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or aneurysm, or a thrombotic or embolic stroke It is the pace of the neurologic symptoms of migraine, more than their character, that reliably distinguishes the condition from epilepsy Ophthalmoplegic migraine will suggest a carotid aneurysm, but in normotensive younger individuals, saccular aneurysm is a great rarity; in very few cases has carotid arteriography revealed such an abnormality Transient monocular blindness from carotid stenosis is likewise a rarity in the age group affected most by migraine, but the antiphospholipid syndrome (page 735), which has some ill-de ned relationship to migraine, does cause episodic unilateral visual loss in this group and should be sought as a unifying diagnosis There have been many claims that the invariant occurrence of migraine on the same side of the head increases the likelihood of an underlying arteriovenous malformation (AVM) R D Adams, who studied more than 1200 patients with AVM, found that the headaches, which occurred in over 30 percent of these individuals, usually did not include the other features of either migraine or cluster headache However, in about 5 percent of these patients, the headaches were indeed associated with visual aura, making them indistinguishable from neurologic migraine In most, the AVM was in the occipital region, on the side of the headache; usually, there was an initial visual aura Approximately half of the patients with AVM and migraine had a family history of migraine Thus, AVM must be regarded as an acknowledged cause of recurrent headache, and the latter may be frequent and troublesome for years before the malformation is revealed by a hemorrhage or discovered by other manifestations A special but quite common problem relates to paroxysms of throbbing headache that are not hemicranial in distribution, not preceded by a neurologic aura, and not accounted for by other known causes It is dif cult to be certain whether these are examples of common (nonneurologic) migraine or of some other type of cephalalgia Unfortunately, since diagnosis depends on the interpretation of the patient s symptoms and since there is as yet no valid con rmatory laboratory test, the controversy as to where migraine begins and ends tends to become polemical Favoring the diagnosis of migraine are onset in childhood or adolescence, lifelong history, positive family history, previous attacks or more typical hemicranial migraine, and response of the headache to ergotamine or triptan medication The observation that pattern and ash visual stimulation induces fast waves of high amplitude in children with migraine may, if corroborated, prove to be helpful (Mortimer et al) Treatment of Migraine This topic may logically be subdivided into two parts control of the individual acute attack and prevention The time to initiate treatment of an attack is during the neurologic (visual) prodrome at the very onset of the headache (see below) If the headaches are mild, the patient may already have learned that acetylsalicylic acid, acetaminophen, or another nonsteroidal anti-in ammatory drug (NSAID the most effective type of drug for mild and moderate cases in our experience) will suf ce to control the pain Insofar as a good response may be obtained from one type of NSAID and not another, it is advisable to try two or three preparations in several successive attacks of headache and to use moderately high doses if necessary Some of our colleagues state that reliable patients can be given small amounts of codeine or oxycodone, usually combined with aspirin or acetaminophen, for limited periods The combination of aspirin or acetaminophen, caffeine, and butalbital, though popular with some patients, is usually incompletely effective if the headache is severe and is also. open pdf file in asp.net using c# How to Open PDF Files in Web Brower Using ASP . NET - C# Corner
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