Gas and Bloating

INTRODUCTION – Everyone has gas. It is normally eliminated from the body through belching and by passing it through the anus. The average adult produces about one to three pints of gas each day and passes gas through the anus about 14 to 23 times per day. Burping occasionally before or after meals is also normal. The amount of gas varies depending upon diet and individual factors. Some people feel that they pass too much gas from below (flatulence) or burp too frequently, both of which can be a source of embarrassment and can be uncomfortable. However, most people who complain of excessive gas do not produce more than the average person. Instead, they probably have increased awareness of normal amounts of gas. On the other hand, several foods and certain medical conditions are associated with excessive gas production. Understanding the sources of intestinal gas, conditions possibly associated with increased sensitivity to gas, and measures that may help to reduce symptoms can offer relief to many patients. WHAT EXACTLY IS "GAS"? – Gas within the digestive or gastrointestinal (GI) system–which includes the esophagus, stomach, small intestine, and large intestine–primarily consists of odorless vapors, such as oxygen, nitrogen, carbon dioxide, hydrogen, and methane. These comprise more than 99 percent of eliminated intestinal gas. Minor components of "flatus"–or gas expelled through the anus–that may be associated with unpleasant odor include trace amounts of sulfur-containing gases released by bacteria that are normally present within the large intestine. SOURCES OF GAS – There are two primary sources of intestinal gas: gas that is ingested (mostly swallowed air) and gas produced by bacteria that normally reside in the colon (a process called fermentation). Air swallowing – Air swallowing is the major source of gas in the stomach. Everyone typically swallows a relatively small amount of air when eating and drinking and with every normal swallow. Larger amounts of air may be swallowed when eating food rapidly, gulping liquids, chewing gum, or smoking. Most swallowed air appears to be eliminated from the stomach by belching (or "eructation"), so that only a relatively small amount passes from the stomach into the small intestine. However, posture may influence how much air passes to the small intestine. In an upright position, most swallowed air tends to pass back up to the esophagus and be expelled through the mouth. On the other hand, in a lying position, swallowed air tends to pass into the small intestine. In addition, some of the oxygen and nitrogen within swallowed air may be absorbed through the walls of the GI tract into the blood. Belching may be voluntary or occur unintentionally. Involuntary belching is a normal process that typically follows eating and results from the release of swallowed air after enlargement or stretching (distension) of the stomach. In addition, belching may increase with certain foods that relax the ring-shaped muscle (sphincter) around the lower end of the esophagus where it joins the stomach. Such foods include peppermint, chocolate, and fats. Bacterial production – The normal colon provides a home for billions of harmless bacteria, some of which may actually promote the health of the bowel. The bacteria survive by consuming foods that are not digested in the upper portions of the intestine. Their preferred foods are carbohydrates (a general term that refers to sugar, starches, and fiber in foods). Carbohydrates are normally digested by the action of enzymes in the small intestine. However, certain carbohydrates are incompletely digested, leaving them available for the bacteria in the colon to digest. The by-products of bacterial digestion include carbon dioxide, hydrogen, and methane. Some carbohydrates, such as raffinose, are not well digested, and therefore produce increased amounts of gas. Raffinose is contained in a number of vegetables such as cabbage, Brussels sprouts, asparagus, broccoli, and some whole grains. As a result, these foods tend to cause increased amounts of gas and flatulence in most people. Another factor is variation among individuals in their ability to digest carbohydrates. A classic example is lactose, the major sugar contained in dairy products. Much of the world's adult population has a limited ability to digest lactose. Thus, consumption of large amounts of lactose by such people will lead to the production of gas often accompanied by cramping and diarrhea. Certain diseases can also lead to difficulty digesting carbohydrates. One example is bacterial overgrowth, in which excessive amounts of bacteria are present in the small intestine. The bacteria compete with the body's efforts to digest carbohydrates, leading to excessive gas often with diarrhea and weight loss. Bacterial overgrowth can be seen in patients with a variety of underlying conditions, such as those who have undergone some forms of intestinal bypass surgery and those with disorders that can slow emptying of the intestines (such as diabetes mellitus). WHAT ARE THE SYMPTOMS OF GAS ? – As mentioned above, people who complain about gas usually mean that they pass excessive amounts of gas from below or burp too frequently. Other frequent complaints attributed to gas are abdominal distension and crampy abdominal pain. Such pain may be perceived in areas that the gas may become trapped, such as bends in the colon, which occur naturally in the area under the liver (upper to mid right part of the abdomen), and in the area under the spleen (upper to mid left part of the abdomen). DISORDERS ASSOCIATED WITH HEIGHTENED SENSITIVITY TO NORMAL AMOUNTS OF INTESTINAL GAS – The link between any of the symptoms described above and the actual amount of gas in the intestines is not always clear. The vast majority of people who complain about gas-related symptoms do not have excessive amounts of gas in the intestine when measured by sensitive testing. Such people may have increased awareness of normal amounts of gas in the intestine. This can happen in a variety of circumstances. Irritable bowel syndrome – One of the most common examples is a disorder known as irritable bowel syndrome (IBS). Its cardinal symptoms are abdominal pain and altered bowel habits, but these symptoms have no identifiable cause. Many patients also complain of visible abdominal distension although they do not have increased amounts of gas in the intestine. Many researchers believe that some of the symptoms of IBS may be caused by heightened sensitivity of the intestines to normal events that occur within them. This theory proposes that nerves carrying sensory messages from the bowel are overactive in people with IBS, so that normal amounts of gas or movement in the gastrointestinal tract are perceived as excessive and painful. In support of this theory is the observation that some patients with severe IBS feel better when treated with medications (such as low doses of imipramine or nortriptyline) that decrease the sensations coming from the intestine. Functional dyspepsia – Dyspepsia describes recurrent or persistent pain or discomfort that is primarily located in the upper abdomen. It is experienced by approximately 25 percent of the population in the United States and other western countries. Dyspepsia can arise from various underlying conditions. However, the most common type of dyspepsia seen by physicians is known as "functional" (or "nonulcer") dyspepsia. This refers to dyspepsia that occurs without an