Physician's Notebooks 5 - http://physiciansnotebook.blogspot.com - See Homepage Update 16 Aug. 2021
This section also has Chapter 7. Fever, Scroll Down.
6. Headache (HA) and Pain about Head
I shall deal here with headaches that cause problematic pain, tend to become chronic, or are worrisome because of fear of brain hemorrhage, stroke or tumor.
In this group are Migraine, tension headache, cluster headache, post trauma headache or any headache that causes a fear of brain tumor.
Migraine is the most common. Generally, (according to DSM-5) one diagnoses migraine as recurrent headaches (at least 5) with or without an aura (unpleasant psychic or visual experience preceding) lasting 4 hours or more, usually one-sided and tending to wax and wane or throb (But not in sync with the pulse, in which case it should suggest vascular HA preceding a stroke.), and often with nausea or other mild GI upset and made worse by usual physical activities. More frequent in women and related to reproductive functions (menses, birth control pills; tends to improve or disappear with menopause).
First approach to migraine is to try aspirin 325 mg (if not allergic or risk of hemorrhage) or acetaminophen (Tylenol, Panodol, Paracetamol 300 to 500 mg; not more than twice a day). If no success, then next level is the best NSAID, Ibuprofen as Motrin, Advil), up to 850 mg a day. If still a problem go to the triptans (always by M.D. Rx and with advice). For prevention, best to use Aaron Beck’s cognitive behavioral psychotherapy (CBT, but you need to find a clinical psych adept at CBT for migraine) with medication assist (beta-blocker best) by an experienced neuropsychiatrist. If beta-blocker cannot be used, two AEDs (anti-epileptic drugs), Divalproex sodium or topiramate are FDA-approved for Migraine, both having shown superiority compared to placebo with Level A (top level) evidence of efficacy and minimal side effects.
Migraineurs are at increased risk for stroke and should use preventive strategies (See Chapter on stroke). Especially women on birth control pill (Stop it!).
A Vignette: The following, from recent experience. I quote from the patient: “I am a 28 years old American woman and I live and work as a teacher in Tokyo. This attack isn’t my first migraine, I used to have them frequently in high school but in the last few years they are rare, occurring only once every three months and they go away promptly with one Advil-migraine capsule. The migraine I experienced since Monday afternoon, however, is a bit different. On Monday it was an acute upset and I was very dizzy and unable to see properly so I passed out in the teacher’s lounge. I took two Advil-migraines and have been taking them steadily since but the migraine has persisted. I can see fine now; however, it’s just a low-medium pain in my head. ... .”
My (Dr Stim) comment: Here we see an unusual worsening of Migraine, and an almost stroke-like picture. The patient is a 28-y-o woman so I asked her, “Are you taking birth control pills?” And she replied, “Right now I am taking birth control pills as treatment from my gynecologist for polycystic ovary syndrome.”
As soon as I read that, I thought, Eureka! Here, she started taking BCP and gets the worst migraine of her life and can’t make it go away! I advised her to immediately stop the BCP, switch from the Advil to two aspirin (650 mg) a day, (In the general treatment principle that when a stop-symptom medication stops working one should switch to an alternate) and reassured her she had not yet had a migraine stroke but warned her she might if she kept on taking the BCP. She followed my advice and the migraine disappeared next day.
Tension headaches involve the whole head in a non pulsatile, a dull aching, often starting in back of head, spreading and sometimes like a tightening band, and last more than 30 minutes, sometimes days. Best treated with aspirin or acetaminophen or, in difficult case with Ibuprofen, like migraines.
Cluster headaches are rare. These are intense attacks, several a day, over a 1- to 2-month separated by headache-free intervals for as long as 1- to 2-years. Patients complain loudly and bitterly in highly agitated state (Opposite of migraine and tension HA) Almost always in men. Severe, boring piercing pain is located behind the eye. First line treatment is subcutaneous sumatriptan (by doctor Rx and instruction) and home oxygen from portable tank at high flow, 100% concentration via a non-rebreathable mask at 12 to 15 Liters per minute for up to 20 minutes. Attacks are brought on or made worse by alcohol or smoking.
Post head-trauma headaches or any severe or chronic headaches that excite worry should have an MRI of brain with dye.
Brain Tumor Headache is worse on wakening and gradually gets better during morning but may worsen with cough or sneeze or other strain. MRI will show it earliest.
All problematic or worry-some new, lasting or recurring headaches should have MRI of cranium with dye (if no allergy to the dye and good kidney function).
This section also has Chapter 7. Fever, Scroll Down.
6. Headache (HA) and Pain about Head
Migraine
A Vignette
A Vignette
Tension Headache
Cluster Headache
Post Trauma Headache
Brain Tumor Headache
I shall deal here with headaches that cause problematic pain, tend to become chronic, or are worrisome because of fear of brain hemorrhage, stroke or tumor.
