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Annette
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CH episode triggered by emotional stress
« on: Feb 4th, 2008, 10:36pm » |
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Onset of cluster headache triggered by emotional effect: a case report
P S Sandor1, P Irimia1, H R Jager2, P J Goadsby3, H Kaube3
1 Headache Group, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
2 Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery
3 Headache Group, Institute of Neurology
Correspondence to:
Correspondence to:
P S Sandor
Headache and Pain Unit, Neurology Department, University Hospital,CH-8091 Zurich, Switzerland; Peter.Sandor@usz.ch
Cluster headache is a strictly unilateral headache that occurs in association with autonomic symptoms. Stress is a recognised precipitant of migraines, but not of cluster attacks. We describe the case of a patient having migraine for years, in whom extreme emotional stress triggered cluster headache attacks.
Background
Neuroimaging has contributed considerably to the knowledge about the neurobiology of cluster headache. Activation in the region of the posterior hypothalamus is observed,1 coinciding with subtle structural abnormalities in the same region.2
Genetic studies indicate an autosomal dominant inheritance with low penetrance and an increase in risk of 4–18 times for cluster headache in first-degree relatives when compared with the general population.3
Although the triggers for individual episodes are well recognised, the most important ones being nitroglycerin,4 alcohol,5 increased body heat and exertion,6 this is not the case for the triggers for bouts.
Case report
A man, about 50 years old, had been treated by us for a decade. He had experienced migraine without aura from his early teens. He had a positive family history of headache, with both his parents and two siblings having migraine. A typical migraine episode consists of pain that is mostly unilateral but with the side changing, periorbital or temporal, and sometimes bifrontal, accompanied by nausea, phonophobia, photophobia and often osmophobia. Our patient never had any autonomic signs accompanying his migraine episodes. The headache would typically be severe, with a throbbing character and exacerbated by movement. The episode lasted from 1 hour, when treated, to several days and prevented him from carrying out his daily activities.
The episodes responded best to subcutaneous sumatriptan 6 mg and only partially to combined over-the-counter painkillers or non-steroidal anti-inflammatory drugs. The frequency of episodes varied between twice a month and twice weekly over the 10 years of review. Overuse of drugs for acute migraine had been a recurring problem and attempts to reduce the number of days of taking drugs for acute headache on an outpatient basis proved successful and were followed by periods of prophylactic treatment. During phases of increased frequency of episodes and owing to overuse of drugs for acute headache, the headache had less features and was less severe, but returned to its original characteristics and frequency after withdrawal of treatment. In the past, the patient had used several ß-adrenoreceptor blockers and tricyclic antidepressants, as well as valproate and gabapentin, to prevent migraine.
The patient is a non-smoker and does not drink alcohol. A few years ago, he had severe mouth ulcers and was examined to exclude possible Behçet disease. He has hypercholesterolaemia and arterial hypertension, which is treated with pravastatin (20 mg/day) and ramipril (10 mg/day). He is an academic and has held several responsible positions. After 10 years of marriage, he had gone through a difficult divorce and subsequently struggled to maintain contact with his three children. His private life has become quieter only in the past few years. He had remarried and his 21-year-old son had been living in his house for a few years.
He came to see us via an emergency appointment in autumn 2004, because of a new, previously unknown type of headache that had started 2 weeks before the appointment. At this time, he was not taking any migraine prophylactics, had not changed his regular drugs and did not use any psychotropic substance, including illicit drugs.
"Totally unexpectedly", his son had announced that he was moving back in with his mother, the patient’s ex-wife. The patient described this as the worst moment of the past years, of having had the feeling that "everything is taken away"; he was tearful while describing it. He said, "... during the afternoon I tried to rationalize this ... but it did not work and I had to cry several times". In the early evening of the same day, after an afternoon of intense worrying, he started to have a type of headache, which he had not had previously. The new headache occurred regularly thereafter, with a frequency of one to two attacks every 24 h, mostly occurring during the night and waking him up. This pain, starting abruptly, peaked in minutes, was strictly left temporoparietal and was accompanied by lacrimation and conjunctival injection. Whereas the previous headaches were worsened by movement and he preferred to lie down and rest, the new headaches were not exacerbated by movement, and he was restless and paced around. The intensity of the new episodes was higher than those previously experienced, with 10 out of 10 on a verbal rating scale. The pain was stabbing, not pulsating. As the pain was so unbearably severe, he always treated it with subcutaneous sumatriptan 6 mg, with resolution in 15–30 min. A magnetic resonance image with gadolinium showed no abnormality and particularly no hypothalamic or cavernous sinus or pituitary lesions.