identifiable cause. People with functional dyspepsia tend to have increased sensitivity to distension in the upper intestines. Irritation of the anus or esophagus – People who have irritation around their anus due to external hemorrhoids or other problems may also experience more discomfort when they pass gas. Similarly, people who have irritation of the esophagus (esophagitis) may find burping painful. DISORDERS AND FOODS ASSOCIATED WITH INCREASED GAS – As discussed above, the vast majority of people with gas-related complaints do not produce excessive amounts of gas. However, there are several conditions that may indeed lead to increased gas formation. The following sections will discuss some of the more common causes. Aerophagia – Chronic, repeated belching usually results from habitual swallowing of large amounts of air (ie, aerophagia). Aerophagia is typically an unconscious process occurring with anxiety. The diagnosis is made after excluding other possible causes (such as gastroesophageal reflux disease). Treatment focuses on methods to help people refrain from swallowing excessive amounts of air, such as advising people to eat slowly without gulping, and avoid carbonated beverages, chewing gum, and smoking. Specific anti-anxiety treatment may also be necessary. Foods that cause gas – As discussed above, several foods contain the carbohydrate raffinose, which is poorly digested and leads to gas production by the action of colonic bacteria. Common foods containing raffinose include beans, cabbage, cauliflower, Brussels sprouts, broccoli, and asparagus. Starch and soluble fiber are other forms of carbohydrates that can contribute to gas formation. Potatoes, corn, noodles, and wheat produce gas while rice does not. Soluble fiber (found in oat bran, peas and other legumes, beans, and most fruit) also cause gas. Some laxatives contain soluble fiber and may cause gas, particularly during the first few weeks of use. Lactose intolerance – Intolerance to lactose-containing foods (primarily dairy products) is a common problem. In Europe and the United States, lactose intolerance affects 7 to 20 percent in Caucasians (being lowest in those of northern European extraction), 80 to 95 percent among Native Americans, 65 to 75 percent of Africans and African Americans, and 50 percent of Hispanics. More than 90 percent of the population is affected in some regions in eastern Asia. Lactose intolerance is caused by an impaired ability to digest lactose, the principle sugar in dairy products. Clinical symptoms of lactose intolerance include diarrhea, abdominal pain, and flatulence after ingestion of milk or milk-containing products. Lactose intolerance can be diagnosed by a lactose breath test, in which a measured amount of lactose in consumed, and the amount of hydrogen in breath samples is measured. Treatment involves avoidance of dairy products that contain lactose and/or supplementation with the enzyme lactase, which is available in over-the-counter products. People who avoid dairy products should take calcium supplements, since dairy products are a valuable source of calcium. Intolerance to other sugars – In addition to lactose and raffinose, some individuals may be intolerant to other sugars contained in foods. Two common examples are fructose (contained in onions, artichokes, and pears and in some fruit drinks or soft drinks where it appears as "high fructose corn syrup") and sorbitol (a sugar substitute contained in some sugar free candies and chewing gum). Diseases associated with increased gas – A number of diseases can cause impaired absorption of carbohydrates (carbohydrate malabsorption), which can lead to increased gas. In addition to bacterial overgrowth described above, carbohydrate malabsorption can occur in patients with celiac disease (a disease caused by intolerance to a protein contained in wheat), short bowel syndrome, and those who have rare primary disorders of the enzymes needed to digest specific forms of carbohydrates. Infections – Infections of the intestine are generally not a frequent cause of gas. However, infection with a parasite known as Giardia lamblia ("giardiasis") may cause abdominal discomfort, nausea, bulky stools, and carbohydrate malabsorption. Giardiasis occurs in people who ingest the cysts of the parasites, which are found in some rivers, streams, and wells. DIAGNOSIS – The first steps in evaluating patients who complain of gas are obtaining a thorough medical history and performing a physical examination. Additional testing depends upon the specifics in each individual. Those with "alarm" symptoms such as diarrhea, weight loss, abdominal pain, anemia, blood in the stool, lack of appetite (anorexia), fever, or vomiting usually require specific testing. For patients without alarm symptoms, such diagnostic assessment rarely detects a specific underlying problem. For those who require testing, specific tests may include: • Examination of stool to detect the presence of blood, abnormally increased levels of fat (steatorrhea), or the presence of Giardia lamblia. • A lactose tolerance test, during which patients are provided with a test dose of lactose by mouth. After receiving the test dose, those with lactose intolerance may soon develop abdominal discomfort, diarrhea, and excessive flatulence. Breath or blood samples are obtained during the test to confirm the presence of lactose intolerance. • X-ray examination of the small intestine. • Upper endoscopy, sigmoidoscopy, or colonoscopy (in which the inside of the stomach, upper intestines or colon are examined via a tube with a camera at the end). • Breath or blood tests for carbohydrate malabsorption. • Antibody tests for celiac disease. TREATMENT – Doctors may recommend several measures to help reduce bothersome gas and associated discomfort or distress. The approach depends upon the individual, the type of symptoms, and the cause. Specific recommendations may include: • Avoidance of foods that appear to aggravate symptoms. These may include milk and dairy products, certain fruits or vegetables, whole grains, artificial sweeteners, and/or carbonated beverages. Physicians may recommend that patients keep a diary of the foods and beverages they consume over a certain time period and suggest systematically eliminating one food or group of food at a time to help determine which may be most responsible for symptoms. • Over-the-counter products that contain simethicone, such as certain antacids , or activated charcoal , which is a powerful absorbent. Simethicone, which causes gas bubbles to break and join together, is widely used to help alleviate gas, even though its value is questionable. Evidence concerning the benefit of activated charcoal is contradictory: its effect in alleviating symptoms of intestinal gas has been supported by some studies yet refuted by others. As a result, physicians may recommend that patients consider trying activated charcoal to see whether its use may result in some symptom relief in their case. • Bismuth subsalicylate can reduce the odor of unpleasant smelling gas due to the presence of hydrogen sulfide, a sulfur-containing compound. • Antibiotic therapy in patients who have been diagnosed with bacterial overgrowth. • Restricting lactose in the diet, and using certain lactose-digestive aids, such as lactose-reduced milk, or over-the-counter "lactase" supplements in patients who have been diagnosed with lactose intolerance. As mentioned above, those who avoid dairy products should take calcium supplements.

