FitSugar

RDI: What About All Those B Vitamins?

FitSugar — Sun, 28 Oct 2007 02:00:00 -0700

So I gave you a quiz about your RDI of the basic vitamins and minerals. I didn't mention anything about B vitamins though.

When it comes to B vitamins, there are so many that it can be confusing to know what is what. So, take this quiz to stay on track and learn a bit more about the B world.

Take the quiz

Know your A, B, Cs: Riboflavin

FitSugar — Fri, 01 Dec 2006 02:00:00 -0800

How many times have you seen Riboflavin listed as an ingredient and thought "another food additive." Well it is not. Riboflavin is the scientific name for vitamin B2.

Like other B vitamins, Riboflavin aids in the production of metabolizing food by converting carbs into sugar which is burned to produce energy. B2 joins forces with the other B vitamins to break down fats and protein. It also promotes healthy skin, hair and nails and general good health.

Riboflavin is also used as food coloring because of its bright yellow-orange hue. It is the culprit for turning your pee that intense yellow if you take a multi-vitamin, which you should consider since the body does not store riboflavin.

Spinach and asparagus are both high in B2s as are milk, cheese, almonds, yeast and liver – does any one out there eat liver anymore? I am truly curious.

Wondering how much of Riboflavin you need - the RDA for adult women is 1.2 mg and a cup of spinach contains about 25% of your daily need. Worried that you are not getting enough of it? Signs of deficiency include cracked and red lips, inflammation of the lining of mouth and tongue, mouth ulcers, cracks at the corners of the mouth, and bloodshot or itchy eyes.

Riboflavin

admin — Thu, 04 Sep 2008 18:56:04 -0700

Illustrations

Vitamin B2 benefit

Vitamin B2 source

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Riboflavin is a type of B vitamin. It is water soluble, which means it is not stored in the body. You must replenish the vitamin every day.

Alternative Names

Deficiency - vitamin B2; Vitamin B2 deficiency; Diet - riboflavin; Vitamin B2

Function

Riboflavin (vitamin B2) works with the other B vitamins. It is important for body growth and red blood cell production and helps in releasing energy from carbohydrates.

Food Sources

Lean meats, eggs, legumes, nuts, green leafy vegetables, dairy products, and milk provide riboflavin in the diet. Breads and cereals are often fortified with riboflavin.

Because riboflavin is destroyed by exposure to light, foods with riboflavin should not be stored in glass containers that are exposed to light.

Side Effects

Deficiency of riboflavin is not common in the United States because this vitamin is plentiful in the food supply. Symptoms of significant deficiency syndromes include sore throat, swelling of mucous membranes, mouth or lip sores, anemia, and skin disorders.

Because riboflavin is a water-soluble vitamin, leftover amounts leave the body through the urine. There is no known poisoning from riboflavin.

Recommendations

Recommended daily allowances (RDAs) are defined as the daily levels of essential nutrients a persons needs. The best way to get the daily requirement of essential vitamins is to eat a balanced diet that contains a variety of foods from the food guide pyramid.

Specific recommendations for each nutrient depend on age, gender, and other factors (such as pregnancy). Ask your health care provider what is best for you.

Review Date: 1/2/2007

Reviewed By: William McGee, M.D., M.H.A., Assistant Professor of Medicine and Surgery, Tufts University School of Medicine, Boston, MA, and Chairman, Nutrition Committee, Baystate Medical Center, Springfield, MA. 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).

A.D.A.M. Copyright

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. © 1997-2010 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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Source Doc: 1_002411

Are You an Egghead? Egg Whites vs. Whole Eggs

FitSugar — Tue, 09 Feb 2010 05:50:23 -0800

If you're looking to cut calories, fat, and cholesterol from your diet, you may choose an omelet made of egg whites instead of whole eggs for breakfast. But is choosing egg whites over whole eggs really the best choice nutritionally? The only way to find out is to do a little comparing, so check out my chart when you read more.

As you can see from the chart, choosing straight up egg whites does lower the omelet's calories, fat, and cholesterol content, but it also makes the meal void of vitamins B2, B12, D, and iron. If you're concerned about getting enough of those nutrients, a good option would be to eat an omelet made of one whole egg and two egg whites. It's still low in calories, fat, and cholesterol, but you'll get some vitamins from the egg yolk.

How to Eat the Vitamins and Minerals You Need

FitSugar — Wed, 02 Dec 2009 03:47:18 -0800

Many people I know take a multivitamin because they're worried about getting all the vitamins and minerals they need each day. Hopefully you're already meeting your daily nutritional requirements with your diet. But since it's hard to remember how much you need of each nutrient, and how much of each food helps you obtain it, I made a handy little chart to help us all meet the recommended daily intake (RDI) of many vitamins and minerals.

To see the rest, read more.

Cataracts

FitSugar — Wed, 08 Oct 2008 17:35:39 -0700

In This Report

Highlights
Introduction
Causes
Symptoms
Prognosis
Risk Factors
Prevention
Diagnosis
Treatment
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Medical Societies Issue Tamsulosin (Flomax) Warning

In August 2006, the American Society of Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology, and the American Urological Association (AUA) issued a joint warning concerning Tamsulosin (Flomax). The societies advised patients to be sure to inform their eye surgeons if they are taking this drug. Tamsulosin is frequently prescribed to treat prostate enlargement.

The ACSRS has developed specific cataract surgery techniques for cataract patients who take this drug. Recent research suggests that these new techniques produce successful surgical outcomes.
The AUA warns that while men are primarily at risk, more women may be at risk in the future as Tamsulosin is increasingly being prescribed for urinary retention.

Cost of Cataracts

Cataracts cost the United States nearly $7 billion a year in medical services and pharmaceutical costs, according to a 2006 report in the Archives of Ophthalmology.

Can Statins Reduce Cataract Risk?

Statin drugs, which are used to manage cholesterol levels, are associated with a lower risk of nuclear cataract -- the most common type of age-related cataract -- according to a 2006 study in the Journal of the American Medical Association. Researchers think that the antioxidant properties of statins may account for this association.

Cataract Surgery

A new surgical technique, phacoviscocanalostomy, works well for patients who have both glaucoma and cataracts, suggests a 2006 study in the Journal of Cataract and Refractive Surgery.
Newer methods of administering local anesthesia are resulting in fewer complications than older methods, indicates a 2006 study in the British Journal of Ophthalmology.

Intraocular Lenses (IOLs)

The Tecnis ZM001 IOL helped produce better reading clarity and reading speed than several other newer multifocal IOLs, according to a 2006 comparison study. Multifocal IOLs are used for patients who need correction for both farsightedness and nearsightedness.

Introduction

A cataract is an opacity, or clouding, of the lens of the eye.

The lens of an eye is normally clear. If the lens becomes cloudy or is opacified, it is called a cataract.

The prevalence of cataracts increases dramatically with age. It typically occurs in the following way:

The lens is an elliptical structure that sits behind the pupil and is normally transparent. The function of the lens is to focus light rays into images on the retina (the light-sensitive tissue at the back of the eye).
In young people, the lens is elastic and changes shape easily, allowing the eyes to focus clearly on both near and distant objects.
As people reach their mid-40s, biochemical changes occur in the proteins within the lens, causing them to harden and lose elasticity. This causes a number of vision problems. For example, loss of elasticity causes presbyopia, or far-sightedness, requiring reading glasses in almost everyone as they age.
In some people, the proteins in the lens, notably those called alpha crystallins, may also clump together, forming cloudy (opaque) areas called cataracts. They usually develop slowly over several years and are related to aging. In some cases, depending on the cause of the cataracts, loss of vision progresses rapidly.
Depending on how dense they are and where they are located, cataracts can block the passage of light through the lens and interfere with the formation of images on the retina, causing vision to become cloudy.

Click the icon to see an image of eye anatomy.

Cataracts can form in any of three parts of the lens and are named by their location.

Nuclear cataracts. These form in the nucleus (the inner core) of the lens. This is the most common variety of cataract associated with the aging process.
Cortical cataracts. These form in the cortex (the outer section of the lens).
Posterior subcapsular cataracts. These form toward the back of a cellophane-like capsule that surrounds the lens. They are more frequent in people with diabetes, who are overweight, or those taking steroids.

Causes

Although older age is the primary risk factor for cataracts, experts are still not certain about the exact biologic mechanisms that tie cataracts to aging.

Researchers have been focusing on particles called oxygen-free radicals as a major factor in the development of cataracts. They cause harm in the following way:

Oxygen free radicals (also called oxidants) are molecules produced by natural chemical processes in the body. Toxins, smoking, ultraviolet radiation, infections, and many other factors can create reactions that produce excessive amounts of these oxygen free radicals.
Oxidants are missing an electron, so they are unstable and tend to chemically bind with other molecules in the body. When oxidants are overproduced, these chemical reactions can be very harmful to nearly any type of cell in the body. At times these reactions can even effect genetic material in cells.
Cataract formation is one of many destructive changes that can occur with overproduction of oxidants, possibly in concert with deficiencies of an important protective anti-oxidant called glutathione.
Glutathione occurs in high levels in the eye and helps clean up these free radicals. One theory posits that in the aging eye, barriers develop that prevent glutathione and other protective antioxidants from reaching the nucleus in the lens, thus making if vulnerable to oxidation.

Sunlight and Ultraviolet Radiation. Sunlight consists of ultraviolet (referred to as UVA or UVB) radiation, which penetrates the layers of the skin. Both have destructive properties that can promote cataracts. The eyes are protected from the sun by eyelids and the structure of the face (overhanging brows, prominent cheekbones, and the nose). Long-term exposure to sunlight, however, can overcome these defenses.

UVB radiation produces the shorter wavelength, and primarily affects the outer skin layers. It is the primary cause of sunburn. It is also the UV radiation primarily responsible for cataracts. Long-term exposure to even low levels of UVB radiation can eventually cause changes in the lens, including pigment changes, which contribute to cataract development. (UVB also appears to be responsible for macular degeneration, an age-related disorder of the retina.) Some scientists suggest that global warming and ozone depletion may increase people’s exposure to UVB, leading to a greater incidence of cataracts.
UVA radiation is composed of longer wavelengths. They penetrate more deeply and efficiently into the inner skin layers and are responsible for tanning. The main damaging effect of UVA appears to be the promotion of the release of oxidants.

Radiation Treatments. Cataracts are common side effects of total body radiation treatments, which are administered for certain cancers.

Electromagnetic Waves. Questions have been raised about the hazards of low-level radiation from computer screens. To date, no study has demonstrated an association between cataract development and video display terminals. It is a good idea, in any case, to sit at least a foot away from the front of a screen.

Cataracts are one of the many ill effects caused by smoking. Many studies have implicated smoking in the development of nuclear cataracts. The major damaging effects of cigarette smoke appear to be enhancement of free oxygen radicals, the chemical byproducts in the body that can damage cells, including those in the eye.

Corticosteroids. Long-term use of oral steroids is a well-known cause of cataracts. Studies have been conflicting, however, over whether inhaled and nasal-spray steroids increase the risk for cataracts. Information on cataract risk from inhaled steroids is important because they are commonly used by asthma patients, and steroid spray use is increasing among allergy sufferers. Studies have suggested a higher risk for cataracts among middle-aged and elderly patients treated with beclomethasone (Beclovent, Vanceril). However, newer inhaled steroids are available, and their effects on the eye are unclear. In children, cataracts are rare, and the benefits of inhaled steroids for asthma far outweigh any small additional risk.

Other Medications Associated with Cataracts.

Psoralens, a class of drugs used along with light therapy to treat skin disorders, such as psoriasis
Antipsychotic medications such as chlorpromazine (Thorazine)
Glaucoma medications

Many others drugs have been weakly associated with cataracts, including allopurinol, tamoxifen, amiodarone, tricyclic antidepressants, potassium-sparing diuretics (but not other diuretics), thyroid hormone, tetracyclines, sulfamidase, and mepacrine. According to a 2006 study in the Journal of the American Medical Association, statin drugs (used for managing cholesterol) may possibly reduce the risk for nuclear cataracts.

Click the icon to see an animation about cataracts.

Glaucoma. Glaucoma and its treatments, including certain drugs (notably miotics) and filtering surgery, pose a high risk for cataracts. The glaucoma drugs posing a particular risk for cataracts including demecarium (Humorsol), isoflurophate (Floropryl), and echothiophate (Phospholine).

Uveitis. Uveitis is chronic inflammation in the eye, which is often caused by an autoimmune disease or response. Often the cause is unknown. It is a rare condition that carries a high risk for cataracts.

A number of medical conditions appear to be associated with a higher risk for cataracts either because of a direct effect or because of the medications used for them, or both. They include the following:

Diabetes. Cataracts in patients with diabetes appear to form when high levels of blood sugar react with proteins in the eye to form byproducts that accumulate in the lens (sugar cataracts).
High blood pressure (hypertension).
Autoimmune diseases including rheumatoid arthritis, psoriasis, multiple sclerosis, systemic lupus erythematosus, Behcet's disease, and others.

Rarely, about 1 in every 10,000 births, a baby is born with cataracts (called congenital cataracts).

Inherited disorders are often involved in the development of congenital cataracts in children. Such cataracts are most often due to inborn abnormalities in the structure or shape of the lens, including its capsule. Dozens of variations can affect the lens causing, susceptibility to cataracts. Researchers are also investigating genetic factors that may cause mutations in alpha crystallins -- major proteins in the lens, which form cataracts. (Genetic factors also may play a role in some adult cataract cases. The exact hereditary predispositions have yet to be established.)
Infection during pregnancy can lead to cataracts.
Pregnant women who abuse alcohol or drugs increase the risk for cataracts (along with other more serious birth defects) in their infants.

Surgery in children with early-onset cataracts can help correct this problem in many cases, but it should be performed as soon as possible for full benefit. Experts recommend routine examination of the face of a fetus during ultrasound for abnormalities.

Symptoms

During the early stages, cataracts have little effect on vision. The symptoms of a cataract may include:

Cloudy vision, double vision, or both may be the first signs.
Images may take on a yellowish tint as color vibrancy diminishes.
Reading may become difficult over time because of a reduced contrast between letters and their background.
Sensitivity to bright lights may make it difficult or impossible to drive at night because of glare from the headlights of oncoming cars. (People with diffuse cataracts in the rear walls of their lenses are particularly prone to glare sensitivity because bright light tends to scatter in their lenses.)
In very advanced cases, the pupil, which is normally black, looks milky or yellowish. The patient's vision is reduced to being able only to distinguish light from dark.

This photograph shows a cloudy white lens (cataract) over the pupil. Cataracts are a leading cause of decreased vision in older individuals, but children may have congenital cataracts. With new surgical techniques, the cataract can be removed, a new lens implanted, and the person can usually return home the same day.

Nuclear Cataracts. Cataracts of the lens nucleus are most commonly associated with aging. Symptoms include:

Hazy distance vision and increasing glare.
Progressive nearsightedness and the need for frequent changes in eyeglass prescriptions. This effect may even temporarily counteract age-related farsightedness and provide a temporary improvement in overall vision in some people. The improvement fades when the cataract advances sufficiently to overwhelm the inherent farsightedness. Eventually, as the cataracts grow worse, stronger glasses can no longer correct the patient's vision.

Click the icon to see an image of normal, near, and farsighted vision.

Cortical Cataracts. Cortical cataracts usually start on the outside of the cortex (the outer area of the lens).

They have very little initial effect on vision.
Glare can develop as these cataracts increase and approach the center of the lens.
Problems with distance vision, contrast sensitivity, and clarity may occur as the cataracts progress further.