Cluster headache was diagnosed, and we started him on a course of steroids with prednisolone 60 mg over 5 days, tapering it down over 5 days. We introduced methysergide, which was increased to 5 mg/day, when no further headaches occurred. Eventually the dose was titrated down to 2 mg/day, with control of the headache and bearable, mild side effects. When the dose of methysergide was reduced to below 2 mg after 1 and 4 months, the new type of headache recurred twice daily, and was controlled when the patient increased the methysergide back to 2 mg daily. During the 2 weeks between the onset of the new headache and the appointment, and while he was on methysergide, no episodes of migraine occurred.
Discussion
This patient presented with a new type of headache fulfilling the International Headache Society criteria7 for cluster headache after having been treated in our specialised headache clinic for migraine without aura for 10 years and headache caused by the overuse of drugs. A careful study of the clinical notes and correspondence over the past 10 years did not suggest any previous occurrence of cluster headache.
Several cases of cluster headache triggered by, or secondary to, lesions localised in the trigeminal territory, such as those caused by head injury,8 dental extraction,9 impacted superior wisdom tooth10 and ocular enucleation,11 have been published.
Emotional triggers are well recognised for cardiac death,12 stroke13 and also for migraine.14 For cluster headache, the only reported emotional trigger for a first-time cluster headache is orgasm.15 The emotional stress temporally associated with the onset of cluster headaches was extreme in our patient and he became tearful, even when talking about it 4 months later.
Cluster headache is very rare, with a prevalence of about 0.2%,3 and an incidence of 1.6 per million people per person-year.16 Against this background, we propose a causal relationship between the extreme emotional stress in our patient and the onset of his cluster headaches. Clinical or imaging hints for a secondary origin of the new type of headache were absent.
In conclusion, we describe a patient who had migraine for years and in whom extreme emotional stress triggered a new type of headache. Placebo effects in the treatment of cluster headache are mediated by information and induce neurobiological changes. In a recent review, it was described as comparable in magnitude to migraine.17 Emotional stress as a trigger, also mediated by information, may be another example that the heritage in research from Descartes, of trying to conceptually separate the brain from the results of its function, is outdated.
FOOTNOTES
Competing interests: PJG is a Wellcome Trust Senior Research Fellow.
Informed consent was obtained from the patient for publication of his details in this report.
References
May A, Bahra A, Buchel C, et al. Hypothalamic activation in cluster headache attacks. Lancet 1998;352:275–8.[CrossRef][Medline]
May A, Ashburner J, Buchel C, et al. Correlation between structural and functional changes in brain in an idiopathic headache syndrome. Nat Med 1999;5:836–8.[CrossRef][Medline]
Russell MB. Epidemiology and genetics of cluster headache. Lancet Neurol 2004;3:279–83.[CrossRef][Medline]
Sances G, Tassorelli C, Pucci E, et al. Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches. Cephalalgia 2004;24:110–9.[CrossRef][Medline]
Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology 2002;58:354–61.[Abstract/Free Full Text]
Blau JN, Engel HO. A new cluster headache precipitant: increased body heat. Lancet 1999;354:1001–2.[CrossRef][Medline]
Headache Classification Committee of the International Headache Society. The international classification of headache disorders. 2nd edn. Cephalalgia 2004;24 (Suppl 1) :1–160.
