Migraine Headache

What is a migraine headache?

A migraine headache is a form of vascular headache. Migraine headache is caused by a combination of vasodilatation (enlargement of blood vessels) and the release of chemicals from nerve fibers that coil around the blood vessels. During a migraine attack, the temporal artery enlarges. (The temporal artery is an artery that lies on the outside of the skull just under the skin of the temple.) Enlargement of the temporal artery stretches the nerves that coil around the artery and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the artery magnifies the pain.

Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called "fight or flight" response. The increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea. Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed. The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches. The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet. The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.

What are the symptoms of migraine headaches?

Migraine is a chronic condition of recurrent attacks. Most (but not all) migraine attacks are associated with headaches. Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain can be located in the forehead, around the eye, or the back of the head). The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral. The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor). A migraine headache usually is aggravated by daily activities like walking upstairs. Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.

An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include sleepiness, irritability, fatigue, depression or euphoria, yawning, and cravings for sweet or salty foods. Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.

An estimated 20% of migraine headaches are associated with an aura. Usually, the aura precedes the headache, although occasionally it may occur simultaneously with the headache. The most common auras are 1) flashing, brightly colored lights in a zigzag pattern (fortification spectra), usually starting in the middle of the visual field and progressing outward and 2) a hole (scotoma) in the visual field, also known as a blind spot. Some elderly migraine sufferers may experience only the visual aura without the headache. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side or pins-and-needles sensations around the mouth and the nose on the same side. Other auras include auditory (hearing) hallucinations and abnormal tastes and smells.

Complicated migraines are migraines that are accompanied by neurological dysfunction. The part of the body that is affected by the dysfunction is determined by the part of the brain that is responsible for the headache. Vertebrobasilar migraines are characterized by dysfunction of the brainstem (the lower part of the brain that is responsible for automatic activities like consciousness and balance). The symptoms of vertebrobasilar migraines include fainting as an aura, vertigo (dizziness in which the environment seems to be spinning) and double vision. Hemiplegic migraines are characterized by paralysis or weakness of one side of the body, mimicking a stroke. The paralysis or weakness is usually temporary, but sometimes it can last for days.

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

How are migraine headaches treated?

Treatment is can include non-medication and medication approaches.

Non-medication therapies for migraine

Therapy that does not involve medications can provide symptomatic and preventative therapy. Using ice, biofeedback, and relaxation techniques may be helpful at stopping an attack once it has started. If possible, sleep is the best medicine. Preventing migraine takes motivation for the patient to make some life changes. Patients are educated as to triggering factors that can be avoided. These include smoking cessation, avoiding certain foods especially those high in tyramine (sharp cheeses) or those containing sulphites (wines) or nitrates (nuts, pressed meats). Generally, leading a healthy life style with good nutrition, adequate water intake, sufficient sleep and exercise may be useful. Acupuncture has been suggested to be a useful non-medication therapy.

Medication therapies for migraine

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

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

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

NSAIDs relieve pain by reducing the inflammation that causes the pain (They are called non-steroidal anti-inflammatory drugs or NSAIDs because they are different from corticosteroids such as prednisone, prednisolone, and cortisone which also reduce inflammation). Corticosteroids, though valuable in reducing inflammation, have predictable and potentially serious side effects, especially when used long-term. NSAIDs do not have the same side effects that corticosteroids have.

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

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

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

What are migraine triggers?

A migraine trigger is any factor that causes a headache in individuals who are prone to develop headaches. Only a small proportion of migraine sufferers, however, clearly can identify triggers. Examples of triggers include stress, sleep disturbances, fasting, hormones, bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate, nitrites, aspartame, and caffeine. For some women, the decline in the blood level of estrogen during the onset of menstruation is a trigger for migraine headaches. The interval between exposure to a trigger and the onset of headache varies from hours to two days. Exposure to a trigger does not always lead to a headache. Conversely, avoidance of triggers cannot completely prevent headaches. Different migraine sufferers respond to different triggers, and any one trigger will not induce a headache in every person who has migraine headaches.

Sleep and migraine

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

Fasting and migraine

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

Bright lights and migraine

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

Caffeine and migraine

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

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

Chocolate has been reported to cause migraine headaches, but scientific studies have not consistently demonstrated an association between chocolate consumption and headaches. Red wine has been shown to cause migraine headaches in some migraine sufferers, but it is not clear whether white wine also will cause migraine headaches. Tyramine (a chemical found in cheese, wine, beer, dry sausage, and sauerkraut) can precipitate migraine headaches, but there is no evidence that consuming a low-tyramine diet can reduce migraine frequency. Monosodium glutamate (MSG) has been reported to cause headaches, facial flushing, sweating, and palpitations when consumed in high doses on an empty stomach. This phenomenon has been called Chinese restaurant syndrome. Nitrates and nitrites (chemicals found in hotdogs, ham, frankfurters, bacon and sausages) have been reported to cause migraine headaches. Aspartame, a sugar-substitute sweetener found in diet drinks and snacks, has been reported to trigger headaches when used in high doses for prolonged periods.

Female hormones and migraine

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

What should migraine sufferers do?

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

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

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

• Do not skip meals, and avoiding prolonged fasting.

• Limit stress through regular exercise and relaxation techniques.

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

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

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

What are prophylactic medications for migraine headaches?

Prophylactic medications are medications taken daily to reduce the frequency and duration of migraine headaches. They are not taken once a headache has begun. There are several classes of prophylactic medications: beta blockers, calcium-channel blockers, tricyclic antidepressants, antiserotonin agents and anticonvulsants. Medications with the longest history of use are propranolol (Inderal), a beta blocker, and amitriptyline (Elavil), an antidepressant. When choosing a prophylactic medication for a patient the doctor must take into account the drug side effects, drug-drug interactions, and co-existing conditions such as diabetes, heart disease, and high blood pressure.

