Tag Archives: Anesthesia

Inguinal hernia

Description:
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. Symptoms are present in about 66% of affected people.
It occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting protrusion can be painful, especially when you cough, bend over or lift a heavy object, exercise, or bowel movements. Often it gets worse throughout the day and improves when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.

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An inguinal hernia isn’t necessarily dangerous. It doesn’t improve on its own, however, and can lead to life-threatening complications. Your doctor is likely to recommend surgery to fix an inguinal hernia that’s painful or enlarging. Inguinal hernia repair is a common surgical procedure.

Sign & symptoms:
Hernias present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. They are rarely painful, and the bulge commonly disappears on lying down. Mild discomfort can develop over time. The inability to “reduce”, or place the bulge back into the abdomen usually means the hernia is ‘incarcerated’ which requires emergency surgery.

Causes & Risk Factors:
There isn’t one cause for this type of hernia, but weak spots within the abdominal and groin muscles are thought to be a major contributor. Extra pressure on this area of the body can eventually cause a hernia.

*heredity
*personal history of hernias
*premature birth
*being overweight or obese
*pregnancy
*cystic fibrosis
*chronic cough
*frequent constipation
*frequently standing for long periods of time

Significant pain is suggestive of strangulated bowel (an incarcerated indirect inguinal hernia).

As the hernia progresses, contents of the abdominal cavity, such as the intestines, liver, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed “strangulated” and gut ischemia and gangrene can result, with potentially fatal consequences. The timing of complications is not predictable. Emergency surgery for incarceration and strangulation carry much higher risk than planned, “elective” procedures. However, the risk of incarceration is low, evaluated at 0.2% per year. On the other hand, surgical intervention has a significant risk of causing inguinodynia, and this is why minimally symptomatic patients are advised to watchful waiting.

Diagnosis:
There are two types of inguinal hernia, direct and indirect, which are defined by their relationship to the inferior epigastric vessels. Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal, which is formed by the transversalis fascia. Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis.

Direct inguinal hernia: Enters through a weak point in the fascia of the abdominal wall (Hesselbach triangle)

Indirect inguinal hernia: Protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the processus vaginalis after the testicle passes through it.

In the case of the female, the opening of the superficial inguinal ring is smaller than that of the male. As a result, the possibility for hernias through the inguinal canal in males is much greater because they have a larger opening and therefore a much weaker wall through which the intestines may protrude.

A physical exam is usually all that’s needed to diagnose an inguinal hernia. Your doctor will check for a bulge in the groin area. Because standing and coughing can make a hernia more prominent, you’ll likely be asked to stand and cough or strain.

If the diagnosis isn’t readily apparent, your doctor might order an imaging test, such as an abdominal ultrasound, CT scan or MRI.

Treatment:

If your hernia is small and isn’t bothering you, your doctor might recommend watchful waiting. In children, the doctor might try applying manual pressure to reduce the bulge before considering surgery.

Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious complications.

There are two general types of hernia operations — open hernia repair and laparoscopic repair.

Open hernia repair:
In this procedure, which might be done with local anesthesia and sedation or general anesthesia, the surgeon makes an incision in your groin and pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing it with a synthetic mesh (hernioplasty). The opening is then closed with stitches, staples or surgical glue.

After the surgery, you’ll be encouraged to move about as soon as possible, but it might be several weeks before you’re able to resume normal activities.

Laparoscopy:
In this minimally invasive procedure, which requires general anesthesia, the surgeon operates through several small incisions in your abdomen. Gas is used to inflate your abdomen to make the internal organs easier to see.

A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other incisions to repair the hernia using synthetic mesh.

People who have laparoscopic repair might have less discomfort and scarring after surgery and a quicker return to normal activities. However, some studies indicate that hernia recurrence is more likely with laparoscopic repair than with open surgery.

Laparoscopy allows the surgeon to avoid scar tissue from an earlier hernia repair, so it might be a good choice for people whose hernias recur after traditional hernia surgery. It also might be a good choice for people with hernias on both sides of the body (bilateral).

Some studies indicate that a laparoscopic repair can increase the risk of complications and of recurrence. Having the procedure performed by a surgeon with extensive experience in laparoscopic hernia repairs can reduce the risks.