Gallstones

INTRODUCTION –The development of gallstones is a common digestive disease, but fortunately, most people with gallstones do not develop any symptoms or complications and do not require treatment. In many cases, such "silent gallstones" are detected incidentally through the routine use of ultrasonography for the evaluation of another problem, particularly abdominal pain or pelvic disease, or blood tests that suggest abnormal liver function. WHAT IS THE GALLBLADDER? – The gallbladder is a pear-shaped sac-like muscular organ that is approximately 3 to 6 inches long, located in the right upper side of the abdomen just underneath the liver . It connects with the liver and intestine through small tubes called the bile ducts. The primary purpose of the gallbladder is to store and concentrate bile. Bile, a greenish-brown fluid, is produced by the liver and stored in the gallbladder. Eating fatty foods causes the gallbladder to contract and empty its bile through the cystic duct, common bile duct, and the valvular opening of the sphincter of Oddi (show figure 1) into the intestine where it is needed for fatty food digestion and absorption, as well as the absorption of a number of important fat soluble vitamins. Bile is a water based fluid that contains bile salts, cholesterol, and other fatty substances (lipids), as well as waste products, such as bilirubin, a pigment that gives bile its distinctive color. During fasting, the gallbladder is relaxed and the sphincter of Oddi is closed, causing the bile that is secreted by the liver to flow through the cystic duct into the gallbladder where it is stored and concentrated by absorption of much of its water content through the gallbladder walls. This allows the gallbladder to take in and store more than 10 times its volume in bile. With meals, the entrance of fatty foods into the small intestine triggers the secretion of a hormone (cholecystokinin), which stimulates contraction of the gallbladder and the opening of the sphincter of Oddi. This results in partial emptying of the concentrated gallbladder bile through the common bile duct into the upper region of the small intestine (known as the duodenum) to aid in the digestion and absorption of fats and fat-soluble vitamins. A few hours later the gallbladder relaxes and starts to store bile secreted by the liver again. WHAT ARE GALLSTONES? – Gallstones are lumps of rock-like material that form inside the gallbladder. Medical science is just beginning to uncover the causes of gallstone formation. Studies suggest that stones can form in the gallbladder if there is a change or imbalance in the composition of bile, such as too much cholesterol, increased amounts of pigment material, and/or reduced levels of bile acids which are "detergent-like" substances that help keep the cholesterol in solution form. Evidence suggests that gallstone development may also result from an impairment of gallbladder contraction, which would lead to incomplete emptying of the gallbladder in response to a fatty meal. Due to such factors, cholesterol or other bile components may "precipitate" or settle out from liquid bile in the form of crystals that would then clump together, leading to stones. The number of gallstones can be variable. In some instances, patients may have an accumulation of minute crystals in the form of sand (called biliary sludge) but no obvious gallstone formation. Gallstones may be as small as tiny specks or as large as the gallbladder itself. The vast majority, however, are smaller than 1 inch and may be one of two major types: • Cholesterol gallstones, which account for approximately 80 percent of gallstone cases.in industrialized countries, including the United States. • Pigment stones, composed mainly of calcium salts of bile pigments and other compounds, account for about 20 percent. Gallstone type is important since cholesterol stones are more likely to respond to non-surgical treatments. WHO IS AT RISK FOR GALLSTONES? – The exact reason (or reasons) why some people develop gallstones are still being uncovered. However, there are a number of factors that may be associated with an increased risk of cholelithiasis: Gender – Women are more likely to develop gallstones than men. Age – The risk of gallstones is known to increase with age. The condition is extremely rare in childhood and becomes progressively more frequent over time, with age 40 representing a possible cut-off between relatively low and high rates. Gallstones are present in about 10 percent of men and 20 percent of women by the age of 60. Ethnicity – Gallstones appear to occur more frequently in Native American, Hispanic, and western Caucasian individuals. In contrast, there appear to be lower rates of cholelithiasis in African American, natives of South Africa, and Japanese populations. Family history and genetics – Studies of family histories indicate that cholelithiasis runs in certain families, suggesting that genetics has a role in gallstone development. Other factors – An increased risk of cholelithiasis may also be associated with a number other factors including: • Pregnancy • Use of estrogen preparations (such as birth control pills) • Obesity • Frequent fasting • Rapid weight loss • Lack of physical activity • Diabetes mellitus • Sickle cell disease (and other conditions associated with rapid destruction of red blood cells such as in patients with mechanical heart valves) • Cirrhosis, or severe scarring, of the liver • Certain medications (eg, octreotide, estrogen preparations, clofibrate) WHAT IS GALLSTONE DISEASE? – The majority of people who have gallstones do not have symptoms and their stones remain "silent." Silent stones do not need to be treated since the initial symptoms are usually mild. Experts feel that the risk from surgical removal of the gallbladder is greater than the risk from not treating silent stones. When gallstones start to produce symptoms, the condition is then referred to as gallstone disease. WHAT ARE THE SYMPTOMS OF GALLSTONES? – Once a patient experiences the first episode of symptoms, the chance of having further and more severe symptoms becomes more likely, indicating a need for treatment. Biliary colic – This is the most common symptom also referred to as gallstone pain or biliary pain. It is characterized by episodic attacks of abdominal pain, which is most often located in the right upper abdomen just under the margin of the ribs but can also be felt in the back and right shoulder. Biliary colic is usually caused by the gallbladder contracting in response to a fatty meal and pressing the stones against and blocking the gallbladder outlet (cystic duct opening). As the gallbladder relaxes several hours after the meal, the stones often fall back from the cystic duct and the pain subsides. Other associated symptoms include nausea, vomiting, and intolerance to fatty foods. Acute cholecystitis – Recurrent biliary pain and cystic duct blockages can progress to total obstruction, causing acute inflammation of the gallbladder (acute cholecystitis). Unlike biliary colic in which symptoms abate within a few hours, pain continues in patients with acute cholecystitis. This is a serious condition that is associated with fever and requires immediate medical attention. In such cases, patients require hospitalization where they are typically treated with intravenous fluids, pain medications, and often antibiotics. Surgical removal of the gallbladder is usually recommended during the hospitalization or shortly thereafter. If not treated, acute cholecystitis may lead to gallbladder rupture, a life-threatening condition. Other complications of gallstone – Other complications may result if the gallstones migrate through the cystic duct and block the common bile duct causing jaundice (a yellow discoloration of the skin and eyes) with or without pain. It may also lead to infection of the bile ducts (acute cholangitis) causing pain, chills, and fever. This condition requires prompt intervention, which usually involves a procedure in which the offending gallstone is removed by way of a tube with a video camera inserted through the mouth (a procedure known as endoscopic retrograde cholangiopancreatography or ERCP). Acute inflammation of the pancreas (pancreatitis), which is associated with severe abdominal pain, may also occur. If the bile duct remains blocked for a long period of time, irreversible liver damage may occur (secondary biliary cirrhosis). Symptoms of questionable relationship to gallstones – Gallstones are very common, as are complaints related to the digestive system such as bloating, belching, heartburn, and gas. While it is easy to mistakenly attribute these symptoms to the presence of gallstones, they usually indicate other types of gastrointestinal disorders such as gastroesophageal reflux and dyspepsia. On the other hand, episodic nausea and vomiting and intolerance to fatty foods may sometimes be suggestive of gallstone disease, although these too can be due to other causes. HOW ARE GALLSTONES DIAGNOSED? – Gallstones can be detected by a variety of methods. X-ray – An x-ray will detect only pigment stones. Ultrasound – Ultrasound is the most commonly used and most accurate screening technique since it is more sensitive than x-ray and does not involve the use of radiation. HIDA Scan – HIDA scan identifies obstructions of the cystic duct, evaluates the ability of the gallbladder to contract, and diagnoses acute cholecystitis. Endoscopic retrograde cholangiopancreatography (ERCP) – ERCP is required when gallstones are suspected in the bile ducts. A flexible tube with a video camera is inserted through the mouth and small intestine, then a smaller tube is advanced through the first tube into the bile duct through which contrast is injected and an x-ray is taken to visualize the stones. This procedure also allows the extraction of stones from the ducts without