Beta blockers

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

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

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

Tricyclic antidepressants

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

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

TCAs should not be used with drugs that inhibit monoamine oxidase such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and procarbazine (Matulane), since high fever, convulsions and even death may occur. TCAs are used with caution in patients with seizures, since they can increase the risk of seizures. TCAs also are used with caution in patients with enlargement of the prostate because they can make urination difficult. TCAs can cause elevated pressure in the eyes of some patients with glaucoma. TCAs can cause excessive sedation when used with other medications that slow the brain's processes, such as alcohol, barbiturates, narcotics, and benzodiazepines, e.g. lorazepam (Ativan), diazepam (Valium), temazepam (Restoril), oxazepam (Serax), clonazepam (Klonopin), zolpidem (Ambien). Epinephrine should not be used with amitriptyline, since the combination can cause severe high blood pressure

Antiserotonin medications

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

Calcium channel blockers

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

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

Anticonvulsants

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

Calcium Deficiency

Calcium deficiency is usually due to an inadequate supply or a failure in metabolism of calcium. Calcium, the main structural element of bones and teeth, is one of the most important minerals that helps in the growth and maintenance and reproduction of the human body. In addition to helping to maintain bone and dental health, calcium is also involved in a wide variety of other functions, including blood coagulation, the transmission of nerve impulses, muscle contraction and relaxation, normal heartbeat, stimulation of hormone secretion and the activation of enzyme reactions.

When blood calcium levels drop too low, the vital mineral is “borrowed” from the bones. It is returned to the bones from calcium supplied through the diet. If an individual’s diet is low in calcium, there may not be sufficient amounts of the element available in the blood to be returned to the bones … leading to a net loss in bone mass, a condition called osteopenia . Osteopenia can lead to osteoporosis, or porous bone. Osteoporosis is responsible for 1.5 million bone fractures in the U.S. every year.

The Problem of Calcium Deficiency is Serious

Low calcium intake is recognized as a major public health problem in the United States, with more than 75 percent of Americans not meeting the current calcium recommendations for their age/gender group, putting them at risk for osteoporosis. The top priority of the Surgeon General, Vice Admiral Richard Carmona, M.D., M.P.H., F.A.C.S., is to prevent debilitation and premature mortality from all causes, including bone disease and injury. Concerns about the large toll that osteoporosis — by far the most common bone disease — is inflicting on the nation led Dr. Carmona to release The Surgeon General's Report on Bone Health and Osteoporosis on October 14, 2004.

Because osteoporosis is largely preventable, The Surgeon General's Report on Osteoporosis and Bone Health details the need for a greater public health focus on osteoporosis — even among racial and ethnic minorities, men, children and adolescents and the frail elderly. It also addresses the pressing issue of inadequate calcium consumption.

The Consequences of Untreated Calcium Deficiency

Low calcium intake is associated with the risk of osteoporosis, colon cancer and hypertension.

		Osteoporosis is a major public health threat for an estimated 44 million Americans, or 55 percent of people 50 years of age and older and is responsible for more than 1.5 million fractures annually. Ten million individuals are estimated to have osteoporosis today and almost 34 million more are estimated to have low bone mass (or osteopenia), placing them at increased risk for the disease in the future.
		Taking calcium supplements helps prevent the recurrence of polyps in the colon, a risk factor for colorectal cancer. In a well-controlled clinical trial, published in the Journal of The National Cancer Institute, calcium supplements reduced the advanced polyps growth which is most strongly associated with invasive colorectal cancer. While it’s not known exactly how the calcium may help prevent the polyps, researchers speculate that calcium prevents the irritating and cancer-promoting effect of bile acids and other fats in the bowel. To help reduce the risk of colon cancer you should follow the dietary recommendations for daily calcium intake.
		Hypertension, also known as high blood pressure, can occur in children or adults. It affects about 50 million — or 1 in 4 — adult Americans and is especially common among African Americans and older people. Uncontrolled hypertension directly increases the risk of coronary heart disease — which can potentially lead to heart attack.

Studies show an association in women who have a calcium intake of 800 mg/day or more have a 23 percent lower risk of developing high blood pressure than women with an intake of 400 mg/day or less. The benefits of calcium are even greater among pregnant women. Controlled trials in women with habitually low calcium intakes have found that women who consume between 1500 - 2000 mg/day of calcium reduce their risk of developing pregnancy-induced hypertension by as much as 50 percent. It has also been shown that maternal calcium intake positively affects the infant's blood pressure. In one clinical trial, women with high calcium intakes gave birth to babies with higher birth weights and lower blood pressures. This lower pressure persisted throughout at least the first five years of life.

Also calcium deficiency is a major concern in the United States. Over 75% of Americans don't get what they need. Calcium is an essential element vital to many body functions. It is stored up in the bones during the first 30 to 35 years of life. The two causes of calcium deficiency are a diet low in calcium and an inability to absorb and metabolize the mineral. Calcium is the main component of bones and teeth and is involved in maintenance, growth and reproduction of the human body. Other functions are transmitting nerve impulses, regulating heartbeat, blood coagulation, muscle contraction and relaxation, stimulating hormone secretion and the activation of enzyme reactions. Calcium deficiency is linked to osteoporosis, colon cancer and high blood pressure.

A low calcium level in the blood because of poor diet causes the body to leach calcium from the bones. The body returns calcium to the bones when it receives it through diet. If the diet continues to be poor in calcium there will not be enough calcium in the blood to give back to the bones. Eventually this leads to osteoporosis.

Among the youth of America there is widespread calcium deficiency putting them at risk for many major health problems. Infants have been developing rickets, a disease usually associated with vitamin D deficiency, around the age of twenty months. This is due to lack of calcium in the diet after breast feeding was discontinued. According to the National Institutes of Health, only about 25% of boys and 10% of girls get enough calcium in their diets. Osteoporosis in Americans aged 50 years old and up is the reason for 1.5 million fractures every year. It is estimated that 10 million people have osteoporosis and 34 million more have low bone mass placing them at risk for osteoporosis.

