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Patrick Dempsey Has Mastered the Art of Racing in the Rain

PopSugar — Thu, 15 Oct 2009 07:45:00 -0700

Patrick Dempsey braved the gloomy weather as he dodged raindrops while running errands in LA yesterday. The car enthusiast has spent his past few weekends at the tracks in Maine and Florida, where he raced. He's taking his passion to the big screen for The Art of Racing in the Rain, but before that we'll see him costarring with everyone in Valentine's Day. Tonight, the Grey's Anatomy crew is back and afterwards Bailey will be headed from Seattle Grace down to see Addison on Private Practice for a crossover episode.

For more photos of Patrick just read more.

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Ellen Works Out and Gets Back to Work as Meredith Grey

PopSugar — Thu, 15 Oct 2009 02:00:00 -0700

Ellen Pompeo spent some time away from baby Stella to take a yoga class in LA yesterday. She stayed fit all through her pregnancy so it's not a surprise that she's already back to working out. The new mom will also be back to work on Grey's Anatomy soon so Seattle Grace won't be without Meredith for a single episode. Tonight is another special Grey's Anatomy and Private Practice crossover event, and if you're a fan of Ellen's show be sure to check out the Grey's Anatomy Junkies group in our community.

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Depression

FitSugar — Wed, 08 Oct 2008 17:34:54 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Depression is a mood disorder in which feelings of loss, anger, sadness, or frustration interfere with everyday life. Depression affects about 17 million Americans each year. It can be mild, moderate, or severe and occur as a single episode, recurring episodes, or chronic depression (lasting more than 2 years).

The primary types of depression include:

Major depression -- five or more symptoms must be present. An episode must last at least 2 weeks, but tends to continue for 20 weeks. (A mood disorder is classified as minor depression if less than five depressive symptoms are present for at least 2 weeks.)
Dysthymia-- a chronic, generally milder form of depression. Symptoms are similar to major depression but more mild in degree.
Atypical depression-- depression accompanied by unusual symptoms, such as hallucinations, delusions, and physical rigidity

Other common forms of depression include:

Postpartum depression-- experienced by 8 - 20% of women following delivery
Premenstrual dysphoric disorder (PDD)-- experienced by 3 - 8% of women. Depressive symptoms occur 1 week prior to menstruation and disappear following menstruation.
Seasonal affective disorder (SAD)-- experienced by 5% of adults, the majority of whom are women. It occurs during the fall-winter season and disappears during the spring-summer season.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Signs and Symptoms

While it is normal for most people to feel "down in the dumps" on occasion, someone with major depression feels significantly depressed for a prolonged period of time, has difficulty enjoying acts that were once pleasurable, and experiences at least five of the following symptoms for 2 weeks or more:

Sleep disturbances -- at least 90% of people with depression have either insomnia (sleeplessness) or hypersomnia (excessive sleeping).
Significant change in appetite (often resulting in either weight loss or weight gain)
Fatigue and loss of energy
Feelings of worthlessness, self-hate, and inappropriate guilt
Extreme difficulty concentrating
Either agitation, restlessness, and irritability or inactivity and withdrawal
Recurring thoughts of death or suicide
Feelings of hopelessness

Although not generally considered to be defining characteristics of depression, many people with the condition report a lack of sex drive and sudden bursts of anger.

Causes

The causes of depression are complex and involve a combination of biologic, genetic, and environmental factors. People with depression may have abnormal levels of certain brain chemicals, including serotonin, acetylcholine, and catecholamines (such as dopamine). The following may alter the levels of these brain chemicals and contribute to development of depression:

Heredity -- a recently identified gene called SERT that regulates the brain chemical serotonin has been linked to depression.
Chronic stress (such as from loss, abuse, or deprivation in early childhood)
Amount of exposure to light
Sleep disturbances
Social isolation
Nutritional deficiencies
Serious medical conditions, such as heart attack or cancer
Certain medications, including those for high blood pressure, high cholesterol, or irregular heartbeat

Risk Factors

Although depression is a condition that can affect anyone, regardless of age, race, or gender, the following factors may increase your risk for an initial or recurrent episode of depression:

Prior episodes of depression
Family history of depression
Suicide attempt -- a previous attempt of suicide during a major depressive episode increases the likelihood of another episode of depression.
Female gender -- the incidence of depression appears to be greater in women than in men. Some researchers speculate, however, that women may simply report their symptoms more frequently than men, and that men may be more apt to mask their depressive symptoms with alcohol. Therefore, it is still unclear whether women truly have a greater risk for depression.
Young adulthood or middle age -- the highest occurrence of depression is between the ages of 25 - 44. The elderly are also at particular risk due to death of loved ones, physical illness, and loss of independence.
Stressful life events (such as the death of a loved one), particularly if the event occurs at a young age
Postpartum period
Chronic medical or psychological conditions, including autoimmune diseases (such as lupus), cancer, heart disease, chronic headaches, chronic pain, anxiety, obsessive-compulsive disorder, and borderline personality disorder. Medical conditions that cause shifts in hormones, such as thyroid disorders or menopause, may also contribute to depression.
History of abuse (such as mental, physical, or sexual)
Lack of social support system (such as a network of close friends or family)
Current or past alcohol or drug abuse -- 25% of people with addictions have depression.

Diagnosis

If feelings of depression or any of the related symptoms are present, it is important to address them with a doctor or someone who can help direct care appropriately. Unfortunately, many people with depression tend to refrain from disclosing any or all of their symptoms in this setting. Occasionally, even when the symptoms are discussed during an appointment, a doctor may try to treat them individually, rather than recognizing the complete picture of depression. Working together with a primary care doctor is extremely important because they are often the health care providers who make a referral to a psychiatrist who, in turn, makes a definite diagnosis of depression. Proper diagnosis of depression is the first step toward proper treatment.

Only psychiatrists can prescribe medication, but psychologists and social workers, as well as psychiatrists, use psychotherapy as an important mode of treatment. These specialists will often administer a screening test, such as the Beck Depression Inventory or the Hamilton Rating Scale, which consists of about 20 questions that assess an individual's risk for depression. Even before these psychological screening tests, however, several blood tests will be performed to determine whether nutrient deficiencies or underlying medical conditions (such as a thyroid disorder) may be causing or contributing to depression.

Although the vast majority of people with depression are treated as outpatients, hospitalization is necessary for people who intend to, or do, attempt suicide, and may be necessary under other circumstances as well.

Preventive Care

The following steps can help prevent depression or decrease the chances of relapse:

Adequate sleep, regular exercise, and a balanced, healthy diet may help prevent depression and diminish symptoms of this mood disorder.
Mind-body techniques, such as biofeedback, meditation, and tai chi, are effective ways to prevent or reduce symptoms associated with depression.
Psychotherapy directed at coping skills generally helps prevent relapse.
Family therapy may prevent children or teens of depressed parents from becoming depressed later in life.
Compliance with the prescribed treatment regimen decreases the chance of relapse.

Treatment Approach

People with depression have several options for treatment, but a combination of psychotherapy and antidepressant medications is the regimen of choice, particularly for people with major depression. Cognitive-behavioral therapy appears to be the most effective type of psychotherapy, particularly for adolescents and people with atypical or postpartum depression. As many as 90% of people with depression improve from a combination of psychotherapy and antidepressants. However, adverse side effects from certain medications make it difficult for many to take their medications. Some complementary and alternative therapies may be helpful in reducing the side effects from such medications, while other complementary and alternative therapies may actually diminish the symptoms of depression.

Lifestyle

Exercise

Studies have consistently shown that regular exercise (either aerobic or strength and flexibility training) significantly reduces depressive symptoms in people with mild to moderate depression and improves the mood of people with major depression. Some even suggest that exercise may be as effective as psychotherapy for people with mild-to-moderate depression, although additional research is needed. In the meantime, exercise can be used safely in conjunction with medication for those with depression.

Medications

Antidepressant medications are very effective; reports indicate that they are 90% successful in treating depression. In general, medications are taken for at least 4 - 6 months to assure complete and effective treatment. However, antidepressants often cause adverse side effects, making it difficult for some people to comply with taking their medications. Medications must not be stopped before first talking with a physician. Most antidepressants cause withdrawal symptoms if they are not discontinued slowly over time with guidance from a physician.

There are several classes of antidepressant medications, including:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs increase the activity of a chemical in the brain called serotonin. Most health care providers will prescribe SSRIs before any other antidepressant medication for depression, in part because the side effects associated with SSRIs are generally fewer than for other classes of antidepressants. Typical side effects caused by SSRIs include stomach upset, weight gain or loss, drowsiness, sexual dysfunction (such as impotence, decreased libido, and diminished orgasm), headache, jaw grinding, and apathy. Very unusual side effects from this class of prescription drugs include extreme agitation, impulsivity, tremors, and insomnia. People who discontinue taking SSRIs due to side effects usually attribute their discontent to sexual dysfunction.

Drugs classified as SSRIs include:

Fluoxetine
Sertraline
Paroxetine -- most likely in this class to cause sexual dysfunction
Fluvoxamine
Citalopram -- least likely in this class to cause sexual dysfunction

Another group of antidepressant medications (which are similar to SSRIs, but target other brain chemicals in addition to serotonin) may cause fewer negative sexual side effects. These include:

Bupropion -- should not be used if there is history of or risk for seizure
Nefazodone -- no sexual dysfunction reported. It begins to work very quickly and may cause a decrease in blood pressure when going from lying or sitting to standing.
Venlafaxine -- may impair sexual function and is not recommended in the elderly. It may improve quality of life more effectively than other antidepressants, but can cause irregular heart rhythm. Withdrawal from the medication is difficult.
Mirtazapine -- may be particularly effective if feelings of anxiety are also present. It helps with insomnia but may cause drowsiness, blurred vision, weight gain, and damage to production of cells in the bone marrow (very rare).
Maprotiline -- may cause dry mouth, drowsiness, sensitivity to the sun, and seizures

Tricyclic Antidepressants

Tricyclics increase the activity of the brain chemicals serotonin and norepinephrine. They are as effective as SSRIs, but are usually prescribed only to those who do not respond well to SSRIs because side effects are quite common and are usually less tolerable. Tricyclic antidepressants include:

Amitriptyline
Amoxapine -- increases risk of seizure in those who are prone to have a seizure
Clomipramine -- used for obsessive-compulsive disorder
Desipramine
Doxepin -- may help with insomnia
Imipramine -- may cause a rare lung disorder called idiopathic pulmonary fibrosis
Nortriptyline -- less risk of irregular heart rhythm than others in this class
Protriptyline -- less drowsiness than others in this class and may even cause weight loss and sun sensitivity
Trimipramine -- high risk for irregular heart rhythm

Side effects of tricyclics may include:

Dry mouth
Blurred vision
Constipation
Sexual dysfunction
Weight gain
Dizziness
Drowsiness
Urinary urgency (a sense that one has to urinate even when the bladder is empty)
Drop in blood pressure when going from lying or sitting to standing (causes dizziness and lightheadedness)
Irregular heart rhythm

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs boost levels of norepinephrine, dopamine, and serotonin in the brain. MAOIs are generally prescribed only when other antidepressants have not been effective, which may occur in people with atypical depression. People who take MAOIs may experience a sharp increase in blood pressure after consuming food or drink containing the amino acid tyramine (found in such foods as aged cheeses and red wine). MAOIs also negatively interact with other medications, including Ritalin (used for attention deficit hyperactivity disorder) and pseudoephedrine (decongestant in many over-the-counter and prescription medications), and should not be taken with other classes of antidepressants.

MAOIs include:

Phenelzine -- should be avoided by people with a history of seizures or bipolar disorder (manic-depression)
Isocarboxazid -- side effects include drowsiness, sexual dysfunction, weakness, trembling, and blurred vision.
Tranylcypromine -- should not be used if there is any history of kidney disease or bipolar disorder

Surgery and Other Procedures

Electroconvulsive Therapy (ECT) for depression is usually reserved for when all other therapies have been unsuccessful. In this procedure, a small electrical current induces a seizure lasting approximately 40 seconds. A muscle relaxant and mild sedative are administered prior to the procedure. ECT is generally repeated every 2 - 5 days for a total of six treatments. It may cause temporary confusion, memory impairment, headache, muscle aches, irregular heart rhythm, or nausea.
Magnetic Resonance Imaging (MRI)-Guided Cingulotomy involves the application of an electrical current to a specific part of the brain. The MRI is used as a guide for an exact placement. Long-term improvement has been reported using this technique in over 50% of people with depression who have not responded to other treatment methods.

Nutrition and Dietary Supplements

A comprehensive treatment plan for depression may include a range of complementary and alternative therapies. Preliminary studies suggest that nutritional supplements may reduce the symptoms of some depression. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

Following these nutritional tips may help reduce symptoms:

Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables such as kelp and dulce.
Avoid refined foods, such as white breads, pastas, and especially sugar.
Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
Use healthy oils for cooking, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise at least 30 minutes daily, 5 days a week.

You my address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
Omega-3 fatty acids, such as fish oil, one to two capsules or one tablespoonful oil one to three times daily, to help decrease inflammation and help with mental balance.
Vitamin C, 500 - 1000 mg one to three times daily, as an antioxidant and for immune support.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization. Ask your health care provider about potential prescription interactions.
Probiotic supplement (containing Lactobacillus acidophilus and other species), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for mood improvement.
Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months. It is recommended to use DHEA under the supervision of a qualified health care provider. If adverse effects develop, discontinue use.
L-theanine, 200 mg one to three times daily, for nervous system support.
Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

St. John's wort (Hypericum perforatum) standardized extract, 300 mg two to three times per day, for depression. Check with your health care provider if you are taking prescription medications.
Kava kava (Piper methysticum) standardized extract, 100 - 250 mg one to three times daily, as needed for symptoms of stress and anxiety. Talk with your health care provider before taking kava kava if you have an unhealthy liver.
Ginkgo (Ginkgo biloba) standardized extract, 40 - 80 mg three times daily, for blood flow and depression.
Green tea ( Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and general health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
Rhodiola ( Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and anti-stress activity.

Acupuncture

Two randomized, controlled, clinical trials suggest that electroacupuncture may reduce symptoms of depression as effectively as amitriptyline, a tricyclic antidepressant medication. Electroacupuncture involves the application of a small electrical current through acupuncture needles. Other studies suggest that acupuncture may be effective for people with mild depression and for those with depression related to a chronic medical illness. Further research is warranted in this area.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies to alleviate the symptoms of depression based on their knowledge and experience.

Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. A few homeopathic remedies that may work for depression include:

Ignatia -- for a sudden sense of grief or disappointment following the death of a loved one, the end of a romantic relationship, or an unexpected loss of one's job
Natrum muriaticum -- for grief following the death of a loved one or sadness from the end of a romantic relationship

Massage and Physical Therapy

Studies of formerly depressed adolescent mothers, children hospitalized for depression, and women with eating disorders, suggest that massage decreases stress hormone levels, feelings of anxiety, and symptoms of depression. Giving massage may also be beneficial for people who are depressed. Elderly volunteers with depression showed notable improvement in their symptoms when they massaged infants.

Aromatherapy, or the use of essential oils in massage therapy, may also be of value as a supplemental treatment for depression. Theoretically, the smells of the oils elicit positive emotions through the limbic system (the area of the brain responsible for memories and emotions). However, the benefits of aromatherapy appear to be related to the relaxation effects of the treatment as well as to the recipient's belief that the treatment will be beneficial. Essential oils used during massage for depression are quite varied and include:

Lavender ( Lavandula officinalis)
Basil (Ocimum basilicum)
Orange (Citrus aurantium)
Sandalwood (Santalum album)
Lemon (Citrus limonis)
Jasmine (Jasminum spp.)
Sage (Salvia officinalis)
Chamomile (Chamaemelum nobile)
Peppermint (Mentha piperita)
Rosemary (Rosmarinus officinalis)

Mind-Body Medicine

Mind-body therapies and techniques that may be useful as a part of an overall treatment regimen for depression include:

Psychotherapy

Cognitive-behavioral therapy is a type of psychotherapy in which individuals learn to identify and change distorted perceptions about themselves and adapt new behaviors to better cope with the world around them. This therapy is frequently considered the treatment of choice for people with mild-to-moderate depression, but it may not be recommended for those with severe depression. Studies of people with depression indicate that cognitive-behavioral therapy is at least as effective as tricyclic antidepressants. Compared to those treated with antidepressants, people treated with cognitive-behavioral therapy demonstrated similar, or better, results and lower relapse rates.

Other therapeutic approaches that may be applied by a psychiatrist, psychologist, or social worker include:

Psychodynamic psychotherapy -- based on Freud's theories about unresolved conflicts in childhood and depression as a grief process
Interpersonal therapy -- acknowledges childhood roots of depression, but focuses on current problems contributing to depression and is considered very effective treatment for depression
Supportive psychotherapy -- nonjudgmental advice, attention, and sympathy, and this approach may improve compliance with taking medication

Relaxation

One study suggests that relaxation techniques, such as yoga and tai chi, may improve symptoms of depression in people with mild depression.

Meditation

Some researchers believe that mindfulness meditation may prevent depression from recurring in people who once had the condition.

