Stroke

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A stroke is a disorder in which the arteries to the brain become blocked or rupture, resulting in death of brain tissue.

 A stroke is a cerebrovascular disorder, so called because it affects the brain (cerebro-) and the blood vessels (vascular).

In western countries, strokes are the 3rd most common cause of death and the 2nd most common cause of disabling neurologic damage after Alzheimer's  disease. In the US, over 600,000 people have a stroke and about 160,000 die of stroke each year. Strokes are much more common among older people that among younger adults, usually because the disorders that lead to strokes  progress overtime. Over 2/3 of all stokes occur in people older than 65 years old. Slightly more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. Blacks are more likely than whites to have a stroke and to die of it.

There are two types of strokes: ischemic and hemorrhagic. 

About 80%  of strokes are ischemic-due to blocked artery. Brain cells, thus deprived of their blood supply, do not receive enough oxygen and glucose which are carried by blood.

A transient ischemic attack (TIA), sometimes called a mini stroke, is often an warning sign of and impending ischemic stroke. TIAs are caused by an inadequate blood supply to part of the brain  but only for a brief time. Because of the blood supply is restored quickly, brain tissue does not die, as it does in a stroke.

The other 20% if strokes are hemorrhagic-due to bleeding in or around the brain. In this type of stroke, a blood vessel ruptures, interfering with normal blood flow and allowing blood to leak into brain tissue. Blood that comes into direct contact with brain tissue irritates the tissue and can cause scarring, leading to seizures.

The major risk factors for both types of stroke are;

1. atherosclerosis (the narrowing or blockage of arteries by patchy deposits of fatty material in the walls of arteries),
2. high BP,
3. diabetes and
4. smoking.

Atherosclerosis is more important risk factor for ischemic stroke, and high BP is  a more important risk factor for hemorrhagic stroke.

Other risk factor for hemorrhagic stroke include,

1. use of anticoagulants,
2. cocaine,
3. amphetamines,
4. aneurysms in the arteries within the skull,
5. arteriovenous malformation; and
6. vasculitis.

The incidence of strokes has decline in recent decades, mainly because people are more  aware of the importance of controlling high BP and high cholesterol levels. Controlling these factors reduces the risk of atherosclerosis.

Image taken from http://news.bbc.co.uk/

Symptoms

The effects of a stroke or TIA vary depending on the precise location of the blockage or bleeding in the brain. Each area of the brain is supplied by specific arteries. For example, if an artery supplying the area of the brain that control the left leg's muscle movements is blocked, the leg becomes weak or paralyzed.

If the area of the brain that senses touch in the right arm is damaged, sensation in the right arm is lost. Because early treatment can help loss of function and sensation, everyone should know what the early symptoms of stroke are. People who have such a symptom should see a doctor immediately, even if the symptom does not cause pain or if it goes away quickly. Starting treatment within 3 to 6 hours can help prevent the more severe consequences of a stroke.

The most common early symptoms of an ischemic stroke are;

1. sudden weakness or paralysis of the face and leg on one side of the body;
2. slurred speech;
3. sudden confusion with difficulty speaking or understanding speech;
4. sudden dimness or loss of vision, particularly in one eye;
5. loss of balance and coordination, leading to falls;
6. sudden severe headache; and
7. abnormal sensations or loss of sensation in an arm or a leg or one side of the body.

Symptoms of TIA usually disappear within minutes and rarely last more than 1 or 2 hours.

Symptoms of hemorrhagic stroke are largely the same as those of an ischemic stroke but may also include;

1. sudden severe headache,
2. nausea and vomiting,
3. temporary or persistent loss of consciousness, and
4. very high blood pressure.

In both types of stroke, an abnormal pattern of breathing can occur. Slow, irregular breathing may be caused by herniation of the brain. Herniation may develop when very high pressure within the skull forces the brain downward in the skull and distorts the respiratory center in the lower part of the brain stem.

In most people who have had a ischemic stroke, the loss of function caused y a stroke is usually greatest immediately after the stroke occurs. However, in about 15 to 20%, the stroke is progressive, causing greatest loss of function after a day or two. In people who have had a hemorrhagic stroke, loss of function usually occurs progressively over minutes to hours.

One days to months, some function is usually regained because even though some brain cells die, others are only damaged and may recover. Also, certain areas of the brain can sometimes switch to the functions previously performed by the damaged part-a characteristic called plasticity.