Posterior Subcapsular Cataracts. Posterior subcapsular cataracts typically start near the center of the back part of the capsule surrounding the lens. These cataracts often advance rapidly. For many patients, major impairment of eyesight, including near-vision problems and glare, develops within several months.

Prognosis

Some cataracts stop progressing after a certain point. Cataracts are never reversible, however, even after eliminating factors, (such as drugs or illnesses), which might have promoted their development. If extensive and progressive cataracts are left untreated they can cause blindness. In fact, cataracts are the leading cause of blindness among adults age 55 and older. About 20.5 million Americans have at least one cataract. By 2020, that number is expected to jump to 30.1 million.

Fortunately, cataracts nearly always can be successfully removed with surgery. However, surgery is unavailable in certain parts of the world, leaving millions at risk for vision loss. Even in the U.S., where surgery has greatly reduced the risk of blindness, tens of thousands still lose their sight and millions more have poor vision because of cataracts. Cataracts also exact a financial burden. According to 2006 data, cataracts cost the U.S. nearly $7 billion each year in medical services and drug treatments.

In a 2001 study, cataracts were associated with a significantly higher mortality rate in older women, although not older men. These higher rates did not seem to be caused by certain health risks (for example, diabetes) that are often associated with both cataracts and lower survival rates. A 2004 study published by scientists in Italy appears to confirm the association between shortened lifespan and cataracts, especially cataracts confined to the lens nucleus and those that had already required surgery. A few other studies have also linked cataracts and vision impairment with poorer survival, regardless of accompanying health problems. One study reported that even middle-aged people with cataracts, particularly those in ethnic minority groups, had lower survival rates than their peers, perhaps because of premature aging.

Effect on Survival by Location of the Cataract. Some studies have suggested poorer survival specifically in patients with nuclear or mixed cataracts but not in those with cataracts in the cortex or capsule. Not all studies have found these differences. In any case, nuclear cataracts are highly associated with smoking and diabetes, although some studies have found lower survival rates in patients with nuclear cataract regardless of these health risks.

A 2002 study reported twice the rate of automobile accidents in patients who do not have cataract surgery compared to those who had surgery. This finding, however, is obscured by the possibility that patients who choose not to have surgery may have other health problems that put them at risk for accidents. Also, driving skills decline with age in nearly everyone. Cataract surgery, then, is no insurance against age-related accidents.

Reduced vision ranks third only behind arthritis and heart disease as a cause of impaired function in older people. Extensive cataracts can compromise the ability to earn a living, read, drive, or live independently. Although vision loss has been associated with a number of major adverse effects, few studies have reported on the effect of vision on daily activities.

Both blurred vision and problems in seeing contrasts contribute to impaired activity. The degree of these impairments, however, may have different effects on disability depending on individual tasks and needs. For example, even a slight loss in vision sharpness and contrast can impair the ability to recognize faces or slow down reading speed. For those who read very quickly, this may not be significant, but it could be very disabling for slower readers. In one study, people under age 65 rated blurred vision as reducing their quality of life more than any other chronic medical problem except shortness of breath.

Nevertheless some people who have small cataracts can see well enough around the clouded areas to live normally. But for many people, cataracts are extensive enough to interfere greatly with daily activities.

Risk Factors

Aging is the primary risk factor for cataracts, but other factors are also involved.

Nearly everyone who lives long enough will develop cataracts to some extent. A major study reported that:

About 40% of people age 55 - 64 years had some opaque areas in their lenses, and 5% had fully-developed cataracts.
About 70% of people age 65 - 74 years had opaque areas, and 18% had cataracts.
More than 90% of people age 75 - 84 years had opaque areas, and almost 50% had cataracts.

One study indicated that posterior subcapsular cataracts are the most common type in people under 70 years old, while nuclear and mixed cataracts are most common in people over age 80. The risk for nuclear cataracts also increases with age.

Women face a higher risk than men. Women who started menstruating late are at an even higher risk.

Eye Features. People who are nearsighted and those with brown eyes may be at higher than average risk. (Not all studies, however, report a higher risk in people with darker eyes.)

Obesity and Height. Studies are now reporting obesity as a risk factor for cataracts, notably posterior subcapsular cataracts, which form toward the back of the lens. A study of 17,150 people found a specifically higher rate of cataracts in overweight people who are tall and whose fat distribution is primarily in the abdomen.

A 9-year population study, published in 2004, revealed that African Americans have nearly twice the risk of developing cataracts than do Caucasians. Analysis of the 3,000 participants also demonstrated for the first time that the risk of cortical cataracts is 3 times higher in African Americans than Caucasians. Earlier studies also identified a higher cataract risk in the black population, suggesting that it may be due to other medical illnesses, particularly diabetes. It has long been known that African Americans are much more likely to become blind from cataracts and glaucoma than Caucasians, mostly due to lack of treatment.

Hispanic Americans are also at increased risk for cataracts. In fact, cataracts are the leading cause of visual impairment among Hispanics. A 2005 study found that cataracts were about 3 times more common in Hispanic patients age 65 - 84 years than in similarly aged white or African Americans. (The study evaluated Hispanic patients of Mexican descent.) As with African Americans, Hispanic patients often face barriers to access to care.

People with certain medical conditions, notably diabetes, are at high risk for cataracts, either because of a direct effect of the disease, its treatments, or both.

Autoimmune Diseases and Conditions Requiring Steroid Use. Medical conditions requiring high use of corticosteroids (commonly called steroids) pose a particularly high risk. Many of these medical conditions are autoimmune diseases, including rheumatoid arthritis, psoriasis, multiple sclerosis, systemic lupus erythematosus, Behcet's disease, and others.

Diabetes and People with High Blood Glucose Levels. People with diabetes type 1 or 2 are at very high risk for cataracts and are much more likely to develop them at a younger age. They also have a higher risk for nuclear cataracts than nondiabetics. Cataract development is significantly related to high levels of blood sugar (called glycemia), and cataracts in people with diabetes are sometimes referred to as so-called sugar cataracts. Even people without diabetes but with higher-than-normal blood sugar levels are at high risk for cataracts. Some doctors now recommend that children with diabetes undergo an eye exam to check for cataracts at the time they are diagnosed.

Insulin is a hormone produced by the pancreas that is necessary for cells to be able to use blood sugar.

Exposure to even low-level UVB radiation from sunlight increases the risk for cataracts. A 2003 study published provided new evidence supporting the link between sun exposure and nuclear cataracts. The risk was highest among those who had significant sun exposure at a young age. Additional studies suggesting risk associated with sunlight exposure report:

The closer people live to the equator the greater the chance for cataracts. As suggested by a study in Southern France, sunlight exposure in these climates also increases the risk for severe cortical or mixed cataracts. In this study, even wearing sunglasses did not reduce the risk for these cataracts, although it did for posterior subcapsular cataracts.
People whose jobs expose them to sunlight for prolonged periods are at higher risk. People in southern climates whose occupations, such as fishing or oyster farming, exposed them to very intense sunlight were at high risk for all cataracts, including posterior subcapsular cataracts. (People in more northern climates with similar occupations may not have as high a risk.)
Occupational exposure to very intense artificial light, such as arc welding, increases the risk for cataracts.

Smokers. A study of nearly 18,000 doctors showed that those who smoked 20 or more cigarettes a day had approximately twice the risk of developing cataracts. Smokers are at particular risk for cataracts located in the nuclear portion of the lens, which limit vision more severely than cataracts in other sites. Quitting smoking may reverse some of this damage.

Alcohol Users. Chronic drinkers are at high risk for a number of eye disorders, including cataracts. Alcohol has been implicated in cataract development in a number of studies. Wine provided the least risk, and the more moderate the drinking the lower the risk. Alcohol may work directly on the proteins in the lens itself and indirectly by affecting absorption of nutrients important to the lens.

Long-term environmental lead exposure may increase the risk of developing cataracts according to a study published in the Journal of the American Medical Association. Researchers assessed bone lead levels in 795 men aged 60 years and older. Because lead tends to accumulate over time in the skeleton, the researchers measured lead levels in the men’s shin bones. Men with the highest levels of lead were three times more likely to have cataracts than men with the least amount of lead.

A poor diet may deprive the body of amino acids and B vitamins that are essential for eye health. A French study of elderly adults found that lower blood levels of the protein albumin were associated with an increased risk of cataracts.

Other conditions that can trigger the process leading to cataracts include:

Physical injury to the eye (such as a hard blow, cut, or puncture)
Chemical burns
Electrical shock injuries
Chronic exposure to intense heat or cold

Prevention

Although cataracts are not completely preventable, their occurrence can be delayed. Quitting smoking, avoiding overexposure to sunlight, drinking alcohol in moderation, and eating plenty of fresh fruits and vegetables can delay the formation of cataracts. No evidence exists that using eye drops or ointments or performing eye exercises will stem the onset of cataracts.

The simplest and most effective way to protect against ultraviolet (UV) radiation is to stay out of the sun. A hat and cover-up should be worn outside, particularly when the sun is most intense (10 AM - 3 PM). A wide-brimmed hat can reduce eye exposure to UVB radiation by 30 - 50%. Because the sun's rays are highly reflective, sitting in the shade or under an umbrella by itself does not guarantee protection.

Clothing that blocks or screens the harmful rays of the sun (UVA and UVB), in combination with wide-brimmed hats, sunglasses, and sunscreen, all help prevent damage to the eyes and skin. Any one of these by itself, even the sunscreen, may not be enough to prevent sun damage.

Note: Avoidance of the sun should not be taken to extremes. Some sunshine is desirable. Moderate sun exposure provides an important source of vitamin D, which is essential for healthy bones. There is a link between lack of sun exposure and depression (known as seasonal affective disorder, or SAD).

Click the icon to see an image of vitamin D.

Sunglasses. Protective sunglasses do not have to be expensive. Sunglasses are classified into three categories based on UVA and UVB protection:

Cosmetic purpose sunglasses block at least 70% UVB and up to 60% UVA. People should avoid these glasses if they have any risk for cataracts or eye problems.
General purpose sunglasses block at least 95% UVB and a minimum of 60% UVA. At the very least, people should purchase general purpose sunglasses that are labeled "Meets ANSI Z80.3 General Purpose UV Requirements." Labels should indicate that sunglasses block UV radiation up to 400 nm.
Special purpose sunglasses block at least 99% UVB and a minimum of 60% UVA rays. These are the optimal sunglasses for people at risk for cataracts. Ideally they should have the Skin Cancer Foundation's Seal of Recommendation for Sunglasses. Special purpose glasses should wrap around the head and block light coming from above, below, and both sides of the glasses. They should also fit snugly on the nose.
Lenses that are simply dark but not coated with UV-absorbing material may actually increase the risk of cataracts because the pupil widens to compensate for the shaded glass. This may allow more harmful ultraviolet waves to enter. Polarized glasses cut glare but have no effect on UV radiation. Mirror finishes without additional processing for UV blockage are also not fully protective. There is some controversy over whether blue light is harmful to the eyes. Some people prefer amber lenses, which block out the blue spectrum.

Antioxidant vitamins C and E. Because of the role oxidants may play in cataract formation, researchers are investigating the benefits of antioxidant vitamins and other food chemicals. Vitamins C, E, and riboflavin (a B vitamin), for example, are helpful in preserving levels of glutathione, an enzyme that helps protect against oxidation in the eye. Low levels of vitamin C in the lens of the eye have been particularly strong predictors of cataracts. Some evidence also suggests that ultraviolet B radiation interacts with deficiencies in certain antioxidants, such as vitamin E and zinc, to increase damage in the corneas and lenses of the eye.

Evidence on the benefits of supplements of vitamin E or C, or vitamin-rich foods, is conflicting. For example, in two identically constructed trials in the US and Britain, the American group derived apparent benefits from vitamins E, C, and beta carotene while the British group reported very little cataract protection. A 2005 study suggested that long-term use of vitamin E supplements may slow cataract development. However, in a major on-going American study called the Age-Related Eye Disease Study (AREDS), researchers reported no difference in the incidence of cataracts after 7 years in people who took the antioxidant vitamins compared to those who took sham vitamins.

High doses of vitamins may have harmful effects. It is always wise, in any case, to pursue a healthy diet that is low in fats, high in complex carbohydrates, and rich in fruits and vegetables.

B vitamins. Some studies report some protection from a number of B vitamins, including vitamins B1 (thiamin) B2 (riboflavin), B3 (niacin) and B12 (folate). Riboflavin, for example, plays a critical role in the production of glutathione, an enzyme that helps protect against oxidation in the eye. All forms of vitamin B are widely available in dairy products, fortified grains, and meat.

Carotenoids. Carotenoids are a group of more than 700 fat soluble nutrients that produce the colors in foods such as carrots, pumpkins, sweet potatoes, tomatoes, and other deep green, yellow, orange, and red fruits and vegetables. Many are proving to be very important for health. Different carotenoids may be more beneficial then others. They include:

Xanthophylls are compounds that form a particular category of carotenoids. The xanthophylls lutein and zeaxanthin are found in the lenses of the eye and may be of significant importance for people at risk for cataracts. Some evidence indicates supplements of xanthophyll-rich foods may help retard the aging process in the eye and protect against cataracts. In fact, some experts suggest that the higher risk of cataracts in women compared to men may be partly due to a lesser ability to transport these carotenoids from the blood into the eye. Xanthophylls can be obtained from dark green leafy vegetables (such as spinach), broccoli, and eggs.
Lycopene is an important carotenoid that may also play an important role in eye health as a person ages. Tomatoes are the importance sources of lycopene.
Beta carotene is the most widely studied carotenoid and is a powerful antioxidant. It has been specifically studied for cataract protection. Most studies, however, have found little or no benefits. A 2003 study did suggest that beta carotene may protect against cataracts in smokers, although it is important to note that other studies report a higher risk for lung cancer in smokers who take beta carotene.

Click the icon to see an image of folate sources.

Click the icon to see an image of vitamin B12 sources.

Click the icon to see an image of riboflavin sources.

Phytochemicals. Phytochemicals are substances in plants that have beneficial effects. Dark colored (green, red, purple, and yellow) fruits and vegetables usually have high levels of important plant chemicals and have been associated with a lower risk for cataracts. Tea contains certain plant chemicals called polyphenols that have been associated with protection against cataracts.

Click the icon to see an image of phytochemicals.

Diagnosis

Either an ophthalmologist or an optometrist can examine patients for cataracts, but only ophthalmologists are qualified to treat cataracts.

An ophthalmologist is a doctor who specializes in the medical and surgical care of the eye.
An optometrist is engaged in the practice of eye care, but is not a doctor and cannot prescribe medication or perform surgery.

The eye professional can observe cloudy areas on the lenses with a direct physical examination, even before the cataracts begin to interfere with vision. Cameras can measure the cataract density. Various vision tests are also performed.

Snellen Eye Chart. To determine how clearly a person can actually see, the Snellen eye chart is used, with rows of letters decreasing in size:

From a specified distance, usually 20 feet, a person reads the letters using one eye at a time.
If a person can read down to the small letters on the line marked 20 feet, then vision is 20/20 (normal vision).
If a person can read only down through the line marked 40 feet, vision is 20/40; that is, from 20 feet the patient can read what someone with normal vision can read from 40 feet.
If the large letters on the line marked 200 feet cannot be read with the better eye, even with glasses, the patient is considered legally blind.

The visual acuity test can be performed in many different ways. It is a quick way to detect vision problems and is frequently used in schools or for mass screening. Driver license bureaus often use a small device that can test the eyes individually and then together.