Other Considerations

Pregnancy

Postpartum depression is experienced by 8 - 20% of women following delivery.
The safety of SSRIs and tricyclic antidepressant medications during pregnancy remains uncertain. The physician will provide guidance regarding use or avoidance of antidepressants during pregnancy. The risks and benefits to the mother and the fetus must be weighed in each individual case in order to determine the most appropriate regimen during pregnancy. MAOIs cause birth defects and should be avoided during pregnancy.
Many of the dietary supplements and herbs mentioned here have not been tested for safety during pregnancy. Talk with your doctor or pharmacist.

Warnings and Precautions

People with Parkinson's disease should avoid SSRIs.
People with coronary artery disease should avoid tricyclic antidepressants.
Several herbal remedies and supplements should not be combined with antidepressant medications. Be sure to inform your health care provider of all herbs and supplements you take to avoid adverse interactions.

Prognosis and Complications

Depression is a serious condition that can have a devastating effect on people's lives. It can directly and indirectly contribute to chronic medical conditions, such as heart disease and stroke, because depressed people with these conditions are less likely to engage in healthy behaviors (such as exercise) and more likely to engage in unhealthy behaviors (such as smoking). Suicide is a significant factor in depression. About 15 % of people with a major depressive disorder commit suicide. Depression also significantly shortens the lifespan of the elderly and is associated with the development of memory impairment and dementia.

When left untreated, depression can last up to 2 years. Rates of recurrence are variable: 50% of people who have had one depressive episode will have a second major depressive disorder, 70% will have a third, and 90% will have a fourth. Symptoms of depression usually disappear after menopause in women with premenstrual dysphoric disorder or seasonal affective disorder. Fortunately, there are several treatment options available for people with depression, and the prognosis improves tremendously for those who seek treatment and comply with their regimen.

Supporting Research

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Anonymous. SAMe for depression. Med Lett Drugs Ther. 1999;41(1065):107-108.

Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med. 2000;62(5):633-638.

Beniamini Y, Rubenstein JJ, Zaichkowsky LD, Crim MC. Effects of high-intensity strength training on quality-of-life parameters in cardiac rehabilitation patients. Am J Cardiol. 1997;80(7):841-846.

Benjamin J, Agam G, Levine J, Bersudsky Y, Kofman O, Belmaker RH. Inositol treatment in psychiatry. Psychopharmacol Bull. 1995;31(1):167-175.

Benton D, Cook R. The impact of selenium supplementation on mood. Biol Psychiatry. 1991;29(11):1092-1098.

Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. 1998;3(4):271-280.

Bottiglieri T. Folate, vitamin B12, and neuropsychiatric disorders. Nutrition Rev. 1996;54(12):382-390.

Bottiglieri T, Laundy M, Crellin R, Toone BK, Carney MW, Reynolds EH. Homocysteine, folate, methylation, and monoamine metabolism in depression. J Neurol Neurosurg Psychiatry. 2000;69(2):228-232.

Bottiglieri T, Hyland K, Reynolds EH. The clinical potential of ademetionine (S-adenosylmethionine) in neurological disorders. Drugs. 1994;48(2):137-152.

Brenner R, Azbel V, Madhusoodanan S, Pawlowska M. Comparison of an extract of hypericum (LI 160) and sertraline in the treatment of depression: a double-blind, randomized pilot study. Clin Ther. 2000;22(4):411-419.

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Bruinsma KA, Taren DL. Dieting, essential fatty acid intake, and depression. Nutrition Rev. 2000;58(4):98-108.

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Eich H, Agelink MW, Lehmann E, Lemmer W, Klieser E. Acupuncture in patients with minor depressive episodes and generalized anxiety. Results of an experimental study. Fortschr Neurol Psychiatr. 2000;68(3):137-144.

Einat H, Karbovski H, Korik J, Tsalah D, Belmaker RH. Inositol reduces depressive-like behaviors in two different animal models of depression. Psychopharmacology. 1999;144:158-162.

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Review Date:
11/6/2006
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

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The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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Syncope

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

Overview

Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
Treatment Options
Prognosis/Possible Complications
Following Up
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Syncope, or fainting, is a sudden loss of consciousness caused by decreased blood flow to the brain. Recovery occurs within seconds or minutes for many causes of fainting. About 3 - 4% of people, mostly the elderly, experience episodes of fainting.

Signs and Symptoms

You may experience the following signs and symptoms before you faint:

Lightheadedness
Blurred vision
Sweating
Heaviness in your lower limbs
Giddiness
Confusion
Yawning
Nausea, and sometimes vomiting

During a fainting episode, in addition to loss of consciousness, you may experience the following symptoms:

Abnormal paleness
Falling down if standing, slumping if seated
Spasmodic jerks of your body
Weak pulse
Drop in blood pressure

What Causes It?

Fainting often occurs from a simple, non-medical cause, but may be the result of a serious health condition, such as heart disease (decreased blood flow to the heart or irregular heart rhythm), low blood sugar (often related to diabetes), seizures, panic attacks, and problems regulating blood pressure.

Who's Most At Risk?

People with the following conditions or characteristics are at risk for fainting:

Over 65 years of age
Preexisting heart disease
Recreational drug use
Taking certain medications such as antihypertensives, insulin, oral hypoglycemics, diuretics, antiarrhythmics, or anticoagulants
Pregnancy

What to Expect at Your Provider's Office

If you have fainted, you should see your health care provider. Your health care provider will ask questions, do a physical examination, and perform diagnostic tests. Tests may include blood tests, electrocardiogram (ECG), and imaging of the brain, such as magnetic resonance imaging (MRI). Your provider will focus on symptoms associated with the current fainting episode, medications you take, preexisting medical conditions, and your description of any similar episodes you may have experienced in the past. This will help your health care provider pinpoint the cause of the fainting episodes and identify or rule out particular health conditions. If seizures are suspected, your health care provider may also perform a test called an electroencephalogram (EEG).

Treatment Options

Prevention

Some cases of fainting may be preventable, depending on the cause.

Avoid fatigue, hunger, and stress.
Avoid changing positions quickly, especially rising from a sitting or lying-down position.
Sleep with the head of your bed elevated.
Avoid standing for long periods of time.
You may wear elastic stockings.
Diuretics and other prescription and non-prescription medicines can contribute to the problem, so check with your health care provider.
Avoid tight clothing around the neck.
Turn the whole body and not just the head when looking around.
To prevent injuries, cover floors with thick carpeting and avoid driving or operating mechanical equipment.
Avoid caffeine and alcohol.

Treatment Plan

Any serious underlying health condition must be treated. At the time of the fainting episode, make sure the person is in a position that increases blood flow to the brain, such as with the legs elevated. Loosen all tight clothing, apply cold water to the person's face, and turn the person's head to the side to prevent vomiting or choking. A pregnant woman should lie on her left side to relieve pressure on the heart.

Drug Therapies

When irregular heart rhythm causes fainting, your health care provider may prescribe medications such as beta-blockers or antiarrhythmics. Mineralocorticoids (such as fludrocortisone) or salt tablets may also be prescribed.

Surgical and Other Procedures

A cardiac pacemaker may be necessary in some cases where fainting is caused by an underlying heart condition, such as a slow or rapid heartbeat.

Complementary and Alternative Therapies

A wide variety of alternative therapies help protect the heart and vascular systems. Taking these supplements may help decrease episodes of fainting. Fainting may be caused by a serious underlying health condition, so check with your health care provider before taking any herbs or supplements. Always tell your health care provider about the herbs and supplements you are using or considering using.

You may experience warning signs before fainting. Hypnosis, deep breathing, relaxation techniques, and biofeedback may help you avoid fainting. These techniques may also help you control fainting related to nervous system regulation of your blood pressure.

Nutrition and Supplements

Following these nutritional tips may help reduce symptoms:

Eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
Eat more high fiber foods, including beans, oats, root vegetables (such as potatoes and yams), and psyllium seed.
Avoid refined foods such as white breads, pastas, and especially sugar.
Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
Use healthy cooking oils, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, excess sugar, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise at least 30 minutes daily, 5 days a week.

Nutritional deficiencies may be addressed with the following supplements:

Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil one to two times daily, to help decrease inflammation and improve heart health. Cold-water fish, such as salmon or halibut, are good sources.
A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins and trace minerals, such as magnesium, calcium, folic acid, zinc, and selenium.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, heart, and muscular support.
Acetyl-L-carnitine, 500 mg daily, for antioxidant and heart protective activity.
Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.
L-arginine, 1 - 2 grams one to two times daily, for vascular support.
L-theanine, 200 mg one to three times daily, for stress and nervous system support.
Adrenal hormonal extract, 100 - 200 mg daily, for adrenal stress. Laboratory tests may confirm the need for adrenal hormonal. Ask your health care provider.

Herbs

Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
Bilberry (Vaccinium myrtillus) standardized extract, 80 mg two to three times daily, for antioxidant and vascular system support.
Ginkgo (Ginkgo biloba) standardized extract, 40 - 80 mg three times daily, for antioxidant and heart health support.

Homeopathy

Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced and certified homeopath will assess your individual constitution and symptoms, and then recommend remedies. Below are common remedies used for fainting or pre-fainting symptoms:

Carbo vegetabilis, used for fainting or lightheadedness after rising in the morning, from loss of fluids, or from becoming overheated.
Opium, used for fainting due to excitement or fright.
Sepia, used for fainting following prolonged standing, exercise, or fluid loss due to fever.

Acupuncture

Acupuncture may be helpful in treating syncope. A clinical analysis of 102 serious cases of loss of consciousness reported that acupuncture helped in a large percentage of these cases.

Acupuncture is known for rarely causing side effects or complications. However, some patients faint during acupuncture treatments although it is not considered a serious complication.

Prognosis/Possible Complications

In most people, simple fainting is not a sign of a life-threatening disease, particularly if it only happens once. The elderly are at increased risk for injury after a fainting episode, especially from fractures.

Following Up

Many people with syncope, especially the elderly and those with preexisting heart disease, may be hospitalized to look for a cause. Continuous ECG monitoring can identify irregular heartbeat as a cause of fainting, especially in people who have recurring fainting episodes.

Supporting Research

Adams RD, Victor M. Principles of Neurology. 6th ed. New York, NY: McGraw-Hill; 1997:902–912.

Ahlemeyer B, Krieglstein J. Neuroprotective effects of Ginkgo biloba extract. Cell Mol Life Sci. 2003;60(9):1779-92.

Basu HN, Liepa GU. Arginine: a clinical perspective. Nutr Clin Pract. 2002;17(4):218-25.

Bast A, Haenen GR. Lipoic acid: a multifunctional antioxidant. Biofactors. 2003;17(1-4):207-13.

Beers MH, et al. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:1651-1654.

Bell DR, Gochenaur K. Direct vasoactive and vasoprotective properties of anthocyanin-rich extracts. J Appl Physiol. 2006;100(4):1164-70.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Newton, Mass: Integrative Medicine Communications; 1998:161-162, 333-335.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea--a review. J Am Coll Nutr. 2006;25(2):79-99.

Carillo-Vico A, Reiter RJ, Lardone PJ, et al., The modulatory role of melatonin on immune responsiveness. Curr Opin Investig Drugs. 2006;7(5):423-31.

Castro M. The Complete Homeopathy Handbook: A Guide to Everyday Health Care. New York, NY: St. Martin's Press; 1990:67-68, 127, 148.

Castro V, Nacht R. Cocaine-induced bradyarrhythmia: an unsuspected cause of syncope. Chest. 2000;117:275-277.

Fang-Pey C, Hwang SJ, Lee HP, Yang HY, Chung C. Clinical study of syncope during acupuncture treatment. Int J Acupunct Electrother Res. 1990;15:107-119.

Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:100-107.

Fontani G, Corradeschi F, Felici A, et al. Cognitive and physiological effects of Omega-3 polyunsaturated fatty acid supplementation in healthy subjects. Eur J Clin Invest. 2005;35(11):691-9.

Gaby AR. The role of coenzyme Q10 in clinical medicine: Part 1. Alt Med Rev. 1996; 1(1):11-17.

Gruenwald J, Brendler T, Jaenicke C, et al, eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Company; 1998:779,1204-1205.

Guha S, Dawn B, Dutta G, Chakraborty T, Pain S. Bradycardia, reversible panconduction defect and syncope following self-medication with a homeopathic medicine. Cardiology. 1999;91(4):268-271.

Guize L, Iliou MC, Bayet G, Lavergne T, Le Heuzey JY. [Torsades de pointes.] Arch Mal Coeur Vaiss. 1993;86(5 suppl):769-776.

Hirschmann JV, Raugi GJ. Adult scurvy. J Am Acad Dermatol. 1999;41(6):895-906.

Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble Books; 1995:215.

Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med. 1995;122(4):286-295.

Kelley WN, et al. Textbook of Internal Medicine. Vol. 1. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1997:343–350.

Kerr D, Sherwin R, Pavalkis F, et al. Effect of caffeine on the recognition of and response to hypoglycemia in humans. Ann Intern Med. 1993;119(:799-804.

Kimura K, Ozeki M, Juneja LR, Ohira H. l-Theanine reduces psychological and physiological stress responses. Biol Psychol. 2006 Aug 21.

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Review Date:
9/5/2006
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Tension headache

FitSugar — Wed, 08 Oct 2008 17:34:54 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Treatment Approach
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Tension headaches are very common, affecting as many as 40% of teenagers and adults. Pain is caused by tightness (contraction) of your neck and scalp muscles. With a tension headache, the pain often starts at the back of your head and moves forward, so that it eventually includes your neck, scalp, and head. It’s often described as feeling like you have a tight band across your head. It may be caused by stress, but sometimes there is no obvious cause. If your headaches happen 15 or more days in a month for several months, they are considered chronic tension headaches. If they occur less frequently, they are called episodic tension headaches.

Although tension headaches can be painful, they are rarely a sign of a more serious illness. A combination of lifestyle changes, relaxation techniques, and traditional and complementary therapies can help reduce the number of tension headaches you have.

Signs and Symptoms

Headache starts at the back of your head and spreads forward
Dull pressure or a squeezing pain, often described as a tight band around the head
Muscles in your neck, shoulders, and jaw can feel tight and sore
Affects both sides of your head equally
May have difficulty sleeping or eating

Causes

Exactly what causes a tension headache isn’t clear. For years, researchers thought that it was caused by tightening the muscles in your shoulders, neck, scalp, and jaw when you are tense. But new tests that measure muscle tension have shown that the muscles of people with tension headaches aren’t any tighter. Newer theories suggest tension headaches are caused by changes in brain chemicals (neurotransmitters, including serotonin), similar to what happens with a migraine. Scientists don’t know why the levels of neurotransmitters go up and down, but they think it activates pain pathways in the brain. Tight muscles may help trigger the changes in neurotransmitters, or muscle tightness may be a result of fluctuating levels of brain chemicals.

Triggers may include:

Stress
Depression
Anxiety
Holding your head in one position for a long time (like using a computer)
Sleeping in an awkward position or in a cold room
Eye strain
Fatigue
Overexertion
Skipping meals
Head or neck injury, even years after the injury
Clenching your jaw or grinding your teeth (bruxism)
Medications, including some headache medications (leading to rebound headaches)
Arthritis

Certain foods or food additives may also be a trigger for some people (see Nutrition and Dietary Supplements section)

Pain that originates from other areas, such as your sinuses, can also trigger tension headaches or a combined sinus/tension headache

Risk Factors

Gender – women tend to have more headaches than men
Changes in estrogen levels (during a woman’s period or at menopause)
Premenstrual syndrome
Stress
Chronic overwork
Too much or too little sleep
Missing meals
Alcohol or drug use

Diagnosis

Your doctor will take a detailed history in order to distinguish tension headaches from headaches of other causes, such as migraines. He or she will ask questions about when your headaches occur, how long they last, how frequently they come on, the location of the pain, and any symptoms that accompany the headaches. Sometimes it helps to keep a diary about your headaches before seeing the doctor; this way, you'll have an accurate recording of how often they happen.

Your doctor will examine your head, neck, eyes, and sinuses and do a neurologic examination. Don't be surprised if the doctor asks you some questions to test your short term memory. On exam, the physician is likely to find musculoskeletal tenderness around your neck and scalp.

If you have unusual symptoms, you doctor may order these tests:

Computed tomography (CT) scan or magnetic resonance imaging (MRI), to rule out a tumor or aneurysm, or to check for sinusitis
X-ray of the neck to look for arthritis or spinal problems; x-ray of the sinuses to look for sinusitis
Electroencephalogram (EEG), a brain wave study, to look for any seizure activity

Treatment Approach

A comprehensive treatment plan including relaxation (see Mind/Body Medicine), exercise and other lifestyle changes, and occasional medication can be very effective in reducing the frequency and intensity of tension headaches.

Biofeedback, yoga, and relaxation techniques, for example, can help relieve pain and lower the number of headaches you have. Regular exercise helps, too.

Lifestyle

Keeping a headache diary can help identify the source of your tension headaches and how you can change your environment and habits to avoid them. When a headache starts, write down the date and time it began. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were doing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.

Good health habits are important for helping to lessen stress and tension headaches:

Get adequate sleep
Eat a healthy diet
Get regular exercise
Quit smoking
Use relaxation techniques (see Mind/Body Medicine section)

Medications

Medications are used both to relieve pain and to prevent headaches if you have chronic tension headaches.

To relieve pain:

Over-the-counter (OTC) analgesics – are usually effective. Don’t take these medications more than two days per week, and take only the amount recommended on the package. Talk to your doctor about which of these is best for you.

