.   Migraine—This   type   of   headache   is characterized   by   a   paroxysmal   attack   often preceded  by  psychologic  or  visual  disturbance  that is  followed  by  drowsiness.  Women  are  affected more  often  than  men.  Migraine  headaches  are believed  to  be  the  result  of  vascular  changes. SYMPTOMS—There  is  usually  a  throbbing sensation or pain resulting from vasoconstriction followed   by   dilation.   The   patient   often experiences nausea and vomiting. Often there is a family history of migraines, and the frequency of attacks may vary from daily to once every few years.  The  pain  is  usually  unilateral  and  may  last for  2  or  3  days. TREATMENT—Cafergot^® is the most widely used drug in the treatment of migraines. It should be  administered  at  the  first  sign  of  headache (provided a history of migraine is obtained or you have actually diagnosed it). Place the patient on bed rest for a few hours in a darkened room and withhold any food or drink. At times the pain is so  severe  that  narcotics  maybe  necessary  for  pain; Demerol  is  the  drug  of  choice.  Codeine  is contraindicated. . Cluster—There is usually no clear history of headaches in the patient’s family. Middle-aged males are most often affected, and the headaches may  be  precipitated  by  the  use  of  vasodilators, alcohol,  or  histamine. SYMPTOMS—The   onset   is   sudden   and   is characterized by severe unilateral pain that may disappear after 1 or 2 hours as rapidly as it came. Nocturnal  attacks  are  common,  and  the  patient may  have  associated  symptoms  such  as  redness and  lacrimation  of  the  eyes,  rhinorrhea,  and  nasal congestion. TREATMENT—The pain of this headache is so severe that the patient should be kept on bed rest until the pain ceases. Administer Sansert ® (methysergide  maleate)  to  help  prevent  cluster headaches  from  becoming  vascular  headaches. Cluster  headaches  are  so  severe  and  of  such  short duration   that   adequate   therapy   is   difficult; however,  administering  antihistamines  may  be effective. .   Hypertensive—Normally these headaches are the result of chronic hypertension. They are characterized by a persistent bilateral throbbing pain. The best treatment is to control the patient’s hypertension.   The   patient   may   be   helped   by analgesics,  understanding,  and  reassurance. Epilepsy This  is  a  convulsive  disorder  that  is  character- ized  by  abrupt  transient  symptoms  of  a  motor, sensory,  psychic,  or  autonomic  nature.  Attacks are   usually   accompanied   by   altered   levels   of consciousness,  and  there  is  usually  a  history  of epilepsy  in  the  patient’s  family.  The  onset  of epilepsy is usually before the age of 30. There are several  types  of  epileptic  seizure  classifications. The  three  major  classifications  are  generalized, partial,   and   unclassifiable   epilepsies.   The generalized  epilepsies  are  the  most  commonly encountered and include the petit mal and grand mal  types. .  Grand  Mal  Seizures—These  are  divided into  the  following  two  groups. l   Jacksonian   Seizure—This   type   of seizure  is  characterized  by  an  aura,  often  referred to as a warning, but which in reality is a part of the  seizure.  The  patient  will  experience  convul- sions  without  lapsing  into  unconsciousness.  The seizure may start in the toes or thumbs or in the face (the eyes and head may turn to one side), and the  seizure  may  then  spread  to  other  areas. . Typical Grand Mal Seizure—This type of seizure may have the initial aura as described above.  The  patient  may  fall  down  and  cry  out, lose bladder and bowel control, and froth at the mouth.   There   is   convulsive   movement   of   the body, dyspnea, and cyanosis. Corneal reflexes are usually  absent  and  Babinski’s  reflex  is  positive. Often  the  patient  bites  the  tongue  and,  if  not completely   unconscious,   will   be   confused   and disoriented.   The   seizure   usually   lasts   2   to   5 minutes. A period of deep sleep is common after the  seizure,  and  the  patient  will  complain  of muscle  soreness  and  stiffness  upon  awakening. TREATMENT—Immediate   treatment   is aimed  at  preventing  the  patient  from  injuring himself  or  herself.  A  tongue  depressor  or  other type of padded gag should be placed between the patient’s   teeth   to   prevent   biting   the   tongue; however, this may not be possible if the jaws are clenched.  Don’t  force  it.  Never  try  to  restrain  a patient during convulsions; however, do not leave the patient alone. Loosen the clothing around the neck,  and  turn  the  head  to  the  side  to  prevent 2-29