Артрит – Arthritis

We need to start by dispelling a few myths about migraine. This important point was mentioned earlier: Migraine is not just a. severe headache: it is a special type of headache. Nor is it necessarily a severe headache; many sufferers have relatively minor headaches, but the associated symptoms indicate that without doubt they are suffering from migraine.

Another misconception is that those with migraine are frequently incapacitated by it. While this may be true for severe cases, there are many who have an attack only once or twice a year. There are also many others whose attacks are not severe or disabling enough to prevent them working. This doesn’t mean that those who have frequent severe attacks of migraine are putting it on – far from it. The headache of migraine is one of the worst types of pain known to man, and in its fullest form is completely incapacitating.

Attitudes towards migraine vary according to which part of society you are in. Some groups of society think that migraine is an intellectual’s disease. Other groups believe that migraine is a manifestation of psychiatric illness. Both attitudes are wrong! Migraine attacks people of all socio-economic groups. There is no link with having a high IQ and no direct link with being neurotic (though quite understandably, people with frequent severe migraines can become anxious or depressed as a result).

Perhaps the most surprising fact of all about migraine is that probably only fifty per cent of people suffering from it have ever consulted their doctor about it. Almost more remarkable is that a very large percentage of patients with migraine only ask their doctors about it once, and then don’t go back. It seems that many migraine sufferers don’t realise what can be done for them and resign themselves, unnecessarily, to their fate.

The point of all this is quite simple – the medical profession can now do a great deal to curb developing migraine attacks and to prevent attacks occurring. If you haven’t yet consulted your doctor about your migraines, then please do, because it may make a considerable difference to the quality of your life.

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Of course, your doctor will diagnose your headaches in a slightly different way, because he or she has the advantage of being able to examine you as well.

However, don’t be misled. Many patients think (wrongly) that the examination tells the doctor everything, and that a diagnosis without one means it’s probably wrong. In fact, almost the reverse is true. With headaches it is mainly careful, painstaking questioning that leads to the most accurate diagnosis. Perhaps your doctor finds out the critical information that the headache came on suddenly, like a blow to the back of the head; or else that the headache comes on if you miss a meal; or, maybe, there’s a background of marital discord or stress at work. It’s a bit like detective work, piecing information together until it all clicks into place.

Having said this, the importance of the physical examination should be stressed, because there are one or two items that your doctor will certainly want to check. What the doctor examines will vary according to the answers you’ve given to the

questions asked. For example, if the history is highly suggestive of sinusitis, then your doctor may only need to press on the bone overlying the sinus to confirm the diagnosis. A thorough examination of the muscles or nerves would be unnecessary. On the other hand, these will need to be examined if your story points towards a slipped disc in the neck.

The sort of examination your doctor gives you depends upon the symptoms and the history. Some or all of the following may be necessary – blood pressure measured, temperature taken, examination of the movements of your neck to see if you can bend your neck properly, not just forwards but also from side to side. You may be examined for trigger spots and painful areas in the muscles of the neck and back, and your spine may be checked. Your doctor may also examine your temples – to discover whether or not there are prominent pulses and tender arteries -investigate the power you can develop in your arms and legs, tap your reflexes, and even tickle the bottom of your feet! (This is a very quick way to tell whether you have had a stroke or a similar brain injury.) Finally, your doctor may look into your eyes, test your pupil reflexes, press against the bones in your face to see if they’re tender, look at your teeth, and check the way your mouth closes.

The combination of history-taking, examination and appropriate prescription may deal with your headaches fully. As we discussed earlier, your response to the treatment is also an important diagnostic pointer. In just a few cases the doctor may be unsure of the diagnosis and under those circumstances will use the resources of the hospital laboratory and X-ray department.

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‘Diagnose first, treat second.’ This statement may appear obvious, but it’s very easy to make the mistake of treating symptoms (such as pain or nausea) without getting to the root of the condition or disease causing the symptoms. Treatment is much more effective if there is an accurate initial diagnosis!

It’s all too easy to treat a headache with a couple of aspirins, without stopping to think why that headache is occurring. Then, when the headache doesn’t go away, you can’t help but wonder if you should increase the dose … and then you’ve fallen neatly into the trap. Diagnose first, treat second means that you stop to think before you reach for those painkillers, even on the first occasion.

However, diagnosing the cause of your headache may not always be easy, because there can be so much overlap between symptoms. For example, headaches caused by neck problems can sometimes imitate a migraine; temporal arteritis (an inflammation of the arteries in the forehead) can produce a headache similar to one that has arisen from tension; and arthritis in the neck can mimic tension headaches. Unfortunately, there are few hard and fast diagnostic rules: knowing the site or type of pain may not be enough to tell you its cause. Accurate diagnosis of the source of your headaches will probably depend not upon one specific symptom, but on carefully balancing the importance of a number of different symptoms and observations.

Here lies a trap for the amateur doctor! When reading a medical book like this, it’s all too easy to come up with the worst possible diagnosis, and then force your own symptoms to fit it. This is the ‘medical student syndrome’. When medical students start to learn about disease they often try to self-diagnose their own aches and pains – usually with disastrous results. Every medical school health centre has a constant trickle of students who have convinced themselves (usually erroneously) that they are about to die from some dreadful disease.