High blood pressure affects around 50 million Americans and is very common among African Americans and older people. A study done on women with a diet continually low in calcium revealed that women who take 1500-2000 mg of calcium daily reduce the risk of getting high blood pressure from pregnancy by as much as 50%. It was also found that pregnant women who had a calcium rich diet, had babies that weighed more and had lower blood pressure that continued at least through the first five years of life.

Calcium may be Beneficial in Prevention and Treatment of Several Health Conditions

Cataracts

Osteoporosis

Colon Cancer

High Blood Pressure

Kidney Stones

Premenstrual Syndrome

Pregnacy induced High Blood Pressure

Inflammatory Bowel Disease

Foods RIch in Calcium

The best sources of calcium are spinach, collard greens, mustard seeds and turnip greens.

Other great sources include kale, swiss chard, blackstrap molasses, mozzarella cheese swiss chard, yogurt, cow's milk, goat's milk, basil. cinnamon, thyme, dill seed, and peppermint leaves.

Good sources include, broccoli, romaine lettuce, celery, brussel sprouts, oranges, asparagus, sesame seeds, fennel, cabbage, summer squash, basil, thyme, dill seed, cinnamon, and peppermint leaves, cow's milk, and goat's milk.

Note: The amount of calcium in food is not affected by cooking or storage.

Calcium Supplements

Supplements can be purchases in different forms. The most common are carbonates or citrates. Calcium citrate is the best choice for maximum absorption and bioavailability in the body.

The recommended daily intake of calcium is as follows:

210mg for 0 to 6 months old

270mg for 6 to 12 months old

500mg for1 to 3 years old

800mg for 4 to 8 years old

1300mg for 9 to 18 years old

1000mg for 19 to 50 years old

1200mg for 51 years old and above

Conclusion

Calcium is one of the essential minerals needed to maintain life. Most people in America today are calcium deficient and are in danger of serious health conditions developing. By taking preventative measure today you can avoid the undesirable and inevidable outcome of calcium deficiency.

• Understanding Vitamin D Deficiency
  It is quite alarming that people of all ages are being affected by vitamin D deficiency. The problem is much more serious than anyone realized.

• Understanding Magnesium Deficiency
  A recent government study shows that 68% of Americans don't consume enough magnesium on a daily basis. Magnesium deficits are linked to allergies, asthma, attention deficit disorder, anxiety, heart disease, muscle cramps and other conditions.

Cluster Headache

A type of vascular headache, cluster headache suggests clustering of headaches in the head. It behaves peculiarly in the sense, that it may occur for a period of few weeks or months and then may disappear completely, sometimes, even for years altogether. Considered to be quite rare, the reasons behind cluster headaches are still unclear.

Just as a vascular headache, it is thought to be caused by the swelling of blood vessels in the head with chemically active proteins found in nerve endings around blood vessels of the trigeminal nerve. It is also believed that there is some abnormality in the autonomic nervous system that leads to this disorder. A disturbance in the neurotransmitter serotonin is also being held responsible for the disease.

Cluster headache starts suddenly without giving any warning except a slight discomfort or a mild burning sensation in one side of the head. This warning may last for a period of 30 - 45 minutes but the actual headache may last for a few hours usually occurring at around the same period almost every day. Generally, the sufferers complain of it during the night or early morning hours. The patients may even be awakened by it. It is because of this quality that these are called ‘alarm clock headaches’. Other names attributed to cluster headaches are histamine headache, red migraine and Hortony's headache.

The pain in cluster headaches is described as intense, severe and of a piercing kind. It may either be throbbing or constant. In fact, cluster pains are so intense that the scalp becomes tender, the arteries can be seen pulsating and the patient can not sit still.

With some patients, these headaches may occur seasonally. But, with others, it may be a regular feature of the calendar.

Types of cluster headaches:

Cluster headaches are commonly divided into two types: episodic and chronic cluster headache.

Episodic cluster headache attacks, quite true to their name, occur in episodes of one or more daily, usually at a particular time. They last for a few weeks or months. Then there is a pain-free interval which may last for a few months or if the patient is lucky, a few years as well.

Chronic cluster headache may last for a period of even a few years with these headaches occurring almost on a daily basis. If one experiences episodic cluster headache with not even a month of pain-free remission, then these headaches can be labeled as chronic cluster headaches. Almost 10 – 15 % of the sufferers experience the chronic variety of headache. Hence, the control of these headaches is more difficult because the patient does not respond quite well to the conventional forms of cluster therapy.

The episodic cluster may change to a chronic form and vice versa. And remission of even decades has been reported between their attacks.

Symptoms of cluster headache:
Considered to be an excruciatingly bad pain, the symptoms of a cluster headache are varied. These are as follows:

•Like a migraine attack, the pain in this case is also on one side of the head. But it may change direction and occur on the other side of the head when a new series of attacks starts.
•The pain is localized behind the eye and the region around it.
•It can radiate to the gum, forehead, nose, temple, cheek or chin on the affected side.
•It is often seen that the eyelid of the affected side swells and becomes droopy.
•The nostril on the affected side may become congested. Nasal discharge is also seen often.
•All this is accompanied by sweating as well as a flushing of the face on the affected side.
•There can also be conjunctival infection leading to red, watery eyes. Constriction of pupil, either stiffness or tenderness in neck, and jaw and teeth pain are also reported.

A person may start getting cluster headaches when he is in his adolescence or early 20s. The individual attack lasts for less than two hours. And when the pain ends, there are additional stabs of pain. Whereas a migraine patient needs rest during the attack, a cluster headache patient gets restless, active and violent. Lying down further aggravates the already bad condition of the patient suffering from cluster headaches.
What Triggers Off A Cluster Headache

Just like no one cause can be pinpointed as the cause of many diseases, similarly there is not one single factor that can lead to a cluster headache. A multitude of factors may be responsible for the same.