Prevention and Outlook of Inguinal Hernias:
Although you can’t prevent genetic defects that may cause hernias, it’s possible to lessen the severity of hernias by:

*Maintaining a healthy weight
*Eating a high-fiber diet
*Not smoking
*Avoiding heavy lifting

Early treatment can help cure inguinal hernias. However, there’s always the slight risk of recurrence and complications, such as infection after surgery, scars.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
https://en.wikipedia.org/wiki/Inguinal_hernia
http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/home/ovc-20206354
http://www.healthline.com/health/inguinal-hernia?isLazyLoad=false#causes3

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Previous studies have found that people with red hair are typically more sensitive to pain and more resistant to anesthesia — and require about 20 percent more of it to be effective.

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Resources:
BBC News August 11, 2009
Journal of the American Dental Association 2009 Vol 140, No 7, 896-905

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Cystourethrogram

Definition:
A cystourethrogram is an X-ray test that takes pictures of your bladder and urethra while your bladder is full and while you are urinating. A thin flexible tube (urinary catheter) is inserted through your urethra into your bladder. A liquid material that shows up well on an X-ray picture (contrast material) is injected into your bladder through the catheter, then X-rays are taken with the contrast material in your bladder. More X-rays may be taken while urine flows out of your bladder, in which case the test is called a voiding cystourethrogram (VCUG).

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By filling your bladder with a liquid dye that shows up on x-rays, your doctor can watch the motion of your bladder as it fills and empties and can see if your urine splashes backwards toward your kidneys as the bladder muscle squeezes. This kind of test can help your doctor to better understand problems with repeated urinary-tract infections or problems involving damage to the kidneys. It can also be useful for evaluating urine leakage problems.

If X-rays are taken while contrast material is being injected into the urethra, the test is called a retrograde cystourethrogram because the contrast material flows into the bladder opposite the usual direction of urine flow.

Why It Is Done
A cystourethrogram is done to:

*Find the cause of repeated urinary tract infections.
*Look for injuries to the bladder or urethra.
*Find the cause of urinary incontinence.
*Check for structural problems of the bladder and urethra.
*Look for enlargement (hypertrophy) of the prostate or narrowing (stricture) of the urethra in men.
*Find out if urinary reflux is present. See a picture of abnormal backflow of urine.
*Look more carefully at abnormalities first found by intravenous pyelography.

How To Prepare
Tell your doctor before the test if:.

*You are or might be pregnant.
*You have symptoms of a urinary tract infection.
*You are allergic to the iodine dye used in the contrast material or any other substance that contains iodine. Also tell your doctor if you have asthma, are allergic to any medicines, or have ever had a serious allergic reaction (anaphylaxis), such as after being stung by a bee or from eating shellfish.

*Within the past 4 days, you have had an X-ray test using barium contrast material, such as a barium enema, or have taken a medicine (such as Pepto-Bismol) that contains bismuth. Barium and bismuth can interfere with test results.

*You have an intrauterine device (IUD) in place.

You may be asked to sign a consent form authorizing this procedure. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results may mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?) .

If you are breast-feeding, give your baby formula for 1 to 2 days after the test.

How It Is Done

A cystourethrogram is done by a urologist or a radiologist. The doctor may be assisted by an X-ray technologist. You usually will not have to be admitted to the hospital.

You will need to take off all or most of your clothes, and you will be given a cloth or paper covering to use during the test. You will be asked to urinate just before the test begins.
You will be asked to wear a hospital gown and  lie on your back on an X-ray table. Your genital area will be cleaned and draped with sterile towels. Men may be given a lead shield that covers their genitals to protect them from radiation. But women’s ovaries cannot be shielded without blocking the view of the bladder.

A part of your genital area is cleaned with soap on a cotton swab. Then a soft, bendable rubber tube called a urinary catheter is inserted into your bladder, usually by a nurse. The tube is first coated with a slippery jelly and then pushed gently through the opening of the urethra (at the end of the penis for men and near the opening of the vagina for women).

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A sterile flexible cystoscope in an operating theatre

A catheter will be placed through your urethra and into your bladder. Contrast material will then slowly be injected through the catheter until your bladder is full.

You will feel some pressure while the tube slides into the urethra. Once it is in place, a tiny balloon on the end of the tube is filled with air to hold it in position. The other end (about 6 inches of tubing) hangs outside of your vagina or penis. The doctor uses this tube to fill your bladder with fluid containing a dye that shows up on x-rays. You will feel pressure in your bladder as it begins to expand.

