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Although hyperventilation causes respiratory alkalosis buy rogaine 5 60 ml otc prostate yellow sperm, it also causes changes that inhibit ventilation (i proven rogaine 5 60 ml prostate cancer books. With both respiratory acidosis and alkalosis buy rogaine 5 mastercard prostatic urethra, more than 95% of the chemical buffering occurs within cells best order rogaine 5 androgen hormones. In the case of respiratory acidosis, the cells contain many proteins and organic phosphates that can + + bind H. An example illustrates how chemical buffering reduces a fall in pH during respiratory acidosis. When the urine becomes more alkaline, titratable acid excretion vanishes, and little ammonia − − is excreted. The difference between the two situations is largely a result of renal compensation. Metabolic acidosis is a condition in which tissue and blood pH is abnormally low due to an increase in nonvolatile acids. An increase in nonvolatile acids, such as lactic acid, leads to metabolic acidosis. If a strong acid increases in the body, the reactions (35) + − are pushed to the right. In renal failure, the kidneys cannot excrete H fast enough to keep up with metabolic acid production, and in uncontrolled diabetes mellitus, the production of ketone body acids increases. The respiratory response develops promptly (within minutes) and is maximal after 12 to 24 hours. If the underlying cause of metabolic acidosis is corrected, then healthy kidneys can correct the blood pH in a few days. The anion gap is a useful concept, especially when trying to determine the possible cause of metabolic acidosis. Plasma anion gap is calculated from sodium, chloride, and bicarbonate concentrations. In any body fluid, the sum of the cations and the sum of the anions are equal because solutions are electrically neutral. For blood plasma, we can write: (38) or (39) + 2+ 2+ The unmeasured cations include K, Ca, and Mg ions. Because these are present at relatively low + concentrations (compared with Na ) and are usually fairly constant, we choose to neglect them. The unmeasured anions include plasma proteins, sulfate, phosphate, citrate, lactate, and other organic anions. If we rearrange the above equation, we get: (40) + In a healthy person, the anion gap falls in the range of 8 to 14 mEq/L. In several types of metabolic acidosis, the low blood pH is accompanied by a high anion gap (Table 24. Again, the chief value of the anion gap concept is that it allows a clinician to narrow down possible explanations for metabolic acidosis in a patient. Acidosis occurs because insulin deficiency leads to decreased glucose use, a diversion of metabolism toward the use of fatty acids, and an overproduction of ketone body acids (acetoacetic acid and β-hydroxybutyric acids). Re-entrant arrhythmias and a decreased threshold for ventricular fibrillation can occur. Severe acidemia causes impaired brain metabolism and cell volume regulation, leading to progressive obtundation and coma. The labored,2 3 deep breathing that accompanies severe uncontrolled diabetes is called Kussmaul respiration. They also increase the excretion of titratable acid, part of which is composed of ketone body acids. These acids can only be partially titrated to their acid form in the urine, because the urine pH cannot go below 4. Thus, ketone body acids are excreted mostly in their anionic form; because of the requirement of + + electroneutrality in solutions, increased urinary excretion of Na and K results. An important compensation for the acidosis is increased renal synthesis and excretion of ammonia. The severe acidemia, electrolyte disturbances, and volume depletion that accompany uncontrolled diabetes mellitus may be fatal. Correction of the acid–base disturbance is best achieved by addressing the underlying cause, rather than just treating the symptoms. Therefore, the administration of a suitable dose of insulin is usually the key element of therapy. A variety of situations can produce metabolic alkalosis, including the ingestion of excessive amounts of antacids, + vomiting of acidic gastric juice, and enhanced renal H loss (e. As a result, the buffering for metabolic alkalosis that occurs in cells is much smaller. With a loss of fluid volume in the body, aldosterone will be produced to reabsorb sodium in the distal nephron. This though will also stimulate acid secretion in that part of the nephron that will tend to extend or exacerbate the alkalosis in the body. Therefore, for the body to be able to best compensate for a metabolic alkalosis with a volume loss, the volume loss must be corrected first before compensatory mechanisms for alkalosis can be fully effective. Fluid loss leads to a decrease in effective + arterial blood volume and engagement of mechanisms that reduce Na excretion, such as decreased glomerular filtration rate and increased plasma renin, angiotensin, and aldosterone levels (see Chapter + + + 23). Renal