Any vasodilator, that is, a substance leading to swelling of the blood vessels can lead to an acute attack of cluster headache. Nitroglycerin and histamine have been labeled as the possible culprits. So is alcohol which is a well-known vasodilator. Even minimal amounts of it can be harmful as it leads to a rapid change in the blood vessels. Smoking is another factor that can contribute to cluster headaches. But during the headache-free period, alcohol and smoking do not appear to be a factor. It is only during one of the attacks that these substances lead to aggravation of the Hormonal changes in women either during periods or menopause do not seem to be the cause of cluster headaches. Also, it is seen that the sufferer gets affected during the spring or autumn. But then this headache is not seasonal and not even associated with business stress. In fact, these seasons vary from patient to patient. Somebody may get affected in the winters while another may suffer during the summers.

Some studies point out that glare or even ingestion of specific types of food can lead to a cluster headache, just as in the case of migraine.

Even exposure to hydrocarbons as found in petroleum solvents and petrol has been recognized as a trigger. If the patient has low tolerance to heat, then heat may also act as an aggravating factor. Surprisingly, even innocent things like napping might trigger the headache in certain susceptible people.

All this clearly shows that though there are specific triggers, in the form of vasodilators, that cause cluster headaches, the triggers for aggravating the problem are highly individualized owing to your vulnerability and susceptibility to certain things.

Prevalence of cluster headaches:

It is often seen that it is the older population which is more at risk of developing cluster headaches. Also, men are more prone to it than women.

But, over the past few decades, it has been found that the gap between the sexes, as far as cluster headaches are concerned, is decreasing. This can probably be because now more and more women are being afflicted and diagnosed with it.

The statistics for the rest of the world are not available, but it is estimated that approximately 1 to 4 in every thousand people in the United States and Western Europe suffer from this condition. It is more common as you move away from the equator towards the poles.

Although no single gene has been identified which can result in this condition, if any one in your immediate family has this disease, then you are also likely to be a candidate for the same.

Diagnosis of cluster headaches:

The symptoms of cluster headaches are so distinctive that it is relatively easy for the physician to pinpoint the condition. However, some tests may be recommended to confirm the presence of cluster headaches. This is because there are some other conditions which may mimic the symptoms of cluster headaches. An aneurysm of the carotid artery in the head, a tumor, sinusitis and glaucoma - all of these conditions can exhibit similar symptoms.

Also, if the pain occurs at regular intervals throughout the day and gets worse with lying down, it is a sure shot sign of a cluster headache. Sometimes, even some doctors are unfamiliar about this disease and they may misconstrue it as drug-seeking behavior. But actually the victim is under a lot of pain and needs to be promptly attended to.

Asthma

What is asthma?

Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The result is difficulty breathing. The bronchial narrowing is usually either totally or at least partially reversible with treatments.

Bronchial tubes that are chronically inflamed may become overly sensitive to allergens (specific triggers) or irritants (nonspecific triggers). The airways may become "twitchy" and remain in a state of heightened sensitivity. This is called "bronchial hyperreactivity" (BHR). It is likely that there is a spectrum of bronchial hyperreactivity in all individuals. However, it is clear that asthmatics and allergic individuals (without apparent asthma) have a greater degree of bronchial hyperreactivity than nonasthmatic and nonallergic people. In sensitive individuals, the bronchial tubes are more likely to swell and constrict when exposed to triggers such as allergens, tobacco smoke, or exercise. Amongst asthmatics, some may have mild BHR and no symptoms while others may have severe BHR and chronic symptoms.

Asthma affects people differently. Each individual is unique in their degree of reactivity to environmental triggers. This naturally influences the type and dose of medication prescribed, which may vary from one individual to another.

From the past to the present

Physicians in ancient Greece used the word asthma to describe breathlessness or gasping. They believed that asthma was derived from internal imbalances, which could be restored by healthy diet, plant and animal remedies, or lifestyle changes.

Allergy jargon

Asthma is derived from the Greek word Panos, meaning panting.

Chinese healers understood that xiao-chiran, or "wheezy breathing," was a sign of imbalance in the life force they called qi. They restored qi by means of herbs, acupuncture, massage, diet, and exercise.

The Hindu philosophers connected the soul and breath as part of the mind, body, and spirit connection. Yoga uses control of breathing to enhance meditation. Indian physicians taught these breathing techniques to help manage asthma.

Allergy fact

Maimonides was a renowned 12th-century rabbi and physician who practiced in the court of the sultan of Egypt. He recommended to one of the Royal Princes with asthma that he eat, drink, and sleep less. He also advised that he engage in less sexual activity, avoid the polluted city environment, and eat a specific remedy-chicken soup.

The balance of the "four humors," which was derived from the Greco-Roman times, influenced European medicine until the middle of the 18th century. In a healthy person, the four humors, or bodily fluids -- blood, black bile, yellow bile, and phlegm -- were in balance. An excess of one of these humors determined what kinds of disorders were present. Asthmatics who were noted for their coughing, congestion, and excess mucus (phlegm) production were therefore regarded as "phlegmatic."

By the 1800s, aided by the invention of the stethoscope, physicians began to recognize asthma as a specific disease. However, patients still requested the traditional treatments of the day, such as bloodletting, herbs, and smoking tobacco. These methods were used for a variety of conditions, including asthma. Of the many remedies that were advertised for asthma throughout the 19th century, none were particularly helpful.

Allergy fact

As early as 1892, the famous Canadian-American physician Sir William Osler suggested that inflammation played an important role in asthma.

Bronchial dilators first appeared in the 1930s and were improved in the 1950s. Shortly thereafter, corticosteroid drugs that treated inflammation appeared and have become the mainstay of therapy used today.

The scope of the problem

Asthma is now the most common chronic illness in children, affecting one in every 15. In North America, 5% of adults are also afflicted. In all, there are about 1 million Canadians and 15 million Americans who suffer from this disease.