However, the early effects of stroke, including paralysis, can become permanent. Muscle may become permanently spastic and stiff, and painful muscle spasm may occur. Walking, swallowing, physically saying words clearly, and performing daily activities may remain difficult.

Problems with memory, thinking, attention, or learning may persist.The person may be unable to recognize parts of the body and may be unaware of the stroke's effects.

The person may continue to be unable to control emotions and to feel depressed. The peripheral field of vision may be reduced, and hearing may be partially lost. Dizziness and vertigo may be continuing problems. Control of bowel or bladder function may be permanently impaired.

Certain factors suggest that the outcome of a stroke is likely to be poor. Strokes that cause unconsciousness or that affect a large part of the left side of the brain are particularly grave. In adults who have had an ischemic stroke, neurologic losses that remain after 6 months are likely to be permanent, although children continue to improve slowly for many months. Older people fare less well than younger people who already have other serious disorders (such as dementia, recovery is more limited.

If a hemorrhagic stroke is not massive and pressure within the brain is not very high, outcome is likely to be better after than that after an ischemic stroke.

Blood (in a hemorrhagic stroke) does not damage brain tissue to the extent that an inadequate supply of oxygen (in and ischemic stroke) does. People who have had a hemorrhagic stroke may continue to improve for many months, even years.

Prevention
 

Preventing strokes is preferable to treating them. The main preventive strategy is managing the major risk factors.

High blood pressure and diabetes should be controlled; cholesterol levels should be measured and, if high, lowered to reduce the risk of atherosclerosis.

Other recommendations include stopping smoking, not using amphetamines or cocaine, consuming alcohol only in moderation, exercising regularly, and, if overweight, losing weight.

Taking an anti platelet drug, such as aspirin, reduces the risk of stroke (and heart attack). Anti platelet drugs reduce the tendency of platelets to clump and to promote clot formation, a common cause of stroke.

Aspirin, one of the most effective anti platelet drugs, is usually prescribed as 1/2 of an adult's tablet or 1 children's tablet (which is 1/4 of an adult's tablet) a day.

Dipyridamole is sometimes prescribed, but for most people, it is not effective unless it is taken with aspirin. Taking aspirin with dipyridamole is more effective than taking aspirin alone.

Ticlopidine or clopidogrel (other anti platelet drugs) may be given to the people who cannot tolerate or have not responded to aspirin.

People who have had TIAs or strokes due to blood clots originating in the heart may be given warfarin, an anticoagulant.

Rehabilitation

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Intensive rehabilitation can help many people overcome disabilities after a stroke. The exercises and training of rehabilitation help develop the plasticity of the brain (the ability of one area to shift to different functions) and teach the person new ways to use muscles unaffected by the stroke to compensate for losses in function.

The goals of rehabilitation are to regain as much normal function as possible, to maintain and improve physical condition, and to help people relearn old skills and learn new ones as needed.

Success depends on the area of the brain damaged and the person's general physical condition, functional and cognitive abilities before the stroke, social situation, learning ability, and attitude. Patience and perseverance are crucial.

Hemorrhagic Stroke (Pathology of Nervous System)

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A hemorrhagic stroke is damage to brain tissue resulting from bleeding inside the skull.

• There are two main types of hemorrhagic strokes: intracerebral hemorrhage and subarachnoid hemorrhage.
• Intracerebral hemorrhage occur within the brain while subarachnoid hemorrhage occur within a space between pia and arachnoid mater of the tissue covering the brain (meninges).
• Bleeding inside the skull can also result in epidural and subdural hematomas, which are usually caused by a head injury and cause different symptoms.

Intracerebral Hemorrhage  

 

An intracerebral hemorrhage is bleeding within the brain.

•  Intracerebral hemorrhage accounts for about 10% of all strokes but for a much higher  percentage of death due to stroke.
• Among people older than 60, intracerebral hemorrhage is more common than subarachnoid hemorrhage.
• Causes of intracerebral hemorrhage include high blood pressure and in older people, fragile blood vessels.
• Bleeding disorders and use of anticoagulants increase the risk of dying from an intracerebral hemorrhage.