tubular Na /H + exchange is stimulated by volume depletion because the tubules reabsorb Na more avidly than usual. Extracellular alkalosis results in a shift of + + K into cells (including renal cells) and thereby promotes K secretion and excretion. Treatment for the metabolic alkalosis primarily depends on eliminating the cause of vomiting. Because replacement of Cl is a key component of + − therapy, this type of metabolic alkalosis is said to be “chloride responsive. Acid–base data should always be interpreted in the context of other information about a patient. For example, a low blood pH indicates acidosis; a high blood pH indicates alkalosis. Values on the right side of the diagram (alkalemia, or an elevated blood pH) are caused by respiratory alkalosis or metabolic alkalosis. The shaded areas include 95% of2 people with the designated simple acid–base disturbance. Note that a distinction is made between acute and chronic respiratory disturbances of acid–base balance but not between acute and chronic metabolic disturbances of acid–base balance. This is because the renal compensation for a respiratory disturbance may take days, whereas the respiratory compensation for a metabolic disturbance is prompt (minutes to hours). Mixed acid–base disturbances often, but do not always, fall outside of the shaded areas. Values for a patient with a simple disturbance could fall outside the shaded area if insufficient time has elapsed, especially for renal compensation. A complete history and physical examination provide important clues in deciding what acid–base disturbances may be present in a patient.
The lens & B-scan ultrasonography cheap rogaine 5 express prostate cancer robotic surgery, or the B- capsule is seen toward the left of the display purchase 60 ml rogaine 5 with mastercard prostate cancer journals, and the mode discount 60 ml rogaine 5 with amex prostate oncology of san antonio, produces a two-dimensional discount rogaine 5 prostate 3 3, optic nerve is seen toward the right. A vector line cross-sectional display of the globe through the B-scan demonstrates the position of the A-scan information. The image is displayed in variable shades of gray, and the shade depends on the echo strength. The A-scan is used predominantly for tissue characterization, whereas the B-scan is used to obtain architectural information. A-scans are also helpful in determining intraocular lens calculations for cataract surgery (see question 41). The topography (location, configuration, and extension) of a lesion is evaluated most often by the two-dimensional B-scan. The quantitative features include the reflectivity, internal structure, and sound attenuation of a lesion. The internal reflectivity refers to the amplitude of echoes within a lesion and correlates with its histologic architecture. Regular internal structure indicates a homogeneous architecture and is noted by minimal or no variation in the height of spikes on the A-scan and a uniform appearance of echoes on the B-scan. In contrast, an irregular internal structure is noted in a lesion with a heterogeneous architecture and is characterized by variations in the echo appearance. Sound attenuation may produce decreased signal strength and a void posterior to the lesion that is referred to as shadowing. Substances such as bone, calcium, and foreign bodies typically produce sound attenuation (Fig. The rapid movement of a vitreous hemorrhage is distinguished from the slower, undulating movement of the retina in an acute rhegmatogenous retinal detachment. The A-scan is used to measure the axial length of the globe, which is required in the formula to calculate the intraocular lens power. The B-scan is useful if the ocular media are opaque to assess for a retinal disorder that may affect visual outcome after cataract surgery. Ultrasound may be used for diagnosis, to plan treatment, and to evaluate tumor response to therapy. Specifically the tumor shape, dimensions (such as thickness and basal diameter), and tissue Figure 5-7. B-scan image of a metallic foreign body characteristics are evaluated, along with located on the surface of the retina. Describe the ultrasound patterns in the differential diagnosis of choroidal melanoma. The B-scan reveals a collarbutton- choroidal hemangioma, metastatic shaped mass with a regular internal structure. A choroidal carcinoma, choroidal nevus, serous retinal detachment extends from the margin choroidal hemorrhage, and a disciform of the tumor. The A-scan reveals a strong initial echo from the retinal tissue overlying the tumor followed lesion. It should be combined with by a rapid decline in the A-scan echo amplitude (low clinical information because there are internal reflectivity) within the tumor tissue. High more tumor types than differentiating reflectivity is noted again at the level of the sclera ultrasound patterns (Table 5-2). Within a choroidal hemangioma, the adjoining cell and tissue layers have marked differences