To create a clear picture, your bladder needs to be filled with as much fluid as it can hold. You will probably feel a very strong urge to urinate. A few pictures are taken with the bladder completely full, and then the balloon is emptied and the tube is pulled out. You are given a urinal container or a bedpan and asked to urinate while you are still on the table under the x-ray camera. Several pictures are taken while your bladder is emptying. Many patients find this part of the test embarrassing, but it is routine and the doctor thinks nothing of it.

X-rays will be taken when you are standing up and sitting and lying down. The catheter is removed and more X-rays will be taken while you are urinating. You may be asked to stop urinating, change positions, and begin urinating again. If you are unable to urinate in one position, you may be asked to try it from another position.

After the test is over, drink lots of fluids to help wash the contrast material out of your bladder and to reduce any burning on urination.

This test usually takes 30 to 45 minutes.

How It Feels
You will feel no discomfort from the X-rays. The X-ray table may feel hard and the room may be cool. You may find that the positions you need to hold are uncomfortable or painful.

You will feel a strong urge to urinate at times during the test. You may also find it somewhat uncomfortable when the catheter is inserted and left in place. You will have a feeling of fullness in your bladder and an urge to urinate when the contrast material is injected. You may be sore afterward. If so, soaking in a warm tub bath may help.

You may feel embarrassed at having to urinate in front of other people. This procedure is quite routine for the X-ray staff. If you find yourself feeling embarrassed, take deep, slow breaths and try to relax.

During and after the test you may feel a burning sensation when you urinate. You may need to urinate frequently for several days after the test. You may also notice some burning during and after urination. Drink lots of fluids to help decrease the burning and to help prevent a urinary tract infection.

Risks Factors:
A cystourethrogram does not usually cause problems. Occasionally this test may lead to a urinary tract infection. If the contrast material is injected with too much pressure, there is some chance of damage to the bladder or urethra.

There is a small chance of having an allergic reaction to the x-ray dye used in the test. Some patients have some temporary irritation of their urethra after the tube has been in place, and this might result in some burning during urination for a few hours afterward. Let your doctor know if burning or pain with urinating lasts longer than a day; this could mean you have developed an infection.

As with all x-rays, there is a small exposure to radiation. In large amounts, exposure to radiation can cause cancers or (in pregnant women) birth defects. The amount of radiation from x-ray tests is very small-too small to be likely to cause any harm. X-rays such as this kind in the pelvic area should be avoided in pregnant women, because the developing fetus is more sensitive to the risks from radiation.

There is always a slight chance of damage to cells or tissue from radiation, including the low levels of radiation used for this test. However, the chance of damage from the X-rays is usually very low compared with the benefits of the test.

After the procedure
It is normal for your urine to have a pinkish tinge for 1 to 2 days after the test. Contact your doctor immediately if you have:

*Blood in your urine after 2 days.
*Lower belly pain.
*Signs of a urinary tract infection. These signs include:
*Pain or burning upon urination.
*An urge to urinate frequently, but usually passing only small amounts of urine.
*Dribbling or leaking of urine.
*Urine that is reddish or pinkish, foul-smelling, or cloudy.
*Pain in the back just below the rib cage on one side of the body (flank pain).
*Fever or chills.
*Nausea or vomiting.

Results
A cystourethrogram is an X-ray test that takes pictures of your bladder and urethra while you are urinating. Some results may be available immediately after the cystourethrogram. Final results are usually available within 1 to 2 days.

Cystourethrogram  Normal:

*The bladder appears normal.

*Urine flows normally from the bladder.

*The bladder empties all the way.

*The contrast material flows evenly out of the bladder through a smooth-walled urethra.

Cystourethrogram  Abnormal:

*Bladder stones,
*tumors,
*narrowing or pouches in the wall (diverticula) of the urethra or bladder are seen in the bladder.

*If the test was done because of possible injury to the bladder, a tear is found in the bladder wall or urethra.

*Urine flows backward from the bladder into the ureters (vesicoureteral reflux).

*Contrast material leaks from the bladder.

*The bladder does not empty all the way.

*The prostate gland is enlarged.