The number of new cases and the yearly rate of hospitalization for asthma have increased about 30% over the past 20 years. Even with advances in treatment, asthma deaths among young people have more that doubled.

Allergy fact

There are about 5,000 deaths annually from asthma in the U.S. and about 500 deaths per year in Canada.

Normal bronchial tubes

Before we can appreciate how asthma affects the bronchial airways, we should first take a quick look at the structure and function of normal bronchial tubes.

The air we breathe in through our nose and mouth passes through the vocal cords (larynx) and into the windpipe (trachea). The air then enters the lungs by way of two large air passages (bronchi), one for each lung. The bronchi divide within each lung into smaller and smaller air tubes (bronchioles), just like branches of an inverted tree. Inhaled air is brought through these airways to the millions of tiny air sacs (alveoli) that are contained in the lungs. Oxygen (O₂) passes from the air sacs into the bloodstream through numerous tiny blood vessels called capillaries. Similarly, the body's waste product, carbon dioxide (CO₂), is returned to the air sacs and then eliminated upon each exhalation.

Normal bronchial tubes allow rapid passage of air in and out of the lungs to ensure that the levels of O₂ and CO₂ remain constant in the bloodstream. The outer walls of the bronchial tubes are surrounded by smooth muscles that contract and relax automatically with each breath. This allows the required amount of air to enter and exit the lungs to achieve this normal exchange of O₂ and CO₂. The contraction and relaxation of the bronchial smooth muscles are controlled by two different nervous systems that work in harmony to keep the airways open.

The inner lining of the bronchial tubes, called the bronchial mucosa, contains: (1) mucus glands that produce just enough mucus to properly lubricate the airways; and (2) a variety of so-called inflammatory cells, such as eosinophils, lymphocytes, and mast cells. These cells are designed to protect the bronchial mucosa from the microorganisms, allergens, and irritants we inhale, and which can cause the bronchial tissue to swell. Remember, however, that these inflammatory cells are also important players in the allergic reaction. Therefore, the presence of these cells in the bronchial tubes causes them to be a prime target for allergic inflammation

How does asthma affect breathing?

Asthma At A Glance

• Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The bronchial narrowing is usually either totally or at least partially reversible with treatments.
• Asthma is now the most common chronic illness in children, affecting one in every 15.
• Asthma involves only the bronchial tubes and usually does not affect the air sacs or the lung tissue. The narrowing that occurs in asthma is caused by three major factors: inflammation, bronchospasm, and hyperreactivity.
• Allergy can play a role in some, but not all, asthma patients.
• Many factors can precipitate asthma attacks and are they are classified as either allergens or irritants.
• Symptoms of asthma include shortness of breath, wheezing, cough, and chest tightness.
• Asthma is usually diagnosed based on the presence of wheezing and confirmed with breathing tests.
• Chest X-rays are usually normal in asthma patients.
• Avoiding precipitating factors is important in the management of asthma.
• Medications can be used to reverse or prevent bronchospasm in patients with asthma.

References: Murray, J., Nadel, J. (2000). Textbook of Respiratory Medicine. Third edition. Philadelphia: W.B. Saunders Company.

Medically Reviewed By: Ellen Reich, MD, Board Certified in Allergy and Immunology, Board Certified in Pediatrics

A berief discussion about Anemia

Anemia, one of the more common blood disorders, occurs when the level of healthy red blood cells (RBCs) in the body becomes too low. This can lead to health problems because RBCs contain hemoglobin, which carries oxygen to the body's tissues. Anemia can cause a variety of complications, including fatigue and stress on bodily organs.

Anemia can be caused by many things, but the three main bodily mechanisms that produce it are:

1. excessive destruction of RBCs
2. blood loss
3. inadequate production of RBCs

Among many other causes, anemia can result from inherited disorders, nutritional problems (such as an iron or vitamin deficiency), infections, some kinds of cancer, or exposure to a drug or toxin.

Anemia Caused by Destruction of RBCs

Hemolytic anemia occurs when red blood cells are being destroyed prematurely. (The normal lifespan of RBCs is 120 days; in hemolytic anemia, it's much shorter.) And the bone marrow (the soft, spongy tissue inside bones that makes new blood cells) simply can't keep up with the body's demand for new cells. This can happen for a variety of reasons. Sometimes, infections or certain medications — such as antibiotics or antiseizure medicines — are to blame.

In autoimmune hemolytic anemia, the immune system mistakes RBCs for foreign invaders and begins destroying them. Other kids inherit defects in the red blood cells that lead to anemia; common forms of inherited hemolytic anemia include sickle cell anemia, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and hereditary spherocytosis.

• Sickle cell anemia is a severe form of anemia found most commonly in people of African heritage, although it can affect those of Caucasian, Saudi Arabian, Indian, and Mediterranean descent. In this condition, the hemoglobin forms long rods when it gives up its oxygen, stretching red blood cells into abnormal sickle shapes. This leads to premature destruction of RBCs, chronically low levels of hemoglobin, and recurring episodes of pain, as well as problems that can affect virtually every other organ system in the body. About 1 out of every 625 African-American children is born with this form of anemia.
• Thalassemia, which usually affects people of Mediterranean, African, and Southeast Asian descent, is marked by abnormal and short-lived RBCs. Thalassemia major, also called Cooley's anemia, is a severe form of anemia in which RBCs are rapidly destroyed and iron is deposited in the skin and vital organs. Thalassemia minor involves only mild anemia and minimal red blood cell changes.
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency most commonly affects males of African heritage, although it has been found in many other groups of people. With this condition the RBCs either do not make enough of the enzyme G6PD or the enzyme that is produced is abnormal and doesn't work well. When someone born with this deficiency has an infection, takes certain medicines, or is exposed to specific substances, the body's RBCs suffer extra stress. Without adequate G6PD to protect them, many red blood cells are destroyed prematurely.
• Hereditary spherocytosis is a genetic disorder of the RBC's membrane that can cause anemia, jaundice (yellow-tinged skin), and enlargement of the spleen. The RBCs have a smaller surface area than normal red blood cells, which can cause them to break open easily. A family history increases the risk for this disorder, which is most common in people of northern European descent but can affect all races.