the need for surgery. CT-scan – CT scan is used to determine which gallstones are suitable for some of the non-surgical gallstone elimination modalities. However, it is a poor initial test with which to look for gallstones. HOW ARE GALLSTONES TREATED? – There are three general options for people with gallstones; the best option depends upon the clinical setting: • Expectant management: Do nothing, wait and watch. • Surgical therapy: Removal of the gallbladder with its stones. • Non-surgical therapy: Elimination of the stones while preserving the gallbladder People with asymptomatic gallstones – People with gallstones who are asymptomatic usually require no specific intervention. As mentioned above, silent stones do not need to be treated since the initial symptoms are usually mild. Experts feel that the risk from surgical removal of the gallbladder is greater than the risk from not treating silent stones. Thus, preventive gallbladder removal in asymptomatic gallstones is not recommended since many such individuals will remain asymptomatic for a very long time, possibly even for the rest of their lives. Individuals with silent gallstones must be educated as to the initial symptoms of gallstone disease because treatment should be sought once the first symptoms occur since the chance of recurrent and more severe symptoms becomes very high. WHAT ARE THE SURGICAL TREATMENT OPTIONS? – The gallbladder is an important organ, but is not essential for life. Therefore, the standard treatment for symptomatic patients who suffer from gallstones has been to have the gallbladder removed surgically along with its contained stones. Removing the gallbladder may have little or no effect on digestion. Loose stools, gas, and bloating may develop in about half the patients, but in most they are mild, requiring no dietary restrictions after the gallbladder is removed. Open cholecystectomy – Cholecystectomy, surgical removal of the gallbladder, is one of the most commonly performed surgical procedures; more than 700,000 are performed in the United States each year. There are two versions of this operation. The first is the classic open cholecystectomy which leaves a 4- to 6-inch scar and usually requires three to five days of hospitalization and several weeks of recuperation. The operation is extremely safe (complications occurring in only 6 percent of patients but major complications are very rare). However, the risk increases with age and in patients with other medical problems. Laparoscopic cholecystectomy – The second and newer surgical technique is laparoscopic cholecystectomy. Under general anesthesia, a video-endoscope and instruments are introduced into the abdomen through four or five very small non-muscle cutting incisions and used to visualize and remove the gallbladder. The patient is typically hospitalized for one to two days and requires a recovery time of one to two weeks. Over the past few years laparoscopic cholecystectomy quickly became the standard operation for removing the gallbladder. Experience with this technique has shown this operation to be safe and well tolerated by the patient but the chance of complications relating to common bile duct injury is somewhat higher than that of the other procedure. Most cholecystectomies are now performed laparoscopically. However, both open and laparoscopic approaches may have particular advantages in certain situations. For example, laparoscopic cholecystectomy may not always be possible in emergency settings and in about 5 to 10 percent of patients a laparoscopic operation has to be converted to an open cholecystectomy during the surgery for a variety of reasons. Physicians, surgeons, and other members of the healthcare team will recommend the most appropriate method for a patient's particular clinical situation. There have been reports of an increase in the risk of colon cancer in patients whose gallbladders have been removed. This is thought to be due to the chronic leakage of bile into the colon in patients who do not have a gallbladder. However, experts feel that studies are conflicting and inconclusive. If anything there may be a slight increase in the risk of right-sided colon cancer as reported in some studies. WHAT NON-SURGICAL TREATMENT OPTIONS ARE AVAILABLE?– Nonsurgical approaches are available for the treatment of gallstones. These require no surgical incision or general anesthesia and eliminate the stones while preserving the gallbladder. Four non-surgical approaches are currently available for the treatment of gallstones. Oral bile acid pill –. It contains a natural bile acid that slowly dissolves predominantly cholesterol gallstones over a period of one to three years. However, about two-thirds of patients become symptom free about two to three months after the bile acid pill is started and remain as such even though it may take several years for the stones to actually disappear. Nevertheless, because of its slow action its use is not practical in patients with recurrent or acute symptoms. It is very safe and well tolerated, but mild transient diarrhea may occur in a minority of patients. Its use is limited to small cholesterol stones, it requires a functioning gallbladder, and is typically effective in only 50 percent of patients who are qualified to take it. Topical gallstone dissolution – The second non-surgical approach is topical gallstone dissolution, which is not approved and still in the investigational stages in the United States. It involves dissolving the stones by bathing them with a gallstone dissolving solution (solvent). At the present time it is limited only to gallstones that are mostly cholesterol by composition as determined by a specialized CT-scan. For this procedure, a small tube (catheter) about the size of a strand of spaghetti is inserted into the gallbladder through a tiny needle puncture while the patient is under local anesthesia. The catheter is then used to instill the solvent, which is used to irrigate the gallbladder and dissolve the stones. This would typically take a few hours to complete after which the solvent is evacuated from the gallbladder and the patient goes home and returns a few days later to have the catheter removed. While the patient is at home, the catheter is comfortably taped to the skin and does not normally affect the patient's daily activities or work. Because of its rapid action and because it does not require general anesthesia or significant recuperation time, it is especially desirable for the treatment of patients who are at higher risk of complications from surgery or general anesthesia. Percutaneous endoscopic laser or electrohydraulic lithotripsy – The third non-surgical approach is Percutaneous endoscopic laser or electrohydraulic lithotripsy. In this procedure, a catheter is inserted into the gallbladder under local anesthesia and remains in place for two weeks. The patient would then return when the catheter track is slightly enlarged to the size of a small straw. A laser probe is then used to apply short bursts of laser energy to fracture the stones into small pieces that are then washed out of the gallbladder. The devices for this procedure are currently approved and available in the United States and it is the only non-surgical approach that is effective for all types of stones. Thus, it is useful for non-cholesterol pigment stones. The main disadvantage is that it is a prolonged procedure requiring three to four outpatient visits over several weeks for completion. It is also labor intensive and, therefore, rarely done only on patients at high-risk who have non-cholestesterol stones. Extracorporeal shock wave lithotripsy – The fourth approach is extracorporeal shock wave lithotripsy (ESWL). Shock waves generated outside the body are focused on the gallstones to fracture them into smaller fragments and "sand," which can then be dissolved more efficiently by the oral bile acid pill. ESWL has been approved and used extensively in the treatment of kidney stones. It was recently approved for the treatment of gallstones as well. Since it relies on bile acid therapy to clear the fractured stones and residue, it can only treat cholesterol stones. It is not effective for more than three stones or large stones and a functioning gallbladder is required. Studies to date show that its success rate is not very high and may be painful, necessitating sedation. It may also cause attacks of biliary pain as fragments pass through the bile duct into the intestine. The shock waves may cause some internal organ damage, which usually is not significant. Gallstone recurrence – The main disadvantage of any of the non-surgical treatment options is that since the gallbladder is not removed, gallstone recurrence is possible. With oral therapy, stones appear to recur in only 50 percent of patients and typically only in the first five years. Generally, it takes many years for the recurrent stones to grow. Even if stones recur, most patients will continue to be symptom free because studies show that gallstone symptoms develop at a low rate of 1 to 2 percent per year. GALLSTONE PREVENTION – Some doctors recommend the following to help prevent the development of gallstones: • Consumption of three well balanced meals daily, with each meal containing some fat to ensure good gallbladder contraction. This would prevent stagnation in the gallbladder, which is one of the factors of gallstone formation in susceptible individuals. • Maintenance of a diet that is high in fiber and calcium and low in saturated fats. • Maintenance of a normal standard body weight through proper calorie restriction and regular, appropriate exercise. Obese people (with and without known gallstones) who are undergoing a rapid weight-loss program should be supervised by their physician and may require specific treatment with oral bile acids to prevent the development of gallstones during weight loss.