What Affects the Test
Reasons you may not be able to have the test or why the results may not be helpful include:
*Having barium (from a previous barium enema test), gas, or stool in the bowel.
*Being unable to urinate on command because of embarrassment at having to urinate in front of other people.
*Pain caused by having the catheter into the urethra. This may also cause problems with your urinary stream. You may have a muscle spasm or not be able to fully relax the muscles that control your bladder.
*A cystourethrogram is not usually done during pregnancy because the X-rays could harm an unborn baby.
Resources:
https://www.health.harvard.edu/fhg/diagnostics/cystourethrogram.shtml
http://www.webmd.com/a-to-z-guides/cystourethrogram-16691

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Video-Asisted Thoracic Surgery (VATS)

Introduction:
Video-assisted thoracic surgery (VATS) is a recently developed type of surgery that enables doctors to view the inside of the chest cavity after making only very small incisions. It allows surgeons to remove masses close to the outside edges of the lung and to test them for cancer using a much smaller surgery than doctors needed to use in the past. It is also useful for diagnosing certain pneumonia infections, diagnosing infections or tumors of the chest wall, and treating repeatedly collapsing lungs. Doctors are continuing to develop other uses for VATS.
..VATS->…  CLICK & SEE
When compared with a traditional open chest procedure, VATS has reduced the amount of chest wall trauma, deformity, and post-operative pain. While an open procedure generally requires a 30-40 cm incision, video-assisted biopsies can be performed through three 1 cm ports , and a VATS lobectomy, a resection of one lobe of the lung, is performed using a 5-8 cm incision.

How do you prepare for the test?
Discuss the specific procedures planned during your chest surgery ahead of time with your doctor. VATS is done by either a surgeon or a trained pulmonary specialist. You will need to sign a consent form giving the surgeon permission to perform this test. Talk to your doctor about whether you will stay in the hospital for any time after the procedure, so that you can plan for this.

You may need to have tests called pulmonary function tests (see page 33) before this surgery, to make sure that you can recover well.

If you are taking insulin, discuss this with your doctor before the test. If you take aspirin, nonsteroidal anti-inflammatory drugs, or other medicines that affect blood clotting, talk with your doctor. It may be necessary to stop or adjust the dose of these medicines before your test.

You will be told not to eat anything for at least eight hours before the surgery. An empty stomach helps prevent the nausea that can be a side effect of anesthesia medicines.

Before the surgery (sometimes on the same day), you will meet with an anesthesiologist to go over your medical history (including medicines and allergies) and to discuss the anesthesia.

What happens when the test is performed?

VATS is done in an operating room. You wear a hospital gown and have an IV (intravenous) line placed in your arm so that you can receive medicines through it.

VATS is usually done with general anesthesia, which puts you to sleep so you are unconscious during the procedure. General anesthesia is administered by an anesthesiologist, who asks you to breathe a mixture of gases through a mask. After the anesthetic takes effect, a tube is put down your throat to help you breathe. Your anesthesiologist can use this tube to make you breathe using only one of your lungs. This way the other lung can be completely deflated and allow the surgeon a full view of your chest cavity on that side during the procedure.

If VATS is being used only to evaluate a problem on the inside of the ribcage (not the lung itself), then it can sometimes be done using regional anesthesia. With regional anesthesia, you are not asleep during the surgery, but are given medicines that make you very groggy and that keep you from feeling pain in the chest. This is done with either a spinal block or an epidural block, in which an anesthesiologist injects the anesthetic through a needle or tube in your back or neck. You do your own breathing with this type of anesthesia, but one of your lungs will be partly collapsed to allow the doctors to move instruments between the lung and the chest wall.

When you meet with the thoracic surgeon, a physical exam will be performed and your treatment options will be discussed. The thoracic surgeon will discuss the benefits and potential risks of the surgical procedure that is recommended for you.

In general, preoperative tests include: (links will open in a new window)

*Blood tests
*Pulmonary function test (breathing test)
*CT scan
*Electrocardiogram

Your surgeon will determine if any additional preoperative tests are needed, based on the type of procedure that will be performed. If a cardiac (heart) evaluation is necessary, a consultation with a cardiologist will be scheduled in our internationally-renowned Miller Family Heart & Vascular Institute.

As part of your preoperative evaluation, you will meet with an anesthesiologist who will discuss anesthesia and post-operative pain control.

The thoracic surgery scheduler will schedule any additional tests and consultations that have been requested by your surgeon. In general, after your first meeting with your surgeon, all tests are scheduled on a single returning visit for your convenience.