Anemia Caused by Blood Loss

Blood loss can also cause anemia — whether it's because of excessive bleeding due to injury, surgery, or a problem with the blood's clotting ability. Slower, long-term blood loss, such as intestinal bleeding from inflammatory bowel disease (IBD), can also cause anemia. Anemia sometimes results from heavy menstrual periods in teen girls and women. Any of these factors will also increase the body's need for iron because iron is needed to make new RBCs.

Anemia Caused by Inadequate Production of RBCs

Aplastic anemia occurs when the bone marrow can't make enough RBCs. This can be due to a viral infection, or exposure to certain toxic chemicals, radiation, or medications (such as antibiotics, antiseizure drugs, or cancer treatments). Some childhood cancers can also cause aplastic anemia, as can certain chronic diseases that affect the ability of the bone marrow to make blood cells.

High levels of hemoglobin and RBCs help fetal blood carry enough oxygen to developing babies in the relatively oxygen-poor environment in utero. After the child is born, more oxygen is available and the baby's hemoglobin level normally drops to a low point at about 2 months of age, a condition known as physiologic anemia of infancy. This temporary and expected drop in the blood count is considered normal and no treatment is required because the infant's body soon starts making RBCs on its own.

Anemia also occurs when the body isn't able to produce enough healthy RBCs because of an iron deficiency. Iron is essential to hemoglobin production. Poor dietary iron intake (or excessive loss of iron from the body) can lead to iron deficiency anemia, the most common cause of anemia in kids. Iron deficiency anemia can affect kids at any age, but is most common in those younger than 2 years old. Young children who drink excessive amounts of milk are at increased risk for iron deficiency.

Girls going through puberty also have a particularly high risk for iron deficiency anemia because of the onset of menstruation; the monthly blood loss increases the amount of iron they need to consume in their diets.

Signs and Symptoms

If your child has anemia, the first symptoms might be mild skin paleness and decreased pinkness of the lips and nailbeds. These changes may happen gradually, though, so they can be difficult to notice. Other common signs include:

• irritability
• fatigue
• dizziness, lightheadedness, and a rapid heartbeat

If the anemia is caused by excessive destruction of RBCs, symptoms also may include jaundice, a yellowing of the whites of the eyes, an enlarged spleen, and dark tea-colored urine.

In infants and preschoolers, iron deficiency anemia can result in developmental delays and behavioral disturbances, such as decreased motor activity and problems with social interaction and attention to tasks. Research indicates that developmental problems may last into and beyond school age if the iron deficiency is not properly treated.

Diagnosing Anemia

In many cases, doctors don't diagnose anemia until they run blood tests as part of a routine physical examination. A complete blood count (CBC) may indicate that there are fewer RBCs than normal. Other diagnostic tests may include:

• Blood smear examination: Blood is smeared on a glass slide for microscopic examination of RBCs, which can sometimes indicate the cause of the anemia.
• Iron tests: These include total serum iron and ferritin tests, which can help to determine whether anemia is due to iron deficiency.
• Hemoglobin electrophoresis: Used to identify various abnormal hemoglobins in the blood and to diagnose sickle cell anemia, the thalassemias, and other inherited forms of anemia.
• Bone marrow aspiration and biopsy: This test can help determine whether cell production is happening normally in the bone marrow. It's the only way to diagnose aplastic anemia definitively and is also used if a disease affecting the bone marrow (such as leukemia) could be causing of the anemia.
• Reticulocyte count: A measure of young RBCs, this helps to determine if RBC production is at normal levels.

In addition to running these tests, your doctor may ask about a family history of anemia and your child's symptoms and medications. This may lead the doctor to perform other tests to look for specific diseases that might be causing the anemia.

Treatment

Treatment for anemia depends on its cause. It's important not to assume that any symptoms your child may be having are due to iron deficiency. Be sure to have your child checked by a doctor.

If your child has iron deficiency anemia, the doctor may prescribe medication as drops (for infants) or as a liquid or tablet (for older kids), which usually must be taken for as long as 3 months to rebuild the body's store of iron. The doctor also may recommend adding certain iron-rich foods to your child's diet or reducing milk intake.

If your teenage daughter is anemic and has heavy or irregular menstrual periods, her doctor may prescribe hormonal treatment to help regulate the bleeding.

Folic acid and vitamin B12 supplements may be prescribed if the anemia is traced to a deficiency of these nutrients, although this is rare in children.

Anemia caused by an infection will usually improve when the infection passes or is treated. If a certain medication appears to be the cause, your doctor may discontinue it or replace it with something else — unless the benefit of the drug outweighs this side effect.

Depending on the cause, treatment for more severe or chronic forms of anemia may include:

• transfusions of normal red blood cells taken from a donor
• removal of the spleen or treatment with medications to prevent blood cells from being removed from circulation or destroyed too rapidly
• medications to fight infection or stimulate the bone marrow to make more blood cells

In some cases of sickle cell anemia, thalassemia, and aplastic anemia, bone marrow transplantation may be used. In this procedure, bone marrow cells taken from a donor are injected into the child's vein; they then travel through the bloodstream to the bone marrow and begin producing new blood cells.

Caring for a Child With Anemia

The type, cause, and severity of your child's anemia will determine what kind of care is needed. Rest assured, though, that kids often tolerate anemia much better than adults.

In general, a child with significant anemia may tire more easily than other kids and therefore need to limit activity levels. Make sure that your child's teachers and other caregivers are aware of the condition. If iron deficiency is the cause, follow the doctor's directions about dietary changes and taking any iron supplements.