Diabetes What it is

Diabetes mellitus is a common condition characterized by high blood glucose (sugar) levels. This condition occurs when the pancreas produces insufficient amounts of the hormone insulin, or the body's tissues become resistant to normal or even high levels of insulin, or a combination of both of these problems. Diabetes is a chronic medical condition requiring regular monitoring and treatment. Treatment can effectively control blood glucose levels and minimize a person's risk for the complications of diabetes. Lifestyle adjustments and self-care also play a large role in the treatment of diabetes over time. TYPES OF DIABETES – In the past, several different systems were used to classify the different types of diabetes. Today, diabetes is classified as either type 1 or type 2 diabetes. Type 1 diabetes – Type 1 diabetes usually begins in childhood or young adulthood, but can occur at any age. This type of diabetes occurs when the pancreas produces very little insulin or no insulin at all. People with type 1 diabetes have to take insulin regularly, and if they do not, they develop a serious condition called diabetic ketoacidosis. Type 2 diabetes – Type 2 diabetes begins in adolescence or adulthood. This type of diabetes occurs when the body's tissues respond poorly to normal or even high levels of insulin (called insulin resistance). In addition to insulin resistance, the pancreas produces insufficient amounts of insulin. Insulin treatment may not be necessary, and patients rarely develop diabetic ketoacidosis. However, people with type 2 diabetes often need to take oral medications and follow special diets to lower their blood glucose levels. Diabetes with features of both type 1 and type 2 diabetes – Occasionally, it is difficult to determine the type of diabetes because a person has manifestations of both type 1 and type 2 diabetes. For example, some people with type 2 diabetes develop diabetic ketoacidosis and have an absolute requirement for insulin. Unusual patterns of diabetes appear to be more common in black people. Gestational diabetes – Gestational diabetes refers to diabetes that develops during pregnancy.. Impaired glucose tolerance – Impaired glucose tolerance (sometimes called impaired fasting glucose) is characterized by borderline elevations of blood glucose. Many people with impaired glucose tolerance eventually develop type 2 diabetes, and people with this condition have an increased risk for cardiovascular disease even if they do not develop diabetes. Impaired glucose tolerance is very common: about 11 percent of all people between the ages of 20 and 74 years have impaired glucose tolerance. CAUSES OF DIABETES – A wide range of different factors can cause diabetes. Type 1 diabetes – Type 1 diabetes most often occurs when the person's own immune system destroys the insulin-producing cells of the pancreas. This is called an autoimmune disease and can be detected by finding antibodies directed against the pancreas. When these antibodies are present, it is called type 1A diabetes. Sometimes, despite evidence of pancreatic damage, blood tests do not reveal the presence of antibodies; in this case, the condition is called type 1B diabetes. Type 2 diabetes – Type 2 diabetes results from a complex interaction of predisposing genetic factors and environmental factors. Genetic conditions that affect insulin-producing cells – About 2 to 4 percent of people with type 2 diabetes have an unusual, inherited form of diabetes caused by specific genetic defects that impair the function of insulin-producing cells in the pancreas. Genetic conditions that affect insulin action – Rarely, diabetes is caused by genetic defects that block the binding of insulin to tissues or that alter the physical structure of insulin. Both of these defects interfere with the normal action of insulin. Other conditions of the pancreas – Any condition that damages the pancreas or requires surgical removal of part of the pancreas can cause diabetes. These conditions include cystic fibrosis, hemochromatosis, and pancreatitis (inflammation of the pancreas). Endocrine conditions – Hormone levels in the body are carefully balanced, and several endocrine disorders can indirectly alter the production and action of insulin and lead to diabetes. They include Cushing's syndrome, acromegaly, pheochromocytoma, and hyperthyroidism. Exposure to drugs and chemicals – Certain drugs and chemicals can alter the production and action of insulin, and trigger diabetes. These drugs include beta blockers (which are used to treat hypertension and cardiovascular disease), steroids, and protease inhibitors (which are used to treat human immunodeficiency virus [HIV] infection). Viral infection – Infection with certain viruses may damage the pancreas and cause diabetes. Pregnancy – About 2 percent of pregnant women develop gestational diabetes. This type of diabetes results from the combined effects of placental hormones and the increased dietary intake during pregnancy. SYMPTOMS OF DIABETES – Some people with diabetes have symptoms of high blood glucose levels, including excessive thirst, consumption of large quantities of liquids, excretion of large quantities of urine, weight loss, and blurred vision. However, many people with diabetes have no symptoms at all. DIAGNOSIS OF DIABETES – The diagnosis of diabetes is based on the symptoms noted during a medical history and physical examination and on the results of laboratory tests. Medical history and physical examination – Because heredity plays a role in diabetes, your doctor will ask if any family members have diabetes or conditions commonly associated with diabetes, such as hypertension, high blood lipid levels, and obesity. Although a person may have symptoms of diabetes, a physical examination often reveals few signs of high blood glucose levels early in the course of diabetes. Laboratory tests for diabetes – Several simple blood tests are used to diagnose impaired glucose tolerance and diabetes. Additional tests can determine the type of diabetes and its severity. Random blood glucose test – Blood glucose can be measured at any time throughout the day, regardless of when a person last ate. A random blood glucose level of 200 mg/dL or higher suggests the presence of diabetes. Fasting blood glucose test – Measurement of blood glucose test after a person has fasted for 8 to 12 hours (usually overnight) is the most accurate test for diagnosing diabetes. A level of less than 110 mg/dL is considered normal. A level between 111 and 125 mg/dL suggests that a person has impaired fasting glucose, which is very similar to impaired glucose tolerance. A level of 126 mg/dL or higher suggests that a person has diabetes. Oral glucose tolerance test – In the past, the oral glucose tolerance test was used to diagnose diabetes. Today, this test is rarely used clinically, except to diagnose the diabetes associated with pregnancy (gestational diabetes). During an oral glucose tolerance test, a person is asked to drink a glucose solution, and blood glucose is measured hourly for several hours. A blood glucose level of 200 mg/dL (11.1 mmol/L) or higher 2 hours after drinking the solution suggests that a person has diabetes. Tests for antibodies – In most people with type 1 diabetes, blood tests reveal the presence of antibodies that target the insulin-producing of the pancreas; these antibodies are called islet-cell antibodies. Blood tests may also reveal antibodies directed against glutamic acid decarboxylase, insulin itself, or against insulin receptors. Hemoglobin A1c test – The hemoglobin A1c blood test is not used alone to diagnose diabetes or impaired glucose tolerance. However, this test may provide more