, and chocolate. Of course MSG is in all of our salted snacks and most of our “prepared” foods in the freezer section.

Not surprisingly, many of my migraine patients when asked to keep a food diary, find they consumed large amounts of MSG the night before an attack, usually a potato chip, Doritos, or Frito binge. Citrus such as orange juice; wine, particularly the reds; hard aged cheeses; meats cured in nitrates; pickles; peanuts; and mint, to name only a few, are well known culprits. Don't forget about the beer, partcularly, "the darks".
 
The non-food triggers are classic: too much or not enough sleep; the computer screen you’re looking at right now; stressful life styles, including the classic "workaholic"; drugs of all kinds, including aspirin and acetaminophen; and lastly, medicinal hormones such as progesterone, yeah, your birth control pills. This is one of the reasons why women are more prone to migraine.

Yes, a huge connection with progesterones and vascular engorgement in the turbinates of the nose as well as migraine is well documented. This is also why many women suffer during their menstrual cycles, and even pregnancy.
 
Because headaches are so prevalent, they can become a huge topic in any casual conversation with any doctor. Perhaps one needs to write a book on the subject to produce a concise literary treatment which the chronic headache sufferer can utilize. But there have been so many. All written by doctors and non-doctors alike. All that folk medicine and traditional medicine out there, it can become easily confusing.

Especially with all those quacks out there with their, "infomercials" and "snake oil" they try to sell you. What does the headache sufferer do? Hopefully this article will help you choose the right book.

In the mean time, watch those foods, try some way to lower your stress, (excuse me, "get off your ass, and find a sport you like to do, and do it"), don’t forget to drink plenty of water. Throw away all of your MSG. Oh, and throw out anything with high fructose corn syrup in it. Do it right now.

If you are a true migraineur, or a chronic headache sufferer, you should see your doctor right away, and don’t forget to check out The National Headache Foundation
 
 




Dr. Counce






 

Kidney Stones! They Hurt!

Kidney stones! They hurt! And they’re on the rise. That’s right. They're becoming more and more common. They're becoming what many would consider epidemic.  Everywhere you turn, someone says something like, “yeah, I had one last spring, put me down for 3 days. It was so bad I puked for 2 days, even while I was on all that medication”. There's more, “It’s the most excruciating pain I’ve ever had and that was my second one”. Or this one, "Where's Bob? Heard he was in the hospital with a kidney stone, again!"
 
 What’s going on? Why are more and more people being diagnosed and treated for this problem? As a physician I have seen many presentations of this extremely painful condition, moreover, just this last year, I had 3 friends who were not patients, people I consider very healthy, who had struggled with this problem.

One was a very young professional woman I work with who practices a very healthy lifestyle, and I have to tell you I was astounded by her graphic complaint of pain, loss of work, and fear of continued attacks. Truly afraid of another stone, this young lady is in her twenties, is a physical trainer, and says there was no family history of urinary stones until her protracted presentation to an emergency room last spring with a stone in her right ureter.

What’s going on? First, you should know that there is a well known region in the United States called “the kidney stone belt”. It exists basically for three reasons. First, it’s warm. Second, dehydration is common because it’s warm, and thirdly, folks there, eat greens. You guessed it, the south, “The Bible Belt”.

People here, are in the heat about 8 months out of the year.  Dehydration at the kidney level tends to form crystals of ionic electrolyte minerals we process daily, like calcium, uric acid, and cysteine, the products of metabolism that our bodies excrete regularly, the biggest of these being calcium. But what’s interesting, is it really isn’t the calcium that’s the culprit in most kidney stones. It’s another salting agent we call oxalic acid. And when it acts on calcium it becomes the salt, calcium oxalate.

Oxylates are a huge component of “greens”. Very popular in the south, collard, spinach, mustard greens, and even Polk salad are full of the stuff. Moreover, a well indulged product of southern living, “iced tea”, is packed with this salt. The result is a lot of excruciating back pain and kidney disease induced by lifestyle, and climate. The southern states are well known harbors of kidney stone disease, Arizona being number one.