Reik L Jr. Cluster headache after head injury. Headache 1987;27:509–10.[CrossRef][Medline]
Soros P, Frese A, Husstedt IW, et al. Cluster headache after dental extraction: implications for the pathogenesis of cluster headache? Cephalalgia 2001;21:619–22.[CrossRef][Medline]
Romoli M, Cudia G. Cluster headache due to an impacted superior wisdom tooth: case report. Headache 1988;28:135–6.[CrossRef][Medline]
Evers S, Soros P, Brilla R, et al. Cluster headache after orbital exenteration. Cephalalgia 1997;17:680–2.[CrossRef][Medline]
Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med 1996;334:413–9.[Abstract/Free Full Text]
House A, Dennis M, Mogridge L, et al. Life events and difficulties preceding stroke. J Neurol Neurosurg Psychiatry 1990;53:1024–8.[Abstract]
Wacogne C, Lacoste JP, Guillibert E, et al. Stress, anxiety, depression and migraine. Cephalalgia 2003;23:451–5.[CrossRef][Medline]
Klimek A. Orgasm—a new trigger factor of cluster headache? Cephalalgia 1990;10:205–6.[CrossRef][Medline]
Swanson JW, Yanagihara T, Stang PE, et al. Incidence of cluster headaches: a population-based study in Olmsted County, Minnesota. Neurology 1994;44:433–7.
Nilsson Remahl AI, Laudon Meyer E, Cordonnier C, et al. Placebo response in cluster headache trials: a review. Cephalalgia 2003;23:504–10.[CrossRef][Medline]
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seasonalboomer
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Re: CH episode triggered by emotional stress
« Reply #1 on: Feb 4th, 2008, 10:38pm » |
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My mother in law has triggered cluster hits for me before.....
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George_J
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Re: CH episode triggered by emotional stress
« Reply #2 on: Feb 5th, 2008, 9:43am » |
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Interesting report, on several levels. The point made that activity by the brain can cause neurobiological changes within the brain is supported by lots of other research, elsewhere.
Speaking only for myself, however, I'm unable to point to any emotional incidents that precipitated individual attacks, let alone indicate any particular trauma, physical or emotional, that occurred at the time of onset.
I suspect (without any particular evidence) that emotional trauma is an uncommon factor surrounding the onset of cluster headache...but it's very interesting that it could be a factor at all--providing further evidence that emotional states can alter physical states within the brain.
Thanks for bring this to our attention, Annette.
Edited to add:
I'd be interested to know whether similar case reports exist. One report may indicate simple coincidence, but more of them might increase suspicion that emotional trauma can be a significant factor in the onset of individual cases of CH.
Best wishes,
George
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DennisM1045
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Re: CH episode triggered by emotional stress
« Reply #3 on: Feb 5th, 2008, 11:39am » |
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on Feb 4th, 2008, 10:38pm, seasonalboomer wrote:| My mother in law has triggered cluster hits for me before..... |
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You aren't alone there Scott! 
Thanks for posting this Annette. Very interesting...
-Dennis-
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starlight
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Re: CH episode triggered by emotional stress
« Reply #4 on: Feb 5th, 2008, 1:02pm » |
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Thanks Annette.
I think emotional stress can definitely play a role. My feeling though is that it is a complicated puzzle and that may be one piece of the puzzle.
Hey, is that true--cluster headache strikes 1.6 per 1 million people--is that the percentage? I thought it was more like 1 per 1,000--anyone know?
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starlight
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Re: CH episode triggered by emotional stress
« Reply #5 on: Feb 5th, 2008, 1:09pm » |
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I have had CH come on when I was cognitively overloaded (no pot shots there please)--either reading tons all at one time like 8 hrs. in a row for a class (that I dropped) or even when the CH first set in I was working with one of those old fashioned cash registers at a grocery store where you are constantly looking at numbers and subtracting in your head along with hearing constant beeping--not that that is the most intellectually challenging thing in the world but maybe it is the constantness of it--also this is one of the reasons I think Dr. Gupta's article has some merit where he talks about the EYE playing a role--sometimes I really think that both of those things were hard on my eyes (or maybe only on my left eye) although I have no vision problems at all, don't wear glasses, one eye is better than 20/20, but it just seems odd than I can sometimes even start shadowing from reading for long period. I think the eye plays a role. Emotional stress, sure that can factor in, and it must, as it tends to make any physical condition worse. Just my two cents, Star
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sandie99
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Re: CH episode triggered by emotional stress
« Reply #6 on: Feb 5th, 2008, 1:33pm » |
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Star,
what you wrote about reading & getting shadows is familiar to me as well. I'm working on my dissertation and I need to read lots and lots of media theory and I've had to stop more than once because of shadows (in the past, I got hit as well). I do wear glasses, but before ch I could easily read school materials for hours without problems...