information in people with borderline fasting blood glucose values. Normal values for hemoglobin A1c are usually 6 percent or lower. This test is most useful for monitoring blood glucose in people with known diabetes. PREDICTORS OF TYPE 2 DIABETES – Certain factors are helpful for identifying people who are likely to develop type 2 diabetes, although some people with these risk factors never develop diabetes. Impaired glucose tolerance – People with impaired glucose tolerance have an increased risk of type 2 diabetes and an increased risk of cardiovascular diseases such as coronary artery disease. The likelihood of progression from impaired glucose tolerance to type 2 diabetes is greater in certain ethnic groups; for example, Hispanic people more than white people . Obesity also increases the likelihood that a person with impaired glucose tolerance will develop type 2 diabetes. Results of laboratory tests – The results of the oral glucose tolerance test and the hemoglobin A1c test help predict the likelihood that a person will develop type 2 diabetes. In a group of nondiabetic people with risk factors for type 2 diabetes, diabetes later developed in 38 percent of those with an abnormal oral glucose tolerance test, 50 percent of those with an abnormal hemoglobin A1c test, and 69 percent of those with abnormal results on both tests. Obesity – For people of all ages, the risk of developing impaired glucose tolerance or type 2 diabetes increases with increasing body weight, which makes the body's tissues less responsive to insulin. Conversely, weight loss decreases the risk of type 2 diabetes in obese people, and weight loss can improve blood glucose control in people who already have type 2 diabetes. Two additional aspects of obesity have also been linked to the risk of diabetes: the pattern of body fat distribution and birth weight. Body fat distribution – Obese people who have fat distributed in their upper body or abdomen have the greatest risk for type 2 diabetes. Fat distribution is determined by calculating the waist-to-hip ratio. Obese men with a ratio greater than 0.95 and obese women with a ratio greater than 0.85 have the greatest risk for type 2 diabetes. Birth weight – For unknown reasons, low weight at birth is associated with an increased risk for type 2 diabetes later in life. This association is particularly strong in people with a low birth weight who become overweight in middle age. Gestational diabetes – Women who develop gestational diabetes have an increased risk of developing type 2 diabetes. The results of an oral glucose tolerance test 4 to 16 weeks after delivery help predict the risk over the subsequent 5 years. In one study of women who developed gestational diabetes, 84 percent of women with an abnormal test result (impaired glucose tolerance) developed type 2 diabetes, compared with 12 percent of women with a normal test result. Polycystic ovary syndrome – Polycystic ovary syndrome is characterized by irregular menstrual cycles with acne or excessive facial hair growth. Women with this syndrome are at increased risk of both impaired glucose tolerance and type 2 diabetes. Therefore, all women with this syndrome should be evalauated for diabetes. PREDICTORS OF TYPE 1 DIABETES – Type 1 diabetes occurs in genetically susceptible subjects and is probably triggered by one or more environmental agents. It usually progresses over many months or years. Genetic markers can be used to predict the risk of type 1 diabetes in close relatives of a patient with type 1 diabetes. Several antibodies can be detected in blood before the onset of type 1 diabetes. Three are clinically useful: islet-cell antibodies, insulin autoantibodies, and antibodies to glutamic acid decarboxylase. PREDICTORS OF LATE-ONSET TYPE 1 DIABETES – About 7.5 to 10 percent of adults initially diagnosed with type 2 diabetes later have evidence of type 1 diabetes, including islet-cell antibodies or antibodies to glutamic acid decarboxylase and a poor response to treatments that usually control type 2 diabetes. This type of diabetes is called late-onset type 1 diabetes. PREVENTION OF TYPE 2 DIABETES – Three strategies may prevent type 2 diabetes: exercise, weight loss, and drug therapy. Exercise – Regular exercise can decrease a person's risk for developing type 2 diabetes and can improve glucose tolerance in people with impaired glucose tolerance. In one study, a large group of healthy men was followed for 10 years; the men who exercised regularly were much less likely to develop type 2 diabetes over time, and this benefit was especially apparent in obese men who exercised. In another study, a group of men with impaired glucose tolerance was followed for 5 years; 76 percent of the men who exercised regularly had improved glucose tolerance, whereas glucose tolerance worsened in 67 percent of men who did not exercise. Furthermore, type 2 diabetes developed in only 11 percent of the men who exercised but in 29 percent of the men who did not exercise. The Diabetes Prevention Program has reported preliminary results from a trial of 3234 obese individuals with impaired glucose tolerance ("pre-diabetes"). The subjects who were assigned to intensive lifestyle changes (diet and exercise) were less apt to develop type 2 diabetes than those who were assigned to receive medication (metformin). Thus, diet and exercise are extremely important for the prevention of type 2 diabetes. Weight loss – In people with type 2 diabetes, sustained weight loss can improve glycemic control. In those with impaired glucose tolerance, sustained weight loss can improve glucose tolerance and prevent progression to type 2 diabetes. Drug therapy – Three groups of drugs are being evaluated to see if they may prevent type 2 diabetes or slow the progression from impaired glucose tolerance to type 2 diabetes. Metformin – Metformin makes tissues more responsive to insulin. In a study in men with risk factors for type 2 diabetes, metformin was more effective than placebo in promoting weight loss and reducing fasting blood glucose levels. This drug is being tested in a large trial in the United States (called the Diabetes Prevention Program, or DPP). Thiazolidinediones – Rosiglitazone and pioglitazone are thiazolidinedione drugs that increase muscle sensitivity to insulin, improve insulin secretion, and help normalize glucose tolerance in people with impaired glucose tolerance; these findings suggest that this class of drugs may stop or slow the progression to type 2 diabetes. Troglitazone, another drug in this class, was included in the DPP but was withdrawn because of concerns about its safety. Angiotensin-converting enzyme (ACE) inhibitors – ACE inhibitors are most often used to treat cardiovascular disease. However, a large study in people with cardiovascular disease suggested that these drugs may also protect people against type 2 diabetes. In this study, diabetes developed in 3.6 percent of people taking an ACE inhibitor and in 5.4 percent of those taking a placebo. PREVENTION OF TYPE 1 DIABETES – Methods to prevent type 1 diabetes are still in the investigational stage. Several drugs, including azathioprine, cyclosporine, nicotinamide, and insulin, have been given alone or in combination, to decrease the immune-mediated destruction of insulin-producing cells that occurs in type 1 diabetes with modest and usually temporary benefit. Much further research is needed before these methods can be used in the greater population at risk for type 1 diabetes. A large trial in the United States (called the Diabetes Prevention Trial for type 1 diabetes, or DPT-1) is testing the use of insulin (either by mouth or as an injection) in the close relatives of people with type 1 diabetes.

