Thursday, September 23, 2010

5.(6-7) Headache & Migraine and Fever

Physician's Notebooks 5  - - See Homepage  Update 5 December 2018

This section also has Chapter 7. Fever, Scroll Down.

6. Headache (HA) and Pain about Head
  If you get worried over your headaches, ask: Are the headaches a new pattern from the usual, and are they persisting? (Coming several times a week for more than a week?) If the answer is yes to either one, get brain MRI (Not CT which gives less info and lots of x-ray). That should end brain tumor worry.
  Next: What to do about the HA?  One half to 1 pill of 325 mg acetaminophen (apap, Tylenol) pill, chewed or dissolved under the tongue may relieve your common headache within 15 minutes. (Assuming you put yourself in a state of relaxation and also the “relieve” may not be 100%) By using the fractional, fractured pill you may repeat, if no relief, every 30 minutes for 4 doses, which you could not do if you took usual advised 1 to 2 full size pills at once.
  I advise acetaminophen instead of aspirin because of aspirin’s increasing the risk of hemorrhage especially with high blood pressure especially in brain. But if you only have aspirin or NSAID and no hypertension or bleeding problems, try it. 
 What about migraine?  It is a usually one-side of head, throbbing (The Throbbing, which is very typical for classic migraine and nothing else, should mean 'pulsating" and not the usual "waxing and waning" pain of many non migraine headaches) headache with sensitivity to light, noise and smells; and, in classic migraine, the headache is preceded by minutes of visual effects, the aura. The classic migraine is more in women, starts young, only rarely starts after age 30, but once started recurs, and each headache has nausea. It tends to run in families and in women is often premenstrual. The severity of migraine tends to lessen after age 40. Classic migraine is important to recognize because although its cause is not clear, its mechanism is spasm of the smaller brain arteries and persons with it are at increased risk for brain stroke as they get older. Everyone with classic migraine should get an MRA by age 40 (the A for angiography) of brain, looking for potential hemorrhage or vascular malformation. Women with migraine should not use birth control pill. Many migraine variants occur - the unifying symptom is the one-sided headache but two variants that are not true migraine need comment: 
1) Cluster Headaches occur in a cluster of nightly headaches for several weeks or months; the headaches are 1-sided but localized around an eye and on its temple side, intense and non-throbbing, lasting from 30 to 45 minutes, and they come on usually in early morning hours after falling asleep, awakening the patient, and are so exactly timed that another name is alarm-clock headache. 
 2) Indomethacin Responsive Headaches are migraine-like but without aura, tend to come on during sexual intercourse and other exercise exertions and are stopped quickly by a 25 mg Indomethacin, best for quickest effect dissolved in mouth before swallowing. 
Recognizing these 2 variants is useful because they have effective treatments and once you alert your doctor to the diagnosis, the problem is solved.  
Treatment of the migraine headache should start like any common headache with acetaminophen and lying down in a not strongly lighted place. If that does not work, it is best to consult a migraine specialist who is usually a neurologist 
  Many common headaches are fibromyalgias coming from trigger points in the rear of the upper neck or scalp that are easy to detect because they become sore and tender to touch during the headache. I have one that is clearly related to my head on pillows and head position in sleep or at the computer. These respond nicely to acetaminophen or aspirin.
  The NSAID's (Advil, and others) are too expensive and in general do not work better than apap or aspirin but, if you already have some, try one.
   Vascular headache (from ruptured arteries, aneurysms): you will not need a book to tell you to go to ER when you get it; it will be very severe, like nothing you experienced before. Prevent by not taking amphetamine or cocaine or methylphenidate (Ritalin) stimulants, by not constantly adding salt to your foods, by treating your hypertension and by checking with an MRA if any suggestion or risk factor for vascular headache.
                                                            End of Chapter
7. Fever
Body temperature is a vital sign, a marker for hidden disease, and a way to prevent pregnancy or diagnose it very early.

Unit of Body Temperature used in US is Fahrenheit (F); but in rest of world it is Celsius (C). To convert C to F, multiply its number by 9, divide by 5 and add 32. To reverse from F to C, subtract 32 from F then multiply remainder by 5 and divide by 9. 

Thermometer: Mercury thermometer or electronic digital? Digital has advantage of easier to read and less error of inexperience. Since glass mercury thermometer is often broken in use, the higher price digital, costs less in long run.