Other Tests. A number of other tests are used to diagnose cataracts or to determine if surgery is needed.

A chart similar to the Snellen chart, which has the same size letters, but in different contrasts with background, is used to test contrast sensitivity,
Glare sensitivity is tested by having the patient read a chart twice, with and without bright lights.
Tests of macular function, which evaluate the eye's acute vision center, can help the ophthalmologist determine the expected improvement from surgery.
The corneal endothelium, a layer of cells lining the cornea, is sensitive to surgical trauma and should be evaluated before any intraocular operation.
Patients with other eye disorders may require a number of other pre-operative tests.

Although eye tests aid in making a diagnosis for cataracts, results do not always reflect the quality of life and how effectively people function at home:

Some people with cataracts perform poorly on the tests yet appear to have no difficulty functioning normally day-to-day.
Others perform well on the tests but insist that their eyesight is bad enough to curtail ordinary activities, such as driving.

Standard eye tests, therefore, may not be useful for determining whether a patient actually needs cataract surgery.

In general, even if cataracts are diagnosed, the decision to remove them should be based on the patient's own perception of vision difficulties and needs and the effect of vision loss on normal activity. The patient should also be aware of all the risks and costs of surgery. In order to determine the quality of life, the patient may be given a questionnaire such as National Eye Institute Visual Function Questionnaire, which asks 39 questions related to vision and daily activities. This test or others may be useful for determining if eye disease is actually impairing the ability to function.

Treatment

Although surgery is the only remedy for cataracts, it is almost never an emergency. Most cataracts cause no problem other than reducing a person's ability to see, so there is no harm in delaying surgery.

Early cataracts may be managed with the following measures:

Stronger eyeglasses or contact lenses
Use of a magnifying glass during reading
Strong lighting
Medication that dilates the pupil. (May help some people with capsular cataracts, although glare might be a problem with this treatment.)

It is important to note, however, that no treatments will prevent cataract formation or progression or make a cataract disappear.

Progression of Cataracts. Patients and their families usually have plenty of time to consider options carefully and discuss them with an ophthalmologist. There is no constant rate at which cataracts progress:

Some develop to a certain point and then stop.
Even if a cataract does progress, it may be years before it interferes with vision.
Only in a very few, very rare circumstances is it necessary that cataract surgery be performed immediately.

Each year about 2.8 million cataract operations are performed, making it the most common operation in the U.S. for people over age 65. Cataract surgery may be the oldest procedure in the world, having been introduced to Europe from India by Alexander the Great's army.

In the past, cataract surgery was not performed until the cataract had become well developed. Newer techniques, however, have made it safer and even more efficient to operate in earlier stages. In fact, modern cataract techniques not only remove cataracts but are also becoming important procedures for correcting astigmatism. Cataract surgery improves vision in up to 95% of cases and prevents millions of Americans from going blind.

Nevertheless, considerable evidence suggests that, because of the ease and relative safety of the procedure, it may be performed more often than needed. Patients having operations now tend to have better preoperative vision than those operated on 10 or 20 years ago. In a study of 800 cataract operations, 25% of the patients said that clouding had had no obvious effect on their lives before the procedure.

Cataract surgery is very successful. It has the following advantages:

Nearly all patients enjoy better vision after surgery. Advanced procedures in lens development are allowing correction of astigmatism as well as cataract removal. (Patients with significant eye disease, such as glaucoma or corneal or retinal disease, may not experience the same degree of improvement.)
Many people experience significant improvement in quality of life after the operation.
Some studies indicate that better vision might even help slow down age-related health problems unrelated to the eyes.

In general, surgery is indicated for people with cataracts under the following circumstances:

The Snellen eye test reports 20/40 or worse, with the cataract being responsible for vision loss and glasses or visual aids no longer being helpful.
Everyday activities have become difficult to perform to the point that independence is threatened. Questionnaires that assess the effects of cataracts on quality of life have been developed.
The patient is at risk for falling in low light.

These guidelines are general, however. Whether surgery is appropriate or not further depends on the cataract patient's specific condition and needs. Some examples include the following:

Even if the criteria for surgery are met, a very sick, very elderly person in a nursing home may have less need for sharp vision than an active younger adult. Among very elderly patients (85 years and older), especially those with serious health problems, there are also higher risks for complications during surgery and poor outcomes afterward. Nevertheless, these cautions should not prevent the very elderly from having this procedure; vision improvement rates are still over 85%.
Even if the criteria for surgery are not met, some people with eye tests of 20/40 or better might want surgery because of problems with glare, double vision, or the need to have an unrestricted driver's license.
Even if the criteria for surgery are not met, if retinal disease is also suspected (usually a complication of diabetes), the doctor may perform cataract surgery in order to have a clear view of the eye.

Because of the risks, albeit small ones, of poorer vision or blindness, no one should be forced to have cataract surgery if they don't want it or are not strong enough to undergo the procedure. If there are any doubts about whether or not to undergo cataract surgery, a second opinion should be considered.

The patient should ask the ophthalmologist the following questions before agreeing to cataract surgery:

Is my cataract surgery an emergency?
Are the cataracts the only cause of my poor vision?
How much experience do you have with this procedure?
Do I have other eye diseases that might complicate surgery or reduce my benefit?
Do I have other health problems that might further complicate eye surgery?
Will you be able to implant an intraocular lens?
What type of procedure will you use?
Will I have to stay in the hospital overnight?
Afterwards, what are my chances of having poorer vision or becoming totally blind in that eye?
How well should I ultimately be able to see out of the operated eye?
How long will it take to heal?
How long will it take to achieve my best eyesight?
Will I have to wear glasses or contact lenses after surgery?
When will I get my final eyeglass prescription?
How soon after surgery will I be able to see well enough to go back to work? Drive a car? Return to full activity?
What will the surgery cost?

Cataract surgery is now usually done as an outpatient procedure under local anesthesia and takes less than an hour. Preoperative preparations may include:

Having a general physical examination is important for patients with medical problems such as diabetes. Diabetes can cause damage to the blood vessels of the eye’s retina, a condition called diabetic retinopathy. Recent research suggests that patients who have diabetic retinopathy and poor blood sugar control should not have their blood sugar rapidly corrected before cataract surgery. Correcting blood sugar too quickly before surgery can cause vision problems after surgery.
The ophthalmologist will use a painless ultrasound test to measure the length of the eye and determine the type of replacement lens that will be needed after the operation.
Topical application of so-called fluoroquinolone antibiotics (such as ofloxacin or ciprofloxacin) may be applied preoperatively to protect against postoperative infection.
Most healthy patients are given either a local injection or topical anesthetic. The patients who report the least pain during the operation are those given a sedative followed by a local injection rather than just the topical drug.
Some patients may require a general anesthetic, such as those who are very anxious, those who are unable to cooperate with the surgeon, and those who are allergic to local anesthetics.

All cataract procedures involve removal of the cataract-affected lens and replacing it with an artificial lens.

Phacoemulsification. Phacoemulsification (phaco means lens, emulsification means to liquefy) is now the most common cataract procedure in the United States and accounts for 85% of cases. Benefits are greater than with standard extracapsular surgery, and it may be particularly helpful for people with diabetes.

The procedure generally involves:

The surgeon makes an incision, which is much smaller than with standard cataract extraction.
Ultrasound is then used to break up the clouded lens into small fragments.
The tiny pieces are sucked out with a vacuum-like device.
A replacement lens is then usually inserted into the capsular bag where the natural lens used to be. In most cases, this is an intraocular lens (IOL), which is foldable and slips in through the tiny incision.
Because the incision is so small, it is often watertight and does not require a suture afterward, particularly if a foldable lens has been used. A suture may be needed if a tear or break occurs during the procedure or the surgeon inserts a rigid lens that requires a wider incision.

Click the icon to see an illustrated series detailing cataract surgery.

Phacoemulsification requires only local anesthesia. Newer methods for administering local anesthesia produce few complications. Most phacoemulsification procedures now take about 15 minutes, and the patient is usually out of the operating room in about an hour. There is little discomfort afterward and visual rehabilitation takes about 1 - 3 weeks.

Phacoemulsification is sometimes combined with viscocanalostomy, a glaucoma surgical procedure, for patients who have both glaucoma and cataracts. Recent research suggests that phacoviscocanalostomy (as this combined procedure is called) is safe and effective for this group of patients.

Surgeons in the U.S. and Europe are currently investigating Microphaco, a new approach to cataract surgery that uses two smaller (micro) incisions. The smaller incisions measure about 1.6 mm compared to the traditional 3 mm. Experts say this procedure is expected to revolutionize refractive and cataract surgery.

Other Lens Removal Techniques. The AquaLase device uses pulses of fluid to wash away the clouded lens. Some experts believe this approach causes less trauma to the eye, and allows for a quicker recovery time for the patient, than the ultrasound used in phacoemulsification.

Extracapsular or Intracapsular Cataract Extraction. Extracapsular cataract extraction was the original standard procedure, but is now generally used only in patients who have an extremely hard lens. It typically involves the following steps:

The ophthalmologist works under an operating microscope to make a small incision in the cornea of the eye.
The surgeon then extracts the clouded lens through this incision.
The capsule is left in place, which adds structural strength to the eye and enhances the healing process. (Less commonly, in intracapsular cataract extraction, the surgeon removes the lens and the entire capsule. There are greater risks with this procedure for swelling and retinal detachment.)
A replacement lens is then usually inserted.
A small suture is needed to stitch the incision together.

It takes about 2 - 4 weeks to completely restore vision.

With the clouded lens removed, the eye cannot focus a sharp image on the retina. A replacement lens or eyeglass are therefore needed:

Intraocular Lenses (IOL). In about 90% of cataract operations, an artificial lens, known as an intraocular lens (IOLs), is inserted. Until recently, IOLs used a pair of little spring-loaded loops to hold the lens in place. Most IOLs are now foldable, which makes insertion easier. In fact, a prefolded lens is now available that unrolls to fit the eye as body temperature warms it.

IOLs are available as monofocal or multifocal. Monofocal lenses correct only one type of vision range (such as distance vision). Multifocal lenses are designed for patients who need correction for a range of vision. A 2006 study suggested that the Tecnis IOL works particularly well for patients who require a multifocal IOL.

Although all the lens materials are presumably chemically inert, there are some reports of specific problems, notably a risk for causing a reaction that leads to the development of secondary cataracts, a condition called posterior capsular opacification. IOLs include the following materials:

Acrylic: The majority of IOLs are made from acrylic, which allows a controlled unfolding of the lens. Evidence indicates that this material provides a better visual outcome and fewer complications than other standard IOLs.
Polymethylmethacrylate (PMMA): Has the longest safety record. A PMMA IOL coated with heparin, a blood thinner drug, helps protect against the development of a secondary cataract after surgery.
Silicone: Can be inserted through a smaller incision than other materials. It has the highest rates of secondary cataracts. Newer forms of silicon IOLs may pose a lower risk.

Other materials are under investigation.

IOL brands include:

Crystalens: The FDA approved the Crystalens IOL in 2003. It is made from a form of silicone called Biosil. The Crystalens uses "hinges" that allow the lens to move, mimicking the eye's natural ability to focus automatically and seamlessly at all distances. Studies indicate that when used along with standard cataract removal methods, the Crystalens can restore a full range of functional vision, from distance to reading vision, without total dependence on glasses or contact lenses.
Array: The Array lens also uses silicon. It is one of a number of so-called second-generation IOLs that is available as a multifocal lens to help correct presbyopia (nearsightedness).
Tecnis: The Tecnis foldable IOL was specifically designed to improve functional vision of cataract surgery patients. Tecnis has a patented surface that reduces light scattering (spherical aberration) of the cornea, which can negatively affect vision. In April 2004, The FDA approved new labeling claims for Tecnis, stating the lens may help improve driving safety for senior cataract patients. In clinical trials, simulated night driving and visual acuity (20/20, 20/40) results were significantly better in eyes implanted with the Tecnis IOL. In addition, spherical aberrations were significantly less when compared to the traditional lens with the spherical optic.
AcrySof Natural: Approved in 2003, the yellow-tinted Acrysof Natural IOL was the first foldable lens to filter ultraviolet and blue-light. Eliminating both UV and portions of the high-energy blue light help prevent retinal damage. This lens also conforms to the natural shape of the human lens capsule so it remains centered over the eye.
AcrySof ReSTOR: The AcrySof ReSTOR IOL is approved in the U.S. for patients with and without presbyopia. The lens enhances vision at near, intermediate, and distant ranges. In clinical trials, 80% of patients who received the lens did not require glasses after cataract surgery. The FDA approved the AcrySof ReSTOR in March 2005.

IOLs are designed to improve specific aspects of vision. The choices include:

Lenses that address a single fixed focal point. Such lenses are suitable either for reading or for distance vision, but not both. If a distance lens is implanted, the surgeon prescribes glasses or contact lenses for reading. If a reading lens is implanted, lenses for seeing distances will be prescribed.
Lenses that address multifocal points. Multifocal lenses can focus at different points for both reading and distance vision. One study reported that more than 80% of patients with multifocal lenses were able to see 20/40 or better without correction. However, contrast may be reduced and some patients experience glare and halos, particularly at night.
Lenses are available that will correct astigmatism after cataract surgery.

The patients and the doctor must make these decisions based on specific visual needs.

Contact Lenses or Cataract Glasses. A few patients do not receive a new lens and rely solely on corrective eyeglasses or contact lenses. Such patients may include:

Patients who are extremely near-sighted
Patients with other eye disorders

In such cases, the patient typically returns to the ophthalmologist for a check up the day after surgery, and three additional check-ups are scheduled over a 2-month period. The ophthalmologist can usually give a final prescription for eyeglasses or contact lenses about three months after surgery.

Choosing Contact Lenses. Contact lenses allow clear vision but do not magnify, so those who choose contact lenses after surgery may have to wear reading glasses. Contacts can be prescribed either for use only during the day or for extended-wear. Occasionally contact lenses cause problems, such as infection. Those who wear them should call their eye doctor if they have red or watery eyes, pain, or sensitivity to light.
Cataract Glasses. Until the advent of contact lenses, people who had cataract surgery had no choice but to wear glasses with thick lenses, sometimes called Coke-bottle glasses. These glasses have gotten thinner and lighter in recent years, but they may still be cumbersome. Cataract glasses are different from ordinary glasses and are sometimes difficult to adjust to. Images can seem distorted and may appear suddenly within the peripheral vision. Distances may be hard to judge.

Sometimes a patient has two cataracts and needs to wear glasses between the first and second operation. They are particularly troublesome during this period. The treated eye will see images magnified while the other eye will view them as they actually are, and the brain cannot blend the two images. This is a temporary state that is resolved by the second operation.

Modern cataract surgery is one of the safest of all surgical procedures. Most complications, even if they occur, are not serious. They can include the following:

Swelling and inflammation. Risk is about 1%. This complication is particularly harmful for patients with existing uveitis (chronic inflammation in the eye, which can be due to various conditions).
Glare. Patients may experience glare after surgery from light scattering at the edges of the new lens, particularly with square-edged IOLs, which are typically used with posterior capsular cataracts. In most cases, this is a temporary problem that resolves after a few weeks. Sometimes, the problem persists, and the patient requires another operation. Some research suggests that glare can be significantly reduced by texturizing the edges of the square lens.
Materials used in some lenses trigger an immune response in about half of patients. This causes inflammation and tiny deposits of tissue in the eye that lead to secondary cataracts -- called posterior capsule opacification. Studies suggest that silicone implants pose the highest rates for inflammation and secondary cataracts, particularly in patients with other eye diseases. Newer silicon IOLs pose less risk. In one study, the lowest rates were with IOLs made of acrylic and heparin-coated PMMA.
Retinal detachment. In rare cases, the retina at the rear of the eye can become detached. Risk is very low (0.1%), and phacoemulsification poses less of a risk for this than standard surgery.
Atonia (loss of muscle tone that results in a disturbing glare). (Phacoemulsification poses less of a risk than standard surgery.)
Glaucoma. This is an eye condition in which the pressure of fluids inside the eye rises dangerously. Risk is very low, but patients should be sure to avoid activities after surgery that increase pressure.