Nevertheless, do make sure that you consult your doctor about your fears. He will be able to see things in a much more balanced light. It is, of course, possible that you are right in your suspicions – but the vast probability is that you won’t be, so don’t worry unnecessarily.

The last thing you should do is use this book in isolation, self-diagnosing your own headaches and then blithely self-medicating yourself. If you’re having trouble with headaches and you haven’t been to your doctor, then make an appointment, discuss your problems and ask for advice. By all means use this book to point yourself in the right direction. And if you’re worried that you have a particular disease, do specifically mention it to your doctor. Once you have discussed the situation and, if necessary, had an examination, listen to the diagnosis and take note of the advice. Doctors have the knowledge, the experience and the objectivity to treat you properly. It’s hard to be objective when the patient is yourself!

So let’s get down to working out what might be the underlying cause of your particular headache.

Although the site of the pain and its pattern can often point to a particular diagnosis, in practice it doesn’t always work out that way; the same source of headache doesn’t produce identical types of pain in everyone. For example, tension headaches often produce pain in the forehead, or a feeling of pressure over the top of the skull. On the other hand, some muscle-tension headaches can produce pain centring over one eye (a type of pain which is more usually associated with migraine). So how do you know which is which?

Because headaches can be so variable there is no one symptom which allows us to make a firm diagnosis. Instead, it’s a matter of finding the pattern of illness which seems to fit most of the facts. The type of pain may point towards two or three possible diagnoses; the time it comes on may point to a slightly different set of possibilities; the things that start it off, to a third group of alternatives; and the accompanying symptoms to a fourth.; put them all together and you may find a single diagnosis which is common to all these groups, and it is this diagnosis which should be top of your list of possible causes.

Obviously, it’s nice if everything points in the same direction – and doctors do like to try to make one diagnosis which covers all the symptoms. On the other hand, this isn’t always possible in the case of headaches.

Because the symptoms of headaches are so variable, rather than producing just one flow chart to identify the cause of your headaches, I’ve created several diagnostic charts and lists. Work through them one after the other. If you get some common answers then you’re probably heading in the right direction. On the other hand, if you get a group of different possibilities it can mean one of several things:

•    Perhaps the source of your headache is producing symptoms in a less common way

•    Maybe you’ve got more than one cause for your headache

•    The possible causes of your headache may need to be sorted out by doing some special tests, for which you will need to see your doctor.

Armed with your answers, consult the relevant chapter of this book, describing the causes of headaches in much greater detail. You may well find that this extra detail allows you to pinpoint the cause of your headache more accurately.

But what if you can’t? Well, don’t forget that several causes of headache can be operating at the same time. Be prepared to have one main diagnosis and one (or even two) secondary diagnoses. It’s quite common to find that causes of headaches multiply together – so a patient whose headaches are caused mainly by arthritis of the neck may also find her headaches are made worse by stress and tension; migraine and tension headaches often work together in this way, too; and someone with high blood pressure may also, quite coincidentally, have a bad neck from an old whiplash accident.

But diagnosis doesn’t stop here. There is a further diagnostic tool: if the treatment works it confirms the diagnosis. (That is assuming, of course, that the treatment is not a catch-all method such as taking high doses of painkillers.) Similarly, if a specific treatment doesn’t work, it may mean that the diagnosis is not as accurate as you supposed. However, this advice needs to be handled with care, because people don’t always respond to the same treatment in the same way. For example, many migraine sufferers find great relief by using metoclopramide (together with a simple painkiller); others find this of no help at all, and prefer one of the ergotamine preparations. The response to treatment can help us to confirm the diagnosis, but it isn’t always specific.

To sum up, try to look at the overall picture and see where it all leads -symptoms, signs, tests and response to treatment. If the majority of answers point in the same direction, you should look up the details of this illness; only if you find no clear answers should you look at the alternatives.

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Of the symptoms that concern patients most, headaches come high on the list. Headaches are the most common cause of pain seen by family doctors, and although only a small percentage are due to any serious disorder, the fear of underlying disease causes a great deal of anxiety, especially among those who’ve suffered from headaches for a long time.

Although the vast majority of headaches aren’t dangerous, a few are due to serious underlying disease; and the remainder may not go away unless you do something to prevent them. The trouble is, how can you be sure which is which? It’s not always easy.

Even when you know the cause of your headaches, there are still many problems. Your headaches may not be lethal, but they still hurt; they’re frustrating; they’re an inconvenience; they may stop you working properly; and for those who have recurring headaches, coping with the pain and trying to prevent further attacks can be a sizeable and exhausting problem.

Most headaches are like this: not always sinister, but always painful, debilitating and frustrating – a real spoil-sport of a complaint, interfering with both work and pleasure. Sometimes your GP or a specialist can help; for example, in the case of migraine, where a wide range of drugs is now available both to treat the attacks, and to stop further ones occurring.