in acoustic impedance (acoustic heterogeneity), which create large echo amplitudes at each interface. The A-scan reveals high internal reflections within the tumor, and lesions appear solid white on the B-scan. A detached retina produces a bright, continuous, folded appearance on B- scan (Fig. When detachment is total or extensive, the retina inserts into both the optic nerve and ora serrata. There is motion of the detached retina with voluntary eye movement; however, it is less mobile than with posterior vitreous detachment. Chronic retinal detachment may show calcification, intraretinal cysts, Figure 5-9. An anteroposterior view reveals the characteristic V- or cholesterol debris in the subretinal shaped appearance with attachment to the optic space. Describe the ultrasound features that differentiate retinal detachment, posterior vitreous detachment, and choroidal detachment. Ultrasound may be used to evaluate the position of the lens and the status of the retina if visualization is impeded by an opaque cornea, hyphema, or vitreous hemorrhage resulting from trauma. It also may diagnose a posterior rupture site in the globe and assess for an intraocular foreign body. The globe should be evaluated visually by slit lamp technique before ultrasonography to determine whether ocular integrity has been severely disrupted and whether ultrasound examination is indicated. It is particularly useful with a nonmetallic intraocular foreign body that may not be visible radiographically. Although computerized tomography is often used for localization, it may not be able to define the exact position of a foreign body that lies close to the ocular wall. Foreign bodies have high reflectivity when the ultrasound probe beam is perpendicular to a reflective surface of the foreign body. On the B-scan, a metallic foreign body produces a bright echo that persists when the gain of the ultrasound output is decreased. Small, spherical, metallic foreign bodies may demonstrate ringing, which is a string of reflections that extends posterior to the foreign body and is produced by reflections of the acoustic pulses within the foreign body. Shadowing is often present behind a foreign body because of nearly complete reflection of the examining probe beam. This technique produces high-resolution images of anterior segment structures (Fig. Color-Doppler ultrasonography is a noninvasive approach to evaluate ocular blood flow. It is useful for assessing morphologic and velocimetric data from the ophthalmic artery, central retinal artery, central retinal vein, and posterior Figure 5-10. Paramagnetic agents produce proton relaxation enhancement by shortening the intrinsic T1 and T2 relaxation times of the tissues in which they are present. Therefore, tissues containing paramagnetic agents will present with increased signal intensity, best seen on T1-weighted images. Melanin, methemoglobin, protein, and gadolinium are the most common paramagnetic agents. For example, a dermatoid cyst with a high proteinaceous content shows a higher signal intensity on T1- and T2-weighted images than a clear inclusion cyst does.
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The fuid losses 60 ml rogaine 5 free shipping man health 99, urination buy rogaine 5 60 ml low cost man health info, recent travel buy generic rogaine 5 60 ml on line prostate cancer what is it, prior hospitalization safe rogaine 5 60 ml mens health institute, and clinician’s responsibility is to establish a correct diagnosis vaccination status (Table 1). A temperature above 38°C Duration Persistent fever beyond day 3 without localizing or 100. This identifes seriously-ill children in need for urgent child continues to appear sick even between referral or treatment. Examination of the of the following: an ill-looking child, lesions larger cemia throat and ear is important and often missed. A systematic than 2 mm in diameter (purpura, capillary refll examination should then be conducted, including the skin time of ≥3 seconds, and neck stifness and nails, head and neck, and the cardiovascular, respiratory, Swelling of a limb or joint, not using an extremity, Septic arthritis/ abdominal, musculoskeletal, and neurological systems. Breathing Normal or abnormal, apnea, type of breathing-rate Tempo and complexity of workup is decided by the pace of and work of breathing. Investigations must be done on all sick children and in altered sensorium indicates serious illness those without localization by 72 hours. Primary goal use of laboratory tests, a rational approach cannot be overe- of treating the febrile child should be to improve the child’s mphasized. Sponging is reserved for patients Most infants and children who have fever and are otherwise with hyperthermia (temperature more than 38. The degree of illness should Antipyretics: the use of antipyretics should be indi- be determined through the child’s interactions with the vidualized and based on the child’s well-being, not