Acetaminophen (Tylenol) – can cause liver damage if used in high doses or over a long period of time
Aspirin – can cause stomach upset and bleeding
Ibuprofen (Advil, Motrin) – can cause stomach upset and bleeding, and raise risk of heart problems
Naproxen (Aleve) – can cause stomach upset and bleeding, and raise risk of heart problems

Prescription analgesics – may be needed if your headaches don’t respond to OTC medications. They include

Naproxen (Naprosyn) – can cause stomach upset and bleeding, and raise risk of heart problems
Indomethacin (Indocin) – can cause stomach upset and bleeding, and raise risk of heart problems
Ketoprofen (Orudis) – can cause stomach upset and bleeding, and raise risk of heart problems

Rarely, if your headaches are very severe and nothing else relieves the pain, your physician may consider prescribing narcotics such as codeine plus acetaminophen (Tylenol with Codeine No. 3) or hydrocodone with acetaminophen (Vicodin).

To prevent chronic tension headaches:

Tricyclic antidepressants - Tricyclic antidepressants are helpful in preventing all kinds of headaches, including migraines and tension headaches. Tricyclic antidepressants include:

Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Doxepin (Sinequan)
Imipramine (Tofranil)

Selective serotonin reuptake inhibitors (SSRIs) – another type of antidepressant that may not be as effective as tricyclics in preventing headaches, but tend to have fewer side effects. They include:

Fluoxetine (Prozac)
Paroxetine (Paxil)
Citalopram (Celexa)
Sertraline (Zoloft)

Anticonvulsants - Some anti-seizure drugs help prevent migraines and tension headaches, although researchers aren't sure why:

Divalproex sodium (Depakote)
Topiramate (Topamax)

Surgery and Other Procedures

If an injury or problem in the cervical spine is contributing to tension headaches, a nerve block, using a steroid to reduce inflammation and muscle contraction, may be considered to lessen the head pain.

Nutrition and Dietary Supplements

Diet

Certain foods can trigger tension headaches, including:

Chocolate
Cheese
Monosodium glutamate (MSG), a flavor enhancer found often in food from Chinese restaurants
Foods containing the amino acid tyramine (found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans)
Nuts
Peanut butter
Some fruits (like avocado, banana, and citrus)
Onions
Dairy products
Meats containing nitrates (bacon, hot dogs, salami, cured meats)
Fermented or pickled foods

If you suspect that any of these foods cause your headaches, you could follow an elimination diet, eliminating all the items on this list from your diet and then reintroducing them one at a time. Pay close attention to when the number of headaches increases after eating particular foods. Then you know which trigger foods to avoid.

The amino acid 5-hydroxytryptophan (5-HTP, 400 to 600 mg per day) is made by the body from tryptophan (another amino acid you get from certain foods) and converted into serotonin, a neurotransmitter. Because researchers think changes in neurotransmitters are related to tension headaches, and some of the drugs used to treat headaches work by affecting serotonin, 5-HTP has been proposed as a treatment for tension headaches. Several studies indicate that 5-HTP may be effective for migraines, but the evidence is mixed for tension headaches. One study found that 5-HTP did not reduce the number of headaches people experienced, but it did allow them to reduce their use of other painkillers. More studies are needed to tell whether 5-HTP is helpful in treating tension headaches. If you take an antidepressant, or supplements such as St. John's wort or SAMe, you should not take 5-HTP.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care, under the supervision of a healthcare practitioner.

Peppermint (Mentha x piperita) - Peppermint oil, applied topically to the forehead, has shown some promise in very early studies. In one study, applying a 10% peppermint oil solution to the temples relieved pain about as well as acetaminophen (Tylenol). But more research I needed to know for sure if peppermint oil is effective.
Tiger Balm (contains various oils including camphor, menthol, cassia oil, and clove oil) -Tiger Balm is an over-the-counter ointment used for muscle pain. One study found that applying Tiger Balm to the forehead helped relieve headache pain better than placebo and about as well as acetaminophen.
Butterbur (Petasites hybridus, 50 to 75 mg of a standardized extract two times per day) - A few studies suggest that butterbur may help reduce both the frequency and duration of migraine attacks, and it has been proposed as a treatment for tension headaches, too. However, so far no studies have been done to see whether it works for tension headaches. If you want to try butterbur for your headaches, ask your doctor about a safe extract and dose. Women who are pregnant or breastfeeding should not take butterbur.
Feverfew (Tanacetum parthenium, standardized leaf extract to 250 mcg parthenolide per day) - Feverfew has been used traditionally to treat headaches, and several well-designed studies have found that it may help prevent and treat migraines (not all studies agree, however). However, it has not been studied specifically to see if it can prevent or treat tension headaches. Feverfew can increase the risk of bleeding, and should not be taken with anticoagulants (blood-thinners). Women who are pregnant or breastfeeding should not take feverfew.

Although there is a lack of scientific studies showing that these herbs work, they are sometimes suggested to treat headaches:

Dong quai (Angelica sinensis)
Devil's claw (Harpagophytum procumbens)
Ginkgo biloba (Ginkgo biloba)
Willow bark (Salix spp.)

Acupuncture

Scientific studies using acupuncture to treat tension headaches have found mixed results; however, researchers do agree that acupuncture appears safe and that it may be effective for some people. Acupuncturists diagnose tension headaches by paying careful attention to the kidney and its associated meridians (energy pathways in the body), as well as liver and gallbladder meridians. The physical location of the headache also helps the acupuncturist create a treatment plan, which (in addition to placing needles in acupuncture points) may include lifestyle/dietary changes or herbal remedies.

Chiropractic

Several clinical trials indicate that spinal manipulation therapy may help in the treatment of tension headaches, especially ones that start in the neck. One study compared spinal manipulation to Elavil and found that people in both groups improved, while those in the spinal manipulation group had less side effects. The benefits if spinal manipulation lasted longer: One month after treatment, the spinal manipulation group still showed improvement, while the Elavil group did not. However, another study comparing spinal manipulation plus massage to a sham laser treatment plus massage found no benefit.

Massage and Physical Therapy

Regular massage may help relieve stress and decrease pain in people with chronic tension headaches, according to one preliminary study. Doing stretches for your head and neck (taught by a physical therapist) may also help. Practicing proper posture is another important factor in reducing your number of headaches; a physical therapist can teach you.

Reflexology, a technique that places pressure on specific "reflex points" on the hands and feet that are believed to correspond to areas throughout the body, has been proposed as a treatment for headaches. Some early studies suggest it may relieve pain and allow people with migraines to take less pain medication. However, more research is needed. Practitioners believe reflexology helps you become more aware of you own body signals, which might help you sense the subtle signals that indicate a migraine is about to occur (before pain starts). They also believe reflexology helps improve general well-being and energy level.

Homeopathy

Studies indicate that homeopathy may be no more effective than placebo in relieving tension headaches. Interestingly, however, one of the most common reasons people seek homeopathic care is to relieve the pain associated with chronic headaches. Many homeopaths report that homeopathy helps treat and prevent recurrent tension headaches. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following remedies are commonly prescribed for tension headaches:

Belladonna - for throbbing headaches that come on suddenly; symptoms tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards.
Bryonia - for headaches with a steady, sharp pain that occurs most often in the forehead but may radiate to the back of the head; symptoms tend to worsen with movement and light touch, but firm pressure alleviates the pain; the person for whom this remedy is most appropriate is usually irritable and may experience nausea, vomiting, and constipation.
Gelsemium - for pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open.
Ignatia - for pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults
Iris versicolor - for throbbing headaches that occur on one side of the head, especially after eating sweets; visual disturbances may also occur; these headaches are worse in the early morning, during spring and fall, and symptoms tend to worsen with vomiting.
Lachesis - for headaches that tend to occur on the left side of the head; symptoms are typically worse in the mornings, before menstruation, and with exposure to warmth and sunlight; symptoms tend to improve with open air and firm pressure.
Nux vomica - for headaches associated with hangovers, overindulgence in foods or alcohol, and overwork; these types of headaches are often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who tend to be constipated and irritable.
Pulsatilla - for headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head and may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school.
Sanguinaria- for right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days); pain is aggravated by motion, light, or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache.
Spigelia - for stinging, burning, or throbbing sinus pain that often occurs on the left side of the head; symptoms tend to worsen with cold weather and motion but may be temporarily relieved by cold compresses and lying on the right side with the head propped up.

Mind/Body Medicine

You can do many things to avoid tension headaches or relieve the pain:

Biofeedback to control muscle tension.
Learn to meditate, breathe deeply, or try other relaxation exercises, such as yoga or hypnotherapy.

Other relaxation techniques that may be helpful include:

Guided imagery
Hypnosis

Other Considerations

Pregnancy

Some women who are prone to headaches will get them more often when they are pregnant. Other women, however, may have fewer headaches during pregnancy, especially during the second trimester.

Warnings and Precautions

Use medications only as directed. Using some medications on a regular basis can cause rebound headaches.

Call your doctor if you experience a new headache, a change in quality of a previous headache or headache pattern, or if a medication that usually takes away the pain no longer works.

Prognosis and Complications

Serious underlying conditions due to headaches, like a tumor or a stroke, are extremely rare. You should seek emergency medical attention if you experience the following:

Sudden and severe headache that persists or increases in intensity over 24 hours
A sudden, severe headache that you describe as "your worst ever," even if you are prone to headaches
Chronic or severe headaches that begin after age 50
Headaches accompanied by memory loss, confusion, loss of balance, change in speech or vision, or loss of strength in or numbness/tingling in any one of your limbs
Headaches after a head injury, especially if you are also drowsy or feel nauseated
Headaches accompanied by fever, stiff neck, nausea and vomiting (may indicate meningitis)
Severe headache localized to one eye, accompanied by redness of the eye (may indicate acute glaucoma)

The good news is that more than 90% of people with tension headaches can get significant relief from a combination of lifestyle changes, relaxation, and medication.

Supporting Research

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Review Date:
12/18/2007
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Parkinson's disease

FitSugar — Wed, 08 Oct 2008 17:35:13 -0700

In This Report

Highlights
Introduction
Symptoms
Risk Factors
Complications
Diagnosis
Treatment
Levadopa (L-dopa)
Other Medications
Surgery
Lifestyle Changes
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approvals

In 2007, the FDA approved the first skin patch drug for treatment of Parkinson’s disease. Transdermal rotigotine (Neupro) is a dopamine agonist drug that may help improve symptoms of early-stage Parkinson’s disease. The patch is applied daily.
Rivastigimine (Exelon), an Alzheimer’s disease drug, was approved in 2006 for treatment of mild-to-moderate dementia associated with Parkinson’s disease.

Drug Withdrawal

In 2007, the FDA withdrew the dopamine agonist pergolide (Permax) from the market due to safety concerns. Several articles published in 2007 in the New England Journal of Medicine indicated that pergolide and a similar drug, cabergoline (Dostinex), are associated with heart valve problems. Cabergoline is not approved in the U.S. for treatment of Parkinson’s disease.

Dietary Supplements

In 2007, the U.S. National Institutes of Health launched a large-scale clinical trial to study whether creatine may help slow the progression of Parkinson’s disease. Creatine is a nutritional supplement that is sometimes used to enhance exercise performance.
Coenzyme Q10, an antioxidant dietary supplement, does not help improve Parkinson’s disease symptoms, according to a study published in 2007 in the Archives of Neurology.

Deep-Brain Stimulation

Deep-brain stimulation outperformed drug therapy in a randomized trial comparing these two treatment approaches. In a study published in 2006 in the New England Journal of Medicine, patients who received deep-brain stimulation had better symptom and quality of life improvement than those who were treated with only medications. However, more serious side effects were reported in the deep-brain stimulation group. Deep-brain stimulation is a surgical technique that involves implanting electrodes in a target area of the brain.

Introduction

Parkinson's disease (PD) is a slowly progressive disorder that affects movement, muscle control, and balance. Parkinson's disease is referred to as idiopathic, which means that the cause is unknown. This term distinguishes the primary disease from parkinsonism, which are the symptoms occurring from a known cause. In addition to its effects on motor control, Parkinson's disease is now recognized as a broader condition that can include cognitive and behavioral disturbances, sleep disorders, speech difficulties, and other problems.

Parkinson's disease occurs from the following process in the brain:

PD develops as cells are destroyed in certain parts of the brain stem, particularly the crescent-shaped cell mass known as the substantia nigra.

Parkinson's disease is a slowly progressive disorder that affects movement, muscle control, and balance. Part of the disease process develops as cells are destroyed in certain parts of the brain stem, particularly the crescent-shaped cell mass known as the substantia nigra. Nerve cells in the substantia nigra send out fibers to tissue located in both sides of the brain. There the cells release essential neurotransmitters that help control movement and coordination.

Nerve cells in the substantia nigra send out fibers to the corpus stratia, gray and white bands of tissue located in both sides of the brain.
There the cells release dopamine, an essential neurotransmitter (a chemical messenger in the brain). Loss of dopamine in the corpus stratia is the primary defect in Parkinson's disease.

Dopamine. Dopamine deficiency is the hallmark feature in PD. It is one of three major neurotransmitters known as catecholamines, which help the body respond to stress and prepare it for the fight-or-flight response. Loss of dopamine negatively affects the nerves and muscles controlling movement and coordination, resulting in the major symptoms characteristic of Parkinson's disease. Dopamine also appears to be important for efficient information processing, and deficiencies may also be responsible for problems in memory and concentration that occur in many patients.

Although it is clear that dopamine deficiency is the primary defect in Parkinson's disease, it is not clear what causes dopamine loss. The culprit is less likely to be a single cause than a combination of genetic and biologic factors, which are triggered by some environmental assault.

Other Changes. The PD disease process also appears to impair nerve endings in the heart to cause dysautonomia-- changes in the autonomic (also called sympathetic) nervous system. Such changes may impair the release of norepinephrine, a hormone that regulates blood pressure, pulse rate, perspiration, and other automatic responses to stress. Evidence suggests this may be responsible for the abrupt drops in blood pressure when standing that occur in PD. Further research is underway to determine if the loss of nerve terminals is confined to the heart or if it affects other organs as well.

Click the icon to see an animation about Parkinson's disease.

Apoptosis and Alpha Synuclein. Important research now suggests that three molecules are critical in the development of inherited PD: alpha synuclein, parkin, and ubiquitin, which all interact in the normal brain. Abnormally high levels of alpha synuclein, which is produced in dopamine-rich nerve cells, may play a central role. Normally, two other molecules, parkin and ubiquitin, are involved in the natural self-destruction of synuclein -- a natural process of programmed cell death called apoptosis. If this process goes awry, for instance, with a defective parkin gene, cell death fails to occur. If synuclein is not eliminated in these cells, it builds up and becomes toxic to dopamine. In such cases, synuclein accumulates in Lewy bodies, the deposits of fibrous tissue found in all patients with PD.

Another protein, beta amyloid, also increases the build-up of synuclein. Beta amyloid is a known factor in Alzheimer's disease, and may help explain the co-existence between Alzheimer's and Parkinson's disease in many patients.

Lewy Bodies. The fibrous deposits known as Lewy bodies are the hallmark signs of Parkinson's disease. They are found in the substantia nigra, the place in the brain where dopamine is first released. It is not clear whether Lewy bodies are the major killers of the nerve cells or whether they are simply a byproduct of the degenerative process. They are found not only in the brains of patients with Parkinson's disease but, in rare cases, may show up in cells in other parts of the body (the heart, intestine), causing severe disabling symptoms. These substances are also present in other diseases that cause dementia, such as Alzheimer's, and can occur in people without neurologic symptoms.

The Mitochondria and Oxygen-Free Radicals. Some research has observed that certain patients with PD have significantly low levels of complex I, an enzyme found in the mitochondria, sausage-like structures that are the primary source of energy within cells. Some theories suggest that low amounts of complex I may make nerve cells vulnerable to the assault of oxygen free radicals (also called oxidants). Oxidants are unstable molecules that bind to other molecules in the body. They are normally produced by the natural chemical processes in the body. If the body is subjected to environmental stresses, however, they can be over-produced. In excess, they can damage any cell, including nerve cells in the brain, and even interfere with their DNA.

NMDA Receptors. Also of interest in PD are processes that occur in an area of the brain called the subthalamic nucleus. Here, receptors known as glutamatergic N-methyl-D-aspartate (NMDA) become persistently overexcited and produce high levels of calcium ions within brain cells. This in turn leads to a cascade of events that trigger oxygen-free radicals and cell damage.

Immune Factors and the Inflammatory Response. An over-responsive immune system triggered by initial damage may also play a role in perpetuating Parkinson's disease. When the immune system becomes overactive, it produces excessive numbers of potent factors called cytokines, which cause inflammation and further injury in brain cells. Important cytokines under investigation are interleukin-1 and tumor necrosis factor.

Specific genetic factors appear to play a strong role in early-onset Parkinson's disease, an uncommon form of the disease. Research from the last several years suggests that multiple genetic factors may also be involved in late-onset Parkinson’s disease. Several important studies, published in 2005, lay the groundwork for potential genetic screening for this disease. Researchers identified the leukine-rich repeat kinase 2 (LRRK2) gene, located on a region of chromosome 12 known as PARK8, as a key gene involved in inherited forms of Parkinson’s. The researchers estimate that a single gene mutation in LRRK2 may be responsible for 5% of inherited Parkinson’s cases and about 2% of isolated cases.

Early Onset PD. The cases of genetic early-onset Parkinson's disease have most often been detected in specific family groups.