Glaucoma is a condition of increased fluid pressure inside the eye. The increased pressure causes compression of the retina and the optic nerve which can eventually lead to nerve damage. Glaucoma can cause partial vision loss, with blindness as a possible eventual outcome.

Infection. This is very rare (0.2%), but is devastating if it does develop.
Blisters on the cornea. There is a higher risk of rupture with phacoemulsification, but the risk is extremely low, particularly for experienced eye surgeons. In 2004, the FDA approved the StabilEyes Capsular Tension Ring (CTR) to help support the eye's capsular bag during cataract surgery, especially in those with weak or broken eye fibers (zonules). A CTR is an open ring made of polymethylmethacrylate (PMMA). The ring goes into the capsular bag itself, stabilizing the eye.
Bleeding can develop inside the eye. Risk is about 1% for minor bleeding and 1 in 10,000 for severe bleeding.
An implanted IOL can become damaged or dislocated. Risk is very low.
The surgery itself can produce vision loss or impairment. The risk for this is 1 in 1,000. (Phacoemulsification poses less of a risk than standard surgery.)
Macular degeneration. Macular degeneration, in which the retina breaks down, is a common cause of vision loss in the elderly. In a 5-year study, people who underwent cataract surgery had twice the risk for progression of age-related macular degeneration. Interestingly, another study reported that cataract surgery significantly helped patients who had existing macular degeneration. More research is needed to refute or confirm this finding.

Click the icon to see an image of macular degeneration.

Phacoemulsification does have some specific complications, although they are rare, particularly with experienced eye surgeons. They include:

Rupture of the lens capsule.
Loss of the lens nucleus into the eye fluid. (This will require removal by a specialist and may result in poorer vision.)
Flying fragments of the lens can damage the cornea or threaten the retina.
Pre- and postoperative changes in blood pressure, which are generally not a problem, should be observed carefully, since in some cases the changes may be extreme.

In about 30% of cases patients develop secondary cataracts within 1 - 5 years after either procedure, which require different treatment choices.

Preventing Infection and Reducing Swelling. The ophthalmologist may prescribe the following medications:

A topical antibiotic (neomycin or, more effectively, gentamicin). This drug protects against infection.
Corticosteroid eyedrops or ointments are often used to reduce swelling. Corticosteroids (commonly called steroids) are potent anti-inflammatory drugs. However, they also pose a risk for pressure in the eye and infection. One study reported less visual sharpness with the use of steroids compared to antibiotics. Some newer steroids such as rimexolone, loteprednol, and fluorometholone may pose a lower risk for abnormal pressure.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, ketorolac, naproxen, and voltaren, also reduce swelling and do not pose the same risks as steroids. Newer NSAIDS that have been approved to treat pain and swelling after cataract surgery include bromfenac (Xibrom) and nepafenac (Nevanac).

In one study, applying an ice pack for 2 hours immediately after phacoemulsification improved comfort level and reduced inflammation, even days after the operation. This simple procedure has no adverse effects and patients should discuss it with their surgeons before the operation.

Factors That Increase Risk for Complications. The risks of complications are greater for the following people:

Patients who have other eye diseases.
People with diabetes. Intracapsular and extracapsular cataract extraction are known to pose a high risk for the development or worsening of retinopathy, a known eye complication of diabetes. Experts have hoped that phacoemulsification would pose a lower risk, but a 2001 study reported a high percentage of retinopathy progression after this procedure. The amount of experience a surgeon has plays a role in whether or not a patient has this complication.
People who have taken tamsulosin (Flomax) or other alpha-1 blocker drugs. Tamsulosin is a muscle relaxant prescribed for treatment of several urinary conditions including benign prostatic hyperplasia (BPH). In 2005, a leading ophthalmologic association and the FDA warned that tamsulosin may cause intraoperative floppy iris syndrome (IFIS), a loss of muscle tone in the iris that can cause complications during eye surgery. Problems have been reported both for patients who were taking the drug during surgery as well as those who had stopped taking the drug weeks or months before surgery. Men who have taken tamsulosin or similar drugs should inform their eye surgeon. The surgeon may need to use different techniques to minimize the risk of IFIS. A 2006 study indicated that patients can have safe and successful surgeries with these modified techniques.

Returning Home and Follow-up Visits.

Patients usually leave the surgical site within an hour of surgery. Cataract surgery almost never requires an overnight hospital stay.
They need to have someone drive them home and stay with them for a few days until their vision is acclimated.
The patient is usually examined the day after surgery and then during the following month. Additional visits are made as required.
Vision usually remains blurred for a while but gradually clears, usually over a 2 - 6 week period. (It can take longer.)
When the doctor decides the condition has stabilized, the patient will receive a final prescription for glasses or contacts.

Protecting the Eye. Postoperative protection of the eye typically involves:

The ophthalmologist usually tapes a bandage over the eye to protect it during the healing process.
When changing the bandage, the eye can be cleaned gently using a washcloth dipped in warm water without soap. A new bandage can then be positioned and taped.
It is very important not to press or rub the eye during this procedure.
An eye shield may be placed over the bandage at night.

Avoiding Glaucoma. Cataract surgery can cause glaucoma, a condition in which the pressure of fluids inside the eye rises dangerously. It is very important to minimize any activity that increases internal eye pressure. Postoperative cataract patients take the following precautions:

Minimize vigorous exercise.
Put on shoes while sitting and without lifting up the feet.
Kneel instead of bending over to pick something up.
Avoid lifting.
Limit reading since it requires eye movement (watching television is all right).
Sleep on the back or on the unoperated side.

Cataracts and Glaucoma. For patients with both glaucoma and cataracts, experts recommend:

In patients with cataracts and poorly controlled glaucoma, a two-step procedure for both eye conditions is needed. The patient first receives a trabeculectomy for glaucoma, followed by cataract surgery. Fluid leakage and the presence of blood in the back chamber of the eye are potential complications of this combined procedure. Phacoemulsification has improved success rates and reduced high complication rates of the double procedure compared with extracapsular cataract extraction. New advances that replace trabeculectomy with nonpenetrating glaucoma surgery may prove to be beneficial.
In patients who have cataracts plus either closed-angle glaucoma or open angle glaucoma that is stabilized with medication, the cataract may be able to be extracted and medication continued for the glaucoma.
A major 2002 analysis suggested that the combined approach generally offers better control over eye pressure for patients with both cataracts and glaucoma. The best surgical procedure, however, is still uncertain.

Cataracts and Corneal Disease. Patients who have both cataracts and corneal disease may undergo one of the following:

Combination Procedure. A single operation that combines three procedures. The combined procedure has been used since the late 1970s and employs extracapsular cataract extraction and intraocular lens insertion with corneal transplantation (called penetrating keratoplasty).
Sequential Procedure. An operation that uses two procedures sequentially. The sequential option performs the cataract procedures and the corneal transplantation separately.

Recovery of vision is usually much more rapid after the combined procedure than after the sequential procedures. Performing the procedures sequentially may also carry a higher rejection rate of the implant, although a 2003 study found no differences in failure rates between the two approaches after a year.

In any case, many experts recommend that for most patients the sequential procedures may be the better option because it appears to have fewer of the following complications than with the combined procedure:

Posterior capsule rupture
Eye fluid loss
Postoperative refractive errors, which result in abnormal distribution of light patterns

The rate of these errors still depends on the skill of the surgeon and the power of the implanted lens no matter what approach is used.

About 30% of patients who undergo extracapsular cataract surgery develop a secondary "after-cataract" called posterior capsular opacification. Posterior capsular opacification generally occurs because of the following events:

After surgery, there are still some natural lens cells left behind that proliferate on the back of the capsule.
The capsule gradually becomes cloudy and interferes with clear vision the same way the original cataract did.

According to a 2001 study, the probability of developing a secondary cataract was 6% at 1 year, 15% at 2 years, 23% at 3 years, and 38% at 9 years. The risk is lower with phacoemulsification. Secondary cataracts are more likely to occur in younger patients, in those with diabetes, or when cataract surgery is combined with vitrectomy (clearance of debris from the fluid in the eye).

Preventing Posterior Capsular Opacification. Studies suggest that acrylic lenses pose the lowest risk for posterior capsular opacification. A number of substances to prevent posterior capsular opacification are under investigation, including tranilast eyedrops, new lens materials, special capsular rings inserted during phacoemulsification, and new coatings on the implanted lens.

Treatment Decisions for Cataracts in the Second Eye. If a person has a cataract in a second eye, the issues for decision making are the same as for the first eye. The time of the procedure in the case of two cataracts is unclear. Doctors have long recommended that surgery on the second eye should be postponed until the first eye has healed and the results known (about a year).

One study has called this recommendation into question. It was conducted in England, where for budgetary reasons, there are long waits for second-eye cataract surgeries. In the study, patients who waited 7 - 12 months for the second-eye surgery reported significant difficulty in reading and performing ordinary tasks during the waiting period. Only 1% of patients who had the second surgery within 6 weeks reported having trouble seeing. In addition, 70% of those who waited experienced problems in depth perception, which can cause difficulty in walking and driving; only 12% who didn't wait reported this problem. Patients with double cataracts should discuss all options with their surgeon.

Treatment for Posterior Capsular Opacification. The standard treatment is laser surgery known as a YAG capsulotomy. (Capsulotomy means cutting into the capsule, and YAG is an abbreviation of yttrium aluminum garnet, the laser most often used for this procedure.)

This is an outpatient procedure and involves no incision.
Using the laser beam, the ophthalmologist makes an opening in the clouded capsule to let light through.
After the procedure the patient should remain in the doctor's office for an hour to be sure that pressure in the eye is not elevated.
An eye examination for any complications should follow within 2 weeks.

Complications. Laser surgery has become so commonplace that some ophthalmologists use it after cataract surgery to prevent later clouding. However, laser surgery carries its own risks and possible complications, similar to those of cataract surgery itself, and can also lead to poorer vision or blindness. About 1% of laser surgery patients develop a detached retina, which is much higher than the risk from the original cataract surgery.

Click the icon to see an image of a detached retina.

In some people, particularly those with glaucoma or who are severely nearsighted, the pressure in the eye may spike after laser surgery. Certain drugs used for treating glaucoma, such as dorzolamide (Trusopt) or apraclonidine (Iopidine), may helpful for preventing this occurrence. It is strongly recommended, however, that this surgery not be performed to prevent a secondary cataract, but only if the lens capsule clouds up again.

Infants. Treatment of infants first depends on whether one or both eyes are affected:

For infants born with cataracts in one eye, the American Academy of Ophthalmology recommends surgery as soon as possible, by 4 months or ideally even earlier. The procedure is followed by contact lens correction and patching of the unaffected eye. Although this approach is successful in many cases, some children still become blind in the affected eye. There is also a high risk for glaucoma after surgery.
In infants with cataracts in both eyes, surgery is not always an option. In some cases, it may be performed sequentially, with the second eye operated on a few days after the first. Phacoemulsification appears to pose a much higher risk for secondary cataracts than standard lens removal.

Toddlers and Older Children. Intraocular lens replacement is now becoming standard treatment for children 2 years and older.

Resources

www.ascrs.org -- The American Society of Cataract and Refractive Surgery
www.aao.org -- American Academy of Ophthalmology
www.nei.nih.gov -- National Eye Institute
www.eyesurgeryeducation.com -- Eye Surgery Education Council
www.lighthouse.org -- Lighthouse International
www.aao.org/aao/find_eyemd.cfm -- Find an ophthalmologist

References

Eke T, Thompson JR. Serious complications of local anaesthesia for cataract surgery: a one-year national survey in the United Kingdom. Br J Ophthalmol. 2006 Nov 23; [Epub ahead of print]

Hutz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading ability with 3 multifocal intraocular lens models. J Cataract Refract Surg. 2006 Dec;32(12):2015-21.

Klein BE, Klein R, Lee KE, Grady LM. Statin use and incident nuclear cataract. JAMA. 2006 Jun 21;295(23):2752-8.

Rein DB, Zhang P, Wirth KE, Lee PP, Hoerger TJ, McCall N, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006 Dec;124(12):1754-60.

Wishart MS, Dagres E. Seven-year follow-up of combined cataract extraction and viscocanalostomy. J Cataract Refract Surg. 2006 Dec;32(12):2043-9.

Review Date:
3/1/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

A.D.A.M. Copyright

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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

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.

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.

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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

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Migraine headaches

FitSugar — Wed, 08 Oct 2008 17:35:00 -0700

In This Report

Highlights
Introduction
Prognosis
Causes
Risk Factors
Diagnosis
Treatment Approaches
Medications Used for Treatm...
Prevention
Medications Used for Preven...
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Migraine Surveys

About 17.1% of women and 5.6% of men suffer migraines, according to the 2007 American Migraine Prevalence and Prevention survey. Nearly a third of respondents reported 3 or more migraine attacks per month. Over half were severely impaired or needed bed rest during attacks. Although many patients met the criteria for preventive medication, only a small percentage actually received it.
About 20% of patients with migraine take potentially addictive opioid and barbiturate drugs, even though these drugs have not been approved by the Food and Drug Administration (FDA) for migraine treatment, according to a 2007 survey commissioned by the U.S. National Headache Foundation.

FDA Actions

The opioid drug fentanyl (Fentora) should not be prescribed "off-label" to patients with migraine or other severe headaches, warns the FDA, following several reports of drug-related deaths. Fentanyl is approved only for treating cancer pain.
In 2007, the FDA pulled 15 unapproved ergotamine preparations off the market because they lacked a warning label describing the risks for serious drug interactions.

Migraines in Adolescents

Many adolescents may stop having migraines, or transition to less severe types of headaches, when they reach adulthood, suggests a small 2006 study in Neurology.
Zolmitriptan (Zomig) nasal spray appears to be safe and effective for adolescent migraine, indicates a 2007 study in Pediatrics. Zolmitriptan, like all migraine drugs, is currently approved only for adults.

Sumatriptan-Naproxen Combination

A combination of the triptan drug sumatriptan (Imitrex) and the nonsteroidal anti-inflammatory drug naproxen (Aleve) works better for migraine pain relief than either drug alone, according to a 2007 study in the Journal of the American Medical Association.

Introduction

The pain from a headache does not start from inside the brain. (The brain itself can not feel pain.) Instead, headache pain begins in one or more of the following locations:

The tissues covering the brain
The structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck

Headache is generally categorized as primary or secondary.

Primary Headache. A headache is considered primary when a disease or other medical condition does not cause it.

Tension headache is the most common primary headache and accounts for 90% of all headaches. [See In-Depth Report # 11: Tension headaches.]
Neurovascular headaches are the second most common primary headaches. This type includes migraines and cluster headaches. [See In-Depth Report # 99: Cluster headaches.] Such headaches are caused by an interaction between blood vessel and nerve abnormalities.

Headaches are usually caused by muscle tension, vascular problems, or both. Migraines are vascular in origin, and may be preceded by visual disturbances, loss of peripheral vision, and fatigue. Over-the-counter pain medications can relieve most headaches.