environment; observing their alertness, playfulness and feeding temperature alone. Antipyretics should be used as pattern with appearance of any new symptoms (Box 2). Both paracetamol (10–15 mg/kg, 4–6 • Febrile neonate hourly) and ibuprofen (5–10 mg/kg, 6 hourly) are efective • Toxic child antipyretics. It is directed towards the probable underlying cause of illness and most probable organism. All such children should be followed up on outpatient department basis continuing with symptomatic treatment at home. Empiric antibiotics should be avoided Physical examination has marked limitations to predict ))The emphasis should be on the child and not his temperature. X-ray chest should be done if child’s age, general well-being, facilities, ease and reliability for a respiratory cause is suspected. Management of fever in children: summary of the Italian Pediatric Society Parents should be made aware that fever is a symptom and not Guidelines. Section on Clinical Pharmacology and Therapeutics; Committee on Drugs, Sullivan than 5% and it is a benign event. Common causes of poisoning in India vary geographically Airway and are dependent on access to various agents. Healthcare providers should be familiar with common poisonings in Presence of abnormal sounds like stridor, gurgling sounds, their area. These may include positioning, oropharyngeal Most children present with nonspecifc symptoms such as airways, laryngeal mask airways, or endotracheal intubation. However, there are Caustic agents, angiotensin converting enzyme inhibitors, and certain toxidromes, which, on recognition, can give us a clinical plants containing calcium oxalate crystals can predispose to diagnosis (Tables 1 and 2). Children with • Abnormal sounds suggest partial airway obstruction decreased consciousness and reduced respiratory efort should • If the patient has altered sensorium, the airway should be receive bag-mask ventilation with 100% oxygen. An enlarged anion gap greater than 18 is found as these can correct hypotension rapidly. In a similar fashion, Hypokalemia is seen in beta agonist and theophylline arrhythmias should be managed with specifc antidotes, poisoning, while hyperkalemia is seen in digoxin ingestion. Clinical Pearls Disability Neurological function is assessed by measuring conscious- • Interpretation of drug concentrations and enzymes in ness, pupillary size, posture, and presence of convulsive neonates difers from children movements. Large pupils suggest amphetamines, ecstasy, theophylline and tricyclic- Poison Elimination antidepressant poisoning (all of these cause hypertonia) Minimizing toxin exposure: this step is especially helpful in while small pupils suggest opiates and organophosphorus cases of topical and inhaled toxin exposure. Convulsions can be treated by lorazepam or decontamination prevents ongoing toxicity to the child midazolam. Prior use of ocular pyretics are not efective and external and internal cooling anesthetics such as tetracaine will ensure better irrigation. Benzodiazepines, dantrolene, or paralysis and Toxin Elimination mechanical ventilation should be used to reduce excessive The evidence for toxin elimination from the gastrointestinal heat production due to agitation or muscle rigidity. In asymptomatic children with nontoxic Monitoring and Investigations ingestions, it is not required. Activated Charcoal Complete blood count, urinalysis, and tests of hepatic and Activated charcoal has a surface area of 1,000 m2/g, is safe and renal function are done. If facilities exist then plasma drug concentrations of a few drugs such as paracetamol, salicylates, can be used in the dose of 1 g/kg per dose and is capable of iron, lithium, theophylline, methanol, digoxin, ethylene glycol, binding a number of poisonous substances without being anticonvulsants, methaemoglobin, and carboxyhemoglobin systematically absorbed. However, they should not be part of the general metals, lithium, cyanides, petroleum distillates, and alcohol. Additionally, used in aspirin, barbiturates, and theophylline as they promote interpretation of results should be carefully done in neonates drug reabsorption from the circulation into the bowel and thus as levels of cholinesterase and carboxyhemoglobin may difer interrupt enterohepatic cycling. This does reduce charcoal’s especially if arrhythmias are suspected, and a chest x-ray activity. Usefulness should be done if there is clinical suspicion of aspiration or of activated charcoal beyond 1 hour of ingestion is limited but pulmonary edema. Results of investigations can assist in identifying drugs that may have caused the poisoning. Metabolic acidosis is Emesis seen with carbon monoxide, iron, methanol, ethylene glycol, Emesis by administration of ipecac syrup is not recommended tricyclic antidepressants, salicylates, tricyclic antidepressants, for gastrointestinal decontamination. It is contraindicated Antihistaminics Activated charcoal or whole bowel in poisonings by most