Headache
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In a two year period, 47 patients with migraine were hospitalized for the management of severe headache; 18 had acute migraine (duration less than 72 hours), 17 had status migrainosus (duration by definition more than 72 hours), and 12 had chronic daily headaches qualitatively of a migraine type. Treatment in all comprised cessation of all previous medication, plus one of the following: intravenous DHE, intravenous lidocaine, a combination of lidocaine + DHE, or subcutaneous sumatriptan. Improvement from DHE, lidocaine, or both was slow and often incomplete. Sumatriptan was not used in patients with chronic daily headaches; in the 8 cases of acute migraine or status migrainosus in which it was used, improvement was rapid and complete in seven.
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Trigeminal neuralgia results from disturbances in the trigeminal root entry zone which generate repetitive action potentials. Drugs which relieve the pain of trigeminal neuralgia depressed these potentials. Anticonvulsants which exert this or related effects, and which have been demonstrated to be efficacious in trigeminal neuralgia, include carbamazepine, phenytoin, clonazepam, and valproic acid. ⋯ The mechanism of action of pimozide for treating trigeminal neuralgia is not known. Carbamazepine is suggested as the drug of first choice; baclofen or clonazepam could be added if carbamazepine monotherapy is ineffective. When these fail, monotherapy with phenytoin, pimozide, or valproic acid would be a reasonable next step.
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A number of clinical reports have revealed an association between the use of alcohol and drugs and the onset or exacerbation of headaches. In order to investigate this association systematically and to examine the temporal relationship between onset of headaches and psychoactive substance use, we analyzed responses to a self-report questionnaire from 267 consecutive admissions to a three-week inpatient substance abuse treatment program. ⋯ The following characteristics were noted in the 236 respondents: 1) Over 89% reported having experienced some type of headache. 2) Headache-free individuals were significantly older than headache sufferers. 3) Women were much more likely to have migraine headaches than men. 4) Onset of migraines occurred prior to onset of substance use, while onset of tension headaches occurred after onset of substance use. Although associational data must be interpreted with caution, an intriguing hypothesis compatible with the finding is that migraines may play a role in the genesis of substance use, while substance use may play a role in the genesis of tension headaches.
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Ketorolac IM was compared to DHE and metoclopramide IV in migraine patients whose regular abortive medication had failed and who presented to a headache clinic for acute treatment. Pain scale ratings and ratings of ability to function were recorded before and after injection. Ketorolac provided moderate relief in headache in six of nine patients compared to eight of nine given DHE and metoclopramide. The average improvement in patients receiving DHE and metoclopramide was greater in pain (p = .031) and disability scores (p = .057), than in those patients given ketorolac.
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Twelve patients presenting to an emergency department in headache crisis were treated with Ketorolac tromethamine 60 mg. intramuscularly. All improved sufficiently to require no further emergent treatment. There was statistically significant improvement on all segments of the short form McGill Pain Questionnaire. This open label trial suggests that Ketorolac Tromethamine may be a useful agent in the treatment of headache crisis, and a controlled study to examine this is warranted.