Symptoms and Diagnosis

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• An intracerebral hemorrhage begin abruptly. In about half of the people, it begins with a severe headache.
• Neurologic symptoms develop and steadily worsen. They include weakness, paralysis, numbness, loss of speech or vision, and confusion.
• Symptoms worsen as the hemorrhage expands. Nausea, vomiting, seizures, and loss of consciousness are common and may occur within seconds to minutes.
• Doctor can often diagnose intracerebral hemorrhages on the basic of symptoms and the results of a physical examination.
• However, CT or MRI scan is usually performed when a stroke is suspected. Both procedures can help doctors distinguish a hemorrhagic stroke from an ischemic stroke. The procedures can also detect how much brain tissue has been damaged and whether pressure is increased in other areas of the brain.
• A lumbar puncture (LP)  is not usually performed. LP cab cause herniation of the brain, a life threatening disorder.

Treatment and Prognosis.

• Treatment of hemorrhagic stroke differs from that of an ischemic stroke.
• Anticoagulants, thrombolytic drugs, and anti-platelet drugs (such as aspirin) are not given, and surgery may save the person's life.
• The goal of surgery is to remove blood that has accumulated in the brain and to relieve the resulting increased pressure.
• Stroke due to intracerebral hemorrhage is more dangerous that ischemic stroke. The stroke is usually large and catastrophic, especially in people who have chronic high blood pressure.
• More than have of the people who have large hemorrhages die within a few days. Those who survive usually recover consciousness and some bran function as the body absorbs the leaked blood.
• Ever after surgery, many people continue to have some neurologic symptoms. The symptoms may include weakness, paralysis, loss of sensation on one side of the body, or difficulty understanding and using language (aphasia).
• However, people with small hemorrhages recover to a remarkable degree.

Subarachnoid Hemorrhage

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A subarachnoid hemorrhage is sudden bleeding into the space (subarachnoid space) between the inner layer (pia mater) and middle layer (arachnoid mater) of the meninges.

• Usually, the cause is the sudden rupture of an aneurysm in a cerebral artery or blood vessel (atriovenous) malformation of the arteries or veins in or around the brain.
• An aneurysm  may rupture because of the pressure  of blood inside the artery; hemorrhage and stroke may result.
• An arteriovenous malformation may be present at birth, but it is identified only if symptoms develop, it may cause bleeding, usually during adolescence or young adulthood, and sudden collapse, stroke, and death may result.
• Rarely, atherosclerosis or a bacterial infection damage a blood vessel, causing it to rupture. Ruptures can occur in people of any age of 25 and 50. A subarachnoid hemorrhage can also result from a head injury.
• A subarachnoid hemorrhage is the only one type of stroke more common among women than among men.

Symptoms and Diagnosis

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• Before rupturing, aneurysms that cause subarachnoid hemorrhages usually produce no symptoms. However, aneurysm sometimes press on a nerve or leak small amounts of blood before a major rupture, thereby producing warning signs, such as headache, facial pain, double vision, or other visual problems.
• The warning signs can occur minutes to weeks before the rupture. People should always report such symptoms to a doctor immediately, because steps may be taken to prevent a massive hemorrhage.
• A rupture usually produces a sudden, severe headache, often followed by a brief loss of consciousness. Some people remain in a coma, but more people wake up, feeling confused and sleepy.
• Blood and cerebrospinal fluid around the brain irritate the layers of tissue covering the brain (meninges), producing dizziness.
• Frequent fluctuations in the heart rate and in the breathing rate often occur, sometimes accompanied by seizures. Within hours or even minutes, people may again become sleepy and confused.
• About 25% of people have neurologic symptoms, usually paralysis on one side of the body.
• A subarachnoid hemorrhage can usually be diagnosed by CT scan, which pinpoints the site of bleeding.
• LP if necessary can detect any blood in the CSF.
• Cerebral angiography is usually performed within 72 hours to confirm the diagnosis and to identify the site of the aneurysm or arteriovenous malformation causing the bleeding, so that surgery can be performed.