Route of Temperature Taking: By mouth, in rectum, or underarm? Rectal is indicated with borderline fever or low body temp, because it most accurately measures body core temp. But it may damage rectum so only trained person should do it. At home, mouth is used in USA. Underarm temp is for infant and other uncooperative or unconscious patient. (In Japan for everyone) If no way of antiseptically cleaning thermometer, then underarm is sole safe method. Rectal is 0.7F (0.4C) higher than mouth. Underarm is 1F (0.6C) lower than mouth.

Taking Temp by Mouth or Underarm: For digital, press indicated button to set; for mercury, shake (or spin on string) down so mercury column is below 96F (35C) line. If mouth, be sure thermometer is cleaned antiseptically. (Alcohol; no heat) For mouth, the measuring tip of thermometer should be carefully placed deep in mouth under tongue and held in place by the lips not the teeth. In armpit, thermometer should be placed with tip as high underarm as comfortable, and angled downward so it is completely held against side chest wall by inner arm and covered over by it.
For mouth or rectum with mercury thermometer give 3 full minutes; electronic digital has a buzz or ring to indicate final temp but if no sound, read instructions. Give armpit 5 minutes.

Condition of Taking Body Temperature for Fever: Be in relaxed state for 15 or more minutes, no bath or shower since 1 hour and, for mouth thermometer, no food or drink 30 minutes. Drinking alcohol or taking corticosteroid, aspirin or NSAID will mask fever. Oral contraceptive or opioid may abnormally increase body temperature.

What is Fever?  Based on studies of healthy persons ages 18 to 40, the average oral temp is 98.2F (36.8C) with low at 6 AM and high at 4 to 6 PM. The max normal oral at 6 AM is 98.9F (37.2C; a little lower for young women) and at 4 PM 99.9F (37.7C). As a rule, 99F (37.2C) to 100F (37.8C) is borderline and above is fever. Always consider context in which temp. is taken. If one feels normal, an oral temp. of 99.2 F (37.3 C) at end of busy day may be normal. Same number in someone with chest cold may be fever. Older persons tend to have slightly lower numbers for fever and children slightly higher. Young women who have ovulation will have slightly lower temperatures before it and slightly higher after it; but should be between 36 and 37 C.

Purpose of Measuring Body Temp: 1) To search for infection or inflammation in order to find diagnosis; 2) To determine exposure to excessive cold or heat, and also determine circulatory collapse to help formulate plan of treatment in case of heat stroke, heart attack, or hypothermia from exposure to freezing environment. 3) To use body temp to predict ovulation as part of birth control or to find out whether one is pregnant or not.
Significance of Fever: Low fever should make one suspect hidden infection. Continued low fever can be sole evidence of deep infection or septicemia (blood infection). Especially in oldster, think small skin ulcer due to prolonged bed rest. Disease like TB (night fever & sweat) or malaria (sudden high fever with severe headache and chattering teeth) is famous for episodic high fever. If no infection, think malignancy, particularly lymphoma (Hodgkin’s), which typically gives rhythmic fever – 10 days on, 10 days off.
One can fake fever by hot mouth before thermometer.

Benefit and Risk: Fever is response of tissue damage. It may also act as defense against germ. In oldster, or any age person with chronic disease like diabetes or heart ailment, or anyone who may become dehydrated, or where fever causes headache or other symptom, a fever should not be allowed. Even young, healthy person should have fever treated if it does not go away within an hour. Fever during acute brain stroke or heart myocardial infarction increases area of brain damage compared to normal temp.

Treatment of Fever: Acetaminophen 325 mg tablet and may repeat in 4 hrs but no more than 2 full tablets in 24 hrs. Aspirin is not ideal because of deadly liver damaging Reye syndrome in children and also because of tendency to cause hemorrhage and worsen peptic ulcer; but it works against fever. The NSAID's are expensive and have potential bleeding complication like aspirin. 
   Very high body temp. due to exposure to heat (heat stroke) or brain stroke should not get aspirin or acetaminophen but needs cooling blanket or specially controlled, cooled intravenous fluid best provided in hospital emergency.

Low Body Temp: <95F (35C) is hypothermia, seen in vascular shock, as in myocardial infarction or exposure to icy air or water as in near drowning, and especially seen in alcoholic drunks in winter weather. Circulatory hypothermia responds to improvement of circulation. Exposure to cold has resulted in body temp as low as 85F (29C) with little permanent harm. Treatment is gradual warming and support of circulation and prevention of heart ventricular fibrillation.  End of Chapter.  To read on next, now, click 5.8 Eyes and Vision

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