Sanna
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Kevin_M
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Re: CH episode triggered by emotional stress
« Reply #7 on: Feb 5th, 2008, 1:40pm » |
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on Feb 5th, 2008, 9:43am, George_J wrote:| suspicion that emotional trauma can be a significant factor in the onset of individual cases of CH. |
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Yeah, I'd have no idea about acquiring clusters through stress, but already having clusters and experiencing a prolonged increase in stress has triggered an upsurge in hits for me.
The beast might find the door slightly ajar in these times; seems whenever you might say, "what else can happen," be prepared when you have clusters.
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starlight
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Re: CH episode triggered by emotional stress
« Reply #8 on: Feb 5th, 2008, 1:54pm » |
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Sandie,
I totally know what you're saying. I read a lot as a kid (bookworm even back then) and had no problem, even read in the dark a lot when I was supposed to be sleeping and had no problems at all. The one thing I can say is that it seems like the shadowing and actual triggering of certain CH cycles was possibly tied in to reading very quickly like trying to get a long novel read for class the next day and literally trying to speed read the thing or rapidly viewing numbers and such--I am naturally a very slow reader even though I like to read. Maybe it is how quickly a person reads or who knows maybe even the content like if it is difficult reading--or a lot of thought going on?? Dunno.
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PollyPocket
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Re: CH episode triggered by emotional stress
« Reply #9 on: Feb 5th, 2008, 3:01pm » |
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on Feb 5th, 2008, 1:40pm, Kevin_M wrote:
........but already having clusters and experiencing a prolonged increase in stress has triggered an upsurge in hits for me.
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I totally agree. Same happened with me. The reading was a non-issue, but stress definitely increased the frequency of hits for me.
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George_J
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Re: CH episode triggered by emotional stress
« Reply #10 on: Feb 5th, 2008, 3:50pm » |
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It's important, I think, to make a distinction here--there are really three levels at which emotional stress might conceivably trigger cluster headache:
1. An individual cluster headache attack when a person with existing CH is in cycle.
2. A round of cluster attacks--a new cycle--in a person with existing
CH.
3. The onset of CH itself, in a person who did not previously have CH.
What is most interesting, I think, about the article is that they're talking about "3"--the observation is made that a period of emotional stress is associated with the initial onset of CH in a person who did not previously have CH, implying that the brain's emotional state can alter the brain's physical state.
If stress, indeed, caused the initial onset of CH, I think that is remarkable. But simply because something happened near the time that something else happened does not mean that one thing caused the other.
At this point, it's really just an observation that a proximity between an emotional state and the onset of CH exists in a single example. That's why I'd like to see more examples.
Interesting, nevertheless.
Best,
George
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Annette
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Re: CH episode triggered by emotional stress
« Reply #11 on: Feb 5th, 2008, 4:10pm » |
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on Feb 5th, 2008, 3:50pm, George_J wrote:
At this point, it's really just an observation that a proximity between an emotional state and the onset of CH exists in a single example. That's why I'd like to see more examples.
Interesting, nevertheless.
Best,
George
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I am looking George 
There is another article reporting NEW episode of CH occuring in people who had never had CH before, although some had other forms of migraine. However, this is not free. You need to have a subscription or pay privately to access the full article.
Here it is in case you would like to read it in its entirety.
" A follow-up study of 60 patients after an assumed first period of cluster headache.