An angiogram shows a left-sided aneurysm

Image taken from www.thecni.org

Treatment and Prognosis

• People who may have had a subarachnoid hemorrhage are hospitalized immediately and instructed to avoid exertion.
• Analgesics such as opioids (but not  aspirin or other NSAID)  are given to control the severe headaches.
• Occasionally, a drainage tube may be placed in the brain to relieve pressure.
• Nimodipine, a calcium channel blocker, is usually given to prevent spasm of an artery. This drug  helps prevent late spasm and ischemic stroke.
• For people who have an aneurysm, surgery that isolates, blocks off, or supports the walls of the weak artery reduce the risk of fatal bleeding later. These procedures are difficult, and regardless of which one is used, the risk of death is high, especially for people whoa are in a stupor or coma.
• The best time for surgery is somewhat controversial and must be decided based on the person's situation.
• Most neurosurgeon  recommend operating within 3 days of the start of symptoms, before the brain becomes swollen and inflamed.
• Delaying in operation 10 or more days reduces the risk of surgery, but bleeding is more likely to recur in the longer interim.
• A common procedure is placement of a metal clip across the aneurysm, which prevents blood from entering  the aneurysm and thus eliminates the risk of rupture. People who have clips remains on place permanently. 
• People who had clips placed years ago cannot undergo MRI: newer clips are not affected by the magnetic forces.
• An alternative procedure, called neuroendovascular surgery, involves the insertion of coiled wires into the aneurysm. The coils are placed using a catheter inserted into an artery and threaded to the aneurysm. Thus, this procedure does not require that the skull be opened.  By slowing blood flow, the coils promote clot formation, which seals of the aneurysm.
• About 35% if people who have a subarachnoid hemorrhage due to an aneurysm die during the first episode because of extensive brain damage.
• Another 15% die within  a few weeks because of subsequent bleeding.
• People who survive for 6 months but who do not have surgery for the aneurysm may have a 3% chance of another rupture each year.
• The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography becayse it has already sealed itself off. In such cases, the outlook is very good.
• Many people recover most or all mental and physical function after a subarachnoid hemorrhage.
• However, neurologic symptoms, such as weakness, paralysis, loss of sensation on one side of the body, or difficulty in understanding and using language (aphases) sometimes persist.
  

Hydrocephalus (Pathophysiology of NS)

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• The fluid surrounding the brain (cerebrospinal fluid, CSF) is produced in spaces within the brain called ventricles. The fluid must be drain to a different area, where it is absorbed into the blood. When the fluid cannot drain, hydrocephalus (water in the brain) develops.
• Hydrocephalus often increases the pressure in the ventricles, which compresses the brain. 
• Many conditions, such as a birth defect, bleeding within the brain, or brain tumours can block drainage and cause hydrocephalus.
• An abnormally large head my be a symptom of hydrocephalus. The infant usually fails to develop normally.
• CT scan, ultrasound, or MRI scan of the head reveals the diagnosis as well as the degree of brain compression.
• The goal of treatment is to keep pressure normal within the brain. A permanent alternate drainage path (shunt) for CSF decrease the pressure and volume of the fluid inside the brain.
• A doctor places the shunt in the ventricles in the brain and runs it under the skin from the head to another site, usually the abdomen (ventriculoperitoneal shunt). The shunt contains a valve that allows fluid to leave the brain if the pressure  becomes too high.
• Although a few children can eventually do without the shunt as they get older, shunts are rarely removed.
• If needed, pressure within the brain can often be temporarily reduced with drugs (such as acetazolamide or furosemide) or repeated lumbar puncture until a shunt is placed.
• Some children with hydrocephalus develop normal intelligence. Others are mentally retarded or have learning disabilities.

Headaches (Patophysiology of NS)

Headache is defined as pain or discomfort in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck.

Headaches are a very common medical problem and a common cause of disability among men and women. Headaches interfere with the ability to work and to perform daily tasks. Some people have frequent headaches; other people hardly ever have them.

Classification of headache are;

• Primary (idiopathic) headache, includes;
  

1. Tension-type of headache
   
2. Migraine (with or without aura)
   
3. Combination of headache
4. Cluster headache
   

• Secondary headache caused by underlying disease

Causes

• Although headaches can be painful and distressing, they rarely indicate a serious condition. Most headaches - tension type, migraine, and cluster headaches - are not caused by another identifiable disorder. Tension type headaches are the most common.
• Less commonly, headaches result from another disorder. Usually, the disorder is not serious. Disorders that cause headaches are often minor or temporary ones that affect the eyes, nose, throat, sinuses, teeth, jaws, ears, or neck.
• Rarely, headaches are caused by a serious disorder. Such disorder include a head injury, stroke, bulge in the wall of an artery supplying the brain (cerebral aneurysm), brain infection (brain abscess, meningitis, and encephalitis), and blood vessel (arteriovenous)malformation near the brain. Infections such as tuberculosis may affect the brain and cause headaches. Disorders that increase pressure within the skull can cause headaches by putting pressure on the brain. Examples area brain tumor, bleeding (hemorrhage), an accumulation of blood (hematoma), and pseudotumor cerebri, in which pressure within the skull increases but ni cause can be identified.
• Other serious diseases that may cause headache include very high blood pressure, which may produce a throbbing sensation in the head. (However, high BP does not usually cause headache.) Lung disorders (such as emphysema) that reduce the oxygen supply to the brain may cause headaches, as may sleep apnea, which temporarily increases levels of carbon dioxide in the blood. Inflammation of large arteries (temporal arteritis), usually in the neck and head, may cause headaches. Temporal arteritis affects older people primarily. Severe cases of influenza and high fever may cause headaches. Lyme disease in its early stages commonly causes headaches.
• Headaches commonly result from withdrawal of caffeine, withdrawal of analgesics after long-term use, and use of certain drugs that widen blood vessels (such as nitroglycerin).