Headache Managment

Headaches can usually be well controlled with a combination of lifestyle adjustments, drugs, and complementary therapies. Treatment is most successful when it is tailored to each person's individual needs and when a person actively participates in therapy. It is therefore important to learn as much as you can about your headaches, to discuss the treatment options carefully with your doctor, and to take an active role in your treatment. This discussion of treatment will focus upon the three major types of non-life threatening headaches: migraine, tension, and cluster headaches. In most people, the frequency and severity of attacks can be well controlled with an individualized combination of lifestyle adjustments, drug treatment, and complementary therapies. LIFESTYLE ADJUSTMENTS – Some simple lifestyle adjustments may reduce the frequency of headache attacks. These include adhering to a routine schedule, exercising regularly, learning stress-management skills, and avoiding known headache triggers whenever possible (see below). Patients with cluster headaches should avoid smoking and alcohol. Headache triggers – Many potential triggers can start a headache attack or worsen a preexisting headache. The specific factors that trigger attacks differ from person to person. Most of these triggers have been noted in people with migraine headache; their role in other headache types is less clear. In particular, food triggers are much more common in people with migraines than in people with tension headaches. Your headache triggers, if any, can sometimes be determined by keeping a headache diary. If you can discover certain things that trigger your headaches and avoid them, you can prevent future headaches. Some triggers are unavoidable; for example, migraines occur about three times more often in women than in men. Hormones have a variable effect on migraines. Some women who take oral contraceptives or estrogen experience worsening headaches, while others improve. Similarly, some women have an increasing headache pattern during pregnancy, while others have diminished headache intensity. Headaches may increase in some women in the days before the menstrual period. When a medication is triggering a headache, talk with your doctor to see if there are any alternatives. DRUG TREATMENT – Doctors usually tailor drug treatment to the frequency, severity, and features of each person's headache attacks. Other factors that will affect the choice of drugs include each person's response to various drugs, side effects, and the presence of other medical conditions. Abortive treatment refers to the use of drugs to halt or lessen the severity of an attack; prophylactic treatment refers to the daily use of drugs to reduce the frequency and severity of headache attacks. Migraine headache – Most people with migraines benefit from treatment with one of the many drugs known to reduce the frequency and severity of these attacks. These drugs are now available in several easy-to-use forms, giving people with migraines greater control over their own symptoms. Abortive treatment of migraines alone is appropriate for people who have infrequent headaches (fewer than four headaches per month) that last less than 12 hours. Prophylactic treatment is usually recommended for people who have more frequent headaches, infrequent but disabling headaches, or long-lasting headaches. Abortive treatment – Abortive treatment is most effective when the drugs are taken at the first indication of an attack (eg, at the onset of aura if one occurs, or at the onset of pain). Mild analgesics (painkilling drugs) are usually sufficient for mild attacks; more severe attacks may require migraine-specific drugs. When migraine headaches are accompanied by marked nausea and vomiting, several drugs can be given by non-oral routes (by injection, rectal suppositories, or intravenous administration). Alternately, antimigraine drugs may be given in combination with drugs that alleviate the gastrointestinal symptoms of migraine (such as metoclopramide, also known as Reglan). It is generally felt that patients who tend to respond to mild analgesics should continue taking these with each attack, as long as they are not being used more than once or at most twice per week. Patients who do not typically respond to analgesics, however, should find the migraine-specific drug that works best for them and stick with it for future attacks [1]. • Mild analgesics are painkilling drugs that are often available over the counter. These drugs include aspirin, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen , indomethacin, and naproxen . Indomethacin comes in a rectal suppository, which makes it particularly effective for patients who experience nausea during their headaches. Mild analgesics are also available in combination with caffeine, which enhances their antimigraine effect; as an example, Excedrin contains a combination of acetaminophen, aspirin, and caffeine. Mild analgesics are often recommended first for mild to moderate migraine attacks. However, they should not be used regularly because overuse can readily lead to rebound headaches (chronic, daily headaches caused by the medications themselves). If the judicious use of mild analgesics does not effectively control migraines, your doctor will likely recommend other drugs. People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take products containing aspirin or NSAIDs. • Moderate and strong analgesics provide greater pain relief than mild analgesics; some of these drugs also have a sedative effect.. • Ergotamine drugs are migraine-specific drugs that promote constriction of blood vessels. These drugs are often combined with caffeine (Cafergot, Wigraine). Nevertheless, compared with newer antimigraine drugs, ergotamine drugs are often less effective and more likely to produce side effects. These drugs are usually recommended for people with very long headaches (greater than 48 hours) or those who have headaches that frequently recur. People with hypertension, vascular disease, and kidney or liver disease should not take ergotamines. • The triptans are a newer class of migraine-specific drugs. These drugs include sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), and rizatriptan (Maxalt). The triptans can be easily used at home or at work. Sumatriptan, in particular, is available in many different formulas, including tablet, nasal spray, and injectable formulas. Over 70 percent of people experience headache relief within one hour of a subcutaneous (under the skin) injection of sumatriptan; by two hours, 90 percent of people notice improvement [4]. The injection may be repeated after 60 minutes if symptoms improve with the first injection but do not completely resolve. However, a second injection is not helpful if there has been no improvement in headache symptoms after the first hour. Common side effects of the injection include redness around the injection site, chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, a feeling of warmth, and tingling in the extremities. Most of these reactions occur soon after the injection and resolve spontaneously within 30 minutes. There have been rare serious side effects associated with injection of triptans, but generally these drugs are considered safe in appropriate patients. The oral form of sumatriptan is also safe and effective. Intranasal sumatriptan has a faster onset of action that the oral drug and fewer side effects than the injectable drug. The most common side effect of intranasal sumatriptan is an unpleasant taste. Headaches return within 48 hours in about half of all people who take sumatriptan by injection. Older adults and people with hypertension, vascular disease (including coronary artery disease), and kidney or liver disease should not take triptans. Prophylactic treatment – Prophylactic treatment effectively controls migraines in most people, although the benefits of this treatment may not be evident for three to four weeks. In some cases, both abortive treatment and prophylactic treatment are necessary to adequately control migraines. The choice of drug should be tailored to each individual, and is often based upon side effects and other medical illnesses. • Calcium channel blockers are very effective for controlling migraines. They are vasodilators normally used in patients with heart disease and are hypertension. They are safe drugs with few side effects. The calcium channel blockers include the drugs verapamil, nifedipine, and nimodipine. Calcium channel blockers may lose their effectiveness against migraines over time, but this can be remedied by taking a higher dose of the drug or switching to another drug in the same class. • Beta blockers reduce the frequency of migraine attacks in 60 to 80 percent of people [5,6]. These drugs are often used in patients