Defective genes that regulate the molecules alpha synuclein and parkin, which are important in the PD disease process, may be responsible for a number of early-onset cases. For example, genetic abnormalities the alpha synuclein protein have been detected in some early-onset Parkinson's patients of European descent.
The parkin gene may be the cause of many cases of early-onset Parkinson's in young adults. (Parkinson's cases associated with this mutation tend to progress slowly and respond well to treatment, even after years of symptoms. Dementia is also rare with this form.)

Late Onset PD. Two landmark studies published in the Journal of the American Medical Association provided the first evidence of a genetic link to late-onset Parkinson’s disease. In these 2001 studies, researchers found that regions on chromosomes 5, 6, 8, 9, and 17 were implicated with Parkinson’s. The parkin gene (located on chromosome 6) and the tau gene (located on chromosome 17) were both found in families that had late onset Parkinson’s. Parkin was previously thought to be responsible only for early-onset Parkinson’s, but this research identified it in families that had both early- and late-onset disease forms. These studies also bolstered the theory that Parkinson’s does have a genetic component and is not caused solely by environmental factors. A 2005 study found that a G2019S mutation in the LRRK gene, located on the PARK8 region of chromosome 12, was definitively associated with late-onset Parkinson’s disease in North American and European families.

Environmental toxins, infections, and other triggers can provoke excessive production in the body of oxygen free-radicals, damaging particles that may play a major role in the deterioration of nerve cells that lead to Parkinson's.

Infectious Organisms. Some research has identified immune factors that suggest a viral presence in the Lewy bodies and swollen nerve pathways of Parkinson's brains. Influenza and other potent viruses have long been known to be a cause of parkinsonism. In one well-known example, a major flu epidemic causing encephalitis in the early twentieth century left many of its victims with parkinsonism.

Environmental and Industrial Chemicals. Intense exposure to certain environmental and industrial chemicals is also being studied.

Pesticides and Herbicides. Some evidence implicates pesticides and herbicides as important factors in many cases of Parkinson's disease. A higher incidence of parkinsonism has long been noted in people who live in rural areas, particularly those who drink private well water or are agricultural workers. A large 2000 study found a strong link between high exposure to insecticides and herbicides at home and a 50 - 70% increase in risk of Parkinson's.
Other Chemicals. Intense exposure to other industrial chemicals and metals (manganese, copper, lead, iron, mercury, zinc, aluminum, and others) has also been linked with parkinsonism, a cause that is often reversible. The role of long-term exposure in the development of Parkinson's disease is unclear. High levels of iron content observed in critical parts of the brain in PD are under particular scrutiny.

Most, but not all, Parkinson's victims are elderly. Some studies indicate that the very elderly are not susceptible to the disease, indicating that the aging process itself is not the major player in the disease. Aging does appear to reduce the concentration of dopamine in structures called dopamine transporters, which carry the neurotransmitter back and forth between nerve cells. Some researchers posit that any excessive stress on these transporters might trigger Parkinson's disease in the aging, and more vulnerable, brain.

Symptoms

Parkinson's disease (PD) symptoms often start with tremor, which may occur in the following ways:

Tremors may first be only occasional, starting in one finger and spreading over time to involve the whole arm. The tremor is often rhythmic, 4 - 5 cycles per second, and frequently causes an action of the thumb and fingers known as pill rolling.
Tremors can occur when the limb is at rest or when it is held up in a stiff unsupported position. They usually disappear briefly during movement and do not occur during sleep.
Tremors can also eventually occur in the head, lips, tongue, and feet. Symptoms can occur on one or both sides of the body. In one study, 44% of patients reported experiencing internal tremors lasting less than half an hour, but occurring several times a week.

In younger patients tremor is usually predominant and often suggests a less aggressive form of the disease. Some evidence suggests that tremor in PD may occur from mechanisms in the brain that are different from those that cause other PD symptoms.

A number of PD symptoms involve motor impairment caused by the abnormalities in the brain that regulate movement:

Slowness of motion (bradykinesia) is one of the classic symptoms of Parkinson's disease. Patients may eventually develop a stooped posture and a slow, shuffling walk. The gait can be erratic and unsteady. After a number of years, muscles may freeze up or stall, usually when a patient is making a turn or passing through narrow spaces, such as a doorway.
Intestinal motility (the ability to swallow, digest, and eliminate) may slow down, causing eating problems and constipation.
Muscles may become rigid (akinesia). This symptom often begins in the legs and neck. Muscle rigidity in the face can produce a mask-like, staring appearance.
Motor abnormalities that limit action in the hand may develop in late stages. Handwriting, for instance, often becomes diminutive.
Normally spontaneous muscle movements, such as blinking, may need to be done consciously.

The traditional view of Parkinson's disease is shifting to reflect growing awareness that it is much more than a motor disease. Many non-motor components and their treatments are now under study. The following symptoms should be carefully monitored by doctors and caregivers:

Depression is the most common psychiatric problem associated with PD, affecting about 40% of patients. Because depression is a common problem in older people, it is likely not to be recognized as a symptom.
Anxiety affects about 30% of patients.
Dementia and paranoia are more common than previously understood.
Orthostatic hypotension -- some patients experience a sudden drop in blood pressure when they stand. This can cause dizziness and fainting.
Changes in sensations of temperature, hot flashes, and excessive sweating.
Daytime sleepiness and other sleep disorders are common.

Risk Factors

Parkinson's disease affects about 3% of Americans over 65 years old. Experts estimate that this percentage could double in the next 30 - 40 years. The symptoms of parkinsonism (tremor, gait disturbance, bradykinesia, and rigidity) occur in even more people, estimated to be 8 million over age 65. In a study that included very mild symptoms, parkinsonism occurred in about 15% of people 65 - 74 years of age, about 30% in those 75 - 84, and over half of people older than age 85.

The average age of onset of Parkinson's disease is 55. About 10% of Parkinson's cases are in people younger than 40 years old. Older adults are at higher risk for both parkinsonism and Parkinson's disease. There is some evidence, however, that the risk declines significantly after age 75 and that the very elderly are at low risk.

Some research indicates that men may face up to twice the risk as women. Estrogen may offer some protection for women up until menopause. A 2001 study, for example, reported a higher rate of Parkinson's disease in women who had undergone hysterectomy. Other studies suggest that the disease also progresses more rapidly in men than women. Older women seem to be more at risk for gait disturbance and men for rigidity and tremor.

People with siblings or parents who developed Parkinson's at a younger age are at higher risk for Parkinson's disease, but relatives of those who were elderly when they had the disease appear to have an average risk.

African- and Asian-Americans have a lower risk than Caucasians. Some evidence suggests that non-Caucasians may be more vulnerable to an atypical form of PD, which causes early impairment in thinking and has a poor response to levodopa, the primary PD treatment.

Increasing weight gain in middle age was associated with a higher risk of PD in a 2002 study.

Complications

Parkinson's disease (PD) is not fatal, but it can reduce longevity. The disease progresses more quickly in older than younger patients, and may lead to severe incapacity within 10 - 20 years. Older patients also tend to experience freezing and greater declines in mental function and daily functioning than younger people. If PD starts without signs of tremor, it is likely to be more severe than if tremor had been present. Having other family members with PD does not appear to have any effect on the severity of the disease.

Parkinson's disease can seriously impair the quality of life in any age group. The physical and emotional impact on the family should not be underestimated as the patient becomes increasingly dependent on their support.

Treatment advances are increasingly effective in alleviating symptoms and even slowing progression of the disease. Taking many of the medications over time, however, can produce significant side effects. Newer drugs may help reduce these occurrences.

The negative effect of overall motor and muscle impairment on daily life can be considerable. Some motor complications can be life-threatening.

Disturbed gait and unstable posture are common and serious problems in elderly patients, since they increase the risk for falling and injury. Some studies have suggested that the appearance of these symptoms early in the course of the disease predict a faster decline than having tremor as the predominant symptom.
Swallowing problems (dysphagia). The presence of dysphagia is associated with shorter survival time. Motor impairment of the muscles in the throat not only impairs swallowing but it also poses a risk for aspiration pneumonia.
Constipation is a major problem and occurs both as a result of the disease and a side effect of its treatment. Laxatives, stool softeners, and other medications may be prescribed.
Bladder control and urinary incontinence are also important complications of PD.
Speech problems occur in more than 70% of patients, by some estimates. Speech difficulty can be caused by rigidity of the facial muscles, loss of motor control, and impaired breath control. Tone can become monotonous, words may be repeated over and over, or the rate of speech may even be very fast.

Depression is extremely common, affecting up to 40% of patients with Parkinson's. PD poses multiple threats on the emotional health:

The disease process itself causes changes in chemicals in the brain that affect mood and well-being.
The complications of its symptoms have a profound impact on daily life that can be emotionally devastating without help and support.
Some drug treatments (levodopa combined with a dopamine agonist) can cause compulsive behavior, such as gambling, shopping, and increased sexuality. Patients who have pre-existing tendencies to novelty-seeking behavior, or a family or personal history of alcohol abuse, may be more likely to develop compulsive gambling. Deep brain stimulus (DBS) surgery may also increase the risk for compulsive gambling in patients who have a history of gambling.

Impaired Thinking (Cognitive Impairment). Defects in thinking, memory, language, and problem solving skills may occur early on in untreated patients or late in the course of the disease. Medications may play a role in thinking problems. In one study, for example, patients with PD were slower in detecting associations, although (unlike in Alzheimer's disease) once they discovered them they were able to apply this knowledge to other concepts. After they were taken off medication, however, they had no problems with the tasks.

Dementia. Dementia is three to six times more common in the elderly Parkinson patient than in the average older adult. It is most likely to occur in older patients who have had major depression. PD marked by muscle rigidity (akinesia), rather than tremor, and early hallucinations also increase the risk for dementia. (Visual hallucinations can also occur in about a third of patients from PD medication.) Unlike in Alzheimer's, language is not usually affected in Parkinson's related dementia.

A number of other problems associated with Parkinson's disease affect daily life:

Vision Problems. Vision is also affected, including impaired color perception and contrast sensitivity. These problems progress and can impair motor functioning.

Sleep Disorders. Excessive daytime sleepiness and other sleep disorders are common in PD, both from the disease itself and from the drugs that treat it. In general, patients have a 25% higher risk for daytime sleepiness, including suddenly falling asleep, than patients with other neurologic diseases.

Restless legs syndrome, an irresistible urge to move the calves, which often occurs at night, affects many patients. However, Parkinson's disease itself does not seem to increase the risk for RLS. Nor does RLS early in life predispose to Parkinson's later on. The common connection between RLS and Parkinson's disease may derive from iron deficiencies that can play a role in both conditions.

Many patients also suffer from nighttime leg cramps. And, some of the medications cause vivid dreams as well as waking hallucinations.

Impaired Sexuality. Although Parkinson's disease and its treatments can cause compulsive sexual behavior, the disease can also affect patients' self-esteem and inhibit sexuality. This is an area not often studied but which is important for many patients' well-being. A 2000 study reported that not only did sexual dysfunction occur, but also affectionate touching and expression of feelings were reduced, even though both partners maintained a desire for intimacy.

Worsened Sense of Smell. The sense of smell is impaired in about 70% of patients.

Osteoporosis. Parkinson’s disease may increase the risk for low bone density and osteoporosis. Both men and women are at risk. Experts recommend that patients with Parkinson’s disease get tested for osteoporosis, especially if they have problems with walking.

Diagnosis

It is difficult to diagnose Parkinson's in early stages. The disease is primarily diagnosed by its symptoms, and studies indicate that doctors make an incorrect initial diagnosis of Parkinson's disease in 8 - 35% of cases. Even neurologists have difficulties in correctly identifying the disease.

A medical and personal history should include any relevant symptoms as well as any medications taken, and information on exposure to environmental toxins.

Early Symptoms. Early treatment may help slow progression, so an early diagnosis of Parkinson's is highly desirable. Early symptoms are often mild, however, so Parkinson's disease can be missed, particularly in young adults. Repeated assessment of symptoms over time is important for improving the accuracy of diagnosis. Too often a younger person with Parkinson's may be diagnosed with mental illness, because the doctor associates the disease only with older people.

Parkinson's may be suspected in patients with the following symptoms:

Slowness and difficulty of movement. These are usually the first symptoms. The patient will be asked to walk and to get out of a chair, preferably a deep one. Early gait disturbance, however, often indicates a disease other than Parkinson's disease.
A tremor when their limb is relaxed. (As many as 25% of patients, however, will not have a tremor.)
Symptoms on one side of the body.

Later Symptoms. In later stages of Parkinson's disease, the symptoms are usually unmistakable, and the problem can often be diagnosed using simple physical tests and a medical and personal history.

The loss of smell is associated with loss of dopamine receptors in the brain. “Scratch and sniff” smell tests can help a doctor diagnose Parkinson’s disease. Smell tests can help differentiate Parkinson’s disease from other conditions with similar symptoms. Some patients with a very similar condition called multiple system atrophy will have a good initial response to levodopa, but it is not usually sustained.

Levodopa and apomorphine can confirm a diagnosis of Parkinson’s disease. If patients’ symptoms improve when they take these drugs, they likely have Parkinson’s, ruling out other neurological diseases.

According to 2006 guidelines from the American Academy of Neurology, there is not enough evidence to recommend for or against the use of imaging techniques such as computerized tomography (CT), magnetic resonance imaging (MRI), or positron-emission tomographic (PET) to diagnose PD.

When symptoms resemble Parkinson's disease but have an identifiable cause, the syndrome is known as parkinsonism. People who have parkinsonism, but not Parkinson's disease, often have additional neurologic symptoms. A number of conditions can also have similar or some of these symptoms.

Other Neurologic Conditions. Many medical conditions may cause symptoms of Parkinson's disease:

Hardening of the arteries (arteriosclerosis) in the brain can cause multiple small strokes, which can produce loss of motor control.

Click the icon to see an image of plaque in an artery.

Alzheimer's disease can be very similar. In one study 23% of people with Alzheimer's also met the criteria for Parkinson's disease. The two diseases often coexist, and research suggests that Alzheimer's and Parkinson's disease may sometimes share a common biologic origin, the accumulation of the protein alpha synuclein and Lewy bodies in the brain.
Lewy bodies variant (LBV), also called dementia with Lewy bodies, is a separate disease from both Alzheimer's and Parkinson's disease. It has similar symptoms to both but is marked by early dementia.
Encephalitis caused by influenza has been known to cause parkinsonism.
Primary progressive freezing gait is a progression condition, in which freezing gait occurs at the onset. Other Parkinson-like features, such as slow movement, often develop. Although very similar to PD, this condition does not respond to L-dopa or other PD medications.
Essential tremor, unlike the tremor of Parkinson's disease, often occurs in the head and voice and is usually worse during motion, as opposed to rest.
Progressive supranuclear palsy has similar symptoms, but involves less tremor and earlier rigidity, and it tends to affect both sides of the body symmetrically. Magnetic resonance imaging scans that measure parts of the midbrain may be a reliable method for distinguishing between PD and progressive supranuclear palsy.
Multiple system atrophy (previously called Shy-Drager syndrome) is a degenerative nerve disease that also affects movement and blood pressure and has many of the symptoms of Parkinson's disease. Some research suggests that a trial using the drug apomorphine may help differentiate between the two.
Other problems that may mimic Parkinson's disease include Wilson's disease, thyroid abnormalities, hydrocephalus, tumors, having the fragile X trait (but not the full disorder), and a number of degenerative neurologic diseases.

Drugs. Certain drugs or medications account for about 4% of all cases of parkinsonism. According to some studies, patients who experience drug-induced parkinsonism may actually be at an increased risk of developing Parkinson's disease later in life. A number of drugs can cause these symptoms, including antipsychotic and antiseizure drugs. Anyone with parkinsonism should discuss their medications with their doctor.

The American Academy of Neurology (AAN) recommends the Beck Depression Inventory or the Hamilton Depression Rating Scale to screen for depression in patients with Parkinson’s disease. The AAN recommends the MMSE and CAMCOG tests to screen for dementia. During these tests, the patient answers a series of questions.

Treatment

Drugs, physical therapy, and surgical interventions can manage Parkinson's disease. The goals of treatment for Parkinson's disease are to:

Relieve disabilities
Balance the problems of the disease with the side effects of the medications

Treatment is very individualized for this complicated disease. Patients must work closely with doctors and therapists throughout the course of the disease to customize a program suitable for their particular and changing needs. Patients should never change their medications without consulting their doctor, and they should never stop taking their medications abruptly.

The American Academy of Neurology recommends the following therapies for the initial treatment of Parkinson’s disease:

Levodopa (L-dopa). Levodopa, or L-dopa, has been used for years and is the gold standard for treating Parkinson's disease. The drug increases brain levels of dopamine. It is used in nearly all phases of the disease. The standard preparations (Sinemet, Atamet) combine levodopa with carbidopa, a drug that slows the breakdown of levodopa. Levodopa is better at improving motor problems than dopamine agonists but increases the risk of involuntary movements (dyskinesia).

Dopamine Agonists. Dopamine agonist drugs mimic dopamine to stimulate the dopamine system in the brain. These drugs include pramipexole (Mirapex), ropinirole (Requip), bromocriptine (Parlodel), and rotigotine (Neupro). The Food and Drug Administration (FDA) pulled the dopamine agonist pergolide (Permax) from the market in March 2007 over safety concerns that included potentially fatal heart valve damage.