Diagnosis

• Usually, doctors can determine the type or cause of headaches on the basis of the person's medical history, the characteristics of the headache, and results of a physical examinations.
• Characteristics of the headache include its frequency, duration, location, severity, and associated symptoms.
• The following characteristics may indicate that a serious disorder is the cause of headaches, and prompt medical attention is required.

1. Frequent headaches in a person who rarely has headaches,
2. Mild headaches that become severe,
3. headaches that awaken a person from sleep,
4. Any change in the pattern or nature of headaches,
5. Headaches associated with symptoms such as a fever and a stiff neck, changes in sensation, or vision, weakness, loss of coordination, or fainting.
   

• For example, a severe headache with a fever and a stiff neck suggests meningitis - a life threatening infection of the layers of tissue covering the brain and spinal cord (meninges). A headache that occurs suddenly and that is more severe that any others the person has experienced suggests a subarachnoid hemorrhage - often due to ruptured aneurysm.
• When doctors suspect a serious disorder, additional diagnostic procedures are usually performed. If meningitis is suspected, a spinal tap (lumbar puncture) is performed immediately. A spinal tap may also be performed if doctors suspect a ruptured aneurysm. Occasionally, blood tests are performed to check for a disorder such as Lyme disease. The erythrocyte sedimentation rate (ESR - the rate at which RBC settle down to the bottom of a test tube containing blood) may be determined to check for temporal arteritis. A high ESR suggests inflammation.
  
• If doctors suspect a tumor, stroke, hemorrhage, or another structural brain disorder, CT or MRI scan of the head is performed.
  

Tension-Type Headaches
Tension type headache is usually mild to moderate, band-like pain that affects the whole head.

The cause of tension-type headaches is not well understood but may be related to a lower-than normal threshold for pain. Stress clearly understood, and it is not the only explanation for the symptoms.

There are two classification of tension type headache;

1. Episodic type headache - tension type headache that occur fewer than 15 days per month.
2. Chronic type headache - occurs more than 15 days per month for at least 6 months.
   

Symptoms and Diagnosis

• The pain is usually mild to moderate, although it may be severe.
  
• It feels like tightening of a band around the head, making whole head ache. The pain may last 30 minutes to 1 week.
  
• Unlike a migraine headache, a tension-type headache is not associated with nausea and vomiting and is not made worse by physical activity, light, sounds, or smells.
  
• Tension-type headaches typically start several hours after waking and rarely awaken a person from sleep.
• The diagnosis is based on the person's description of the headache and the results of a physical examination.
• No specific procedures can confirm the diagnosis.
• Rarely, CT or MRI scan of the head is performed to rule out other disorders that may be causing the headache, particularly if headaches have developed recently.

Treatment

• For most mild to moderate tension-type headaches, almost any over-the counter analgesic, such as aspirin, acetaminophen, or ibuprofen can provide fast, temporarily relief.
• Massaging the affected area may help relieve the pain.
• Severe headaches may require stronger, prescription analgesics, some of which contains opioid (narcotics), such as codeine or oxycodone.
• For some people, caffeine, an ingredient of some headache preparations, enhances the effect of analgesics.
• However, overuse of analgesics or caffeine can lead to chronic daily headaches. Such headaches. called rebound headaches, occur when a dose of an analgesic is missed or late or when caffeine intake is reduced or stopped.

Migraine Headaches

A migraine headache is throbbing, moderate to severe pain, usually on one side of the head that is worsened by physical activity, light sounds, or smells and that is associated with nausea and vomiting.