with cardiovascular disease. Commonly used beta blockers include propranolol, nadolol, timolol, atenolol, and metoprolol. Beta-blockers may cause depression or impotence in some people. Those who have asthma, diabetes, depression, and certain types of heart disease should not take beta-blockers. • Other drugs that may be helpful in preventing migraines include the tricyclic antidepressants, serotonin reuptake inhibitors (SSRIs), cyproheptadine, methysergide, phenelzine, valproate, nonsteroidal anti-inflammatory drugs (NSAIDs), the blood pressure medication lisinopril, and riboflavin. With most of these drugs, it can be expected that approximately one-half of people will notice a reduction in migraine frequency. • Herbal therapies have been studied for the treatment of migraine headache; feverfew has been the most widely studied herbal remedy. Some studies have found it to be effective for migraine prevention, although most literature reviews suggest that any possible benefits are still unproven [7]. Avoiding overuse of antimigraine drugs – It is essential to use antimigraine drugs according to the prescription and your doctor's instructions. Overuse of these drugs, including over-the-counter drugs such as acetaminophen or NSAIDs, can lead to rebound headaches and a pattern of daily headaches that require increasing quantities of drugs for relief. Rebound headaches occur in people who have persistent headaches that cause them to overuse headache medication. A vicious cycle occurs whereby frequent headaches cause people to chronically take medications, which then cause rebound headaches as the medications wear off, causing more medication use, and so on. Let your doctor know if a treatment is not adequately relieving your migraines or is producing unpleasant side effects. He or she may recommend switching to another drug or switching from abortive treatment to prophylactic treatment. Tension headache Abortive treatment – Abortive treatment of tension headaches consists of the judicious use of analgesics (painkilling drugs) to control the pain of headaches. These drugs include aspirin, acetaminophen (Tylenol), and nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin or Advil), indomethacin, and naproxen (eg, Naprosyn or Aleve). People with tension headaches should avoid analgesics that also contain caffeine (such as Excedrin) because frequent use of these drugs can worsen this headache condition. Analgesics should not be used regularly; overuse can lead to rebound headaches (chronic, daily headaches). If the judicious use of analgesics does not effectively control your tension headaches, your doctor will likely recommend other drugs. People with gastritis (inflammation of the stomach), ulcers, kidney disease, and bleeding conditions should not take NSAIDs. Prophylactic treatment – Prophylactic treatment of tension headaches is usually recommended for people who have frequent headaches despite the use of analgesics. Several different classes of drugs are used for prophylaxis. • Tricyclic antidepressants are the drugs most commonly used for the prophylaxis of tension headaches. The tricyclic antidepressants include the drugs nortriptyline, amitriptyline, and clomipramine. Tricyclic antidepressants can cause weight gain and other side effects in some people. People who have glaucoma, certain types of heart disease, or difficulty urinating should not take tricyclic antidepressants. • Beta blockers can effectively control tension headaches, and they may be particularly effective in people who also have symptoms of migraine headache. The beta blockers include propranolol, nadolol, timolol, atenolol, and metoprolol. Beta blockers produce substantial side effects in some people (see above under migraine). • Calcium channel blockers are also effective for controlling tension headaches and, similar to beta blockers, may be particularly effective in people who also have symptoms of migraine headache. Compared with beta-blockers, calcium channel blockers have fewer side effects. The calcium channel blockers include the drugs verapamil, nifedipine, and nimodipine. • Several new antidepressants may be effective for the prophylaxis of tension headaches. These drugs include the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, and sertraline, as well as the drug bupropion. • Serotonin antagonists have been used to treat headaches for many years. These drugs include cyproheptadine and methysergide (Sansert). The serotonin antagonists may cause sedation and weight gain in some people. Furthermore, people who take methysergide must periodically stop taking the drug to prevent the more serious side effects associated with long-term use. • Anticonvulsants (drugs primarily used to treat seizures) are also effective for the prophylaxis of tension headaches. The anticonvulsants include valproate, phenytoin, carbamazepine, and gabapentin. Anticonvulsants can have several side effects, including cosmetic side effects (such as hair growth with phenytoin) and liver damage (carbamazepine). Because valproate can cause birth defects, this drug may be inappropriate for women of child-bearing age. Cluster headache – Most patients who suffer with cluster headaches will need to take both an abortive and prophylactic medication. Abortive therapy – Abortive therapy may include the following: • The majority of people obtain relief by inhaling 100 percent oxygen by mask. • Sumatriptan (and also possibly zolmitriptan) can stop an acute cluster attack, often within 10 to 15 minutes. Sumatriptan can also be combined with oxygen therapy. • Cafergot, DHE 45, and probably the nonsteroidal antiinflammatory drugs (such as indomethacin) are also effective in aborting cluster headaches. Prophylactic treatment – Prophylactic therapy is usually started at the onset of a new cluster. A number of drugs may be useful: • Verapamil is effective and has few side effects, although there may be a delay of four to six weeks before headache frequency diminishes. • The steroid drug prednisone is very effective prophylactic therapy, but should not be used long-term because of side effects. • Lithium appears to be particularly effective for the chronic form of cluster headaches. • Ergotamine, methysergide, cyproheptadine, and indomethacin have also been shown to be effective. Prophylactic medications can be gradually stopped after the expected duration of the cluster has passed. The drugs can be restarted if symptoms recur. COMPLEMENTARY THERAPIES – Several therapies can complement the lifestyle adjustments and drug treatment in people with headaches. The choice among these therapies depends upon personal preferences and on the presence and underlying cause of other types of headaches. Physical therapy – People with frequent tension headaches (more than 10 headache days per month), frequent mixed migraine and tension headaches, and chronic daily headaches (more than 15 headache days per month) may benefit from a physical therapist with special interest in headache and cervical spine dysfunction. These techniques should be used in people in whom medications either fail or achieve only partial or transient success or in whom medications can't be used (eg, pregnancy and breast feeding). Massage therapy – Massage therapies may help relax tense muscles and relieve ongoing headaches. These therapies include basic massage, manipulation, and ultrasound. Ice massage can help relieve migraine attacks. Nerve blocks or injections – People with chronic headaches that are associated with significant muscular pain and do not respond to a combination of pharmacologic treatments and physical therapy may benefit from injections or nerve blocks. These can range from simple injection of pain relieving medication into muscle tissues (trigger point injection), to injecting medication into the fluid space around the spine (epidural injection). Behavioral therapy – Headache conditions can be worsened by stress, anxiety, depression, and other psychological factors. Behavioral therapy that addresses these factors is often a component of a well-rounded headache treatment plan. There are many different types of behavioral therapy, including psychotherapy, relaxation techniques (meditation, progressive muscle relaxation, and self-hypnosis), biofeedback, and group skill-building exercises. The choice among these therapies is a matter of personal preference. The American Academy of Neurology recommends that relaxation training, biofeedback, and cognitive-behavioral therapy be considered for migraine prevention [8]. Homeopathic remedies – A number of homeopathic remedies have anecdotally been shown to relieve or prevent headaches. The precise effects of certain homeopathic remedies on the frequency and severity of migraine attacks are still being studied. At this time, homeopathic remedies do not have any proven benefits.