Click the icon to see a depiction of migraine cause.

Secondary Headache. Secondary headaches are caused by other medical conditions, such as sinusitis, neck injuries or abnormalities, and stroke. About 2% of headaches are secondary headaches caused by abnormalities or infections in the nasal or sinus passages. [See "Causes of Secondary Headaches," in this report.]

It is not uncommon for someone to experience a combination of headache types.

Click the icon to see a comparison of headache symptoms.

Migraine is now recognized as a chronic illness, not simply as a headache. About 28 million people suffer from migraines annually. They are often classified by whether or not auras (seeing bright "spots" or "stars") accompany them:

Common migraines are without auras. About 75% of migraines are the common type.
Classic migraines are those with auras.

A person may experience one or the other at different times.

In general, there are four phases to a migraine (although they may not all occur in every patient): The prodrome phase, auras, the attack, and the postdrome phase.

Prodrome. The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two. Prodrome symptoms include:

Sensitivity to light or sound
Changes in appetite
Fatigue and yawning
Malaise
Mood changes
Food cravings

Auras. Auras are sensory disturbances that occur before the migraine attack in 1 in 5 patients. Visually, auras are referred to as being positive or negative:

Positive auras include bright or shimmering light or shapes at the edge of their field of vision called scintillating scotoma. They can enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars.
Negative auras are dark holes, blind spots, or tunnel vision (inability to see to the side).
Patients may have mixed positive and negative auras. This is a visual experience that is sometimes described as a fortress with sharp angles around a dark center.

Other neurologic symptoms may occur at the same time as the aura, although they are less common. They include:

Speech disturbances
Tingling, numbness, or weakness in an arm or leg
Perceptual disturbances such as space or size distortions
Confusion

Migraine Attack. If untreated, attacks usually last from 4 - 72 hours. A typical migraine attack produces the following symptoms:

Throbbing pain on one side of the head. The word migraine, in fact, is derived from the Greek word hemikrania, meaning "half of the head" because the pain of migraine often occurs on one side. Pain also sometimes spreads to affect the entire head.
Pain worsened by physical activity
Nausea, sometimes with vomiting
Visual symptoms
Facial tingling or numbness
Extreme sensitivity to light and noise
Looking pale and feeling cold

Less common symptoms include tearing and redness in one eye, swelling of the eyelid, and nasal congestion, including runny nose. (Such symptoms are more common in certain other headaches, notably cluster headaches. In one study, however, they occurred in over 40% of migraine sufferers.)

Postdrome. After a migraine attack, there is usually a postdrome phase, in which patients may feel exhausted and mentally foggy for a while.

In some cases, patients eventually experience on-going and chronic headaches. In fact, in an analysis using two different diagnostic methods, between 87 - 90% of daily chronic headaches were actually migraines. Some doctors believe that, unless otherwise demonstrated, any chronic headache consisting of episodes of disabling pain that recur regularly over years should be considered as a migraine.

Chronic migraines may occur from overuse of migraine medications (called a rebound headache) or may develop over time (called transformed migraine).

Rebound Headache. The most common cause of chronic migraine is the rebound effect, which is a cycle caused by overuse of migraine medications. The process involves the following:

Patients typically have taken pain medication for more than 3 days a week on an ongoing basis.
When the patients stop taking medication, they experience a rebound headache.
They start taking the drugs again.
Eventually the headache simply persists, and medications are no longer effective.

Medications implicated in rebound migraines include nonprescription painkillers (acetaminophen, aspirin, ibuprofen), barbiturates, sedatives, narcotics, and migraine medications, particularly those that also contain caffeine. (Heavy caffeine use can also cause this condition.)

Transformed Migraines. In some cases, migraines themselves evolve into chronic, daily headaches called transformed migraines. Such headaches resemble tension headaches but are more likely to be accompanied by gastrointestinal distress and mental or visual disturbances and, in women, to be affected by menstrual cycles. In one study, the risk for transformed migraines were associated with other factors, including allergies, asthma, hypothyroidism, hypertension, and a daily intake of caffeine.

Migraines are defined by the number and length of attacks and whether an aura is present.

Definition of Migraines without Auras (Common Migraine). To be defined as a migraine without aura, a patient should have at least five attacks that have the following characteristics:

A. Each untreated, or unsuccessfully treated, attack must last 4 - 72 hours.

B. It must have at least two of the following four characteristics:

Pain on one side of the head
Pulsing or throbbing pain
Pain severe enough to impair or prevent daily activities
Pain must be intensified by exertion, such as walking up stairs

C. During a headache at least one of the following symptoms must also be present:

Nausea, vomiting or both
Sensitivity to light and noise

In addition, other neurologic or medical conditions that might be causing this pain must be ruled out, or, if they do occur, they are not related in time to the suspected migraine.

Definition of Migraines with Auras (Classic Migraine). To be defined as a migraine with aura, the patients must have at least two attacks that have three out of four of the following events.

At least one fully reversible aura symptom suggesting the headache starts in the cerebral cortex or brain stem.
At least one aura symptom that develops gradually over more than 4 minutes ,or two or more aura symptoms that occur in succession.
No single aura symptom that lasts more than 1 hour. (There may be successive aura symptoms that extend that time, but each one should not last more than 60 minutes.)
The headache itself may begin before, at the same time, or at an interval of no more than an hour after the aura.

As with common migraines, other neurologic or medical conditions that might be causing this pain must be ruled out or if they occur, they are not related in time to the suspected migraine.

Click the icon to see a definition of a migraine.

Although migraine is considered to be a specific chronic illness, it has various presentations that occur in different individuals.

Menstrual Migraines. Migraines are often tied to a woman’s menstrual cycle. Researchers think that estrogen plays a role. About half of women with migraines report an association with menstruation. Compared to migraines that occur at other times of the month, menstrual migraines tend to be more severe, last longer, and not have auras. Triptan drugs can provide relief and may also help prevent these types of migraines.

The highest incidence of migraines typically occurs during the early follicular phase, (beginning of menstruation). A 2005 study found that women are 1.7 times more likely to have a migraine during the 2 days before menstruation begins. But, women are 2.5 times more likely to have a migraine during the first 3 days of menstruation. During this time, migraines are more likely to be severe, with symptoms that include vomiting.

Ophthalmoplegic Migraine. This very rare headache tends to occur in younger adults. The pain centers around one eye and is usually less intense than in a standard migraine. It may be accompanied by vomiting, double vision, a droopy eyelid, and paralysis of eye muscles. Attacks can last from hours to months. A computed tomography (CT) or magnetic resonance imaging (MRI) scan may be needed to rule out an aneurysm (a rupture blood vessel) in the brain.

Retinal Migraine. Symptoms of retinal migraine are short-term blind spots or total blindness in one eye that lasts less than an hour. A headache may precede or occur with the eye symptoms. Sometimes retinal migraines develop without headache. Other eye and neurologic disorders must be ruled out.

Basilar Migraine. Considered a subtype of migraine with aura, this migraine starts in the basilar artery, which forms at the base of the skull. It occurs mainly in young people. Symptoms may include vertigo (the room spins), ringing in the ears, slurred speech, unsteadiness, possibly loss of consciousness, and severe headaches.

Familial Hemiplegic Migraine. This is a very rare inherited genetic migraine disease. It can cause temporary paralysis on one side of the body, vision problems, and vertigo. These symptoms occur about 10 - 90 minutes before the headache.

Status Migrainosus. This is a serious and rare migraine. It is so severe and lasts so long that it requires hospitalization.

About 90% of people seeking help for headaches have a primary headache disorder. The balance of secondary headaches is caused by an underlying disorder that produces the headache as a symptom. Many conditions cause headaches as a symptom. Some of the most common are listed below.

Sinus Headache. Many primary headaches, including migraine, are misdiagnosed as sinus headaches. Nearly 9 in 10 patients who think they have sinus headaches actually have or probably have had a migraine. Sinus headaches occur in the front of the face, usually around the eyes, across the cheeks, or over the forehead. They are usually mild in the morning and increase during the day and are usually accompanied by fever, runny nose, congestion, and general debilitation. Sinus headaches spread over a larger area of the head than migraines, but telling the difference between these two kinds of headache is difficult, particularly if a headache is the only symptom of sinusitis. The two may even coexist in many cases. Often, the visual changes associated with migraine can rule out sinusitis, but such visual changes do not occur with all migraines. (Rarely, sinusitis can cause double vision and even vision loss, a sign of very serious infection.)

Headache Due to Neck Problems. Some headaches may be caused by abnormalities of the neck muscles resulting from prolonged poor posture (such as that caused by sitting in front of a computer keyboard or driving daily for long periods), arthritis, injuries of the upper spine, or abnormalities in the cervical spine (the spinal bones in the neck). Nerves in the neck converge in the trigeminal nerve in the face and can generate pain signals that the brain may interpret as headache. Pain is usually on one side. Even if it affects both sides of the head, it is usually more severe on one side. The quality of the headache may be similar to an aching tension headache or a mild migraine without aura.

Temporomandibular Joint Dysfunction. Temporomandibular joint dysfunction (TMJ) is caused by clenching the jaws or grinding the teeth (usually during sleep), or by abnormalities in the jaw joints themselves. The diagnosis is easy if chewing produces pain or if jaw motion is restricted or noisy. TMJ pain can occur in the ear, cheek, temples, neck, or shoulders.

Glaucoma. Acute glaucoma is caused by increased pressure in the eye and requires immediate medical attention. Throbbing pain may be felt around or behind the eyes or in the forehead. Patients have redness in the eye and may see halos or rings around lights.

Brain Tumor. Fear of having a brain tumor is common among people with headaches, but a headache is almost never the first or only sign of a tumor. Changes in personality and mental functioning, vomiting, seizures, and other symptoms are more likely to appear first. When the headache does develop, it is often worse early in the morning or may awaken sufferers during the night.

Neuralgia. Neuralgia is pain due to nerve abnormalities, which can occur in the facial area and resemble migraine or sinus headaches.

Hypertension. Although many people attribute headaches to high blood pressure, the two are rarely associated. An exception is malignant hypertension, an uncommon medical emergency, in which the blood pressure abruptly rises to extreme levels, causing damage to blood vessels in the brain, heart, and kidneys.

Strokes Caused by Blood Clots or Hemorrhages. A blood clot or hemorrhage in the brain leading to a stroke can cause a severe headache, sometimes referred to as a thunderclap headache when it is very sudden and severe. The onset of such a headache, particularly if it is associated with confusion, stupor, or other neurologic symptoms, mandates prompt medical attention. It is important to determine if a clot or bleeding is causing the stroke, since treatments are very different.

Head Injuries. It is obvious that a significant blow to the head will cause pain. Post-injury headaches, however, can reflect serious damage, ranging from skull fractures to internal bleeding.

Disorders of the Meninges. The meninges are the membranes covering the brain and the spinal cord. In very rare instances, ordinary physical strain may injure or weaken the meninges, causing a leakage of cerebrovascular fluid (the fluid that bathes the brain). This can cause severe headache and nausea, which are relieved by lying flat. The condition is very treatable. Meningitis, which is an infection or irritation of these membranes, is an uncommon but potentially serious cause of severe headache. Other symptoms include nausea and stiffness or pain in the neck.

Gynecologic Problems. Many clinicians have anecdotally linked gynecologic problems, such as ovarian cysts and menstrual disorders, to chronic headaches, and new data are emerging to support this association.

Temporal (Giant Cell) Arteritis. Certain causes of headaches are unique to the elderly, such as temporal arteritis, also called giant cell arteritis. Inflammation in arteries that carry blood to the head, neck, and sometimes the upper part of the body can cause very severe headaches. The risk for this headache is highest in people over age 70, especially among women, people of European heritage, and patients with polymyalgia rheumatica.

Miscellaneous Causes of Benign Headaches. Rapid consumption of ice cream or other very cold foods or beverages is the most common trigger of sudden headache pain. (It may be prevented by warming the food or drink for a few seconds in the front of the mouth before swallowing.) Other common benign causes of headache include eyestrain, dental problems, allergies, systemic infections, and caffeine withdrawal. Headaches may be induced by sexual activity or intense physical exertion. Leakage from spinal cord fluid is rare but can cause headaches that may be mistaken for brain tumors.

Click the icon to see an image of the sinuses.

Prognosis

For many people, migraines eventually go into remission and sometimes disappear completely, particularly as they age. Estrogen decline after menopause may be responsible for remission in some older women. One study reported that the following people with migraines (called migraineurs) have a better chance of remission if they have:

A family history of migraine with aura
Migraines that are not triggered by light
No other primary headaches

According to another study, a history of head trauma or oral contraceptive use predicted a poorer long-term outlook.

Migraine or severe headache is a risk factor for stroke in both men and women, especially before age 50. About 19% of all strokes occur in people with a history of migraine. Research indicates that migraine also increases the risk for other types of heart problems.

Migraine with aura carries a higher risk for stroke than without auras. A 2005 analysis of over 12,000 participants from an atherosclerosis risk study found that migraine with aura was significantly associated with higher risk for stroke and transient ischemic attacks. Another 2005 study suggested that people who experience migraine with aura tend to have more cardiovascular risk factors than people without migraine. These risk factors included worse cholesterol profile, higher blood pressure, early history of heart disease and stroke, and greater likelihood of using oral contraceptives.

Results from a 2005 study showed that women who have migraine with aura are at increased risk of ischemic stroke compared with those who do not have auras and those who have non-migraine headaches. Women under age 55 had the highest risk, with more than double the risk. A 2006 Women’s Health Study of women ages 45 and older found that migraine with aura also increases women’s risk for heart attack, angina, and death due to ischemic heart disease (in which blood flow is decreased due to narrowing of coronary arteries). Migraine without aura did not increase heart disease and stroke risks.

Studies suggest specific stroke risk factors for younger women with migraines, particularly those with auras. Smoking, high blood pressure, and birth control pills considerably raise one's risk 10 - 20 times.

Researchers are also studying the relationship between patent foramen ovale (PFO) and migraine. A PFO is a hole in the wall dividing the upper left and right heart chambers. About half of patients with PFO have severe migraines with aura. Researchers are investigating whether surgical repair of the PFO may help control migraines in patients with this heart condition.

Migraine and other headaches associated with aura may increase the risk for retina damage (retinopathy) among middle-aged people, suggests a 2007 study.

The negative impact of migraines on quality of life, families, and even work productivity is significant and often underrated as a serious complication. Studies indicate that people with migraines have poorer social interactions and emotional health than patients with chronic medical illnesses, including asthma, diabetes, and arthritis. Anxiety (particularly panic disorders) and major depression are also strongly associated with migraines.

A 2005 National Headache Foundation-sponsored survey of migraine sufferers reported that:

90% of people with migraines could not function normally on the day of a migraine attack
80% experienced abnormal sensitivity to light and noise
75% experienced nausea and vomiting
30% required bed rest
25% missed at least 1 day of work due to migraine in past 3 months

Effect of Pregnancy on Migraines. In one study, pregnant women with tension or migraine headaches experienced 80% fewer headaches, usually after the end of the first trimester.

Effect of Migraine on the Pregnant Woman or Fetus. Migraine headaches do not pose any added risks during pregnancy to the mother or the fetus, although women with migraines may be at higher risk for having smaller (but not premature) babies.

Causes

Until recently, the general theory on the migraine process rested solely on the idea that abnormalities of blood vessel (vascular) systems in the head were responsible for migraines. Now, however, doctors tend to believe that migraine starts with an underlying central nervous system disorder. When triggered by various stimuli, this disorder sets off a chain of neurologic and biochemical events, some of which subsequently affect the brain's vascular system. No experimental model fully explains the migraine process.