So why is it happening everywhere now? The twenty first century lifestyle is the likely culprit. Consider that we are a people on the constant move. More mobile than ever, we are not tethered to our walls or desks with our telephones anymore. Even information is mobile, we carry our phones and the ever-present internet with us everywhere. With this, we reach for quick fixes when we’re not wired in, or maybe I should say, wirelessed in.

What has become a huge fad in the last 15 years, is we are drinking more and more coffee at places like, “Java The Hut”, “Starbucks”, “Dunkin Donuts” and other coffee shops, and really, not just for style, but for effect. Keep in mind that caffeine not only picks us up, but it inhibits an important chemical in our bodies called antidiuretic hormone (ADH), a compound that acts on the distal convoluted tubule of the unit of the kidney called a nephron. ADH works to conserve fluids in our bodies. So caffeine dehydrates directly, and can help promote and concentrate crystals in the kidney.

We also drink alcohol, which also inhibits ADH as well as cause dehydration through respiration and “insensible water loss”, which exacerbates an already dehydrated state. And in our furious business lifestyles, we run around dehydrated most of the time because we do not drink enough water anyway.

The most common of urinary stones is the “calcium oxalate stone”. These are spiculed, mace like and barbed stones which stick and cut on their way out of the kidney after being dislodged. This sounds scary, but usually isn’t very painful, although, sometimes very uncomfortable. Uric acid and other stones can do this too.

What you should understand is that the ureters, the tubes that connect the kidneys  to the bladder, although very tough, and  can withstand squashing and stabbing, do not do well with distension. If a stone lodges somewhere in this tube on its way down, the result is urinary distension behind the stone and excruciating pain described by some women, as intense as the pain of end stage labor contractions! This condition is called “hydronephrosis” and is the real center of kidney stone pain.

Generally a patient presents to the emergency room in fulminate pain, there is usually but not always, vomiting. We give pain medication and antiemetics which palliate pain and also allow the ureter to relax and allow stone passage. We do “stone hunts” with the CAT scanner, generally sending you home with more medicine, and arranging follow up with a kidney surgeon, called a Urologist. Yeah, if things get worse they either blast the stone with ultrasound (The Lithotripter) or operate.

What’s really new is the movement toward alternative medicine, which in recent years shows fascinating results. Although based mostly on anecdotal studies, these therapies have become the most utilized for kidney stones in the western world. One technique is to dissolve the stones instantly with combinations of oils and herbs. Another, which is described as quite common in Europe, is to drink cola and eat asparagus. The method we have found most intriguing for calcium oxalate stones is the “olive oil and lemon juice” technique. This method is described all over the web.

As a physician, I look at these treatments with a raised eyebrow, however, having spoken to many biochemists regarding these techniques, it is very possible that these compounding  therapies work to dissolve the spicules on small stones, allowing them to pass without creating blockage. I have to say, that if I have a kidney stone, I would be tempted to try a little olive oil and lemon juice over fentanyl and phenergan any day. I certainly don’t care to be operated on.

Ultimately, it seems very important that we watch our hydration, and be careful with those greens, not to mention all that iced tea.   
 
Dr. Counce


 

Crohns Disease and Today's Athlete

Crohn’s Disease and Todays Athlete

 Today’s athlete can be described by many as a man or woman of super human strength and endurance that is unstoppable as they fight to earn that medal of being the best in their  field. We think of Michael Jordan and how he changed the game of basketball with his aerodynamic jumps to slam a basketball into the rim, or maybe Iron Mike Tyson, who could knock a guy out in one punch. Who could forget how Tiger Woods brought the game of golf to those who never even thought of picking up a golf club, and of course we can’t forget football and John Elway’s pass on the run that took the Denver Broncos to back to back Super Bowl Championships. These are just some examples of great athletes and their ability to perform; however there are other athletes who carry a stronger fight, Crohn’s Disease.
Crohn’s disease is a chronic condition that causes inflammation, swelling, and deep sores called ulcers in the body’s gastrointestinal (GI) tract (commonly called the digestive tract). Although it can involve any part of the GI tract from the mouth to the anus, Crohn’s disease most often affects the lower portion of the small intestine (the ileum) and the upper portion of the large intestine (the colon).
Crohn’s disease is similar to another chronic inflammatory condition that affects only the colon—ulcerative colitis. These diseases are part of a larger group of illnesses called inflammatory bowel disease (IBD).
Both Crohn’s disease and ulcerative colitis fluctuate between periods of remission (inactivity) and [exacerbation] (increased activity). Neither have a medical cure, but medical and alternative therapies can reduce the symptoms that people with Crohn’s disease and ulcerative colitis experience during times of exacerbation. In many cases, these therapies help people maintain a normal lifestyle with few interruptions from the diseases.
                                                              
