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it should be continued for several months If the patient remains headache-free, the dose can then be tapered and the drug eventually withdrawn Botulinum toxin type A is also effective for migraine prevention in some patients; it has few systemic side effects and need only be given at intervals of several months Although acupuncture has been widely used in the prophylaxis of migraine, a randomized controlled trial failed to show any difference between it and sham acupuncture Calcium channel antagonist drugs may decrease the frequency of attacks after an interval of several weeks, but the severity and duration of attacks are not influenced They should not be used with -blockers The angiotensin-converting enzyme receptor blocker, candesartan, may also be effective and is undergoing evaluation

private void button1_Click( object sender, EventArgs e ) { label1.Text = "Goodbye"; }

4 Cluster Headache (Migrainous Neuralgia)

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Cluster headache affects predominantly middle-aged men Its cause is unclear but may relate to a vascular headache disorder or a disturbance of serotonergic mechanisms Activation of cells in the ipsilateral hypothalamus has been shown to occur There is often no family history of headache or migraine Episodes of severe unilateral periorbital pain occur daily for several weeks and are often accompanied by one or more of the following: ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner s syndrome Episodes often occur at night, awaken the patient, and last for less than 2 hours Spontaneous remission then occurs, and the patient remains well for weeks or months before another bout of closely spaced attacks occurs During a bout, many patients report that alcohol triggers an attack; others report that stress, glare, or ingestion of specific foods occasionally precipitates attacks In occasional patients, typical attacks of pain and associated symptoms recur at intervals without remission This variant has been referred to as chronic cluster headache Examination reveals no abnormality apart from Horner s syndrome that either occurs transiently during an attack or, in

Prophylactic treatment may be necessary if migrainous headaches occur more frequently than two or three times a month Some of the more common drugs used for this purpose are listed in Table 24 1 Their mode of action is unclear and may involve both an effect on extracerebral vasculature and a cerebral effect, eg, by stabilizing serotonergic neurotransmission Several drugs may have to be tried in turn before the headaches are brought under control Once a drug has been found to help,

Of course, once the text of the label has changed, you can t change it back. You could add an if statement that changes the text from Hello to Goodbye , or vice versa, every time the button is clicked. You can see the full source code solution to Exercise 18-1 on the website for this book, although there isn t much to it. Figure A-5 is a picture of the form.

the posterior fossa (eg, Arnold-Chiari malformation), are present in about 10% of cases, and brain tumors or other space-occupying lesions may certainly present in this way Accordingly, CT scanning or MRI should be undertaken in all patients and repeated annually for several years, since a small structural lesion may not show up initially The disorder is usually self-limited, although it may persist for several years For unknown reasons, symptoms sometimes clear completely after lumbar puncture Indomethacin (75 150 mg daily) may provide relief

longstanding cases, remains as a residual deficit between attacks Treatment of an individual attack with oral drugs is generally unsatisfactory, but subcutaneous (6 mg dose) or intranasal (20-mg/spray) sumatriptan or inhalation of 100% oxygen (7 L/min for 15 minutes) may be effective Dihydroergotamine (1 2 mg intramuscularly or intravenously) is sometimes used Butorphanol tartrate, a synthetic opioid agonist-antagonist administered by nasal spray, may also be helpful The dose is 1 mg (one spray in one nostril), repeated after 60 90 minutes if necessary Ergotamine tartrate is an effective prophylactic and can be given as rectal suppositories (05 1 mg at night or twice daily), by mouth (2 mg daily), or by subcutaneous injection (025 mg three times daily for 5 days per week) Various prophylactic agents that have been found to be effective in individual patients are valproate, cyproheptadine, lithium carbonate (monitored by plasma lithium determination), prednisone (20 40 mg daily or on alternate days for 2 weeks, followed by gradual withdrawal), and verapamil (240 480 mg daily) Topiramate (25 200 mg daily) or valproate (750 1500 mg daily) may also be useful in some instances

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