Selegiline (Eldepryl) and rasagiline (Azilect). Selegiline is a monoamine oxidase B (MAO-B) inhibitor that may have some mild benefit as an initial therapy. However, unlike levodopa, it does not slow the progression of Parkinson’s disease. Another MAO-B inhibitor, rasagiline (Azilect), was approved in May 2006. Unlike selegiline, which needs to be taken by mouth twice a day, rasagiline needs to be taken only once a day.

Drug treatments for Parkinson disease do not consistently control symptoms. At certain points during the day, the beneficial effects of drugs wear off, and patients can experience a return of symptoms, such as uncontrolled muscular motor function, difficulty walking, and loss of energy. In 2006, the American Academy of Neurology (AAN) reviewed evidence for the various drugs used to treat “off time.” The AAN found that the following drugs had the strongest evidence for controlling off time symptoms:

Entacapone (Comtan) belongs to a class of drugs called catechol-o-methyl transferase (COMT) inhibitors. COMT inhibitors help prolong the effects of levodopa by blocking an enzyme that breaks down dopamine.
Rasagiline (Azilect) belongs to a class of drugs called monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa.

The AAN also found good evidence for the dopamine agonists ropinirole (Requip) and pramipexole (Mirapex), and the COMT inhibitor tolcapone (Tasmar). Deep brain stimulation is a surgical treatment that may help improve motor fluctuations in some patients.

Both Levodopa and dopamine agonists can cause involuntary movements (dyskinesia). The AAN has not found any strong evidence to recommend any drug for treating dyskinesia. However, weak evidence suggests that the antiviral drug amantadine (Symmetrel) may help reduce stiffness and improve dyskinesia. There is also weak evidence that deep brain stimulation of the subthalamus area may be helpful.

Conditions associated with motor impairment and other symptoms of Parkinson's disease may require a variety of treatments.

Depression. Although depression is very common in PD, there have been surprisingly few controlled studies. Antidepressants used for PD include tricyclics, particularly amitriptyline (Elavil). Some studies have found that selective serotonin-reuptake inhibitors (SSRIs) -- which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) -- may worsen symptoms of Parkinson's. Doctors should monitor patients taking SSRIs.

Psychotic Side Effects. Studies indicate that clozapine (Clozaril) and quetiapine (Seroquel), antipsychotic drugs used to treat schizophrenia, may be the best drugs for treating psychosis in patients with Parkinson's disease. A similar drug, olanzapine (Zyprexa), should not be used for patients with PD because it can worsen their psychotic symptoms.

Dementia. The cholinesterase inhibitor drugs donepezil (Aricept) and rivastigmine (Exelon) are used to treat Alzheimer’s disease. Studies suggest that these drugs may also help treat dementia associated with Parkinson’s disease. In 2006, rivastigimine was approved for treatment of mild-to-moderate dementia associated with Parkinson’s disease.

Daytime Sleepiness. Modafinil (Provigil), a drug used to treat narcolepsy, is proving to be very helpful for patients with sleepiness related to their disease.

Drooling. In search of a simple solution for the problem of drooling, scientists have reported that injections of very small amounts of botulinum toxin effectively reduce saliva production and drooling. In such small amounts the toxin is safe.

Voice Loss. A relatively simple procedure using collagen injections in the neck appears to be a safe and effective method of improving the voice and speech disorders caused by PD. The procedure augments the collagen in the vocal fold and works best in patients who can still initiate speech. A 2001 study reported improvements that lasted from 2 - 7 months in 61% of patients.

Erectile Dysfunction. Sildenafil (Viagra) is proving to be very helpful for men who suffer from impotence from Parkinson's disease. However, the drug may worsen orthostatic hypotension, a side effect of some PD medications.

Eventually, symptoms such as stooped posture, freezing, and speech difficulties may not respond to drug treatment. (Total unresponsiveness is unlikely, however, even after 20 years of treatment.) The following approaches may be tried:

Simply increasing the dose of levodopa or its frequency raises an unacceptable risk of the distressing side effects. Some doctors have tried hospitalizing patients, totally withdrawing the levodopa, and then re-administering it. Benefits were seen for only a few months, however, and there were some dangerous risks to the process of withdrawal, including pneumonia and blood clots in the lungs.

An embolus is a blockage of an artery in the lungs by fat, air, tumor tissue, or blood clot.

Surgical treatments, including deep brain stimulation and pallidotomy, may help some patients.
Research is ongoing to develop drugs and procedures that will manage advanced disease and possibly even reverse the process.

Levadopa (L-dopa)

Levodopa, also called L-dopa, which is converted to dopamine in the brain, remains the gold standard for treating Parkinson's disease. The standard preparations (Sinemet, Atamet) combine levodopa with carbidopa, which improves the action of levodopa and reduces some of its side effects, particularly nausea. Levodopa can also be combined with benserazide (Madopar) with similar results, but Sinemet is almost always used in America. Dosages vary, although the preparation is usually taken in three or four divided doses per day. In 2004, the FDA approved a new oral form of carbidopa-levodopa (Parcopa) that dissolves on the tongue.

In general L-dopa has the following effects on Parkinson's disease:

It is most effective against rigidity and slowness.
It produces less benefit for tremor, balance, and gait.

In many patients, levodopa significantly improves the quality of life for many years. If symptoms do not improve after 2 - 3 months, one of the following reasons may account for the failure:

Other neurologic problems may be causing the symptoms.
Some patients have abnormalities in other brain sites that do not respond to L-dopa.
Sometimes patients are so depressed they cannot tell if the drug is beneficial or not. Only a series of physical examinations by the doctor will indicate that the drug is actually helping.

Studies suggest that levodopa may help slow disease progression and protect against brain cell degeneration.

The toxic effects of levodopa with or without carbidopa are considerable.

Physical Side Effects. The physical side effects are as follows:

Low blood pressure. Low blood pressure is a common problem during the first few weeks, particularly if the initial dose is too high. The addition of extra supplements of carbidopa reduces this effect to some degree. The patient should drink lots of fluids and possibly increase salt intake to maintain normal blood pressure.
Arrhythmia. In some cases the drug may cause abnormal heart rhythms.
Gastrointestinal effects. Stomach and intestinal side effects are common even with carbidopa. Taking the drug with food can alleviate the nausea. However, proteins interfere with intestinal absorption of levodopa, and some doctors recommend not eating any protein until nighttime in order to avoid this interference. The drug can also cause gastrointestinal bleeding.
Effects in the lung. Levodopa can cause disturbances in breathing function, although it may benefit patients who have upper airway obstruction.
Hair loss.

Psychiatric and Mental Side Effects. The major adverse effects of the drug are psychiatric. Patients taking levodopa, especially in combination with other drugs, can experience:

Confusion.
Extreme emotional states, particularly anxiety.
Vivid dreams.
Visual and possibly auditory hallucinations. The drug may even unmask dementia that had not been previously noticed.
Effects on learning. L-dopa appears to have mixed effects on learning. It may improve working memory. However, some evidence suggests that it impairs areas of the brain related to other learning functions and social behavior.
Sleepiness and sleep attacks.

Levodopa causes fewer psychiatric side effects than other drugs used for Parkinson's disease, including anticholinergics, selegiline, amantadine, and dopamine agonists. Because psychiatric side effects often occur at night, if they are severe some doctors recommend reducing or stopping the evening dose.

Within 4 - 6 years of treatment with levodopa, the effects of the drug in many patients begin to last for shorter periods of time (called the wearing-off effect) and the following pattern may occur:

Patients may first notice slowness (bradykinesia) or tremor in the morning before the next dose is due.
Less commonly, some experience painful dystonia, muscle spasms that can cause sustained contortions of various parts of the body, particularly the neck, jaw, trunk, and eyes and possibly the feet.
Patients must increase the frequency of levodopa doses. This puts them at risk for dyskinesia (the inability to control muscles), which usually occurs when the drug level peaks. Dyskinesia can take many forms, most often uncontrolled flailing of the arms and legs or chorea, rapid and repetitive motions that can affect the limbs, face, tongue, mouth, and neck. Dyskinesia is not painful, but it is very distressing.
In some people, eventually L-dopa is effective only for 1 - 2 hours and most patients start to experience motor fluctuations. In about 15 - 20% of patients such fluctuations become extreme, a phenomenon known as the on-off effect, which consists of unpredictable, alternating periods of dyskinesia and immobility. Sometimes the symptoms switch back in forth within minutes or even seconds. (The transition may follow such symptoms as intense anxiety, sweating, and rapid heartbeats.)

Reasons for the Wearing-Off Effect. Debate is ongoing about the cause of the wearing-off effect and dyskinesia. Some theories suggested for these effects are:

The disease progresses beyond the ability of levodopa to control it.
Some patients become tolerant to prolonged exposure to dopamine and, at the same time, the disease is progressing.
The brain's own dopamine neurons become incapable of storing dopamine. When the levodopa wears off, little or no natural dopamine remains.
Levodopa itself accelerates the disease by producing oxygen free radicals, unstable particles that increase injuries to the brain and dopamine degradation.

Preventing the Wearing-Off Effect. To reduce the effects of fluctuation and the wearing-off effect, it is important to maintain as consistent a level of dopamine as possible. Unfortunately, levodopa is poorly absorbed and may remain in the stomach a long time. A number of strategies are being developed to take care of these problems:

Some patients take multiple small doses on an empty stomach, crushing the pills and mixing them with a lot of liquid.
A liquid form of Sinemet may produce fewer fluctuations and a prolonged "on" time compared with the tablet.
A prolonged release version of levodopa and carbidopa (Sinemet CR) is also available to control fluctuations for some people. (Some evidence suggests that there is no actual difference in symptom control between the sustained and immediate release forms, but patients on Sinemet CR tend to experience a better quality of life.)

Other Medications

Selegiline (Eldepryl, Movergan, Zelepar), also known as deprenyl, is an antioxidant drug that blocks monoamine oxidase B (MAO-B), an enzyme that degrades dopamine. Until recently, selegiline was the drug most commonly used in early-onset disease and in combination with levodopa for maintenance. A major 2002 study reported, however, that although selegiline delays the need for L-dopa by a few months, it has no effect on long-term progression.

Rasagiline (Azilect), another MAO-B inhibitor, was approved in May 2006 for the initial treatment of Parkinson’s disease. It is used alone during early-stage PD and in combination with L-dopa for moderate-to-advanced PD. Unlike selegiline, which is taken twice a day, rasagiline is taken once a day.

Other Adverse Effects. MAO-B inhibitors may have severe side effects:

One of the most important side effects is orthostatic hypotension, particularly in people taking Sinemet plus selegiline. This condition is a sudden drop in blood pressure that causes dizziness and lightheadedness when a patient stands up. Orthostatic hypotension can also occur with other Parkinson's drugs.
Can cause high blood pressure (hypertension) if combined with drugs that increase serotonin levels -- such drugs include nearly every major antidepressant. Patients suffering from depression and taking selegiline should discuss all treatment options with their doctor.
Can also cause a dangerous increase in blood pressure if patients eat foods rich in the amino acid tyramine. Patients should avoid the following foods while taking selegiline or rasagiline and for 2 weeks after stopping medication: aged cheeses, air-dried meats, pickled herring, yeast extract, aged red wines, draft beers, sauerkraut, and soy sauce

Debate over Mortality Rates. Some major studies have reported higher mortality rates in patients with advanced PD. Such findings may be due to adverse effects on the heart and blood vessels. Although other studies have not reported lower survival rates, some experts believe that, given its modest effects, selegiline may be a poorer drug choice than others, particularly in patients with risk factors for heart disease.

Dopamine agonists stimulate dopamine receptors in the substantia nigra, the part of the brain in which Parkinson's is thought to originate. Dopamine agonists are effective in delaying motor complications during the first 1 or 2 years of treatment.

Newer Dopamine Agonists. The most commonly prescribed dopamine agonists are pramipexole (Mirapex) and ropinirole (Requip). They are used either alone or in combination with L-dopa. Pramipexole appears to work better and have fewer side effects than ropinirole.

Studies still report, however, that L-dopa is superior for improving motor function. In one study, motor function was no different in disease progression among all of the drugs by the third year of treatment. Recent research suggests that L-dopa is better at improving motor disability and dopamine agonists are better at reducing motor complications. L-dopa has a higher risk for dyskinesia side effects than dopamine agonists, but dyskinesia can also occur with dopamine agonists.

Side Effects. Side effects of pramipexole and ropinirole vary but can be severe and include:

Gastrointestinal side effects (nausea and constipation). Nausea can be controlled by drugs, such as domperidone.
Headache
Orthostatic hypotension (sudden drop in blood pressure upon standing up)
Nasal congestion
Nightmares, hallucinations, and psychosis (more severe than with L-dopa for both drugs)
Sudden sleep attacks. These can be very serious, particularly if patients are driving. (Sleep attacks may occur -- although less commonly -- with other PD drugs.)

Other Dopamine Agonists.

Specific dopamine agonists that contain ergot alkaloids include bromocriptine (Parodel), pergolide (Permax), cabergoline (Dostinex), and lisuride (Dopergin). As of 2007, bromocriptine is the only ergot dopamine agonist approved for Parkinson’s treatment in the United States. In January 2007, the New England Journal of Medicine (NEJM) published two studies indicating that pergolide and cabergoline are associated with heart valve damage. In March 2007, due to these safety concerns, the FDA withdrew pergolide from the U.S. market. Cabergoline and lisuride are not approved in the U.S. for Parkinson’s disease treatment but are used for this purpose in other countries. The NEJM studies did not find any heart valve problems associated with bromocriptine or lisuride.
Rotigotine transdermal (Neupro) is a dopamine agonist that is delivered through a skin patch that is changed daily. In 2007, the FDA approved rotigotine transdermal for treatment of symptoms of early Parkinson’s disease. It is the first skin patch approved for Parkinson’s disease. Side effects are similar to those of other dopamine agonists.
Apomorphine is a dopamine agonist used as a "rescue" drug in people experiencing on-off effects severe enough to require going off L-dopa for a few days. In 2004, the FDA approved apomorphine for treating off-time episodes of Parkinson’s disease. Apomorphine is given by injection. Because it causes severe nausea and vomiting, it must be taken with an anti-nausea drug.

Catechol-O-methyl transferase (COMT) inhibitors increase concentrations of existing dopamine in the brain. Entacapone (Comtan, Stalevo) is the current standard COMT inhibitor. (Stalevo combines entacapone and levodopa into a single pill.) It improves motor fluctuations related to the wearing-off effect and has shown good results in improving on time and reducing the requirements for L-dopa. If the patient does not respond to the drug within 3 weeks, it should be withdrawn. No one should withdraw abruptly from these drugs.

Side Effects. Side effects include:

Involuntary muscle movements
Mental confusion and hallucinations
Cramps, nausea, and vomiting
Insomnia
Headache
Urine discoloration (a harmless side effect but should be reported to the doctor)
Diarrhea
Less commonly, constipation, susceptibility to respiratory infection, sweating, dry mouth

Of major concern are reports of a few deaths from liver damage in patients taking the COMT inhibitor tolcapone (Tasmar). The drug has been taken off the market in many countries and is recommended in the U.S. only for patients who cannot tolerate another other drugs. Entacapone does not appear to have the same effects on the liver and does not require monitoring. A 2003 3-year study suggested that the drug is safe and effective over the long term. Still, patients should watch out for symptoms of liver damage, including jaundice (yellowish skin), fatigue, and loss of appetite.

Jaundice is a condition produced when excess amounts of bilirubin circulating in the bloodstream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes. With the exception of normal newborn jaundice in the first week of life, all other jaundice indicates overload or damage to the liver, or inability to move bilirubin from the liver through the biliary tract to the gut.

Anticholinergics were the first drugs used for PD, but have largely been replaced by dopamine drugs. They are generally used only against tremor in the early stages. They are not as effective against bradykinesia and posture problems and may increase the risk for dementia in late stages. Among the many anticholinergics are trihexyphenidyl (Artane, Trihexy), benztropine (Cogentin), biperiden (Akineton), procyclidine (Kemadrin), and ethopropazine (Parisdol). Orphenadrine (Norflex) is a drug with anticholinergic properties, but is also a muscle relaxant and does not cause urinary retention.

Side effects of Anticholinergics. Anticholinergics commonly cause dryness of the mouth (which can actually be an advantage in some people who experience drooling). Other side effects are nausea, urinary retention, blurred vision, and constipation. These drugs can also increase heart rate and worsen constipation. Anticholinergics can sometimes cause significant mental problems, including memory loss, confusion, and even hallucinations. People with glaucoma should use these drugs cautiously.

Amantadine (Symadine, Symmetrel) stimulates the release of dopamine and may be used for patients with early mild symptoms. It has some benefit against muscle rigidity and slowness and may help some patients in advanced stages who are unresponsive to other drugs. It is less powerful than levodopa and may lose its effectiveness after 6 months. It may also reduce motor fluctuations brought on by levodopa, however, and these benefits appear to persist for at least a year. Large, well-conducted studies are still needed to determine its true benefits and safety.

Side Effects. Side effects are similar to those of anticholinergic drugs and also may include swollen ankles and mottled skin. It can also cause visual hallucinations. Overdose can cause serious and even life-threatening toxicity. Patients with Parkinson's should not withdraw from this drug abruptly. In rare instances, it can cause acute delirium or a life-threatening condition called neuroleptic malignant syndrome. Pregnant or nursing women should not use this drug.