Crohn’s disease affects approximately 700,000 Americans—another 700,000 have ulcerative colitis. Males and females are affected equally by Crohn’s disease, and there are a slightly higher number of males affected by ulcerative colitis. IBD has been considered a disease that primarily affects Caucasians, though it has been found in all races. For example, people of Eastern European (Ashkenazi) Jewish descent are about four to five times more likely to develop IBD. However, reported cases in African Americans have been increasing. (Hispanic and Asian populations have a lower incidence.) Inflammatory bowel diseases most commonly begin causing symptoms during adolescence and early adulthood—from the ages of 15 to 35. There is a second peak of diagnosis after age 50.
Many athletes have learned to adjust their nutritional intake and have modified their workout schedules to be able to perform at full potential during times of remission.
“My Crohn’s disease was a crutch because I was forced to take three years off,” Athlete Drew McFedries-UFC Fighter with Crohn’s disease said. “I did train in that time, but couldn’t really do much of anything because of my energy level.  I’de get into the gym once a week or maybe three times a week, but that was about it.  But when I got through the barrier of that, and getting the right medications and things, it changed my perspective on the fight game.”
 
 
Drew McFedries threw 14 punches in his middleweight bout at UFC 98 against Xavier Foupa-Pokam.  His second punch – a massive right hook – was the only one McFedries needed.  It took all of 37 seconds for McFedries to secure the TKO over Foupa-Pokam, who threw all of zero punches, kicks, [and] knees. “I come ready to throw down,” McFedries said.  McFedries is just one professional athlete who has proved that having Crohn’s disease will not bring him down.
David Garrard played in just six games during his first two seasons. Then in the spring of 2004, his NFL career nearly came to an abrupt end.  Garrard had been complaining of stomach pains, but figured it was just an upset stomach.  When the pain persisted, he saw the team doctor.  The diagnosis he received was an unexpected one.
"I wanted to defeat it," he said. "I couldn’t let Crohn’s take over my life. A lot of pro athletes think they’re invincible. This brought me back to reality. It gave me a gut check, literally."
Despite this chronic illness, today’s athlete with Crohn’s disease can rise to the occasion and prove to be a true athlete without limitations.
 
 
Editorial Comment From Dr. Counce:
 
Inflammatory Bowel Disease, and moreover, Crohns disease, are very difficult to treat. The true mechanism of pathology is not fully understood. Crohns and Ulcerative Colitis look and act the same grossly, causing severe debilitating diarrhea, bleeding, dehydration, sepsis, vascular disease, arthritis, myalgia, and even neurologic illness. Only microscopically, can they be distinguished. It is not uncommon for these individuals to have ten or more bowel movements a day.
Both have been well documented as causing death in severe cases.
Almost all Crohns patients require bowel surgery and resection at some point in their lives. The only treatments other than surgery, have been pharmacological. Many physicians use oral, and enema infused steroid treatments in their patients. A standard chronic drug therapy is the use of sulfasalazine, a salicylate sulfa based drug used to combat the inflammation. The rest of Crohns therapy relies on palliative measures.
Most medical experts agree, however, that as discussed above, a healthy lifestyle and commitment to careful eating habits as well as proper exercise are the only real weapon we have at this time.
 
 
About the Author:
Quentin Shelton is a student in Musculoskeletal Anatomy and Kinesiology. An excellent student, and very well read, he is currently in the Associates Program in Personal Fitness at Intellitec Medical Institute in Colorado Springs.