The Neuromuscular Diamonds (The physical qualities Book 1)


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This review examines the effects caffeine has on cognitive and physical function, since most real-world activities require complex decision making, motor processing and movement.

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Caffeine exerts its effects by blocking adenosine receptors. Many occupations, including military, first responders, transport workers and factory shift workers, require optimal physical and cognitive function to ensure success, workplace safety and productivity. In these circumstances, that may include restricted sleep, repeated administration of caffeine is an effective strategy to maintain physical and cognitive capabilities.

We use cookies to help provide and enhance our service and tailor content and ads. Sign in via OpenAthens. Sign in via Shibboleth. AccessBiomedical Science. AccessEmergency Medicine. Case Files Collection. Clinical Sports Medicine Collection. Davis AT Collection. Davis PT Collection.

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About Search. Enable Autosuggest. Previous Chapter. Next Chapter. Neuromuscular Physical Therapy. Annie Burke-Doe, and Mark Dutton. Accessed November 11, Download citation file: RIS Zotero. Reference Manager. Autosuggest Results.


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Expand All Sections. A meta-analysis of ibuprofen for moderate to severe migraine showed that mg and mg doses were effective for short-term pain relief, but had hour pain-free rates similar to placebo. A study comparing ketoprofen with zolmitriptan Zomig showed zolmitriptan to be modestly more effective two-hour relief in Triptans are migraine-specific drugs that bind to serotonergic receptors. They are considered first-line therapy for moderate to severe migraine, or mild to moderate attacks unresponsive to nonspecific analgesics.

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A Cochrane review found that all triptans are similar in effectiveness and tolerability. Trials suggest that nonresponders to one triptan may respond to another; therefore, switching triptans is also reasonable. Triptans differ from one another in pharmacokinetics. Rizatriptan has a quicker onset of action than sumatriptan; frovatriptan Frova , naratriptan Amerge , and eletriptan have longer half-lives than sumatriptan. Some triptans are available as nasal sprays, rapidly dissolving tablets absorbed despite vomiting , or subcutaneous injections. Some physicians choose a triptan by matching pharmacokinetics to the temporal pattern of their patient's migraine e.

The vasoconstrictive properties of triptans preclude their use in patients with ischemic heart disease, stroke, uncontrolled hypertension, or hemiplegic or basilar migraine. However, the chest pain occurring in 3 to 5 percent of oral triptan users has not been associated with electrocardiographic changes and is rarely ischemic.

Cardiac evaluation is reasonable before triptan initiation in patients with multiple vascular risk factors. Triptans are contraindicated in patients taking monoamine oxidase inhibitors. The true incidence of serotonin syndrome in this setting is unknown.

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A U. Food and Drug Administration FDA alert cited 29 case reports over five years, although almost , patients per year are prescribed both selective serotonin reuptake inhibitors and triptans. One trial showed that the combination provided superior pain relief compared with either monotherapy. Evidence supports a role for parenteral antiemetics in acute migraine, independent of their antinausea effects. A meta-analysis of 13 randomized controlled trials concluded that intravenous metoclopramide Reglan should be considered a primary agent in the treatment of migraine in emergency departments.

No evidence supports migraine-specific effects of oral antiemetics, other than relieving nausea. Intravenous dexamethasone has been used as adjunctive therapy for migraine in emergency departments. Two meta-analyses, each with seven randomized controlled trials in which dexamethasone was added to other standard therapies, showed that about 10 patients needed treatment to prevent headache recurrence within 24 to 72 hours 12 , Like triptans, ergotamines and dihydroergotamine DHE are migraine-specific drugs that bind to serotonergic receptors.

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Although their use has been largely supplanted by triptans, ergot alkaloids still have a role in selected patients. Little evidence supports the use of oral ergotamines. Poor absorption and high rates of adverse events preclude their use in most situations.

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Combination medications containing ergotamines e. Nine placebo-controlled trials have demonstrated the effectiveness of dihydroergotamine nasal spray Migranal , making it an option for nonoral medication. A meta-analysis showed comparable effectiveness to opiates and ketorolac when combined with an antiemetic, but inferiority to phenothiazines and triptans when used alone.

One trial showed similar effectiveness to low-dose sumatriptan when used early in mild to moderate migraine.

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Intranasal lidocaine Xylocaine has a rapid onset of action and may be useful as a temporizing measure until longer-acting treatment can take effect. Acetaminophen alone is not effective therapy for acute migraine. Headache Consortium recommends limiting opiate use in migraine treatment because of its potential for abuse and rebound headache. Calcitonin gene-related peptide is a neuropeptide thought to be central to migraine pathogenesis. Intravenous infusion of a calcitonin gene-related peptide antagonist showed promising results in one small study.

A controlled trial of patients who had migraine with aura showed that this therapy is superior to sham in two-hour pain relief and sustained responses over 24 to 48 hours. Acetaminophen, despite questionable effectiveness, is reasonable in the treatment of migraine in pregnant women because of its established safety. NSAIDs are effective and generally considered safe until the third trimester.


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  • Opiates may be used for intractable cases, but pose risks of neonatal withdrawal and maternal dependence. The safety of isometheptene in pregnancy is unknown, so its use is not recommended. Ergotamines are abortifacients and are therefore absolutely contraindicated in pregnant women and women of childbearing age who are not using reliable contraception.

    Given scant data and cautions regarding medication safety, preventive approaches are key. Many women report migraine or migraine exacerbations occurring exclusively near the time of menses. Long-acting triptans frovatriptan and naratriptan, taken perimenstrually around-the-clock for short-term prevention, have been found effective in reducing frequency and severity of menstrual migraine. Limited evidence is available to guide pharmacologic treatment of acute migraine in children and adolescents. Intranasal sumatriptan and nasal zolmitriptan, but not oral formulations, have shown effectiveness in children and adolescents, perhaps because of the quicker onset of nasal formulations and shorter duration of migraines in children.

    Data Sources : A PubMed search was completed in Clinical Queries using the key terms migraine and treatment, with separate searches for specific drug classes. A similar search was performed using Google Scholar. The Cochrane database was searched for relevant reviews, and the National Guideline Clearinghouse was searched for relevant guidelines.

    Search date: January 4, , repeated September 20, Already a member or subscriber? Log in. Reprints are not available from the authors. International Headache Society. Accessed November 3, Wilson JF. Migraine [published correction appears in Ann Intern Med ; 5 ]. Ebell MH. Diagnosis of migraine headache. Am Fam Physician.

    Morey SS. Accessed August 20, The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Acetaminophen, aspirin, and caffeine in combination versus ibuprofen for acute migraine: results from a multicenter, double-blind, randomized, parallel-group, single-dose, placebo-controlled study. Acetaminophen, aspirin, and caffeine versus sumatriptan succinate in the early treatment of migraine: results from the ASSET trial.

    Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department?

    A meta-analysis and systematic review of the literature [published correction appears in Acad Emerg Med. Acad Emerg Med. Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. Guidelines on migraine: part 2. General principles of drug therapy. Accessed August 21, Fixed-dose sumatriptan and naproxen in poor responders to triptans with a short half-life. Parenteral dihydroergotamine for acute migraine headache: a systematic review of the literature.

    Ann Emerg Med.

    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)
    The Neuromuscular Diamonds (The physical qualities Book 1) The Neuromuscular Diamonds (The physical qualities Book 1)

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