hydrocarbons, alkalis, and acids. In irrigation if extended-release formulations, anticonvulsants, physostigmine children, additional difculty is encountered as the small size of the lavage tube makes it difcult to remove the toxin. Benzodiazepine Flumazenil Children often need to be intubated to facilitate the procedure, β-blockers Glucagon, activated charcoal if early after especially if they have altered sensorium. To Calcium channel Calcium, activated charcoal if early after perform lavage, the child is placed on its left side and a lavage blockers ingestion, whole bowel irrigation for delayed- tube is passed into the stomach. After lavage, the tube can be Cholinesterase Atropine, pralidoxime used for instilling specifc antidote or activated charcoal. A large volume (>1 L) hypotension polyethylene glycol electrolyte solution is administered at a fast rate, via nasogastric tube. Efectiveness is seen until Isoniazid Pyridoxine about 4 hours after ingestion of enteric-coated tablets and Opioids Naloxone sometimes even until about 12–16 hours after administration Salicylates Correct electrolyte imbalance, fuid therapy, of some sustained-release medications. It causes formation urine alkalinizers, hemodialysis of liquid stools and reduces transit time of intestinal contents. Sulfonylurea Dextrose, octreotide Cathartics Tricyclic Activated charcoal, sodium bicarbonate to antidepressants reduce cardiotoxicity, pressor support These are of equivocal efcacy. Saccharide (Sorbitol) and saline (magnesium citrate) cathartics have been administered Cyanide Ensure airway, breating, circulation, 100% as a single dose. Hemodialysis is Ethylene glycol Ethanol or 4-methylpyrazole if level and methanol >20 mg/dL, sodium bicarbonate, calcium, used for salicylates, toxic alcohols, lithium, and theophylline.
In unse- Chronic liver disease lected patients rogaine 5 60 ml online prostate in women, the other causes include malignancy buy rogaine 5 overnight delivery mens health magazine south africa, Liver disease may result in thrombocytopenia generic 60 ml rogaine 5 prostate cancer 7 out of 10, reduced systemic infection and myeloproliferative disorders purchase 60 ml rogaine 5 free shipping mens health december 2015. As the liver retains disease is uncommon in pregnancy, as it may well have normal synthetic function and clotting remains a signifcant impact on fertility in any case. Moreover, Inherited haematological conditions there is not the same risk of developing encephalopa- Von Willebrand disease can be autosomal dominant thy. It leads to defective platelet function and thus epistaxis, bruising, and bleeding afer minor Cirrhosis/chronic liver disease trauma. Other causes Miscellaneous causes Scurvy, a rare cause of haematemesis, is due to Disordered haemostasis vitamin C defciency, and would normally cause Many medical conditions can lead to disordered bleeding, swollen gums, anaemia, and cutaneous haemostasis, some of which are associated with preg- haemorrhages. Generally, by far the most common cause of deranged clotting encountered is iatrogenic second- Endoscopy in pregnancy ary to anticoagulant use. Historically, there was some reluctance to use endos- However, warfarin is teratogenic and heparin in copy during pregnancy. However, it is now consid- pregnancy is used only in specifc clinical scenarios ered to be safe in pregnancy,3,6 ideally carried out afer (e. Alternatively, it could occur as part of dis- for upper gastrointestinal haemorrhage. Emergencies in In pregnancy, the urine is checked with a ‘dipstick’ Gastroenterology and Hepatology. Obstet Gynecol some symptoms of frequency, dysuria, and ofensive 2004; 103: 803–14. Helicobacter pylori women, haematuria may occur as a result of con- infection and persistent hyperemesis grav- tamination from menstrual blood fow. Pregnancy and cirrhosis: man- nary tract infection, stones and insertion of a catheter agement of hematemesis by Warren shunt for any length of time. Management of gastrointestinal and liver Bladder carcinoma may also present with haema- diseases during pregnancy. Gastroenterology 1985; microbiological investigation, an ultrasound scan 88: 1620. Helicobacter pylori countries have adopted guidelines for the investiga- infection rates in duodenal ulcer patients in tion of haematuria, such as the American Urological the United States may be lower than previ- Association and the European Association of ously estimated. It can be divided into: Urethritis Tuberculous infection of kidneys and bladder microscopic haematuria, where blood is found on ‘dip- Trauma stick’ testing; ● renal injury macroscopic haematuria or frank haematuria, which is ● foreign body in bladder including urinary an unusual symptom to present to the gynaecologist. The limited space in the carpal tun- nel would explain why the median nerve gets com- Useful website pressed when the hand swells with oedema. Pregnant women are more prone to intra- and extravascular fuid