You spend the surgery lying on your side. A very small incision (less than an inch long) is made, usually between your seventh and eighth ribs. Carbon dioxide gas is allowed to flow into your chest through this opening, while your lung on that side is made to partly or completely collapse. A tiny camera on a tube, called a thoracoscope, is then inserted through the opening. Your doctor can see the work he or she is doing by watching a video screen.

If you are having a procedure more complicated than inspection of the chest and lung, the doctor makes one or two other small incisions to allow additional instruments to reach into your chest. These additional incisions are usually made in a curving line along your lower ribcage. A wide variety of instruments are useful in VATS. These include instruments that can cut away a section of your lung and seal the hole left in your lung using small staples, instruments that can burn away scar tissue, and tools to remove small biopsy samples such as lymph nodes from your chest.

At the end of your surgery, the instruments are removed, the lung is reinflated, and all but one of the small incisions are stitched closed. For most patients, a tube (called a chest tube) is placed through the remaining opening to help drain any leaking air or fluid that collects after the surgery.

If you are having general anesthesia, it is stopped so that you can wake up within a few minutes of your VATS being finished, although you will remain drowsy for a while afterward.

How long will you stay in the hospital after thoracoscopic surgery?
The length of your hospital stay will vary, depending on the procedure that is performed. In general, patients who have thoracoscopic lung biopsies or wedge resections are able to go home the day after surgery. Patients who have a VATS lobectomy are usually able to go home 3 to 4 days after surgery.
Risk Factors:
It is easier for patients to recover from VATS compared with regular chest surgery (often called “open” surgery) because the wounds from the incisions are much smaller. You will have a small straight scar (less than an inch long) wherever the instruments were inserted. There are some potentially serious risks from VATS surgery. Air leaks from the lung that don’t heal up quickly can keep you in the hospital a longer time and occasionally require additional treatment. About 1% of patients have significant bleeding requiring a transfusion or larger operation.

Sometimes, especially if cancer is diagnosed, your doctors will decide that you need a larger surgery to treat your problem in the safest manner possible. Your doctors might discuss this option with you ahead of time. That way, if necessary, the doctors can change over to a larger incision and do open chest surgery while you are still under anesthesia. Death from complications of VATS surgery does occur in rare cases, but less frequently than with open chest surgery.

General anesthesia is safe for most patients, but it is estimated to result in major or minor complications in 3%-10% of people having surgery of all types. These complications are mostly heart and lung problems and infections.

Irritation of the diaphragm and chest wall can cause pain in the chest or shoulder for a few days. Some patients experience some nausea from medicines used for anesthesia or anxiety.

What will happen after your thoracoscopic surgery?
Your thoracic surgery team, including your surgeon, surgical residents and fellows, surgical nurse clinicians, social workers and anesthesiologist, will help you recovery as quickly as possible. During your recovery, you and your family will receive updates about your progress so you’ll know when you can go home.

Your health care team will provide specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet.

Most patients stay in the hospital for at least one day after a VATS procedure to recover from the surgery. Most patients have a chest tube left in the chest for a few days, to help drain out leaking air or collections of fluid. You should notify your doctor if you experience fever, shortness of breath, or chest pain.

Follow-Up Appointment: A follow-up appointment will be scheduled 7 to 10 days after your surgery. Your surgeon will assess the wound sites and your recovery at your follow-up appointment and provide guidelines about your activities and return to work.

Most people who undergo minimally invasive thoracic surgery can return to work within 3 to 4 weeks.

How long is it before the result of the test is known?
Your doctor can tell you how the surgery went as soon as it is finished. If biopsy samples were taken, these often require several days to be examined.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/video-assisted-thoracic-surgery.shtml
http://www.cancernews.com/data/Article/242.asp
http://my.clevelandclinic.org/thoracic/services/video_assisted.aspx

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Cluster headache

Definition:
A headache is pain or discomfort in the head, scalp, or neck. Serious causes of headaches are extremely rare.Cluster headaches are characterized by an intense one-sided pain centered by the eye or temple. The pain lasts for one to two hours on average and may recur several times in a day.