But, at other times, orthodox medicine seems to have less to offer: there may be no serious underlying cause, but that doesn’t mean the headaches will necessarily go away. Often headaches are related to aspects of your lifestyle that your doctor has little or no knowledge of – the type of pillow you use; your dentures; the car you drive; or the lighting conditions at work.

Sometimes your doctor is able to reassure you that there is nothing seriously wrong and that you ‘only’ have a tension headache. Unfortunately, this doesn’t take away the pain, but it does leave you confused, thinking it’s your fault you’ve got headaches, yet perhaps not wanting to bother the doctor any further.

Many patients with chronic headaches end up like this – suffering, but not always able to get any real, lasting or satisfying help, and puzzled because what seems to trigger off the headaches on one occasion doesn’t always trigger them off on another.

In short, headaches can be a real pain – and that’s where this book comes in. We’ll show you why you’re getting headaches, explain what is going on, and, most importantly, tell you what you can do to stop them. And believe me, there’s a lot that can be done.

Let’s get things straight from the start – a headache is a symptom, not a disease. Headaches can occur for many different reasons and each type needs to be treated according to its cause. A few of the underlying causes are dangerous – meningitis or stroke, for example. Headaches like these need prompt diagnosis and treatment. But don’t become alarmed; most headaches aren’t life-threatening, just painful and annoying. If you’ve suffered from headaches for a long time it’s much more likely that your headache is unpleasant, without being serious. On the other hand, it’s very important to sort out which kind of headache you have, and to make sure that if urgent treatment is needed, you get it.

We all know people who say they’ve never had a headache in their lives. Lucky, aren’t they? For many others, a headache is merely an occasional annoyance -unpleasant, but nothing more. Unfortunately, some people are affected much more than this. Either they get headaches more often, or their headaches are so intense and debilitating that they affect the quality of their life. It’s no joke to have regular migraines. With a headache of this intensity work is impossible and enjoyment out of the question. The knowledge that next week may bring the start of another attack merely adds to the unpleasantness.

A few statistics will show the extent of the problem. Nineteen out of twenty of us get headaches at some time or other. Men and women of all races are equally affected, but, interestingly, older people seem to get them less often. Every fortnight, one in four of us will have a headache bad enough to need painkillers. One in three attacks begins at work, and headaches are a common cause of absenteeism. At least one third of migraine sufferers have to stop work when an attack begins, and most migraine sufferers think that their quality of work and their careers have suffered as a result of their migraines.

Most headaches are caused by one of three things: minor viral infections, migraines and tension. Because minor headaches (those that respond quickly to painkillers) are so common, most of us don’t go to the doctor when we get one; but of those patients whose headaches are serious or persistent enough to make them consult their GP, one in five will be referred to hospital.

As well as being painful, and in some cases debilitating, headaches are upsetting. If you frequently suffer from headaches, there may be a nagging thought at the back of your mind. Is this the tip of the iceberg? What does it mean? Is there something seriously wrong? Uncle Jim had a headache and he was dead in three months from a brain tumour. How do I know I haven’t got one, too?

Even if the cause of your headaches has been sorted out satisfactorily, there is still the problem of living with the frequent pain and the disruption to your lifestyle that they can cause. What do you do when you have migraines associated with your menstrual cycle, when you know that every month you’ll have another three days of misery, vomiting your guts out, with what feels like a piledriver inside your head threatening to split your brain apart? How do you cope emotionally with this, never mind hold down a job, with the frequent absences from work that having migraines implies?

And what about the man or woman who gets frequent tension headaches? Knowing that they’re ‘only’ caused by tension helps – to a point. At least you know you’re not dying. Small consolation, because you often feel as though you are, with that nagging pain that goes on for days at a time, apparently totally resistant to painkillers. Nothing the doctor gives seems to help, except perhaps tranquillisers. How do you feel about being on those all the time? Or not having the tranquillisers, and getting the pain instead? Is there an alternative?

If you have recurrent headaches, then this book is for you. It will help you to sort out what’s likely to be causing them; why headaches like yours occur; and what you can do to stop them. With patience, most headaches can be treated very effectively. Some are helped by orthodox medical or surgical treatment, others with self-help techniques; some can be alleviated with complementary therapies, and some types of headache are best treated using a combination of all three methods.

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By the age of 15, nearly 100 per cent of boys have masturbated (and, as one commentator has said, those who haven’t are liars!). The proportion of girls who masturbate is lower in each age group, but in recent years the proportion is increasing.

It is now accepted by all but a few fearful people that masturbation is a normal sexual outlet and an important sexual learning process, and the anxiety that masturbation will lead to moral or physical decay has declined. Despite this, many adolescents who masturbate feel guilty because they fear that their parents will punish them, and because of inaccurate memories of the dangers of masturbation as discussed by their peers in whispered conversations. The myths which surrounded masturbation have been largely discredited, but they still cause anxiety and guilt.

Despite our knowledge that masturbation is healthy, and that nearly all people masturbate, most people are still ashamed to let it be known that they masturbate. When asked they become reticent and defensive. They are reluctant to tell their friends, lovers, or mates. This is an example of the way in which a normal pleasurable activity has been debased by societal condemnation.

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