Anticonvulsants. Zonisamide (Zonegran), a drug used to treat epilepsy, is showing promise in treating tremors, motor problems, and involuntary movements in patients with Parkinson’s disease.

Budipine and Other Glutamate Blockers. A number of experimental drugs are being investigated for Parkinson's disease because they block the actions of glutamate, an amino acid that is a particularly potent nerve cell killer. Some of these drugs block a receptor group to glutamate called N-methyl-D-aspartate (NMDA). Investigational NMDA antagonists include remacemide, memantine, riluzole, and budipine.

Stem Cell Transplantation. Scientists are investigating whether transplanting embryonic stem cells into the brain may help treat Parkinson’s disease. Researchers hope that the transplanted stem cells may be able to stimulate dopamine production. However, stem cell transplantation research is still in its very early stage. It will be many years before clinical trials will be conducted in humans.

Surgery

Surgical procedures are recommended for specific patients with advanced Parkinson’s disease who no longer respond to drug treatments. Surgical treatment cannot cure Parkinson's disease, but it may help control symptoms such as motor fluctuations and dyskinesia. Pallidotomy and thalamotomy are older procedures that destroy tissue in certain parts of the brain. Deep brain stimulation, the current standard surgical practice for Parkinson’s disease, has largely replaced the older operations.

In deep brain stimulation (DBS), also called neurostimulation, an electric pulse generator controls symptoms. The generator is similar to a heart pacemaker. It sends electrical pulses to specific regions of the brain. Candidates for surgery are generally patients who have responded well to levodopa drug treatment. Patients who have had PD for fewer than 16 years may experience greater benefit from DBS than patients who have had the disease longer.

Evidence indicates that DBS improves motor function and reduces dyskinesia best when the procedure targets the subthalamic nucleus (STN) of the brain. Many studies demonstrate the effectiveness of STN stimulation. Procedures that target the globus pallidus interna or ventral intermediate nucleus of the thalamus can also sometimes treat rigidity and tremors. However, there is not yet enough evidence to support stimulation of these parts of the brain.

The procedure is performed as follows:

The surgeon implants a tiny pulse generator near the collarbone, which is connected to four electrodes that have been implanted in the target area in the brain.
The generator delivers programmed pulses to this area, which the patient can turn on and off using a magnet held over the skin.
When on, the pulses suppress symptoms. Complications occur in 2 - 4% of operations. The most serious ones are bleeding in the brain and infection. Depression is common.

In a 2006 study of patients with advanced Parkinson’s disease and severe motor symptoms, patients who received DBS had better improvement in symptoms and quality of life than those who received only drug therapy. However, patients in the neurostimulation group had more serious side effects than those who were treated only with medications. Researchers are also studying whether DBS can benefit patients with earlier-stage Parkinson’s disease.

Pallidotomy and thalamotomy are surgical procedures that destroy brain tissue in regions of the brain associated with Parkinson’s symptoms such as dyskinesia, rigidity, and tremor. In these procedures, a surgeon drills a small hole in the patient’s skull and inserts an electrode to destroy brain tissue. Pallidotomy targets the global pallidus area. Thalamotomy targets the thalamus. Because these procedures permanently eliminate brain tissue, most experts now recommend deep brain stimulation instead of pallidotomy or thalamotomy.

Surgical complications may include behavioral or personality changes, trouble speaking and swallowing, facial paralysis, and vision problems. Weight gain after surgery is also common.

Scientists are investigating whether stem cells may eventually help treat Parkinson disease. Experimental surgery has shown promise using fetal brain cells rich in dopamine implanted in the substantia nigra area of the brain. Because the use of embryonic stem cells is controversial, researchers are studying alternative types of cells, including stem cells from adult brains and cells from human placentas or umbilical cords. Studies are also using gene therapies and other advanced treatments for transplanting dopamine-producing cells or nerve-protecting cells into the brain. All of this research is still in preliminary stages.

Lifestyle Changes

No special diets or natural foods have been shown to slow down the progression of Parkinson's disease, but there are some dietary recommendations.

Protein. High levels of proteins compete with levodopa for transport to the brain and reduce its effectiveness. Avoiding protein altogether is not the solution, since malnutrition can result. Most experts now recommend trying to maintain a carbohydrate-to-protein ratio of 7:1 throughout the day. This may be difficult to calculate and some doctors recommend simply keeping proteins to 12% of total daily calories.

As an aid in calculation, food labels indicate proteins in grams. One gram of protein equals four calories. Good control of protein intake may help minimize fluctuations and wearing-off and may allow some patients to reduce their daily levodopa dosage.

Fruits and Vegetables and Increasing Fiber. Eating whole grains, fresh fruits, and vegetables is the best approach for any healthy life. A diet rich in fruits and vegetables may help protect nerve cell function. Many of these foods are also often rich in fiber, which is particularly important for helping to prevent constipation.

Dietary fiber is the part of food that is not affected by the digestive process in the body. Only a small amount of fiber is metabolized in the stomach and intestine, the rest is passed through the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber, soluble and insoluble. Soluble fiber retains water and turns to gel during digestion. It also slows digestion and nutrient absorption from the stomach and intestine. Soluble fiber is found in foods such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables, and whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight management. One of the best sources of fiber comes from legumes, the group of food containing dried peas and beans.

People whose diets have been low in fiber should increase it gradually. It is best to obtain dietary fiber, soluble or insoluble, in the natural form of whole grains, nuts, legumes, fruits, and vegetables. If it proves difficult to do so, psyllium, a grain naturally found in India, is an excellent soluble fiber supplement (Metamucil, Fiberall, Perdiem Fiber). Fluids are particularly important in preventing constipation.

Fish Oil. Omega-3 fatty acids, which are found in oily fish, are proving to have powerful anti-inflammatory effects and may also be nerve protective.

Click the icon to see an image of foods that contain omega-3 fatty acids.

Dairy Products. A 2002 study reported a higher risk for Parkinson's disease in men (but not in women) who consumed high amounts of dairy products. This association was not linked to fats in dairy foods and high intake of calcium or protein from other sources did not increase the risk. A 2005 prospective study of men found that milk consumption in midlife was associated with increased risk of Parkinson’s disease. As with prior research, the researchers did not find that calcium itself carried a risk. They suggested that some unidentified neurotoxic contaminant in milk may be responsible.

Vitamins.

B Vitamins. Most B vitamins play important roles in the brain and central nervous system. Vitamin B6 (pyridoxine) theoretically has benefits for PD because it is necessary in the production and metabolism of dopamine. Folate deficiency may increase toxic effects against dopamine neural pathways, perhaps by increasing levels of homocysteine, an amino acid that may play a destructive role in many diseases, including heart and neurologic disorders. Some evidence suggests that L-dopa elevates homocysteine levels, so folate supplements may be particularly important for patients. Although the major food sources of B vitamins are meats and dairy products, which are high in protein, these vitamins are also found in whole grains and are added as supplements to commercial cereals.

Click the icon to see an image of the benefits of vitamin B6.

Click the icon to see an image of foods that contain vitamin B6.

Click the icon to see an image of foods that contain folate.

Vitamin E. Researchers have investigated antioxidant vitamins, especially vitamin E, for their effect on the brain. Some, but not all, studies have reported slower mental decline and lower risk for Parkinson's and Alzheimer's disease in people who ate large amounts of foods rich in vitamin E. Such foods include vegetable oils (particularly wheat germ oil), sweet potatoes, turnip greens, mangos, avocados, nuts, sunflower seeds, and soybeans. Vitamin E supplements, however, do not appear to be helpful for slowing disease progression or improving symptoms.

Both smoking and coffee drinking have been associated with lower risk for PD. Researchers are attempting to discover if these substances protect nerve cells. One interesting study suggested that the early disease process in PD produces changes in the dopamine pathway that actually protects an individual from caffeine and nicotine addiction, so that fewer patients have a history of smoking and caffeine. Research is needed to determine why these toxic substances protect against PD.

Smoking and Nicotine Replacement. Cigarette smokers appear to have a 40% lower risk for Parkinson's disease, indicating some protection by nicotine. This finding, of course, is no excuse to smoke, but such protection may help researchers develop new therapies. Studies on nicotine replacement, such as gum or patches, have been conflicting, however, with some short-term studies reporting no benefits. A 2002 study suggested that nicotine replacement may help smokers with early PD, but not nonsmokers.

Coffee Consumption. Studies have indicated that the risk for PD in coffee drinkers is about 30% lower than for non-coffee drinkers. In a 30-year study of Japanese-American men, coffee consumption was associated with a lower risk for Parkinson's disease, and the more coffee they drank, the lower their risk became. Coffee and tea can reduce fluids by increasing urination, however, and so may increase constipation in PD.

Regular use of ibuprofen may reduce the risk of Parkinson’s disease according to research presented at the 2005 annual meeting of the American Academy of Neurology. In this prospective study, people who took at least two ibuprofen tablets per week for at least 1 year lowered their risk of developing Parkinson’s by 35% compared to nonusers or irregular users. For those who took ibuprofen daily, the comparative risk was 38% lower. Other non-steroidal anti-inflammatory drugs (NSAIDS) did not appear to affect disease risk.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

The following dietary supplements are being studied for treatment of Parkinson's disease:

Creatine. Creatine is a nutritional supplement that is sometimes used to improve exercise performance. In 2007, the U.S. National Institutes of Health launched a large-scale clinical trial to study whether creatine can slow the progression of Parkinson’s disease. The trial will enroll patients who have been diagnosed with PD within the last 5 years and who have received levodopa therapy for no more than 2 years.

Coenzyme Q10 (Ubiquinone). Coenzyme Q10 (also called ubiquinone) is an antioxidant being studied for the treatment of Parkinson's disease. This enzyme is important for cellular energy, which may be impaired in PD. In one study, patients who took coenzyme Q10 had slower decline in daily activities and mental and motor skills compared to patients on placebo. However, a 2007 study found that small doses of coenzyme Q10 had no effect on improving Parkinson’s symptoms. Researchers are still investigating whether larger doses given over a long period of time may benefit patients.

Exercise early in adult life may help protect against later development of Parkinson’s disease. Exercise is also an important component of rehabilitation. Physical therapy is extremely important and usually includes active and passive exercise, gait training, practice in normal activities, and if needed, hot or cold treatments, water therapy, and electrical stimulation. Exercise is also essential for well-being and helps patients maintain productive years. To date, no specific approach has been proven to be better than others.

Exercise Programs. Exercise programs are defined as passive or active.

Passive exercise, mostly stretching and manipulation of muscles by a physical therapist, is aimed at preventing muscles from shortening. A passive exercise program that begins with slow and gentle exercises and becomes progressively more intense may improve mobility in patients with early and mid-stage Parkinson's disease.
Active exercises are used to help range-of-motion, coordination, and speed. Patients should continually make efforts to practice movement, even simple ones, such as marching in place, making circular arm movements, and raising the legs up and down while sitting. Patients who enjoy sports or the use of exercise equipment should continue with these activities even if their skills diminish, assuming there are no other medical conditions that would prevent participation.

Gait Training. Practicing new methods for standing, walking, and turning may help retain balance. The following tips may be helpful:

Take large steps when walking forward, raising the toes at the forward step, and hitting the ground with the heel.
Take small steps while turning.
When walking or turning, have the legs 12 - 15 inches apart to provide a wide base.
Do not wear rubber or crepe-soled shoes because they grip the floor and may cause the patient to fall forward.
Using devices that keep a rhythmic beat, such a metronome (a simple device used by musicians to keep time), may be very effective, possibly more than music itself, in helping patients to walk faster and take longer steps. One study found that setting a metronome rhythm to about 10% faster than the patient's fastest gait offers significant improvement over walking to no rhythm at all or to a rhythm that matches the gait.

Reducing Muscle Freezing. The patient should practice regular daily activities that simplify actions and reduce the incidence of muscle freezing. Most often, freezing occurs when a patient begins to move or is presented with an obstacle. The following tips may be helpful:

Rock from side to side.
If the legs feel frozen, lift the toes. This simple action may free spasm in some cases.
Hum marching tunes. In fact, music has been shown to help people move and to get out of bed in the morning. Some studies report that wearing a Walkman and turning music on in situations associated with freezing, such as crossing a street, is helpful.
Divide actions into separate events, which may prevent freezing that occurs from trying to coordinate too many physical operations at one time. For instance, when going through a doorway, approach the door, stop at the door, open it, stop, and then walk through the doorway.
A cane equipped with a laser pointer may be helpful, at least temporarily.
Simply being touched by another person can sometimes release the patient (although a patient with PD should never be pulled or pushed).

Sleep Deprivation Therapy. Sleep deprivation therapy may have a role in treating some cases of depression and some studies are finding some benefits on the depression, tremor, and rigidity experienced by patients. Scientists believe that sleep deprivation produces certain anticholinergic effects, which may improve both depression and Parkinson's symptoms.

Mental Tasks. Mental training may increase dopamine in the brain. Some studies indicate that being mentally fit may be as important for patients as being physically fit. Helpful approaches include:

Select and learn new hobbies that require finger and hand mobility, such as sewing, carpentry, fishing, or playing cards.
Practice deep breathing and relaxation exercises. These may help maintain proper speech control, control tremor, and reduce anxiety.
Both the patient and any caregivers should consider psychological therapy and support for depression and loss of motivation. If psychological therapy is too costly, inexpensive support programs and groups are widely available and can be invaluable for the patient and the family.

Speech Therapy. Speech therapy may help those who develop a monotone voice and lose volume, particularly in combination with medications. There are no well-conducted studies comparing specific speech therapies, but the Lee Silverman Voice Treatment (LSVT) appears to be an example of an effective technique. It has five major components:

Focus on the voice ("think loud/think shout")
High effort (pushes patients to overcome limitations)
Intensive treatment (16 sessions in 1 month)
Calibration (learning to know and accept the amount of effort needed to produce normal sound so it becomes automatic)
Quantification (continuous feedback to objectively document success)

LSVT may help swallowing as well as speech.

Equipment and Devices. A number of devices can be helpful for maintaining stability and preventing falls. The following are some examples:

Rails installed where the patient needs support in getting up or down, such as along the bed and in the bathroom.
Walkers with locking wheels. (Walkers do not appear to be helpful for freezing.)
Chairs with straight backs, firm seats, and arm rests.
Firm mattresses and satin sheets or less expensive sheets with high thread counts. (These are useful for helping patients slide out of bed.)

Resources

www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.aan.com -- American Academy of Neurology
www.apdaparkinson.org -- American Parkinson's Disease Association
www.pdf.org -- Parkinson's Disease Foundation
www.parkinson.org -- National Parkinson Foundation
www.michaeljfox.org -- Michael J. Fox Foundation for Parkinson's Research
www.wemove.org -- Worldwide Education and Awareness for Movement Disorders
www.parkinsonsaction.org -- Parkinson's Action Network

References

Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schafer H, Botzel K, et al. A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med. 2006 Aug 31;355(9):896-908.

Murata M, Hasegawa K, Kanazawa I. Zonisamide improves motor function in Parkinson disease: a randomized, double-blind study. Neurology. 2007 Jan 2;68(1):45-50.

Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E. Dopamine agonists and the risk of cardiac-valve regurgitation. N Engl J Med. 2007 Jan 4;356(1):29-38.

Schupbach WM, Maltete D, Houeto JL, du Montcel ST, Mallet L, Welter ML, et al. Neurosurgery at an earlier stage of Parkinson disease: a randomized, controlled trial. Neurology. 2007 Jan 23;68(4):267-71. Epub 2006 Dec 6.

Storch A, Jost WH, Vieregge P, Spiegel J, Grelich W, Durner J, et al. Randomized, double-blind, placebo-controlled trial on symptomatic effects of coenzyme Q10 in Parkinson disease. Arch Neurol. 2007 July;64.

Voon V, Thomsen T, Miyasaki JM, de Souza M, Shafro A, Fox SH, et al. Factors associated with dopaminergic drug-related pathological gambling in Parkinson disease. Arch Neurol. 2007 Feb;64(2):212-6.

Watts RL, Jankovic J, Waters C, Rajput A, Boroojerdi B, Rao J. Randomized, blind, controlled trial of transdermal rotigotine in early Parkinson disease. Neurology. 2007 Jan 23;68(4):272-6. Epub 2007 Jan 3.

Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G. Valvular heart disease and the use of dopamine agonists for Parkinson's disease. N Engl J Med. 2007 Jan 4;356(1):39-46.

Review Date:
6/4/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Paroxysmal supraventricular tachycardia (PSVT)

admin — Wed, 03 Sep 2008 17:47:53 -0700

Overview

Definition
Alternative Names
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Expectations (prognosis)
Complications
Calling your health care provider
Prevention
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Paroxysmal supraventricular tachycardia (PSVT) is an occasional rapid heart rate. "Paroxysmal" means from time to time.

Alternative Names

PSVT; Supraventricular tachycardia

Causes, incidence, and risk factors

Normally, the chambers of the heart (atria and ventricles) contract in a coordinated manner. The contractions are caused by an electrical signal that begins in an area of the heart called the sinoatrial node (also called the sinus node or SA node). The signal moves through the upper heart chambers (the atria) and tells the atria to contract.

PSVT starts with events taking place above the lower heart chambers (ventricles). PSVT can be initiated in the SA node, in the upper heart chambers (atria), in the atrial conduction pathways, or other areas.