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Cluster headaches consist of brief periods of pain, often excruciating, in one part of the head. they occur in a characteristic pattern, usually between one and four times a day, and there may be gaps or months or years between each group of headaches. however, a small number of people have chronic cluster headaches that occur at regular intervals with very few remission periods between attacks. Like migraines, cluster headaches are likely to be related to an increase in blood flow as a result of widening of the blood vessels in the brain. Cluster headaches affect about 1 million people in the US, 9 in 10 of whom are men. Smoking cigarettes and drinking alcohol increase the risk. Most people with headaches can feel much better by making lifestyle changes, learning ways to relax, and occasionally by taking medications.

While migraines are diagnosed more often in women, cluster headaches are diagnosed more often in men. The male-to-female ratio in cluster headache ranges from 4:1 to 7:1. It primarily occurs between the ages of 20 to 50 years. This gap between the sexes has narrowed over the past few decades, and it is not clear whether cluster headaches are becoming more frequent in women, or whether they are merely being better diagnosed. Limited epidemiological studies have suggested prevalence rates of between 56 and 326 people per 100,000. Latitude plays a role in the occurrence of cluster headaches, which are more common as one moves away from the equator towards the poles.

Cluster headache, nicknamed “suicide headache,” is a neurological disease that involves, as its most prominent feature, an immense degree of pain. “Cluster” refers to the tendency of these headaches to occur periodically, with active periods interrupted by spontaneous remissions.

Causes:

The cause of the disease is currently unknown.Biochemical, hormonal, and vascular changes induce cluster headaches, but why these changes occur remains unclear. Episodic cluster headaches seem to be linked to changes in day length, possibly signaling a connection to the so-called biological clock. Alcohol, tobacco, histamine, or stress can trigger cluster headaches. Decreased blood oxygen levels (hypoxemia) can also act as a trigger, particularly during the night when an individual is sleeping. Interestingly, the triggers do not cause cluster headaches during remission periods.

Symptoms:
Cluster headaches often develop early in the morning. The major symptoms, which appear suddenly and affect one side of the head or face, include:

· severe pain around one eye or temple.
· watering and redness of the eye.
· drooping of the eyelid.
· stuffiness in the nostril and, sometimes, a runny nose on one side.
· flushing of one side of the face.

Individual episodes of pain may last from a few minutes to 3 hours. The average attack lasts 15-30 minutes. If you have a sudden, severe headache for the first time or if you have symptoms that are different from those of previous headaches, you should consult your doctors at once so that a more serious underlying cause can be excluded.

Cluster headaches are extremely painful, unilateral headaches of a piercing quality. The duration of the common attack is 15 minutes to three hours. Onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine. However, some sufferers report preliminary sensations of diverse description, often referred to as “shadows,” that may warn them an attack is imminent. Though the headaches are almost exclusively unilateral, there are many documented cases of “side-shifting” between cluster periods, or, even rarer, simultaneously (within the same cluster period) bilateral headache. They are often intially mistaken for brain tumors and Multiple Sclerosis often until patients are treated with corticosteroids and then imaged. Trigeminal neuralgia can also bring on headaches with similar qualities.

Pain
The degree of pain involved in cluster headaches is markedly greater than in other headache conditions, including migraine. It has been described by female patients as being more severe than childbirth. The pain is lancinating or boring in quality, and is located behind the eye or in the temple, sometimes radiating to the neck or shoulder. An analogy frequently used to describe the pain is that it is like a red-hot poker inserted into the eye. The condition was originally named Hortons Neuralgia after Dr. B.T Horton who postulated the first theory as to their pathologenesis. His original paper describes the severity of the headaches as being able to take normal men and force them to suicide.

From Horton’s 1939 original paper on cluster headache:

“Our patients were disabled by the disorder and suffered from bouts of pain from two to twenty times a week. They had found no relief from the usual methods of treatment. Their pain was so severe that several of them had to be constantly watched for fear of suicide. Most of them were willing to submit to any operation which might bring relief”

Other symptoms
The cardinal symptoms of the cluster headache attack are ptosis (drooping eyelid), conjunctival injection (red-eye), lacrimation (tearing), rhinorrhea (runny nose), and, less commonly, facial blushing, swelling, or sweating. These features are known as the autonomic symptoms. The attack is also associated with restlessness, the sufferer often pacing the room or rocking back and forth. Less frequently, he or she will have an aversion to bright lights and loud noise during the attack. Nausea is not typical of cluster headache, though it has been reported. The neck is often stiff or tender in the aftermath of a headache, with jaw or tooth pain sometimes present.