If the spleen is enlarged, your child may be prohibited from playing contact sports because of the risk that the spleen could rupture or hemorrhage if your child is hurt. Certain forms of anemia, such as sickle cell anemia, require other more specific kinds of care and treatment.

Preventing Anemia

Whether anemia can be prevented depends on its cause. Currently, there is no way to prevent anemia due to genetic defects affecting the production of RBCs or hemoglobin.

However, you can help prevent iron deficiency, the most common form of anemia. Before following any of these suggestions, be sure to talk them over with your doctor:

• Cow's milk consumption. During the first 6 months of life, babies are usually protected against developing iron deficiency by the stores of iron built up in their bodies before birth. But after month 6, they often don't get enough iron through breast milk alone or regular cow's milk (which contains less iron than fortified infant formula). Regular cow's milk can cause some infants to lose iron from their intestines, and drinking lots of it can make a baby less interested in eating other foods that are better sources of iron. For these reasons, regular cow's milk is not recommended for children until they reach 1 year of age and are eating an iron-rich diet. In addition, they should not drink more than 24-32 ounces (709-946 ml) of milk each day. If you can't get your child to eat more iron-rich foods, speak with your doctor about giving your child an iron supplement.
• Iron-fortified cereal and formula. These products can help ensure that your baby is getting enough iron, especially during the transition from breast milk or formula to solid foods.
• Well-balanced diet. Make sure that your kids regularly eat foods that contain iron. Good choices include iron-fortified grains and cereals, red meat, egg yolks, leafy green vegetables, yellow vegetables and fruits, potato skins, tomatoes, molasses, and raisins. If your child is a vegetarian, you'll need to make an extra effort to ensure sufficient iron sources because iron found in meat, poultry, and fish is more easily absorbed than iron found in plant-based and iron-fortified foods. Also, be aware that certain food combinations can inhibit or promote absorption of iron. For example, drinking coffee or tea (including iced tea) with a meal can significantly lower the amount of iron absorbed. On the other hand, vitamin C helps the body absorb iron.

Arthritis

Introduction

Arthritis is a very common condition. The different forms of arthritis affect nearly 43
million Americans, or about one of every six people, making it one of the most
prevalent diseases in the United States.
There are more than 100 types of arthritis. The most common types of arthritis are
osteoarthritis and rheumatoid arthritis.

Anatomy:
Our bones help us stand up straight and our muscles help our bones to move together.
Bones connect at the joints. The most obvious joints are the shoulders, elbows, wrists,
hips, knees, and ankles.

We have joints between the different bones of our fingers and toes. We also have
joints that allow our vertebrae to move.
A material called cartilage, which keeps the bones from rubbing against each other
during motion, covers the ends of the bones of a joint.
There is a little bag containing a small amount of fluid called synovium between the
two pieces of cartilage in a joint.
The combination of cartilage and synovium allows for smooth, painless motion in any
given joint.

Arthritis

Arthritis occurs when the cartilage and the synovium in joints is destroyed. There are
many types of arthritis.
Osteoarthritis is due to chronic wear and tear. Osteoarthritis is more common in older
people.
Post-traumatic arthritis is due to trauma to a joint. Trauma may happen during a car
accident, sports injury, etc.
If the synovium in a joint becomes inflamed, it could end up being destroyed as well as
the underlying joint. This destruction is called rheumatoid arthritis.
Arthritis usually leads to pain and limited movement in the joint.
Rheumatoid arthritis involves swelling, redness, and tenderness
in the joint.

Signs & Symptoms

All types of arthritis involve destruction of the joints, which
typically causes pain as well as deformity of the joint.
When arthritis is very severe, both bones of the joint may
actually grow into each other, causing them to fuse together.
Rheumatoid arthritis leads to swelling, redness, and tenderness
in the affected joints.

Causes, incidence, and risk factors

Arthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

You may have joint inflammation for a variety of reasons, including:

• Broken bone
• Infection (usually caused by bacteria or viruses)
• An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)
• General "wear and tear" on joints

Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.

With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity. When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age. You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:

• Being overweight
• Previously injuring the affected joint
• Using the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)

Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.

Other types or cause of arthritis include:

• Rheumatoid arthritis (in adults)
• Juvenile rheumatoid arthritis (in children)
• Systemic lupus erythematosus (SLE)
• Gout
• Scleroderma
• Psoriatic arthritis
• Ankylosing spondylitis
• Reiter's syndrome (reactive arthritis)
• Adult Still's disease
• Viral arthritis
• Gonococcal arthritis
• Other bacterial infections (non-gonococcal bacterial arthritis )
• Tertiary Lyme disease (the late stage)
• Tuberculous arthritis
• Fungal infections such as blastomycosis

Physical examination

First, your doctor will take a detailed medical history to see if arthritis or another musculoskeletal problem is the likely cause of your symptoms.

Next, a thorough physical examination may show that fluid is collecting around the joint. (This is called an "effusion.") The joint may be tender when it is gently pressed, and may be warm and red (especially in infectious arthritis and autoimmune arthritis). It may be painful or difficult to rotate the joints in some directions. This is known as "limited range-of-motion."

In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Such joint deformities are the hallmarks of severe, untreated rheumatoid arthritis.

Tests vary depending on the suspected cause. They often include blood tests and joint x-rays. To check for infection and other causes of arthritis (like gout caused by crystals), joint fluid is removed from the joint with a needle and examined under a microscope. See the specific types of arthritis for further information.

Treatment

Treatment of arthritis depends on the particular cause, which joints are affected, severity, and how the condition affects your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.

If possible, treatment will focus on eliminating the underlying cause of the arthritis. However, the cause is NOT necessarily curable, as with osteoarthritis and rheumatoid arthritis. Treatment, therefore, aims at reducing your pain and discomfort and preventing further disability.

It is possible to greatly improve your symptoms from osteoarthritis and other long-term types of arthritis without medications. In fact, making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.