There is certainly a strong genetic component in migraine with or without auras. Researchers have located a single genetic mutation responsible for the very rare familial hemiplegic migraine, but several genes are likely to be involved in the great majority of migraine cases. Numerous chemicals, structures, nerve pathways, and other players involved in the process are under investigation.

Central Nervous Disorder. One theory that attempts to integrate many of the known events in the migraine process is as follows:

Stress or some unknown factor triggers the release of certain protein fragments called peptides (Substance P, calcitonin gene-related peptide, and others).
These peptides dilate blood vessels and produce an inflammatory response that triggers over-excitation of the nerve cells in the trigeminal pathway. [This nerve pathway runs from the brain stem to the head and face. These nerves spread to the meninges (the membrane covering of the brain).]
While the brain itself is insensitive to pain, the meninges and blood vessels around the brain are sensitive to pain. Some doctors suggest that pain occurs when blood drains from the center of the head to the blood vessels around the brain.
Auras are believed to be a response to blood flow changes that cause a rapid reduction in brain activity that reaches the cerebral cortex (the outer layer of the brain), referred to as spreading depression. This effect may be visualized as an electrical wave spreading through the brain just as a wave of water is caused by the dropping of a pebble. Some research suggests that in people with auras, the cortical spreading depression itself activates the inflammation in the trigeminal nerves that triggers pain in the meninges.

One theory of the cause of migraine is a central nervous system (CNS) disorder. The CNS consists of the brain and spinal cord. In migraine, various stimuli may cause a series of neurologic and biochemical events that affect the brain's vascular system.

Abnormal Calcium Channels. Some migraines may be due to abnormalities in the channels within cells that transport the electrical ions calcium, magnesium, sodium, and potassium. Calcium channels appear to play a particularly critical role in migraine:

Calcium channels regulate the release of serotonin, an important neurotransmitter in the migraine process. (A neurotransmitter is a chemical messenger that allows communication between nerves in the brain.)
Magnesium interacts with calcium channels, and magnesium deficiencies have been detected in the brains of patients with migraine.
Calcium channels also play a major role in cortical spreading depression, the brain event that appears to be important in migraine symptoms.

Some patients with migraines may inherit one or more factors that impair calcium channels, making them susceptible to headaches. For example, mutations in a gene that encodes calcium channels appears to be responsible for familial hemiplegic migraine.

Researchers are also investigating factors that are common to both migraines and tension-type headaches. Some research suggests that both problems may result from a continuum of abnormalities in the central nervous system (the nerves in the brain and spine). Such changes trigger a progression of symptoms starting with mild sensations, developing into tension headache, and finally, progressing in some people to a migraine.

Serotonin and Other Neurotransmitter Levels. Neurotransmitters are chemical messengers in the brain. Serotonin is a neurotransmitter (chemical messenger in the brain) that is important for sleep, well-being, and other factors that affect quality of life. Abnormalities in serotonin levels have been observed in both tension-type and migraine headache sufferers. Altered levels of other neurotransmitters, importantly dopamine and stress hormones, also occur with migraine and tension-type headaches.

Dopamine, for example, may act as a stimulant of the migraine process. Some evidence suggests that certain genetic factors make people over-sensitive to the effects of dopamine, which include nerve cell excitation. Such nerve-cell over-activity could trigger the events in the brain leading to migraine. The prodromal symptoms (mood changes, yawning, drowsiness), for example, have been associated with increased dopamine activity. Dopamine receptors are also involved in regulation of blood flow in the brain.

Reduced Magnesium Levels. Magnesium deficiencies have been observed in people with both tension-type and migraine headaches. Researchers have noted a drop in magnesium levels before or during a migraine attack. Magnesium plays a role in nerve cell function. Reduced levels could be a destabilizing factor, causing the nerves in the brain to misfire, possibly even accounting for the auras that many sufferers experience.

Nitric Oxide. Other research suggests that over-excitable neurons release nitric oxide, a small molecular messenger that may be important in triggering in most primary headaches (tension-type, cluster, and migraines). Elevated levels have been observed in blood cells of patients with tension-type headache. Some evidence suggests that the release of this molecule in blood vessels may activate nerve pathways in the brain, muscles, or elsewhere and increase pain.

Estrogen Fluctuations in Women. Tension-type headaches and migraine headaches are slightly more common in females during adolescence and adulthood. Most likely hormone fluctuations, rather than whether levels are elevated or low, trigger headaches. Some research suggests that fluctuations in estrogen levels may impact levels of serotonin and other pain-modulating substances that affect these headaches.

Inflammation in the Maxillary Nerve. Early studies suggest that some chronic tension-type and migraine headaches may be caused by inflammation in the nerve that runs behind the cheekbone (the maxillary nerve) -- not around the covering of the brain. In fact, some work using ice water for reducing swelling in areas of the gums above the last upper molars has relieved some severe migraine and tension-type headaches.

A wide range of events and conditions can alter conditions in the brain that bring on nerve excitation and trigger migraines. They include, but are not limited to:

Emotional stress
Intense physical exertion (exercise, lifting, and even bowel movements or sexual activity)
Abrupt weather changes
Bright or flickering lights
High altitude
Travel motion
Lack of sleep
Low blood sugar and fasting
Chemicals found in certain foods. More than 100 foods may potentially trigger migraine headache. Caffeine is one such trigger. Caffeine withdrawal can also trigger migraines in people who are accustomed to caffeine. Experts recommend that patients keep a headache diary to track which foods trigger migraine.

Risk Factors

About 30 million Americans suffer from migraine headaches. They affect about 17% of all women and 6% of men. In fact, 70% of all migraine sufferers are women. Migraine is more prevalent among women throughout the world and in every culture. Although the incidence of migraine is similar for boys and girls during childhood, it increases in girls after puberty. Most people with migraine have 1 - 4 attacks per month.

Hormone Fluctuations in Women. Most migraines in women develop during the hormonally active years between adolescence and menopause. Fluctuations of estrogen and progesterone, rather than their presence, appear to increase the risk for migraines and their severity in some women.

About half of women with migraines report headaches associated with their menstrual cycle, although true menstrual migraines may actually be less common. True menstrual migraines tend not to have auras and to increase in prevalence between 2 days before and 5 days after the onset of period.
The first 3 months of pregnancy can worsen migraines in some women, although one study reported that pregnancy had little effect one way or the other on severity in most women with chronic headaches.
Women whose migraines are affected by pregnancy or menstruation are also likely to have worse migraines if they take oral contraceptives or hormone replacement therapies.

General Age of Onset. More than 20% of adults with migraines report that their headaches started before age 10, and over 45% say they started before age 20. The incidence of migraine declines in both men and women after age 40.

Migraine in Children. Migraine headaches occur in all ages and can appear in children as young as 4 years of age. Migraines in children are equally prevalent in boys and girls. Studies estimate that about 4 – 10% of all children suffer from migraine. Research indicates that overweight children may be especially susceptible to headaches, although this association is most likely due to poor nutrition and lack of exercise rather than excess weight. Children who have sleep problems, especially difficulty falling asleep, may also be more prone to migraines.

A small 2006 study indicated that some adolescents with migraine may eventually grow out of their condition. By the end of the 10-year study, 38% of patients had stopped having migraines, and 20% had transitioned into less severe tension-type headache. Children with a family history of migraine were more likely to continue having migraines.

Migraine Onset in Older Adults. Although uncommon, late-life migraine occurs in about 1% of the population, usually in men. In such cases, it often occurs as migraine with visual disturbances but without headache.

Migraine headaches can be inherited. If both parents suffer from migraines, their children have a 75% chance of getting them. When only one parent gets migraines, there is a 50% chance that children will be afflicted.

Caucasians have a higher risk than either African-Americans or Asians. Worldwide, one study reported that migraines are most common in North America. They are slightly less prevalent in South America and Europe and far less common in Asia and Africa. Investigators believe that the differences are due to genetic variations, not lifestyle factors.

People with migraine have a higher incidence of other medical conditions, including:

Asthma and allergies. These conditions have also been associated with a higher risk for conversion from having periodic migraines attacks to a chronic form (transformed migraines).
H. pylori infection. People who are infected with the bacteria H. pylori, the major cause of peptic ulcers, are at higher risk for migraines.
Epilepsy. Patients with epilepsy are twice as likely to have migraines as the general population.
Fibromyalgia
Systemic lupus erythematosus
Raynaud syndrome
Mitral valve prolapse
Narcolepsy

One study suggested that women with migraines tend to over-respond to stressful situations. In the study, they were more likely than other women to be diligent, conscientious, and overly sensitive to pressure from others. More likely, however, a person's family history of migraine, rather than any personality trait, is the important risk factor.

Diagnosis

Anyone, including children, who has recurring or persistent headaches should consult a doctor. There are no blood tests or imaging techniques that can be used to diagnose migraine headaches. A diagnosis will be made on the basis of history and physical exam, and, if necessary, tests may be necessary to rule out other diseases or conditions that may be causing the headaches. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.

For an accurate diagnosis, the patient should describe:

Duration and frequency of headaches
Recent changes in their character
Location of pain
Type of pain (throbbing or steady pressure)
Intensity of the headache
Associated symptoms, such as visual disturbances or nausea and vomiting
Behaviors during a headache. This may help distinguish between migraine and tension headaches. The predominant behavior with tension headaches is massaging the scalp, temples, or the nape of the neck. A person with migraines is more apt to use compression (such as tying a scarf around the forehead and temples) or to apply cold. They also tend to isolate themselves, lie down, induce vomiting, and use more pillows than usual. (None of these maneuvers do much good in relieving either headache, unfortunately.)

The presence of auras or other visual disturbances do not always identify migraine:

Patients with severe sinus infections may experience double vision or visual loss. (This is an emergency condition, since it indicates the infection has spread to areas around the eyes.)
Many migraine sufferers have no auras.
Many elderly people with late-onset migraine have auras but no pain.

The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches. Some tips include:

Note all conditions, including any foods eaten, preceding an attack. Often two or more triggers interact to produce a headache. For example, a combination of weather changes and fatigue can make headaches more likely than the presence of just one of these events.
Keep a migraine record for at least three menstrual cycles. For women, this can help to confirm or refute a diagnosis of menstrual migraine.
Track medications. This is important for identifying possible rebound headache or transformed migraine.
Attempt to define the intensity of the headache using a number system, such as:

1 = Mild, barely noticeable

2 = Noticeable, but does not interfere with work/activities

3 = Distracts from work/activities

4 = Makes work/activities very difficult

5 = Incapacitating

The patient should report any other conditions that might be associated with headache, including but not limited to:

Any chronic or recent illness and their treatments
Any injuries, particularly head or back injuries
Any uncharacteristic dietary changes
Any current medications or recent withdrawals from any drugs, including over-the-counter or natural remedies.
Any history of caffeine, alcohol, or drug abuse.
Any serious stress, depression, and anxiety.

The doctor will also need a general medical and family history of headaches or diseases, such as epilepsy, that may increase their risk. Migraine tends to run in families.

In order to diagnose a chronic headache, the doctor will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The doctor may ask questions to test short-term memory and related aspects of mental function.

Diagnosing the cause of persistent daily headache is difficult, even for expert doctors. Studies report that people who visit the emergency room with disabling headache are often misdiagnosed as tension-type headaches instead of migraines. It is important to choose a doctor who is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.

Extensive testing may be advised for anyone with a chronic, daily headache. Tracking times of medications, withdrawal, and headache, using the headache diary, is usually very helpful in diagnosis.

Differentiating Rebound Headaches from Transformed Migraines. Migraines that evolve to chronic headaches must be first differentiated between natural transformed migraines and rebound headaches (the most common cause of persistent migraines):

A transformed migraine is usually more consistent in its severity and its location than a rebound headache.
Transformed migraines are less sensitive to triggers than rebound headaches.

Differentiating Transformed from Tension Headaches. Once rebound headache is ruled out, the doctor must then differentiate natural transformed migraines from tension headaches:

In most cases of transformed migraine (but not tension headache), gastrointestinal or neurologic symptoms are present.
Transformed migraine is also frequently associated with menstrual fluctuations in women.

Imaging tests of the brain may be recommended under the following circumstances:

If the results of the history and physical examination suggest neurologic problems.
For patients with headaches that wake them at night.
For new headaches in the elderly. In this age group, it is particularly important to first rule out age-related disorders, including stroke, hypoglycemia, hydrocephalus, and head injuries (usually from falls).
For patients with worsening headaches.

They are not recommended for patients with migraine and with no other abnormal indications.

The following tests may be used:

A CT (computed tomography) scan may be ordered to rule out brain disorders or headaches caused by chronic sinusitis.
X-rays and other tests may also be used if sinusitis is strongly suspected.
A neck x-ray can reveal arthritis or spinal problems.
Other imaging tests include an MRI (magnetic resonance imaging), EEG (electroencephalogram), lumbar puncture, ultrasound testing, and cerebral angiography, positron emission tomography (PET), and single-photon emission computed tomography (SPECT). These tests are only performed if there is reason to suspect an underlying disease or as part of clinical studies.

A CT (computed tomography) scan is a much more sensitive imaging technique than x-ray, allowing high definition of not only the bony structures but also the soft tissues. Clear images of organs and structures, such as the brain, muscles, joints, veins and arteries, as well as of tumors and hemorrhages, may be obtained with or without the injection of contrasting dye.

Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. (It should again be emphasized that a headache is not a common symptom of a brain tumor.) People with existing chronic headaches, however, might miss a more serious condition by believing it to be one of their usual headaches. Such patients should call a doctor promptly if the quality of a headache or accompanying symptoms has changed. Everyone should call a doctor for any of the following symptoms:

Sudden, severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke).
Sudden, very severe headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm).
Chronic or severe headaches that begin after age 50.
Headaches in the back of the head accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of small stroke in the base of the skull).
Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage).
Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of spinal meningitis).
Headaches that increase with coughing or straining (possibility of brain swelling).
A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma).
A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and has no pulse; scalp is tender (possibility of temporal arteritis, which can cause blindness or even stroke if not treated).
Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain).

Treatment Approaches

Many effective headache remedies are available for treating a migraine attack. Still, a study that analyzed over 800,000 cases of migraine reported that most migraines are not treated according to any recommended guidelines. In the study, 30% of patients were treated with potentially addictive opioids -- most often merepidine (Demerol). Furthermore, 70% of these patients were not offered effective and available anti-migraine drugs. Anti-nausea drugs that have no effect on headaches were used six times more often than drugs that reduce headaches.

A 2007 survey of migraine sufferers, commissioned by the U.S. National Headache Foundation, reported that 20% of patients are prescribed non-approved medications containing opioids or barbiturates. The survey also indicated that patients who take non-approved drugs are more likely to experience drug-related side effects. For mild migraines, non-prescription treatments (Excedrin Migraine, Advil Migraine, Motrin Migraine Pain) are the best first choice. For severe migraines, doctors recommend starting with a triptan drug.

Preventive treatment, used to stop migraine attacks before they happen, may help many patients. According to another 2007 survey, more than 1 in 4 patients with migraine are candidates for preventive therapy but most do not receive it.

As many as 30% of patients with migraine also have accompanying headaches resulting from tension, drugs, infections, or other causes. It is important to distinguish between headache types in order to determine appropriate treatment.