In this group are Migraine, tension headache, cluster headache, post trauma headache or any headache that causes a fear of brain tumor.
Migraine is the most common. Generally, (according to DSM-5) one diagnoses migraine as recurrent headaches (at least 5) with or without an aura (unpleasant psychic or visual experience preceding) lasting 4 hours or more, usually one-sided and tending to wax and wane or throb (But not in sync with the pulse, in which case it should suggest vascular HA preceding a stroke.), and often with nausea or other mild GI upset and made worse by usual physical activities. More frequent in women and related to reproductive functions (menses, birth control pills; tends to improve or disappear with menopause).
First approach to migraine is to try aspirin 325 mg (if not allergic or risk of hemorrhage) or acetaminophen (Tylenol, Panodol, Paracetamol 300 to 500 mg; not more than twice a day). If no success, then next level is the best NSAID, Ibuprofen as Motrin, Advil), up to 850 mg a day. If still a problem go to the triptans (always by M.D. Rx and with advice). For prevention, best to use Aaron Beck’s cognitive behavioral psychotherapy (CBT, but you need to find a clinical psych adept at CBT for migraine) with medication assist (beta-blocker best) by an experienced neuropsychiatrist. If beta-blocker cannot be used, two AEDs (anti-epileptic drugs), Divalproex sodium or topiramate are FDA-approved for Migraine, both having shown superiority compared to placebo with Level A (top level) evidence of efficacy and minimal side effects.
Migraineurs are at increased risk for stroke and should use preventive strategies (See Chapter on stroke). Especially women on birth control pill (Stop it!).
A Vignette: The following, from recent experience. I quote from the patient: “I am a 28 years old American woman and I live and work as a teacher in Tokyo. This attack isn’t my first migraine, I used to have them frequently in high school but in the last few years they are rare, occurring only once every three months and they go away promptly with one Advil-migraine capsule. The migraine I experienced since Monday afternoon, however, is a bit different. On Monday it was an acute upset and I was very dizzy and unable to see properly so I passed out in the teacher’s lounge. I took two Advil-migraines and have been taking them steadily since but the migraine has persisted. I can see fine now; however, it’s just a low-medium pain in my head. ... .”
My (Dr Stim) comment: Here we see an unusual worsening of Migraine, and an almost stroke-like picture. The patient is a 28-y-o woman so I asked her, “Are you taking birth control pills?” And she replied, “Right now I am taking birth control pills as treatment from my gynecologist for polycystic ovary syndrome.”
As soon as I read that, I thought, Eureka! Here, she started taking BCP and gets the worst migraine of her life and can’t make it go away! I advised her to immediately stop the BCP, switch from the Advil to two aspirin (650 mg) a day, (In the general treatment principle that when a stop-symptom medication stops working one should switch to an alternate) and reassured her she had not yet had a migraine stroke but warned her she might if she kept on taking the BCP. She followed my advice and the migraine disappeared next day.
Tension headaches involve the whole head in a non pulsatile, a dull aching, often starting in back of head, spreading and sometimes like a tightening band, and last more than 30 minutes, sometimes days. Best treated with aspirin or acetaminophen or, in difficult case with Ibuprofen, like migraines.
Cluster headaches are rare. These are intense attacks, several a day, over a 1- to 2-month separated by headache-free intervals for as long as 1- to 2-years. Patients complain loudly and bitterly in highly agitated state (Opposite of migraine and tension HA) Almost always in men. Severe, boring piercing pain is located behind the eye. First line treatment is subcutaneous sumatriptan (by doctor Rx and instruction) and home oxygen from portable tank at high flow, 100% concentration via a non-rebreathable mask at 12 to 15 Liters per minute for up to 20 minutes. Attacks are brought on or made worse by alcohol or smoking.
Post head-trauma headaches or any severe or chronic headaches that excite worry should have an MRI of brain with dye.
Brain Tumor Headache is worse on wakening and gradually gets better during morning but may worsen with cough or sneeze or other strain. MRI will show it earliest.
All problematic or worry-some new, lasting or recurring headaches should have MRI of cranium with dye (if no allergy to the dye and good kidney function).
End of Chapter
7. FeverBody 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 USA 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 the F then multiply the 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 0.70 F (0.40 C) higher than mouth. Underarm is 10 F (0.60 C) 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 960 F (350 C) 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 4 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 98.20 F (36.80 C) with low at 6 AM and high at 4 to 6 PM. The max normal oral at 6 AM is 98.90 F (37.20 C; a little lower for young women) and at 4 PM 99.90 F (37.70 C). As a rule, 990 F (37.20 C) to 1000 F (37.80 C) 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: 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 fevers. 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 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 but of them all, ibuprofen (Advil, Motrin) up to 850 mg gives best good effect and lowest bad side effect.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: <950 F (350 C) 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 850 F (290 C) with recovery and 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 VisionBy the way, if you have boring time and need a fun read that will also give good health ideas, click
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