shifs, hormonal fuctuations, and musculoskeletal changes. Tis Transverse Finger flexor is borne out by the fact that symptoms are worse carpal ligament tendons in women with twins and triplets compared with singleton pregnancies. Women can present with Carpal tunnel Median nerve hand pain for the frst time or as an exacerbation of Muscle Blood vessels an existing symptom. Hand pain tends to recur in subsequent pregnancies, and a past history of this symptom is therefore important. Musculoskeletal causes of hand pain can be due to infammatory or mechanical disorders of muscles, tendons, nerves, and joints in the hand or be part of a systemic rheumatic disorder. Women gers and corresponding areas of the palm and the dis- with signifcant hand oedema, which prevents them tal end of the dorsum of the same fngers as shown in from wearing rings, have an increased incidence of Figure 2. Tis explains why women with pre-eclampsia Lumbricals, Opponens pollicis, Abductor pollicis bre- have an increased incidence of this condition. Weakness of thumb oppo- the symptoms are from local compression and not sition may manifest as difculty in buttoning shirts from proximal compression at the level of the brachial and writing. If severe local median nerve In some women symptoms may present in the frst compression is diagnosed, the surgeon can manage and second trimester with a rapid and progressive postoperative expectations more realistically, which is nature. The indication for the use of trimester and has an insidious onset and slower electrodiagnostic studies in the non-pregnant woman progression. As 85 per pregnant or in a previous pregnancy should be cent of symptoms resolve within 2–4 weeks of deliv- ery,5 surgery is rarely performed in pregnant women. Inquiries about gestational diabetes and pre-eclampsia in the index pregnancy should Consequently, there are no standardised guidelines for the use of electrodiagnostic tests in pregnancy. Flexor tendon infam- tion and 2-point discrimination in the distribution mation may be treatment with non-steroidal anti- of the median nerve. Tere elevated blood glucose concentrations and a screen may be evidence of thenar eminence atrophy. Tere for pre-eclampsia with appropriate treatment may are many tests (Tinel’s, Phalen’s, reverse Phalen’s, and improve symptoms. Durkin’s) that aim to compress the median nerve Specifc treatment options for carpal tunnel syn- and reproduce the numbness and tingling in its dis- drome are the same as those for the non-pregnant tribution. Night-time resting splints provide good sensitivity and are therefore not routinely used. Risk factors for gestational diabetes and Surgical decompression in pregnancy is rarely results of a recent oral glucose tolerance test should indicated. Computer use and carpal tunnel pressed demyelination occurs, resulting in a reduced syndrome: a 1-year follow up study. Symptoms and As the muscle gets progressively denervated it shows neurophysiological picture of carpal tunnel fbrillations and a further decrease in recruitment of syndrome in pregnancy. Musculoskeletal Reproductive hormones and, in particular, oes- considerations in pregnancy. J Bone Joint trogen, infuence this system directly and indirectly Surg Am 1994; 76: 1720–30. For example, prior to puberty uation of gender, obesity, age and diabetes males and females are equally afected by migraine, mellitus as risk factors for carpal tunnel but there is a 3 to 1 ratio in favour of females afer syndrome. J Bone Joint Surg not specifc to pregnancy, this classifcation is useful for Am 2010; 92: 218–19. Long term effect of local corticosteroid injection for carpal tunnel syndrome: a relation with electrodiagnostic severity. Trigeminal autonomic cephalalgias ence headaches and about one third of women will 4. Other primary headache disorders (cough, exer- get signifcant headaches while pregnant, particularly tional) in the second trimester. The majority of headaches Part two: secondary headaches (>95 per cent) in pregnancy are benign (primary 5. Headache attributed to trauma or injury to the headaches), but fear of a serious intracranial cause head and/or neck may lead pregnant women to present for review. Headache attributed to cranial or cervical vas- Of those pregnant women with primary headaches, cular disorders e. Headache attributed to nonvascular intracranial The pain of headaches is thought to arise in a disorder (idiopathic intracranial hypertension, widespread network of sensory fbres which sur- post dural puncture, tumours) round intracranial blood vessels. Headache attributed to a substance or its with- originate in the trigeminal ganglia and are found in drawal (alcohol, cocaine, caffeine withdrawal, the adventitial layer of all major cerebral blood ves- medication overuse) sels. Headache attributed to disorder of homeostasis these fbres causing pain or secondary to the infam- (hypoglycaemia, hypoxia) matory efects of vasoactive neuropeptides released 11.