General Guidelines. The general goals of treatment are:

Choose drugs with as few side effects as possible. Patients should talk to their doctors about various methods for administering the medication (pills, injections, nasal spray, or rectal suppositories) and begin with the one they believe will be the least distressing.
Treat the attack rapidly, within an hour of symptom onset if possible. Start with low doses, and build up dosage slowly.
Try to minimize the use of back-up or "rescue medications." (A rescue medication is typically a narcotic opiate drug, which is used for pain relief when other medications fail.)
Try to guard against rebound effect. Nearly all drugs used for migraine can cause rebound headache, and patients should not take any the drugs for longer than 2 days per week.
It may take 2 - 4 months for any drug to be effective.

Stepped-Up Treatment Approach. Some doctors recommend a stepped-up treatment course for an acute migraine attack. This involves starting with the least potent treatments and taking increasingly more powerful drugs until the pain stops. In this approach, patients may need up to five different medications to achieve pain relief. A typical stepped-up approach is the following:

The patient should first use nonprescription pain relievers (NSAIDs, Excedrin Migraine) and stress-reduction techniques.
If these are not effective within 2 hours, the patient should take migraine-specific drugs. Triptans are the first choice, then ergot derivatives.
Patients with migraines associated with severe nausea or vomiting may use injected or rectally administered drugs. Nausea itself should be treated with specific anti-nausea drugs, such as metoclopramide (Reglan).
If migraine medications fail to relieve symptoms within 4 hours, rescue drugs (opioids, corticosteroids) may be used.

Stratified Approach. Many doctors and patients now prefer the stratified approach. The doctor first estimates the severity of the patient's condition based on his or her history. Then, depending on the severity of a typical attack, the doctor decides whether the patient should start with more or less powerful drugs at the first signs of the migraine:

Patients with less disabling migraines start with general pain relievers.
Patients with a history of moderate-to-severe migraines start with migraine-specific prescription medicine, such as a triptan, at the onset of mild pain.

Some studies report dramatic relief with the stratified approach. In one study, zolmitriptan, a newer triptan, reduced the intensity of headaches within 2 hours in 70% of patients with moderate pain but only in 44% of those with severe headaches.

Side effects can be severe with many migraine drugs, although newer drugs, such as the recent generation triptans, may provide effective early relief without significant side effects.

Studies estimate that between 5 - 10% of children have migraines but that the disorder is underdiagnosed in children. An interesting study reported that when children drew pictures in response to their doctors' questions about their migraines, the doctors were able to tell the difference between migraine and non-migraine headaches in the majority of cases.

Symptoms in Children. The standard diagnostic criteria for migraine in adults may apply to only about two-thirds of migraines in children and adolescents. For example, doctors have seen the following differences:

Headaches tend to last for a shorter time (as little as an hour) in children.
Migraine pain tends to occur in the face and on both sides of the head in two-thirds of child patients.
Children often have a form of migraine known as a migraine equivalent or abdominal migraine, which does not cause a headache at all. Instead, children experience periodic bouts of nausea and vomiting (called cyclic vomiting syndrome) or other secondary symptoms found in adult migraine, such as a reaction against light or sound. Cyclic vomiting may occur in nearly 2% of school-aged children with or without a migraine association.
Migraine triggers in children are similar to those in adults, but common ones in children are anxiety and fear, and eating ice cream.

Outlook in Children. Migraine in children is disabling, as it is in adults, and they tend to lose more school days than other children. Children with frequent headaches may also be at higher risk for headaches in adulthood and also for other physical and psychiatric problems. However, some children who have migraine eventually stop having attacks when they reach adulthood, or have less severe types of headaches.

Treatments in Children. Most children with migraines may need only mild pain relievers and home remedies (such as ginger tea) to treat their headaches. The American Academy of Neurology’s 2004 practice guidelines for children and adolescents recommend the following drug treatments:

For children age 6 years and older, ibuprofen (Advil) is recommended. Acetaminophen (Tylenol) may also be effective. Acetaminophen works faster than ibuprofen, but the effects of ibuprofen last longer.
For adolescents age 12 years and older, sumaptriptan (Imitrex) nasal spray is recommended.

Preventive Measures in Children. Non-medication methods, including biofeedback and muscle relaxation techniques may be helpful. In one study of children with migraines and poor sleep habits, who were taught how to sleep better instructions without using medications had significantly fewer migraine attacks.

If these methods fail, then preventive drugs may be used, although evidence is weak on the effectiveness of standard migraine preventive drugs in children.

If medication overuse causes rebound migraines develop, the patients cannot recover without stopping the drugs. (If caffeine is the culprit, a person may need only to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient can usually stop abruptly or gradually. The patient should expect the following:

Most headache drugs can be stopped abruptly, but the patient should talk to their doctor first. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal.
If the patient chooses to taper off standard headache medications, withdrawal should be completed within three days.
The patient may take other pain medicines during the first days. Examples of drugs that may be used include dihydroergotamine (with or without metoclopramide), NSAIDs (in mild cases), corticosteroids, or valproate.
The patient must expect their headache to get worse after they stop taking their medications, no matter which method they use. Most people feel better within 2 weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).
If the symptoms do not respond to treatment and cause severe nausea and vomiting, the patient may need to be hospitalized.

On the encouraging side, some patients experience dramatic long-term relief from all headaches afterward, and one study reported that 82% of patients significantly improved 4 months after medication withdrawal.

Medications Used for Treatment

Many different medications are used to treat migraines. However, the Food and Drug Administration (FDA) has specifically approved only the following types of drugs for migraine treatment:

Non-prescription drugs: Excedrin Migraine, Advil Migraine, Motrin Migraine Pain
Prescription drugs: Triptans and ergotamine

Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-label for migraine treatment. Opioids and barbiturates have not been approved by the FDA for migraine relief, and they can be addictive.

All FDA-approved migraine treatments are approved only for adults. No migraine products have officially been approved for use in children.

Some patients with mild migraines respond well to over-the-counter (OTC) painkillers, particularly if they take the medicine at the very first sign of an attack.

The Food and Drug Administration has approved three OTC (nonprescription) products to treat migraine. Excedrin Migraine (a combination of aspirin, acetaminophen, and caffeine) was the first such medication approved for the temporary relieve of migraine and its symptoms. Studies have reported significant relief in nearly 70% of patients. It may also help menstrual migraines. Advil Migraine and Motrin Migraine Pain, both containing ibuprofen, are also approved to treat migraine headache.

Cooling Pads. Cooling pads may help during an attack. Some products (Migraine Ice, TheraPatch Headache Cool Gel) use a pad containing a gel that cools the skin for up to 4 hours and can be placed on the forehead, temple, or back of the neck.

Non-steroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, and naproxen. They were among the first types of drugs tried to treat mild-to-moderate migraines. Aspirin, ibuprofen (Advil, Motrin), and naproxen (Anaprox, Aleve) are all available without prescription. Naproxen may have specific benefits for migraine. A 2007 study indicated that a combination of naproxen and sumatriptan provides better migraine pain relief than either drug alone.

Other types of NSAIDs are available only by prescription. Some studies indicate that the NSAID combination diclofenac-potassium (Cataflam) may work faster than the migraine drug sumatriptan (Imitrex) and help reduce nausea. The combination is not appropriate for people allergic to aspirin or at risk for bleeding.

Injectable NSAIDs, particularly ketorolac (Toradol), may be very effective for severe and persistent migraines. A 2003 study found that intravenous ketorolac provided greater pain relief than nasal sumatriptan (Imitrex). A 2005 study presented at the annual meeting of the American Headache Society reported that intravenous ketorolac was more effective than opioid drugs for late-stage treatment of severe migraine attacks.

COX-2s are a class of prescription drugs that have the anti-inflammatory effects of NSAIDs, but do not upset most people's stomachs. However, most of these drugs have been withdrawn from the U.S. market due to increased risk for heart attack and stroke. Celecoxib (Celebrex) is the only available COX-2, and it has a strong warning label alerting users of the potential for heart attack, stroke, and serious gastrointestinal problems. (The warning is the same one the Food and Drug Administration recommended for the labels of prescription NSAIDs in 2005.)

NSAID Side Effects. High dosages and long-term use of NSAIDs can increase the risk for heart problems, kidney problems, and stomach bleeding. In April 2005, the FDA asked drug manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes an increased risk for cardiovascular events and gastrointestinal bleeding in people taking these drugs. The FDA also requested manufacturers of over-the-counter NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and gastrointestinal risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions.

Triptans (also referred to as serotonin agonists) were the first drugs specifically developed for use against migraine. They are the most important migraine drugs currently available. They help maintain serotonin levels in the brain, and so specifically target one of the major components in the migraine process.

Triptans are recommended as first-line drugs for adult patients with moderate-to-severe migraines when NSAIDs are not effective. Triptans have the following benefits:

They are effective for most patients with migraine, as well as patients with combination tension and migraine headaches.
They do not have the sedative effect of other migraine drugs.
Withdrawal after overuse appears to be shorter and less severe than with other migraine medications

Sumatriptan. Sumatriptan (Imitrex) has the longest track record and is the most studied of all triptans. It is available as a fast-dissolving pill, nasal spray, or injection. Injected sumatriptan works the fastest of all the triptans and is the most effective, but it can cause pain at the injection site. The nasal spray form bypasses the stomach and is absorbed more quickly than the oral form. Some patients report relief as soon as 15 minutes after administration. The spray tends to work less well when a person has nasal congestion from cold or allergy. It may also leave a bad taste. Sumatriptan is effective for many patients, but headache recurs in 20 - 40% of people within 24 hours after taking the drug.

A 2007 study in the Journal of the American Medical Association suggested that a combination of sumatriptan and naproxen works better than either drug alone.

Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax). Comparison studies with sumatriptan suggest that some of the newer drugs have fewer side effects and are superior to sumatriptan for providing immediate, sustained, and consistent pain relief. Recurrence rates are also lower. They are also being investigated for prevention under certain circumstances, such as menstrual migraines, but benefits appear limited.

Studies on newer triptans indicate:

Almotriptan is as effective as oral sumatriptan and may have fewer side effects, particularly chest pain, than most other triptans.
Rizatriptan may have the most rapid effects of all oral triptans. Zolmitriptan also has a more rapid effect than sumatriptan (although there appears to be no significant difference in adverse effects). Both rizatriptan and zolmitriptan are also available as rapidly dissolving wafers.
Eleptriptan is also very rapidly effective at high doses, but at those levels may have significant adverse effects. (To date, it does not seem to have any advantages over other triptans in head-to-head comparisons.)
Naratriptan and frovatriptan have a delayed response but long duration, few side effects, and lower risk for recurrence than with sumatriptan. Some evidence suggests that they may have specific benefits for stopping prolonged migraines and may even play a role in prevention.
Frovatriptan: A large study of more than 500 women with an average 12-year history of menstrual migraines examined the use of frovatriptan for the short-term prevention of such headaches. Researchers found that the migraines disappeared in over half of the women on the higher dose (5 mg) of frovatriptan.
Zolmitriptan (Zomig): Several studies indicate that zomitriptan nasal spray may be safe and effective for adolescents. In one study, zolmitriptan relieved pain within 2 hours for nearly half of the children (aged 12 - 17 years) enrolled in the trial. Zolmitriptan nasal spray is approved only for adults.

Side Effects. Many of the newer triptans may have fewer severe side effects than sumatriptan. Side effects of most triptans, however, can include:

Tingling and numbness in the toes
Sensations of warmth
Discomfort in the ear, nose, and throat
Nausea
Drowsiness
Dizziness
Muscle weakness
Heaviness, pain, or both in the chest. (About 40% of patients taking sumatriptan experience these symptoms, and they are major factors in discontinuing the drug. Newer drugs, such as almotriptan, produce fewer chest symptoms.)
Rapid heart rate

Complications of Triptans. The following are potentially serious problems.

Complications of heart and circulation. Triptans narrow (constrict) blood vessels. Because of this effect, spasms in the blood vessels may occur and cause serious side effects, including stroke and heart attack. Such events are rare, but patients with an existing history or risk factors for these conditions should generally avoid triptans.
Serotonin syndrome. Serotonin syndrome is a life-threatening condition that occurs from an excess of the brain chemical serotonin. Triptan drugs used to treat migraine, as well as certain types of antidepressant medications, can increase serotonin levels. These antidepressant drugs include serotonin reuptake inhibitors (SSRIs) -- such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) -- and selective serotonin/norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor). It is very important that patients not combine a triptan drug with a SSRI or SNRI drug. Serotonin syndrome is most likely to occur when starting or increasing the dose of a triptan or antidepressant drug. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea, and vomiting. You should seek immediate medical care if you have these symptoms.

The following people should avoid triptans or take them with caution and only with the advisement of a doctor:

Anyone with a history or any risk factors for stroke, uncontrolled diabetes, high blood pressure, or heart disease.
People taking antidepressants that increase serotonin levels.
Children and adolescents. They may be safe, but controlled studies are needed to confirm this. (Triptans should not, in any case, be the first-line treatment for children.)
People with basilar or hemiplegic migraines. (Triptans are not indicated for these migraineurs.)
There is no evidence to date of any higher risk for birth defects in pregnant women who take triptans. Still, women should be cautious about taking any medications during pregnancy and discuss any possible adverse effects with their doctors.

Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood vessels, and are useful for migraine. They were the first anti-migraine drugs available. Ergotamine is available by prescription in the following preparations:

Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal) or by injection, which can be performed at home.
Ergotamine is available tablets taken by mouth, tablets taken under the tongue (sublingual), and rectal suppositories. Some of the tablet forms of ergotamine contain caffeine.

Ergotamine’s role since the introduction of triptans is now less certain. Only the rectal forms of ergotamine are superior to rectal triptans. Injected, oral, and nasal-spray forms are all inferior to the triptans. Ergotamine may still be helpful for patients with status migrainous or those with frequent recurring headaches.

Side Effects. Side effects of ergotamine include:

Nausea
Dizziness
Tingling sensations
Muscle cramps
Chest or abdominal pain

The following are potentially serious problems:

Toxicity. Ergotamine is toxic at high levels.
Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke.

Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is often reversible if the drug is stopped.

The following patients should avoid ergots:

Pregnant women. Ergots can cause miscarriage.
People over age 60.
Patients with serious, chronic health problems, particularly those of the heart and circulation.

Ergotamine can interact with other medications, such as antifungal drugs and some antibiotics. All ergotamine products approved by the Food and Drug Administration (FDA) contain a "black box" warning in the prescription label explaining these drug interactions. In 2007, the FDA pulled 15 unapproved older ergotamine products off the market, in part because they lacked this warning label. The five FDA-approved ergotamine products that remain on the market are:

Migergot suppository (marketed by G and W Labs)
Ergotamine Tartrate and Caffeine tablets (marketed by Mikart and West Ward)
Cafergot tablets (marketed by Sandoz)
Ergomar sublingual tablets (marketed by Rosedale Therapeutics)

Nasal drops containing lidocaine, a local anesthetic, can provide effective and quick pain relief within 15 minutes for many migraine sufferers. However, lidocaine has certain downsides:

It is rather difficult to administer. Patients must be lying down with their head dangling.
The headache often relapses in an hour, and other drugs must then be used.
Side effects include unpleasant taste, burning sensation, and facial numbness.

However, the drug does not cause drowsiness or heart rhythm disturbances as some other migraine treatments do. It should not be used for any other form of headache.

If the pain is very severe and does respond to other drugs, doctors may try painkillers containing opioids. Opioid drugs include morphine, codeine, meperidine (Demerol), and oxycodone (Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be useful as a rescue treatment when others fail.