Cyclical recurrence and regular timing

Cluster headaches are occasionally referred to as “alarm clock headaches”, because of the regularity of its timing and its ability to wake a person from sleep. Thus it has been known to strike at the same time each night or morning, often at precisely the same time during the day a week later. This has prompted researchers to speculate an involvement of the brain’s “biological clock” or circadian rhythm. In some cases, cluster headaches remain “steady” without cyclical ups and downs for days.


Episodic or chronic

In episodic cluster headache, these attacks occur once or more daily, often at the same times each day, for a period of several weeks, followed by a headache-free period lasting weeks, months, or years. Approximately 10–15% of cluster headache sufferers are chronic; they can experience multiple headaches every day for years.

Cluster headaches occurring in two or more cluster periods lasting from 7 to 365 days with a pain-free remission of one month or longer between the clusters are considered episodic. If the attacks occur for more than a year without a pain-free remission of at least one month, the condition is considered chronic.[1] Chronic clusters run continuously without any “remission” periods between cycles. The condition may change from chronic to episodic and from episodic to chronic. Remission periods lasting for decades before the resumption of clusters have been known to occur.

Pathophysiology:
Cluster headaches are classified as vascular headaches. The intense pain is caused by the dilation of blood vessels which creates pressure on the trigeminal nerve. While this process is the immediate cause of the pain, the etiology (underlying cause or causes) is not fully understood.

Hypothalamus:
Among the most widely accepted theories is that cluster headaches are due to an abnormality in the hypothalamus; a British specialist of the disease, Dr. Goadsby has developed this theory. This can explain why cluster headaches frequently strike around the same time each day, and during a particular season, since one of the functions the hypothalamus performs is regulation of the biological clock. Metabolic abnormalities have also been reported in patients.

The hypothalamus is responsive to light—daylength and photoperiod; olfactory stimuli, including pheromones; steroids, including sex steroids and corticosteroids; neurally transmitted information arising in particular from the heart, the stomach, and the reproductive system; autonomic inputs; blood-borne stimuli, including leptin, ghrelin, angiotensin, insulin, pituitary hormones, cytokines, blood plasma concentrations of glucose and osmolarity, etc.; and stress. These particular sensitivities may underlay the causes, triggers, and methods of treatment of cluster headache.

Genetics
There is a genetic component to cluster headaches, although no single gene has been identified as the cause. First-degree relatives of sufferers are more likely to have the condition than the population at large. However, genetics appears to play a much smaller role in cluster headache than in some other types of headaches.

Diagnosis
Cluster headache symptoms guide the diagnosis. A medical examination includes recording headache details, such as frequency and duration, when it occurs, pain intensity and location, possible triggers, and any prior symptoms. This history allows other potential problems to be discounted.

Treatment:
Cluster headaches often go undiagnosed for many years, being confused with migraine or other causes of headache.

Medically, cluster headaches are considered benign, but because of the extreme and often debilitating pain associated with them, a severe attack is nevertheless treated as a medical emergency by doctors who are familiar with the condition. Because of the relative rareness of the condition and ambiguity of the symptoms, some sufferers may not receive treatment in the emergency room and patients may even be mistaken as exhibiting drug-seeking behavior.

Over-the-counter pain medications (such as aspirin, paracetamol, and ibuprofen) typically have no effect on the pain from a cluster headache. Unlike other headaches such as migraines and tension headaches, cluster headaches do not respond to biofeedback.

Some have reported partial relief from narcotic pain killers. Anecdotal evidence indicates that cluster headaches can be so excruciating that even morphine does little to ease the pain. However, some newer medications like fentanyl (and Percocet) have shown promise in early studies and use.

Medications to treat cluster headaches are classified as either abortives or prophylactics (preventatives). In addition, short-term transitional medications (such as steroids) may be used while prophylactic treatment is instituted and adjusted. With abortive treatments often only decreasing the duration of the headache and preventing it from reaching its peak rather than eliminating it entirely, preventive treatment is always indicated for cluster headaches, to be started at the first sign of a new cluster cycle.

In many cases, some doctors have tried the use of beta blockers as a treatment.

Prophylactic treatment
A wide variety of prophylactic medicines are in use, and patient response to these is highly variable. Current European guidelines suggest the use of the calcium channel blocker verapamil at a dose of at least 240 mg daily. Steroids, such as prednisolone, are also effective, with a high dose given for the first five days before tapering down. Methysergide, lithium and the anticonvulsant topiramate are recommended as alternative treatments.