PSVT can occur with digitalis toxicity and conditions such as Wolff-Parkinson-White syndrome.

The condition occurs most often in young people and infants.

The following increase your risk for PSVT:

Alcohol use
Caffeine use
Illicit drug use
Smoking

Symptoms

Anxiety
Chest tightness
Palpitations (a sensation of feeling the heart beat)
Rapid pulse
Shortness of breath

Additional symptoms that may be associated with this condition:

Note: Symptoms may start and stop suddenly, and can last for a few minutes or several hours. A PSVT lasting more than half of the day is considered an incessant PSVT.

Signs and tests

A physical examination during a PSVT episode will show a rapid heart rate.

The heart rate may be 150 to 250 beats per minute (bpm). In children, the heart rate tends to be very high. There may be signs of poor blood circulation such as light headedness. Between episodes of PSVT, the heart rate is normal (60 to 100 bpm).

An ECG during symptoms shows PSVT. An electrophysiology study (EPS) is often necessary for an accurate diagnosis and to recommend the best treatment.

Because of the sporadic nature of the PSVT, its diagnosis may require 24-hour Holter monitoring. For longer recording periods, a "loop recorder" (with computer memory) is used.

Treatment

If you do not have symptoms, PSVT may not require treatment.

If symptoms occur or if you have another heart disorders, treatment may be necessary.

If you have an episode of PSVT, a technique called the Valsalva maneuver can be used to interrupt the fast heartbeat. Hold your breath and strain, as if you were trying to have a bowel movement, or cough while sitting with your upper body bent forward.

Splashing ice water on the face has been reported by some people as helpful.

Emergency treatment of PSVT may include:

Electrical cardioversion, the use of electric shock to restore a rapid heartbeat back to normal.
Medicines through a vein, including adenosine and verapamil. Other medications may be used, such as procainamide, beta-blockers, and propafenone.

Long-term treatment of PSVT may include:

Daily medications such as propafenone, flecainide, moricizine, sotalol, and amiodarone.
Pacemakers to override the fast heartbeat; very occasionally used in children with PSVT who have not responded to any other treatment.
Radiofrequency catheter ablation; currently the treatment of choice for most PSVT's.
Surgery to change the pathways in the heart that send electrical signals; this may be recommended in some cases for people who need other heart surgery.

Expectations (prognosis)

PSVT is generally not life threatening, unless other heart disorders are present.

Complications

The main complication is an increased risk of heart failure.

Calling your health care provider

Call your health care provider if:

You often have a sensation of excessive palpitations and symptoms do not end on their own in a few minutes
You have a history of PSVT and an episode does not go away with Valsalva maneuver, or if other symptoms go along with the rapid heart rate
Symptoms return frequently
New symptoms develop

Prevention

Avoid smoking, caffeine, alcohol, and illicit drugs. Medications used to treat the disorder may be given as a preventive (prophylactic) treatment in people at a high risk or who have had previous episodes of PSVT.

References

Olgin JE, Zipes DP. In: Specific Arrhythmias: Diagnosis and Treatment. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. St. Louis, Mo: WB Saunders; 2007: chap. 35.

Review Date: 5/12/2008

Reviewed By: Larry A. Weinrauch, MD, Assistant Professor of Medicine, Harvard Medical School, and Private practice specializing in Cardiovascular Disease, Watertown, MA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Source Doc: 1_000183

Migraine headache

FitSugar — Wed, 08 Oct 2008 17:34:55 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Treatment Approach
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Migraines are severely painful, recurrent headaches that are sometimes accompanied by other symptoms such as visual disturbances (aura) or nausea. There are two types of migraine – migraine with aura (formerly called common migraines) and migraine without aura (formerly called classic migraines). If you have a migraine with aura, you may experience a visual disturbance (like seeing stars or zigzag lines or a temporary blind spot) about 30 minutes before the headache starts. Even if you don't experience an aura, you may have other warning signs in the period before the headaches starts (called prodrome), such as a craving for sweets, thirst, sleepiness, or depression. Although there is no cure for migraines, you can manage the condition by reducing the frequency of attacks and lessening pain once an attack starts.

Signs and Symptoms

The headache from a migraine, with or without aura, has the following characteristics:

Throbbing, pounding, or pulsating pain
Often begins on one side of your head and may spread to both or stay localized
Most intense pain is often concentrated around the temple(s) (side of the forehead)
Can last from 4 to 72 hours

These symptoms may occur at the same time or before the headache:

Nausea and vomiting
Dizziness, lightheadedness or even vertigo (feeling like the room is spinning)
Loss of appetite
Fatigue
Visual disturbances, like seeing flashing lights or zigzag lines, temporary blind spots (for example, loss of your peripheral vision), or blurred vision
Parts of your body may feel numb, weak, or tingly
Light, noise, and movement – especially bending over – make your head hurt worse; you want to lie down in a dark, quiet room
Irritability

Symptoms that may linger even after the headache is gone:

Feeling mentally dull, like your thinking is not clear or sharp
Sleepiness
Neck pain

Causes

Researchers aren't sure what causes a migraine, although they know it involves changes in the blood flow in the brain. Initially, blood vessels constrict (narrow), reducing blood flow and leading to visual disturbances, difficulty speaking, weakness, numbness, or tingling sensation in one area of the body, or other similar symptoms. Later, the blood vessels dilate (enlarge) leading to increased blood flow and a severe headache. Migraine triggers can include the following:

Alcohol, especially beer and red wine
Certain foods, such as aged cheeses, chocolate, nuts, peanut butter, some fruits (like avocado, banana, and citrus), foods with monosodium glutamate (MSG), onions, dairy products, meats containing nitrates (bacon, hot dogs, salami, cured meats) fermented or pickled foods
Skipping meals
Fluctuations in hormones (for example, during pregnancy, before and during your period, and menopause)
Certain odors, such as perfume or smoke
Bright lights
Loud noises
Stress, physical or emotional (often, the headache occurs during a period of relaxation after a particularly stressful time)
Sleeping too little or too much
Caffeine
Smoking or exposure to tobacco smoke
Some medications

Risk Factors

Gender (women are more likely to get migraines than men)
Having other family members with migraine headaches
Being under age 40; migraines tend to diminish as you age
Taking birth control pills (if your migraines are affected by fluctuations in estrogen levels)
Exposure and sensitivity to any of the potential triggers listed above

Diagnosis

Your doctor will take a detailed medical history in order to distinguish migraine headaches from other types of headaches, such as tension or sinus. He or she will ask questions about when your headaches occur, how long they last, how frequently they come on, the location of the pain, and any symptoms that accompany or precede the headaches. Sometimes it helps to keep a diary about your headaches prior to seeing the doctor, so you'll have an accurate recording of how often they happen. (See Lifestyle section for what information to include in a diary.)

Tests your doctor may order, depending on your symptoms and exam, include:

Computerized tomography (CT) scan, to look for other problems that could be causing your headache
Magnetic resonance imaging (MRI), to look for brain abnormalities, and to look closely at the blood vessels in the brain
Lumbar puncture (spinal tap), if your doctor suspects meningitis or other conditions

You should seek emergency help if you experience the following symptoms:

You have unusual neurologic symptoms you have not experienced before, such as speech problems, change in vision, loss of balance, or difficulty moving a limb.
Your headache pattern or intensity is different
You are experiencing "the worst headache of your life"
Your headache worsens when you are lying down

These may indicate a stroke, a bleed in the brain, or other serious condition.

Treatment Approach

Treatment for migraines is aimed at preventing them from occuring and lesseneing pain once an attack starts.

You can control your migraines with a combination of medications, lifestyle changes, and complementary therapies. Biofeedback (see Mind/Body Medicine) may help you control the initial contraction of blood vessels, while relaxation techniques may reduce both the frequency and intensity of attacks.

Lifestyle

Keeping a migraine diary, particularly when you first begin to experience migraines, can help identify the triggers for your headaches so you can avoid them. When a migraine occurs, write down the date and time it began. Note what you ate for the preceding 24 hours, how long you slept the night before, what you were doing just before the headache, any unusual stress in your life, how long the headache lasted, and what you did to make it stop.

Other lifestyle measures that may reduce the number of migraines include:

Avoiding cigarettes, caffeine, and alcohol
Exercising regularly
Getting enough sleep each night
Relaxing and reducing stress in your life (see Mind/Body Medicine section)

Once a headache or associated migraine symptoms begin, it helps to:

Rest in a quiet, darkened room
Drink fluids to avoid dehydration (especially if you have vomited)

Medications

Medications for migraines can be classified in two major categories: those designed to prevent attacks, and those designed to relieve pain.

Drugs for Prevention

Your doctor may prescribe preventive medications if you have two or more migraines per month, use pain relievers more than twice a week, or if your symptoms are especially debilitating. Depending on your condition and medication, your doctor may recommend taking the medication daily or when a known trigger is about to occur (such as having your period).

Beta-blockers - also used to treat heart disease; researchers aren't sure why they also work for migraines, although they may help keep blood vessels in the brain from constricting and dilating. Beta-blockers include
- Atenolol (Tenormin)
- Metoprolol (Lopressor, Toprol-XL)
- Propranolol (Inderal, Inderal LA)
Calcium-channel blockers - another type of cardiovascular drug that can help prevent migraines, including
- Verapamil (Calan, Isoptin)
- Diltiazem (Cardizem, Dilacor)
Anti-depressants - Tricyclic antidepressants are helpful in preventing all kinds of headaches, including migraines. Tricyclic antidepressants include:
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Doxepin (Sinequan)
- Imipramine (Tofranil)
Anticonvulsants - Some anti-seizure drugs help prevent migraines, although researchers aren't sure why:
- Divalproex sodium (Depakote)
- Topiramate (Topamax)

Drugs for Treatment

To be effective, these medications should be taken as soon as you feel a migraine coming on.

Triptans - This class of medications tends to be the front-line treatment for severe migraines and relieve pain, nausea, and sensitivity to light and sound. They work by constricting the blood vessels in the brain. Triptans include
- Almotriptan (Axert)
- Eletriptan (Relpax)
- Frovatriptan (Frova)
- Naratriptan (Amerge)
- Rizatriptan (Maxalt)
- Sumatriptan (Imitrex)
- Zolmitriptan (Zomig)
Ergots - Ergots also work by constricting blood vessels, but tend to have more side effects than triptans. Ergots include
- Ergotamine (Ergomar, Cafergot)
- Dihydroergotamine (Migranal)
Isometheptene, dichloralphenazone, and acetaminophen (Midrin) - Midrin combines a pain reliever (acetaminophen) and sedative (dichloralphenazone) with a medication that constricts blood vessels (isometheptene) to prevent migraines.

Other medications used to treat the headache pain or associated symptoms:

Anti-nausea drugs
Acetaminophen (Tylenol) for pain
Ibuprofen (Advil, Motrin) or other nonsteroidal anti-inflammatory drugs (NSAIDs)
Narcotics, such as codeine, are sometimes used for people who can't take triptans or ergots; however, they can cause dependency and rebound headaches

Nutrition and Dietary Supplements

Diet

Certain foods may trigger migraine headaches. Some of the include:

Chocolate
Cheese
Monosodium glutamate (MSG), a flavor enhancer found often in food from Chinese restaurants
Foods containing the amino acid tyramine (found in red wine, aged cheese, smoked fish, chicken livers, figs, and some beans)
Nuts
Peanut butter
Some fruits (like avocado, banana, and citrus)
Onions
Dairy products
Meats containing nitrates (bacon, hot dogs, salami, cured meats)
Fermented or pickled foods

If you suspect that any of these foods cause your migraines, you could follow an elimination diet, eliminating all the items on this list from your diet and then reintroducing them one at a time. Pay close attention to when the number of headaches increases after eating particular foods. Then you know which trigger foods to avoid.

5-hydroxytryptophan (5-HTP, 400 to 600 mg per day) - This amino acid is made by the body from tryptophan (another amino acid you get from certain foods) and converted into serotonin, an important brain chemical. Researchers think abnormal serotonin function in blood vessels is related to migraines, and some of the drugs used to treat migraines work by affecting serotonin. Several studies indicate that 5-HTP may be about as effective as some prescription migraine medications, reducing the intensity and frequency of attacks. But not all studies have been so positive – one study found that 5-HTP was less effective than the beta-blocker Inderal. More studies are needed to be sure that 5-HTP is helpful in treating migraines. If you take an antidepressant, or supplements such as St. John's wort or SAMe, you should not take 5-HTP.
Magnesium (200 to 600 mg per day) - People with migraines often have lower levels of magnesium compared to people who do not have migraines, and several studies suggest that magnesium may reduce the frequency of migraine attacks. In one study, people who took magnesium reduce the frequency of attacks by 41.6 percent, compared to 15.8 percent in those who took placebo. Some studies also suggest that magnesium may be helpful for women whose migraines are triggered by their periods.Side effects from magnesium can include lower blood pressure and diarrhea.
Vitamin B2 (riboflavin, 400 mg per day) - A few studies indicate that riboflavin may reduce the frequency and duration of migraines. In one study, people who took riboflavin had more than a 50 percent decrease in the number of attacks. Not all studies have found riboflavin to be effective, however. More research is needed.

Preliminary research indicates that these supplements may also help prevent migraines, although much more research is needed to say for sure:

Coenzyme Q10 (100 mg three times per day)
Melatonin (5 mg per day, taken before bedtime)

Herbs

Butterbur (Petasites hybridus, 50 to 75 mg of a standardized extract two times per day) - A few studies suggest that butterbur may help reduce both the frequency and duration of migraine attacks. The studies used a standardized extract that lowered the amount of alkaloids in the herb, which might potentially be harmful to the liver. If you want to try butterbur for your migraines, ask your doctor about a safe extract and dose. Women who are pregnant or breastfeeding should not take butterbur.
Feverfew (Tanacetum parthenium, standardized leaf extract to 250 mcg parthenolide per day) - Feverfew has been used traditionally to treat headaches, and several well-designed studies have found that it may help prevent and treat migraines (not all studies agree, however). In one study of people with migraines, those who took feverfew capsules every day for 4 months saw a substantial drop in the number of attacks as well as far fewer symptoms, such as nausea and vomiting, compared to those who received placebo. Feverfew can increase the risk of bleeding, and should not be taken with anticoagulants (blood-thinners). Women who are pregnant or breastfeeding should not take feverfew.

Although there are no scientific studies showing that these herbs work, they are sometimes suggested to treat migraines and other types of headaches:

Dong quai (Angelica sinensis)
Devil's claw (Harpagophytum procumbens)
Ginger (Zingiber officinale)
Ginkgo biloba (Ginkgo biloba)
Willow bark (Salix spp.)

Acupuncture

Acupuncture has been studied as a treatment for migraine headache for more than 20 years. While not all studies have shown benefit with acupuncture, researchers do agree that acupuncture appears safe and that it may be effective for some people. Results from a study published in 2003 suggest that receiving an acupuncture treatment when migraine symptoms first begin is as effective as taking the drug Imitrex; as symptoms continue, however, the medication works better than acupuncture.

In addition to needling treatment, acupuncturists may recommend lifestyle changes, such as suggestions for specific breathing techniques, qi gong exercise, and dietary modifications.

Chiropractic

Several clinical trials indicate that spinal manipulation therapy may help in the treatment of migraine headaches. In one study of people with migraines, 22% of those who received chiropractic manipulation reported more than a 90% reduction of attacks and 49% reported a significant reduction of the intensity of each migraine.

In another study, people with migraine headaches were randomly assigned to receive spinal manipulation, a daily medication (Elavil), or a combination of both. Spinal manipulation was as effective as Elavil in reducing migraines and had fewer side effects. There was no added benefit to combining the two therapies.

In addition, researchers reviewed nine studies that tested spinal manipulative therapy for tension or migraine headaches and found that it was as effective as medications in preventing these headaches.

However, not all these studies were of good quality, and they varied in the techniques used. More research is needed to say for sure whether chiropractic is effective for preventing migraines.

Massage and Physical Therapy

Reflexology, a technique that places pressure on specific "reflex points" on the hands and feet that are believed to correspond to areas throughout the body, has been proposed as a treatment for migraines. Some early studies suggest it may relieve pain and allow people with migraines to take less pain medication. However, more research is needed. Practitioners believe reflexology helps you become more aware of you own body signals, which might help you sense the subtle signals that indicate a migraine is about to occur (before pain starts). They also believe reflexology helps improve general well-being and energy level.