Exercise for arthritis is necessary to maintain healthy joints, relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your exercise program should be tailored to you as an individual. Work with a physical therapist to design an individualized program, which should include:

• Range of motion exercises for flexibility
• Strength training for muscle tone
• Low-impact aerobic activity (also called endurance exercise)

A physical therapist can apply heat and cold treatments as needed and fit you for splints or orthotic (straightening) devices to support and align joints. This may be particularly necessary for rheumatoid arthritis. Your physical therapist may also consider water therapy, ice massage, or transcutaneous nerve stimulation (TENS).

Rest is just as important as exercise. Sleeping 8 to 10 hours per night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent exacerbations. You should also:

• Avoid positions or movements that place extra stress on your affected joints.
• Avoid holding one position for too long.
• Reduce stress, which can aggravate your symptoms. Try meditation or guided imagery. And talk to your physical therapist about yoga or tai chi.
• Modify your home to make activities easier. For example, have grab bars in the shower, the tub, and near the toilet.

Other measures to try include:

• Taking glucosamine and chondroitin -- these form the building blocks of cartilage, the substance that lines joints. These supplements are available at health food stores or supermarkets. While some studies show such supplements may reduce osteoarthritis symptoms, others show no benefit. However, since these products are regarded as safe, they are reasonable to try and many patients find their symptoms improve.
• Eat a diet rich in vitamins and minerals, especially antioxidants like vitamin E. These are found in fruits and vegetables. Get selenium from Brewer's yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Get omega-3 fatty acids from cold water fish (like salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.
• Apply capsaicin cream (derived from hot chili peppers) to the skin over your painful joints. You may feel improvement after applying the cream for 3-7 days.

MEDICATIONS

Your doctor will choose from a variety of medications as needed. Generally, the first drugs to try are available without a prescription. These include:

• Acetaminophen (Tylenol) -- recommended by the American College of Rheumatology and the American Geriatrics Society as first-line treatment for osteoarthritis. Take up to 4 grams a day (2 extra-strength Tylenol every 6 hours). This can provide significant relief of arthritis pain without many of the side effects of prescription drugs. DO NOT exceed the recommended doses of acetaminophen or take the drug in combination with large amounts of alcohol. These actions may damage your liver.
• Aspirin, ibuprofen, or naproxen -- these nonsteroidal anti-inflammatory (NSAID) drugs are often effective in combating arthritis pain. However, they have many potential risks, especially if used for a long time. They should not be taken in any amount without consulting your doctor. Potential side effects include heart attack, stroke, stomach ulcers, bleeding from the digestive tract, and kidney damage. In 2005, the U.S. Food and Drug Administration (FDA) asked makers of NSAIDs to include a warning label on their product that alerts users of an increased risk for heart attack, stroke, and gastrointestinal bleeding. If you have kidney or liver disease, or a history of gastrointestinal bleeding, you should not take these medicines unless your doctor specifically recommends them.

Prescription medicines include:

• Cyclooxygenase-2 (COX-2) inhibitors -- These drugs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Celecoxib (Celebrex) is still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Talk to your doctor about whether COX-2s are right for you.
• Corticosteroids ("steroids") -- these are medications that suppress the immune system and symptoms of inflammation. They are commonly used in severe cases of osteoarthritis, and they can be given orally or by injection. Steroids are used to treat autoimmune forms of arthritis but should be avoided in infectious arthritis. Steroids have multiple side effects, including upset stomach and gastrointestinal bleeding, high blood pressure, thinning of bones, cataracts, and increased infections. The risks are most pronounced when steroids are taken for long periods of time or at high doses. Close supervision by a physician is essential.
• Disease-modifying anti-rheumatic drugs -- these have been used traditionally to treat rheumatoid arthritis and other autoimmune causes of arthritis. These drugs include gold salts, penicillamine, sulfasalazine, and hydroxychloroquine. More recently, methotrexate has been shown to slow the progression of rheumatoid arthritis and improve your quality of life. Methotrexate itself can be highly toxic and requires frequent blood tests for patients on the medication.
• Biologics-- these are the most recent breakthrough for the treatment of rheumatoid arthritis. Such medications, including etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), are administered by injection and can dramatically improve your quality of life. Newer biologics include Orencia (abatacept) and Rituxan (rituximab).
• Immunosuppressants -- these drugs, like azathioprine or cyclophosphamide, are used for serious cases of rheumatoid arthritis when other medications have failed.

It is very important to take your medications as directed by your doctor. If you are having difficulty doing so (for example, due to intolerable side effects), you should talk to your doctor.

SURGERY AND OTHER APPROACHES

In some cases, surgery to rebuild the joint (arthroplasty) or to replace the joint (such as a total knee joint replacement) may help maintain a more normal lifestyle. The decision to perform joint replacement surgery is normally made when other alternatives, such as lifestyle changes and medications, are no longer effective.

Normal joints contain a lubricant called synovial fluid. In joints with arthritis, this fluid is not produced in adequate amounts. In some cases, a doctor may inject the arthritic joint with a manmade version of joint fluid. The synthetic fluid may postpone the need for surgery at least temporarily and improve the quality of life for persons with arthritis.

Prevention

If arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms.

Osteoarthritis may be more likely to develop if you abuse your joints (injure them many times or over-use them while injured). Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions.

Excess weight also increases the risk for developing osteoarthritis in the knees, and possibly in the hips and hands. See the article on body mass index to learn whether your weight is healthy.

References

Krishnan E. Reduction in long-term functional disability in rheumatoid arthritis from 1977 to 1998: a longitudinal study of 3035 patients. Am J Med. 2003; 115(5): 371-376.

Maini SR. Infliximab treatment of rheumatoid arthritis. Rheum Dis Clin North Am. 2004; 30(2): 329-347.

Marx J. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:1583-1599.

Simon LS, Lipman AG, Jacox AK, etc. Pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis. 2nd ed. Glenview (IL): American Pain Society (APS); 2002.