Opioids are not approved for migraine treatment and should not be used as first-line therapy. Nevertheless, many opioid products are prescribed to patients with migraine, sometimes with dangerous results. In 2007, following reports of several drug-related deaths, the Food and Drug Administration warned that the cancer pain pill fentanyl (Fentora) should not be used to treat patients with migraine or others conditions for which the drug is not specifically approved.

Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation. There is a risk for addiction, and these drugs can become ineffective with long-term use for chronic migraines. Doctors should not prescribe opioids to patients at risk for drug abuse, including those with personality or psychiatric disorders.

Metoclopramide (Reglan) is used in combinations with other drugs to treat the nausea and vomiting that occurs with other drugs and with migraine itself. Metoclopramide and other anti-nausea drugs, such as domperidone (Motilium), may help the intestine better absorb migraine medications.

New drugs in clinical trials include tonabersat (a gap junction blocker), trexima (a combination triptan and non-steroidal anti-inflammatory drug), GW274150 (a nitric oxide synthase inhibitor), and MK-0974 (a calcitonin gene-related peptide antagonist). Researchers are also investigating a nasal spray containing capsaicin, the chemical found in cayenne peppers.

Prevention

There are several ways to prevent migraine attacks. You should try a healthy diet, the right amount of sleep, and non-drug approaches, such as biofeedback, first for prevention.

Behavioral techniques that reduce stress and empower the patient may help some people with migraines. Studies report between 35 - 50% reduction in migraine and tension-type headaches with these approaches. They generally include:

Biofeedback therapy
Cognitive-behavioral therapy
Relaxation techniques

Behavioral methods may help counteract the tendency for muscle contraction and uneven blood flow associated with some headaches. They may be particularly beneficial for children, adolescents, and pregnant and nursing women, and anyone who cannot take most migraine medications.

Biofeedback. Studies have demonstrated some effectiveness from biofeedback for migraine headaches. Biofeedback training teaches the patient to monitor and modify physical responses, such as muscle tension, using special instruments for feedback.

Cognitive Behavioral Therapy. Behavioral therapy may be useful alone but is particularly beneficial for patients who are on preventive drug treatments. It typically uses the headache diary to track activities and headaches. The patient then works with the therapist to change or add behaviors or medications that will reduce the frequency and severity of attacks.

Alternative non-drug therapies used for headache management and prevention include hypnosis, meditation, visualization and guided imagery, acupuncture, acupressure, yoga, and other relaxation exercises. There is no clear evidence that any of these techniques have specific value for migraines.

Some studies report the following:

Acupuncture. Acupuncture is a Chinese medicine technique that uses thin needles to stimulate specific points aligned with energy pathways in the body. Studies have showed mixed results on the benefits of acupuncture for migraine. A 2005 study published in the Journal of the American Medical Association reported that acupuncture was no more effective than sham acupuncture (needles placed at non-acupuncture points) in preventing migraines. More than 300 people were enrolled in this randomized trial. A 2006 study of 960 people, published in Lancet Neurology, found that real acupuncture, sham acupuncture, and standard drug treatment were all equally effective in preventing migraine attacks.
Relaxation Techniques. Muscle relaxation techniques may be helpful. One study reported that relaxation treatments appeared to help adolescents with migraine but not tension headaches.

Hormonal drugs, such as oral contraceptives or hormone replacement therapy, have a mixed effect on women with migraines. Oral contraceptives have been associated with worse headaches in 18 - 50% of women and have also been linked to a higher risk for stroke in women with classic migraines (with auras). Young women should avoid or stop oral contraception if they have classic migraines, migraines that worsen or change character after oral contraceptives , if they have close relatives with stroke or heart disease, or if they smoke.

Some evidence suggests, however, that oral contraceptives may help prevent true menstrual migraines (which do not have auras). In such cases, their benefits may outweigh the low risk of a serious adverse event. Keeping a migraine record for at least three menstrual cycles can help confirm whether a woman actually has a true menstrual migraine.

Making a few minor changes in your lifestyle can make your migraines more bearable. Improving sleep habits is important for everyone, and especially those with headaches. What you eat also has a huge impact on migraines, so dietary changes can be extremely beneficial, too.

Avoiding Food Triggers. Avoiding foods that trigger migraine is an important preventive measure. Common food triggers include monosodium glutamate (MSG), processed lunch meats that contain nitrates, dried fruits that contain sulfites, aged cheese, alcohol and red wine, chocolate, and caffeine. However, people’s responses to triggers differ. Keeping a headache diary that tracks diet and headache onset can help identify individual food triggers.

Healthy Diet. One study indicated that a diet low in fat and high in complex carbohydrates may significantly reduce the frequency, severity, and duration of migraine headaches. Such a diet is healthy in general, in any case.

Eating Regularly. Eating regularly is important to prevent low blood sugar. People with migraines who fast periodically for religious reasons might consider taking preventive medications.

Fish Oil. Some studies suggest that omega-3 fatty acids, which are found in fish oil, have anti-inflammatory and nerve protecting actions. These fatty acids can be found in oily fish, such as salmon, mackerel, or sardines. They can also be obtained in supplements of specific omega-3 compounds (DHA-EPA).

Exercise is certainly helpful for relieving stress. An analysis of several studies reported that aerobic exercise in particular might help prevent migraines. It is important, however, to warm up gradually before beginning a session, since sudden, vigorous exercise might actually precipitate or aggravate a migraine attack.

Manufacturers of herbal remedies and dietary supplements do not need Food and Drug Administration 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 several reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.

Riboflavin (Vitamin B2). There is reasonable evidence on the benefits of vitamin B2 for migraine sufferers. In one study, patients who took 400 mg of vitamin B2 (riboflavin) reduced their migraine attacks by half, although the vitamin had no effect on the severity or duration of migraines that did occur. In another study, it helped increase the effectiveness of beta-blockers, drugs used to prevent migraines in some people. Vitamin B2 is generally safe, although some people taking high doses develop diarrhea.

Magnesium Supplements. Studies have reported a higher rate of magnesium deficiencies in some patients with migraine, such as those with menstrual migraines. Magnesium helps relax blood vessels. Some patients report relief from supplements.

Feverfew. Feverfew is the most studied herbal remedy for headaches and is effective in some cases. However, like all effective headache remedies, overuse can cause a rebound effect.

Ginger. In general, herbal medicines should never be used by children or pregnant or nursing women without medical counsel. One exception may be ginger, which has no side effects and can be eaten in powder or fresh form, as long as quantities are not excessive. Some people have reported less pain and frequency of migraines while taking ginger, and children can take it without danger.

Medications Used for Prevention

The Food and Drug Administration has approved four drugs for prevention of migraine:

Propanolol (Inderal)
Timolol (Blacadrene)
Divalproex sodium (Depakote)
Topiramate (Topamax)

Propanolol and timolol are beta-blocker drugs. Divalproex and topiramate are anti-seizure drugs. Many other drugs are also being used or investigated for preventing migraines.

Beta-blockers are usually prescribed to reduce high blood pressure. Some beta-blockers, however, are also useful in reducing the frequency of migraine attacks and their severity when they occur. Propranolol (Inderal) and timolol (Blocadren) have been approved specifically for prevention of migraine. Metoprolol (Toprol), atenolol (Tenormin), and nadolol (Corgard) are also being studied for migraine prevention.

Side Effects. Side effects may include:

Fatigue and lethargy are common.
Some people experience vivid dreams and nightmares, depression, and memory loss.
Dizziness and lightheadedness may occur upon standing.
Exercise capacity may be reduced.
Other side effects may include cold extremities, asthma, decreased heart function, gastrointestinal problems, and sexual dysfunction.

If side effects occur, the patient should call a doctor, but it is extremely important not to stop the drug abruptly. Some evidence suggests that people with migraines who have had a stroke should avoid beta-blockers.

Anti-seizure drugs, also called anti-epileptic drugs or anticonvulsants, affect the neurotransmitter gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. GABA may also have a role in migraines. These drugs are commonly used for epilepsy and bipolar disease. Anti-seizure drugs are more expensive than other drugs. They also have significant side effects. Divalproex sodium (Depakote) and topiramate (Topamax) are the only anti-seizure drugs that are approved for migraine prevention. However, if patients do not respond to either of these drugs, doctors may try other types of anti-seizure medications.

Divalproex Sodium (Depakote). Divalproex sodium (Depakote) was first approved in 1996 for migraine prevention. A once-a-day formulation of divalproex (Depakote ER) was approved in 2000. Doctors sometimes prescribe a similar drug, valproate (Depakene). Pregnant patients should not use these drugs, as they may cause birth defects.

Topiramate (Topamax). In 2004, the Food and Drug Administration approved topiramate for prevention of migraines in adults. Studies from 2006 indicated that the drug works well when used on a long-term basis. Patients in these studies experienced significantly fewer migraines for up to 14 months. Topiramate’s most common side effect is a tingling sensation in the arms and legs. Weight loss is also a side effect. In clinical trials, patients lost an average of 3.8% of their body weight.

Other Anti-Seizure Drugs Under Investigation. Researchers are studying other types of anti-seizure drugs for migraine prevention. These include levetiracetam (Keppra), gabapentin (Neurontin), pregabalin (Lyrica), zonisamide (Zonegran), tiagabine (Gabitril), and the investigational drug lacosamide (LCM).

Side Effects. Anti-seizure medication's side effects vary by drug but may include:

Nausea and vomiting
Diarrhea
Cramps
Hair loss
Dizziness
Sleepiness
Blurred vision
Weight gain
Valproate and divalproex can cause serious side effects of inflammation of the pancreas (pancreatitis) and damage to the liver

Amitriptyline (Elavil, Endep), a tricyclic antidepressant drug, has been used for many years as a first-line treatment for migraine prevention. It may work best for patients who also have depression or insomnia. Tricyclics can have significant side effects, including disturbances in heart rhythms, and can be fatal in overdose. Although other tricyclic antidepressants may have fewer side effects than amitritpyline, they do not appear to be particularly effective for migraine prevention.

Researchers have investigated newer types of antidepressants, including serotonin-reuptake inhibitors(SSRIs), such as fluoxetine (Prozac). However, studies to date do not indicate that SSRIs are helpful for migraine prevention.

Muscle Relaxants. Botulinum toxin A (Botox) injection, a common wrinkle treatment, causes small muscles to relax. This approach is now being used with some success for treating disorders that involve over-excited muscle activity, including myofascial pain syndrome and migraine. One study reported complete migraine relief in more than half of patients being tested and improvement of more than 50% in another 35% of patients. Relief lasted 3 - 4 months with no adverse effects. A study presented at the 2005 meeting of the American Headache Society reported that patients who regularly received Botox injections every 3 months reduced both the frequency of migraine attacks and their reliance on pain medications

Angiotensin Converting Enzyme Inhibitors. Commonly used for treating high blood pressure, angiotensin converting enzyme (ACE) inhibitors block the production of the protein angiotensin, which constricts blood vessels and may be involved in migraine. Studies using the ACE inhibitor lisinopril (Prinivil, Zestril) are reporting significant reduction in migraine attacks.

Angiotensin-Receptor Blockers. Angiotensin-receptor blockers (ARBs) have actions similar to ACE inhibitors, but may have fewer side effects. In one study, patients who took the ARB candesartan (Atacand) had significantly fewer headaches compared to patients who received placebo.

Neurostimulation Devices. Researchers are investigating a transcranial magnetic stimulation (TMS) device to help stop migraines before they occur. The hair dryer-size device is held to the back of the head and delivers quick magnetic pulses. The device is used when a patient experiences the first signs of a migraine. Other types of nerve stimulation devices are also under investigation.

Inhalation Devices. These devices use heat to vaporize a drug so that it can be inhaled into the lungs. Clinical trials are currently testing this device with procholorperazine (Compazine), a tranquilizer drug that is used to treat nausea and vomiting.

Nasal Devices. New types of nasal sprays and powders are being researched. Some of them use capsaicin, the chemical found in cayenne peppers, to help relieve pain.

Skin Patches. The Actyve transdermal patch uses a small battery-powered system to deliver a triptan drug through the skin.

Drugs. New drugs in development include tonabersat (gap junction blocker), trexima (combination triptan and non-steroidal anti-inflammatory drug), and GW274150 (nitric oxide synthase inhibitor).

Resources

www.headaches.org -- National Headache Foundation
www.americanheadachesociety.org -- American Headache Society
www.aan.com -- American Academy of Neurology
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.clinicaltrials.gov -- Find clinical trials
www.migraineinfo.org -- National Migraine Association

References

Brandes JL, Kudrow D, Stark SR, O'Carroll CP, Adelman JU, O'Donnell FJ, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA. 2007 Apr 4;297(13):1443-54.

Lewis DW, Winner P, Hershey AD, Wasiewski WW; Adolescent Migraine Steering Committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics. 2007 Aug;120(2):390-6.

Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF; AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007 Jan 30;68(5):343-9.

Monastero R, Camarda C, Pipia C, Camarda R. Prognosis of migraine headaches in adolescents: a 10-year follow-up study. Neurology. 2006 Oct 24;67(:1353-6.

Rose KM, Wong TY, Carson AP, Couper DJ, Klein R, Sharrett AR. Migraine and retinal microvascular abnormalities: the Atherosclerosis Risk in Communities Study. Neurology. 2007 May 15;68(20):1694-700.

Review Date:
11/1/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

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Recommended Daily Allowances

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

HEALTH GUIDE REFERENCE FROM A.D.A.M

Recommended Daily Allowances Chart

When you're pregnant or breastfeeding, it's important to take a close look at your diet to make sure that you and your baby are getting all of the calories and nutrients you need. What changes should you make? To find out, look over the table below, which lists the recommended daily allowances for various nutrients before conception, during pregnancy, and while you're nursing your baby. The table also explains the importance of each of these nutrients.

The best way to improve your diet is by eating a variety of healthy foods. Taking a daily prenatal vitamin recommended by your health care provider will help fill in any nutritional gaps. (If you're a vegetarian or are on another special diet, be sure to talk to your caregiver about additional dietary changes you may need to make.) Remember, too, that "eating for two" doesn't mean twice as much. You need just 300 extra calories a day (400 while nursing) - equal to one glass of milk, a banana, and 10 crackers.

These additional nutrient requirements can be taken in by choosing the right kinds of foods. For instance, green leafy vegetables are both high in folic acid and iron. Calcium can be taken in through dairy products and also through foods such as salmon, beans, and tofu. Dairy products are helpful in getting nutrients such as phosphorous, riboflavin, Vitamin A, and Vitamin D.

Although pregnancy requires additional nutrients, it doesn't require a drastic change in caloric intake. Remember, don't skip meals and keep saturated fats to a minimum.

Review Date:
2/20/2007
Reviewed By:
Douglas A. Levine, MD, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

FitSugar

RDI: What About All Those B Vitamins?

Know your A, B, Cs: Riboflavin

Riboflavin

Overview

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Definition

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Function

Food Sources

Side Effects

Recommendations

Are You an Egghead? Egg Whites vs. Whole Eggs

How to Eat the Vitamins and Minerals You Need

Cataracts

In This Report

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Vitamins

Migraine headache

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Causes

Risk Factors

Diagnosis

Treatment Approach

Lifestyle

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Nutrition and Dietary Supplements

Herbs

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Mind/Body Medicine

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Pregnancy

Warnings and Precautions

Prognosis and Complications

Supporting Research

Migraine headaches

In This Report

Highlights

Introduction

Prognosis

Causes

Risk Factors

Diagnosis

Treatment Approaches

Medications Used for Treatment

Prevention

Medications Used for Prevention

Resources

References

Recommended Daily Allowances

Recommended Daily Allowances Chart

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