• Although migraines can start at any age, they usually begin between the ages of 10 and 40.
• In most people, migraines recur periodically, but they usually become significantly less severe or resolve entirely after age 50 or 60.
• Migraines are 3 times more common among women that among men.
• Migraines tend to run in families; more than half of the people who have migraines have close relatives who also have them.
• The cause of migraines is not well understood. According to one theory, migraines occur when arteries to the brain become constrict and then dilate; dilation is thought to activate nearby pain receptors.
• However this theory is too simple to explain the complex changes in blood flow that occur in the brain during a migraine. Furthermore, a series of changes in the nerve cells of the brain occur before the changes in the blood flow.
• A rare subtype of migraine called familial hemiplegic migraine is associated with a genetic defect on chromosomes 1 and 19. The role of genes in the more common forms of migraine is under study.
• Estrogen, the main female hormone, appears to trigger migraines, a possibly explaining why migraines are more common among women.
• During puberty, migraines become much more commons among girls than among boys.
• Some women have migraines just before, during, or just after menstrual periods.
• As menopause approaches (when estrogen level fluctuating), migraines become particularly difficult to control. Oral contraceptives (which control estrogen) and estrogen replacement therapy often make migraines worse.
• Insomnia, changes in barometric pressure, and hunger may also trigger migraines.
• There are two types of migraine;

1. Migraine with aura (classic)
   
2. Migraine without aura (common)
   

Symptoms and Diagnosis

• In a migraine, throbbing pain is typically felt on one side of the head. The pain may be moderate but is often severe and incapacitating.
• Physical activity, light, sounds, or smells may make the headache worse.
• Headache is often accompanied by nausea, sometimes with vomiting.
• A migraine attack often involves more than a headache. It may include a prodrome, an aura, an a postdrome.
• The prodrome is a change in mood or behavior, which can precede the rest of the migraine by 24 hours.
• People may become depressed, elated, irritable, or restlessness.
• Nausea or loss of appetite may also occur.
• About 25% of people experience an aura. The aura involves temporary, reversible disturbances in vision, sensation, balance, movement, or speech.
• Commonly, people see jagged, shimmering, or flashing flashing lights.
• Less commonly, people experience tingling sensations, loss of balance, weakness in an arm or a leg, or difficulty talking.
• The aura occurs within the hour before the migraine and ends as the migraine begins.
• About 25% of people experience a postdrome, which involves changes in mood and behavior after the migraine.
• Migraines attacks may occur frequently for a long period of time but then may disappear for many weeks, month, or even years.
• Migraines are diagnosed on the basics of symptoms. No procedure can confirm the diagnosis.
  
• If headaches have developed recently or if the pattern of symptoms has changed, CT or MRI scan of the head is performed to exclude other disorder.

Prevention &  Treatment

 

• Treatment of migraine headaches involves three types of drugs; drugs to prevent migraines, drug to stop (abort) a migraine as it beginning, and drugs to relive pain.
• People who have more than one migraine a week often benefit from taking drugs every day to prevent migraine attacks.
• Beta blockers, such as propanolol, are often given first.
• Calcium channel blockers, antidepressants, and some anticonvulsants, particularly divalproex, are also effective.
• The choice of a preventive drug is based on the side effects of the drug and another disorders present. For example, if weight gain could cause problems, divalproex is usually not prescribed. If the person is has depression, a tricyclic antidepressant such as nortriptyline may be prescribed.
• To abort a migraine as it is beginning, most doctors prefer a relatively new group of drugs called triptans (5-hydroxytryptophan [5-HT] agonist). Triptans specifically target the receptors that stimulate the nerves supplying the the cerebral blood vessels. Thus, triptans may reverse the dilatation of these blood vessels which contributes to a migraine.
• As soon as people sense a migraine attack is beginning, they take one of these drigs to stop the attack from the processing.
  
• Other drugs used to abort migraines, such as ergotamine, are sometimes used, but they are not as safe or as effective as triptans. Because triptans and ergotamine cause blood vessels to constrict, they are not recommended for people who have angina or other heart disease or for people who have prodromal symptoms that resemble those of stroke (because constriction of arteries may trigger a stroke).
• For less severe migraines, analgesics alone or analgesics that contain caffeine can be useful. They can be taken as needed during a migraine, with or instead of a triptan.
• As for tension-type headaches, overuse of analgesics or caffeine can make the migraine worse.
  
• For more severe migraines, opioids may be needed.
  

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