Muscle relaxants and atypical anti-psychotics have also been used.

Magnesium supplements have been shown to be of some benefit in about 40% of patients. Melatonin has also been reported to help some.

Other neuropathic pain alleviating agents can also be used such as amyltryptaline

Non-established and research approaches
There is substantial anecdotal evidence that serotonergic psychedelics such as psilocybin (mushrooms) and LSD and LSA d-Lysergic acid amide (Rivea corymbosa seeds) abort cluster periods and extend remission periods. Melatonin, psilocybin, serotonin, and the triptan abortive drugs are closely-related tryptamines.

Dr. Andrew Sewell and Dr. John Halpern at McLean Hospital in Boston have investigated the ability of low doses of psilocybin (“magic mushrooms”) to treat cluster headaches. Dr. Sewell examined medical records of 53 patients who had taken hallucinogenic mushrooms and reported in Neurology that the majority of them found partial or complete relief from cluster attacks. A clinical study of these treatments under the auspices of MAPS is being developed by researchers at Harvard Medical School, McLean Hospital.

Within the United States, the Controlled Substances Act (CSA) of 1970 makes it illegal to possess hallucinogens (including psilocybin and LSD), classifying them as Schedule I drugs with no legitimate medical use. Patients who use psilocybin to treat their symptoms face legal prosecution, although there are no known convictions.

What might be done?
Your doctor may prescribe an anti-migraine drug, which will help reduce the length of a cluster attack and decrease the severity of the headaches. anti-migraine drugs should be taken as soon as possible after the headache starts. If these drugs do not help, lithium is some effective.

If the cluster is prolonged, a short course of corticosteroids may help prevent the headaches from recurring. These drugs should be gradually reduced in dose, as advised by your doctor, as the headaches disappear.

If you have cluster headaches, you should not smoke cigarettes or drink even small amounts of alcohol because both increase the risk of an attack.

Cluster headaches may continue for the rest of your life, but you may have prolonged periods of remission.

Home Care
Keep a headache diary to help identify the source or trigger of your symptoms. Then modify your environment or habits to avoid future headaches. When a headache occurs, write down the date and time the headache began, what you ate for the past 24 hours, how long you slept the night before, what you were doing and thinking about just before the headache started, any stress in your life, how long the headache lasts, and what you did to make it stop. After a period of time, you may begin to see a pattern.

A headache may be relieved by resting with your eyes closed and head supported. Relaxation techniques can help. A massage or heat applied to the back of the upper neck can be effective in relieving tension headaches.

Try acetaminophen, aspirin, or ibuprofen for tension headaches. DO NOT give aspirin to children because of the risk of Reye’s syndrome.

Migraine headaches may respond to aspirin, naproxen, or combination migraine medications.

If over-the-counter remedies do not control your pain, talk to your doctor about possible prescription medications.

Prescription medications used for migraine headaches include ergotamine, dihydroergotamine, ergotamine with caffeine (Cafergot), isometheptene (Midrin), and triptans like sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax), almotriptan (Axert), and zolmitriptan (Zomig). Sometimes medications to relieve nausea and vomiting are helpful for other migraine symptoms.

If you get headaches often, your doctor may prescribe medication to prevent headaches before they occur. Examples of these include:

Antidepressants such as nortriptyline (Pamelor), amitriptyline (Elavil), fluoxetine (Prozac, Sarafem), sertraline (Zoloft), or paroxetine (Paxil) for tension or migraine headache
Beta-blockers such as propranolol (Inderal) for frequent migraine headaches
Calcium channel blockers such as verapamil for frequent migraine headaches
Anti-epileptic medicines such as topiramate (Topamax)
If you are using pain medications more than 2 days a week, you may be suffering from rebound headaches. Rebound headaches are caused by a cycle of using pain medications for short-term relief, followed by the headache pain returning for increasingly longer periods of time despite taking more pain medications.

All types of pain pills (including over-the-counter drugs), muscle relaxants, some decongestants, and caffeine can cause this pattern. If you think this may be a problem for you, talk to your health care provider.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Cluster_headache
http://www.charak.com/DiseasePage.asp?thx=1&id=4
www.healthline.com/adamcontent/headache?
http://www.healthatoz.com/