Homeopathy

One of the most common reasons people seek homeopathic care is to treat chronic headaches. However, only one out of four studies included in a scientific review found that individually prescribed homeopathic remedies significantly reduced the frequency, severity, and duration of migraines. Some of these effective remedies are listed below. Professional homeopaths may also recommend various treatments based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account the individual's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following are some of the remedies found to be effective:

Belladonna - for throbbing headaches that come on suddenly; these types of headaches tend to worsen with motion and light, but are partially relieved by pressure, standing, sitting, or leaning backwards
Bryonia - for headaches with a steady, sharp pain in the forehead that may radiate to the back of the head; these types of headaches worsen with movement and light touch, but improve with firm pressure; this remedy is most appropriate for individuals who are irritable and may also experience nausea, vomiting, and constipation
Gelsemium - for pain that extends around the head and feels like a tight band of constriction; pain usually originates in the back of the head and may be relieved following urination; this remedy is most appropriate for individuals who feel extremely weak and have difficulty keeping their eyes open
Ignatia - for pain that may be described as a feeling of something being driven into the skull; these types of headaches tend to be triggered by emotion, including grief or anxiety, and the treatment is appropriate for both children and adults
Iris versicolor - for periodic migraines that begin with blurred vision, especially after eating sweets; pain usually occurs on one side of the head and may be partially relieved by gentle movement and/or fresh air
Kali bichromicum - for aching and pressing pains on the forehead (particularly between and behind the eyes); may be accompanied by sinus congestion or nausea and vomiting; this remedy is most appropriate for individuals who prefer to lie down in a dark room and who experience relief from warmth and eating
Lachesis - for migraines on the left side of the head that are typically worse in the mornings and before menstruation; this type of headache is aggravated by warmth and sunlight and relieved by open air and firm pressure
Natrum muriaticum - one of the most common remedies used for migraine headaches, particularly those that are described as "hammers beating the head;" pain is relieved when the individual is lying down, alone, in a quiet dark room; these migraines may be associated with either menstruation or a grieving experience and are worse in the middle of the day; this remedy is most appropriate for children who look pale and feel nauseated, nervous, and emotional
Nux vomica - for headaches that are described as a "nail being driving into the head;" often accompanied by nausea and/or dizziness; this remedy is most appropriate for individuals who are constipated and irritable
Sanguinaria - for right-sided headaches that begin in the neck and move upwards, recur in a predictable pattern (such as every seven days), and are accompanied by nausea and vomiting; pain is aggravated by motion, light or sun exposure, odors, and noise; this remedy is appropriate for children who may have a craving for spicy or acidic foods, despite having a general aversion to eating due to the headache
Sepia - for migraines that are accompanied by nausea and are relieved when the individual is lying down; light and movement tend to worsen symptoms; this remedy is most appropriate for individuals who are moody and don't like being alone, but worry about being with others

Homeopaths may also prescribe the following remedies based on their knowledge and clinical experience:

Pulsatilla - for headaches triggered by eating rich, fatty foods, particularly ice cream; pain tends to move but may be concentrated in the forehead or on one side of the head; may be accompanied by digestive problems or occur around the time of menstruation; children for whom this remedy is appropriate often develop these symptoms while at school
Spigelia - for migraines described as a stinging, burning, or throbbing pain, often on the left side of the head; symptoms tend to worsen with exposure to cold weather and with motion, but are temporarily relieved by cold compresses and when the individual is lying on the right side with the head propped up

Mind/Body Medicine

Reducing and learning to cope with stress may help reduce the number and intensity of your headaches. Techniques that can help include:

Self-hypnosis
Biofeedback
Joining a support group
Relaxation techniques such as progressive muscle relaxation (alternately contracting and releasing muscles throughout your body), meditation, and guided imagery

Other Considerations

Pregnancy

Many of the medications, herbs, and supplements used to prevent or treat migraines should not be used if you are pregnant. Talk to your doctor before using any medication (over the counter or prescription) or any complementary therapy available prior to becoming pregnant.

Warnings and Precautions

Use medications only as directed. using some medications on a regular basis can cause rebound headaches.

Call your doctor if you experience a new headache, a change in quality of a previous headache or headache pattern, or if a medication that usually takes away the pain no longer works.

Prognosis and Complications

Migraine headaches generally don't pose a threat to your overall health, although they can be chronic, recurrent, frustrating, and interfere with your day to day life. Stroke is an extremely rare complication from severe migraines, possibly due to prolonged constriction (narrowing) of blood vessels, reducing the blood flow to parts of the brain.

Many people find that migraines into remission (meaning that they stop for a long time and happen only very infrequently) or even disappear altogether, especially as you get older. For women, this may be related to lower levels of estrogen after menopause.

Supporting Research

Annequin D, Tourniaire B, Massiou H. Migraine and headache in childhood and adolescence. Pediatr Clin North Am. 2000;47(3):617-631.

Astin JA., Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalagia. 2002;22(:617-623.

Baghdikian B, Lanhers M, Fleurentin J, et al. An analytical study, anti-inflammatory and analgesic effects of Harpagophytum procumbens and Harpagophytum zeyheri. Planta Med. 1997;63:171–176.

Barrows KA, Jacobs BP. Mind-body medicine: an introduction and review of the literature. Med Clin North Am. 2002;86(1):11-31.

Bauman RJ. Behavioral treatment of migraine in children and adolescents. Paediatr Drugs. 2002;499):555-561.

Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Alt MedReview. 1998;3(4):271-280.

Blumenthal M. The Complete German Commission E Monographs. Austin, Tex: American Botanical Council. Boston: Integrative Medicine Communications; 1998.

Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24(7):457-466.

Cady RK, Schreiber CP. Sinus headache or migraine? Considerations in making a differential diagnosis. Neurology. 2002;58(9 Suppl 6):S10-S14.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3rd ed. New York, NY: Penguin Putnam; 1997: 217-220, 343.

Dagenais S. Haldeman S. Chiropractic. Prim Care. 2002;29(2):419-437.

DeBenedittis G, Massei R. Serotonin precursors in chronic primary headache. A double-blind cross-over study with L-5-hydroxytryptophan vs. placebo. J Neurosurg Sci. 1985; 29:239–248.

DeGiorgis G, et al. Headache in association with sleep disorders in children: a psychodiagnostic evaluation and controlled clinical study-L-5-HTP versus placebo. Drugs Exp Clin Res. 1987;13:425–433.

Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention – a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia. 2005;25:1031-41.

De Weerdt CJ, Bootsma HPR, Hendricks H. Herbal medicines in migraine prevention. Randomized double-blind placebo controlled crossover trial of a feverfew preparation. Phytomedicine. 1996;3:225-230.

Demirkaya S, Vural O, Dora B, Topcuoglu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001;41(2):171-177.

Diener HC, Kaube H, Limmroth V. A practical guide to the management and prevention of migraine. Drugs. 1998;56(5):811-824.

Endres HG, Diener HC, Molsberger A. Role of acupuncture in the treatment of migraine. Expert Rev Neurother. 2007 Sep;7(9):1121-34. Review.

Ernst, E. Homeopathic prophylaxis of headaches and migraine? A systematic review. J Pain Symptom Manage. 1999;18(5):353-357.

Ernst E, Pittler MH. The efficacy and safety of feverfew (Tanacetum parthenium L.): an update of a systematic review. [Review] Public Health Nutr. 2000;3(4A):509-514.

Facchinetti F, Sances G, Borella P, Genazzani AR, Nappi G. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. 1991;31(5):298-301.

Gao S, Zhao D, Xie Y. A comparative study on the treatment of migraine headache with combined distant and local acupuncture points versus conventional drug therapy. Am J Acupuncture. 1999;27(1-2):27-30.

Gobel H, Schmidt G, Soyka D. Effect of peppermint and eucalyptus oil preparations on neurophysiological and experimental algesimetric headache parameters. Cephalalgia. 1994;14(3):228-234.

Goslin RE, Gray RN, McCrory DC, Penzien D, Rains J, Hasselblad V. Evidence report: Behavioral and physical treatments for migraine. Technical Review, 2.2, February 1999. Prepared for the Agency for Health Care Policy and Research under contract number. 290-94-2025.

Hesse J, Mogelvang B, Simonsen H. Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation. J Intern Med. 1994;235:451-456.

Johnson ES, Kadam NP, Hylands DM, Hylands PJ. Efficacy of feverfew as prophylactic treatment of migraine. Br Med J. 1985;291:569–573.

Launso L, Brendstrup E, Arnberg S. An exploratory study of reflexological treatment for headache. Altern Ther Health Med. 1999;5(3):57-65.

Linde K, Melchart D, Fisher P et al. Acupuncture for idiopathic headache (Cochrane Review). In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software.

Lipton RB, Göbel H, Einhäupl KM, Wilks K, Mauskop A. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology. 2004 Dec 28;63(12):2240-4.

Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain. 2000;16(4):334-339.

Mauskop A. Alternative therapies in headache. Is there a role? [Review] Med Clin North Am. 2001;85(4):1077-1084.

Mauskop A, Altura BM. Role of magnesium in the pathogenesis and treatment of migraines. Clin Neurosci. 1998;5(1):24-27.

Mauskop A, Altura BT, Altura BM. Serum ionized magnesium levels and serum ionized calcium/ionized magnesium ratios in women with menstrual migraine. Headache. 2002;42(4):242-248.

Melchart D, Linde K, Fischer P, et al. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. Cephalalgia. 1999;19(9):779-786;discussion 765

Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W. Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial. J Intern Med. 2003;253(2):181-188.

Mueller L. Tension-type, the forgotten headache. How to recognize this common but undertreated condition. Postgrad Med. 2002;111(4):25-26, 31-32, 37-38.

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Oelkers-Ax R, Leins A, Parzer P, Hillecke T, Bolay HV, Fischer J, et al. Butterbur root extract and music therapy in the prevention of childhood migraine: An explorative study. Eur J Pain. 2007 Jul 27; [Epub ahead of print]

Palevitch D, Earon G, Carasso R. Feverfew (Tanacetum parthenium) as a prophylactic treatment for migraine: a double-blind controlled study. Phytotherapy Res. 1997;11:508-511.

Peikart A, Wilimzig C, Kohne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalagia. 1996;16(4):257-263.

Penzien DB, Rains JC, Andrasik F. Behavioral management of recurrent headache: three decades of experience and empiricism. Appl Psychophysiol Biofeedback. 2002;27(20:163-181.

Pfaffenrath V, Diener HC, Fischer M, Friede M, Henneicke-von Zepelin HH; Investigators. The efficacy and safety of Tanacetum parthenium (feverfew) in migraine prophylaxis – a double-blind, multicentre, randomized placebo-controlled dose-response study. Cephalagia. 2002;22(7):523-532.

Pfaffenrath V, Wessely P, Meyer C, et al. Magnesium in the prophylaxis of migraine – a double-blind placebo-controlled study. Cephalagia. 1996;16(6):436-440.

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Pittler MH, Vogler BK, Ernst E. Feverfew for preventing migraine. [Review] Cochrane Database Syst Rev. 2000;(3):CD002286.

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Pryse-Phillips WE, Dodick DW, Edmeads JG, et al. Guidelines for the nonpharmacologic management of migraine in clinical practice. Canadian Headache Society. Can Med Assoc J. 1998;159(1):47-54.

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Walach H, Lowes T, Mussbach D et al. The long-term effects of homeopathic treatment of chronic headaches: 1 year follow up. Cephalalgia. 2000;20:835-837.

Walach H, Lowes T, Mussbach D et al. The long-term effects of homeopathic treatment of chronic headaches: one year follow-up and single case time series analysis. Br Homeopath J. 2001;90(2):63-72.

Welch KM. Pathogenesis of migraine. Semin Neurol. 1997;17(4):335-341.

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Review Date:
12/18/2007
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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Glucose-6-phosphate dehydrogenase

admin — Thu, 04 Sep 2008 19:14:00 -0700

Overview

Definition
Alternative Names
How the test is performed
How to prepare for the test
How the test will feel
Why the test is performed
Normal Values
What abnormal results mean
What the risks are
Special considerations
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Glucose-6-phosphate dehydrogenase (G6PD) is a substance, called an enzyme, that helps red blood cells work properly. The G6PD test looks at the amount (activity) of this substance in red blood cells.

Alternative Names

RBC G6PD test; G6PD screen

How the test is performed

Blood is drawn from a vein on the inside of the elbow or the back of the hand. The puncture site is cleaned with antiseptic. An elastic band is placed around the upper arm to apply pressure and restrict blood flow through the vein. This causes veins below the band to fill with blood.

A needle is inserted into the vein, and the blood is collected in an air-tight vial or a syringe. During the procedure, the band is removed to restore normal blood flow. Once the blood has been collected, the needle is removed. The puncture site is covered to stop any bleeding.

For an infant or young child, the area is cleaned with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a small glass tube (pipette), on a slide, onto a test strip, or into a small container. A bandage may be applied to the puncture site if bleeding continues.

How to prepare for the test

No special preparation is usually necessary.

How the test will feel

When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

Why the test is performed

Your doctor may order this test if you have signs of G6PD deficiency. This means you do not have enough G6PD.

Too little G6PD leads to the destruction of red blood cells. This process is called hemolysis. When this process is actively occurring, it is called a hemolytic episode.

Hemolytic episodes can be triggered by infections, severe stress, certain foods (such as fava beans), and certain drugs, including:

Antipyretics
Nitrofurantoin
Phenacetin
Primaquine
Sulfonamides
Thiazide diuretics
Tolbutamide
Quinidine

You should not have this test during a hemolytic episode. The cells most likely to have low G6PD levels (older cells) have been destroyed, and those remaining may show normal G6PD levels.

After recovery from the episode, older cells will show lower levels of G6PD, resulting in a positive test.

Normal Values

Normal results are 8 - 8.6 units/gram of hemoglobin. Normal value ranges may vary slightly among different laboratories. Talk to your doctor about what your specific test results mean

What abnormal results mean

Abnormal results mean you have a G6PD deficiency, which can cause hemolytic anemia.

What the risks are

Excessive bleeding
Fainting or feeling light-headed
Blood collecting under the skin (hematoma)
Infection
Many needle sticks to find veins

Special considerations

Veins and arteries vary in size from one patient to another, and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

References

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. July 2004;114:297-316.

Wilmanski J, Villaneuva E, Deitch EA, Spolarics Z. Glucose-6-phosphate dehydrogenase deficiency and the inflammatory response to endotoxin and polymicrobial sepsis. Crit Care Med. February 2007;35:510-518.

Review Date: 3/22/2007

Reviewed By: Carl T. Henningson Jr., MD, Private Practice specializing in Hematology and Oncology, Mansquan, NJ. Review provided by VeriMed Healthcare Network.

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Source Doc: 1_003671

Sick sinus syndrome

admin — Wed, 03 Sep 2008 17:47:43 -0700

Overview

Definition
Alternative Names
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Expectations (prognosis)
Complications
Calling your health care provider
Prevention
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Sick sinus syndrome is a collection of heart rhythm disorders that include:

Sinus bradycardia -- slow heart rates from the natural pacemaker of the heart
Tachycardias -- fast heart rates
Bradycardia-tachycardia -- alternating slow and fast heart rhythms

Alternative Names

Bradycardia-tachycardia syndrome; Sinus node dysfunction

Causes, incidence, and risk factors

Sick sinus syndrome is relatively uncommon. Sinus bradycardia occurs more often than the other types.

Tachycardias that start in the upper chambers of the heart are also common forms. These include atrial fibrillation, atrial flutter/tachycardia, and supraventricular tachycardia. A period of elevated heart rates is typically followed by very slow heart rates when the tachycardia ends.

Abnormal heart rhythms are often made worse by medications such as digitalis, calcium channel blockers, beta-blockers, and anti-arrhythmics. Disorders that cause scarring, degeneration, or damage to the conduction system of the heart can cause sick sinus syndrome.

Sick sinus syndrome usually occurs in people older than 50, in whom the cause is often a nonspecific, scar-like degeneration of the heart's conduction system.

In children, a common cause of sick sinus syndrome is heart surgery, especially on the upper chambers.

Coronary artery disease, high blood pressure, and aortic and mitral valve diseases may be associated with sick sinus syndrome, although those diseases may have nothing to do with the syndrome.

Symptoms

Usually, no symptoms occur. Symptoms that do occur are nonspecific and may mimic other disorders.

Symptoms may include:

Chest pain or angina
Confusion or other changes in mental status
Fainting or near-fainting
Fatigue
Dizziness or light-headedness
Sensation of feeling the heart beat (palpitations)
Shortness of breath

Signs and tests

The patient's heart rate may be very slow at any time. Blood pressure may be normal or low.

Sick sinus syndrome may cause symptoms of heart failure to occur or worsen. Sick sinus syndrome is diagnosed when the symptoms occur only during episodes of arrhythmia. However, this often is difficult to prove.

An ECG may show various abnormal heart rhythms related to this syndrome.

Holter monitoring is an effective tool for diagnosing sick sinus syndrome because of the episodic nature of the disorder. Extremely slow heart rate and prolonged pauses may be seen during Holter monitoring, along with episodes of atrial tachycardias.

An EPS (intracardiac electrophysiology study) is a very specific test for this disorder, although it is often unable to confirm the diagnosis.

Exercise testing has not proven particularly effective as a screening tool.

Treatment

Treatment may not be necessary if you do not have any symptoms. Your doctor may review the medicines you take to make sure they are not making your condition worse. Do not stop taking any medication unless told to do so by your doctor.

A permanent implanted pacemaker may be needed if your symptoms are related to bradycardia (slow heart rate).

A fast heart rate (tachycardia) may be treated with medications. Sometimes a procedure called radiofrequency ablation is used to cure tachycardia.

Expectations (prognosis)

The syndrome is progresssive, which means it slowly gets worse.

The long-term outlook is excellent for those who have a permanent pacemaker implanted.

Complications

Angina
Falls or injury caused by fainting
Heart failure
Inadequate heart pumping

Calling your health care provider

Call for an appointment with your health care provider if you experience spells of light-headedness, episodes of fainting, palpitations, or other symptoms.

Prevention

It may help to treat related disorders. You may need to avoid some medications, based on the guidance of your physician. Many times, the condition is not preventable.

References

Olgin JE, Zipes DP. In: Specific Arrhythmias: Diagnosis and Treatment. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. St. Louis, Mo: WB Saunders; 2007: chap. 35.

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