Sjostrand C, Waldenlind E, Ekbom K
Cephalalgia, 2000; 20(7): 653-7 "
However, below is the essence of it
" Abstract:
Cluster headache (CH), a primary neurovascular headache syndrome, is characterized by recurrent, unilateral, short-lasting attacks of excruciating pain in the temporal region. The pain is considered one of the most severe pain conditions known to humans. This thesis has focused on studies of the clinical picture, especially in relation to headache classification criteria, studies of the genetic background and a search for pathophysiological mechanisms through gene expression analysis.
In Study I we prospectively evaluated the prognosis after one typical cluster period. We found that 13 (26.5%) had had one cluster period only during a mean observation time of 8.9 years, and conclude that some patients may suffer from one cluster period only. In the new IHS classification (2004) only one period is required for a CH diagnosis. "
What is really interesting is the follow up study found 26.5% ( 13 out of 60 ) diagnosed with their first CH episode did not have another episode for the next 8-9 years or more. Out of those 13, 2 reported having their only CH episode during the time of severe psychological stress.
Link to the full thesis
http://diss.kib.ki.se/2005/91-7140-363-9/
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starlight
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Re: CH episode triggered by emotional stress
« Reply #12 on: Feb 5th, 2008, 5:07pm » |
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George,
I agree with you that that would truly be remarkable--if the condition itself was triggered by emotional stress.
The examples I gave were examples of actual cycles being triggered (although the one in college fit right in with the starting date I always had back then in the fall), the first example when I worked in grocery store was when the condition itself began.
My guess is that what goes on is some kind of perfect storm happening to create the condition itself--predisposition/emotional/cognitive/and/or physical stressor/perhaps maybe even that heart thing that some are said to have.
I find what Dr. Gupta writes about the eye fascinating. And maybe the seasonal changes in light are affecting the eye in some way we don't understand...just my ramblings.
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Re: CH episode triggered by emotional stress
« Reply #13 on: Feb 5th, 2008, 5:12pm » |
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Oh and now that I've gotten off topic, yes, emotional stress has precipitated cycles for me, BUT how do you get around the fact that I like many (used to) have a starting date they could mark on their calender? That's a toughie.
Could it trigger the condition itself? Not without a perfect storm--there are other factors involved in my opinion.
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starlight
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Re: CH episode triggered by emotional stress
« Reply #14 on: Feb 5th, 2008, 5:23pm » |
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My final thought and I completely apologize for the ramblings: whether emotional stress is a big player or not, maybe when the purpose of sleep is understood more fully then CH will be understood. Why the headaches occur (I believe during REM) during sleep for many, the eyes are moving rapidly in REM, maybe the brain is processing information or whatnot during that point in sleep--it's all a mystery. I would say keeping stress levels down is a good thing for CH.
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Annette
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Re: CH episode triggered by emotional stress
« Reply #15 on: Feb 5th, 2008, 6:15pm » |
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Star, thanks for sharing your thoughts
Its obvious that there are MANY factors involved in the development of CH in an individual, ranging from genetic, to head injury to stress to malfunctioning hypothalamus... These factors affect different people differently. Therefore while there are some common denominators, there isnt an universal "laws" that applies to all CHers.
What I find interesting that it is possible for emotional/psychological stress alone to CAUSE CH to develop as a new condition, as well as starting a whole new cycle in someone with pre-existing CH.
This knowledge should lead to a more comprehensive treatment plan for CH, where emotional/psychological stresses need to be addressed/treated more aggressively, which is something not yet seen happening.
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Re: CH episode triggered by emotional stress
« Reply #16 on: Feb 5th, 2008, 6:17pm » |
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All us mammals are graced with pattern recognition.
Especially given the desperation to understand with this condition, I know I myself do silly things like associate an incredibly quckly aborted headache with whatever I ate, or if I exercised that day, etc. And I can find all sorts of connections in that static that convince myself I just have to do this or hold my head this way and it'll never come.
But as my neurologist explains to me, it's not that simple. A series of events cause this - some of the pain is even the result of the onset of an attack and not the attack itself as the trigeminal gets loaded up with signals.
It appears that there are many triggers for cluster headaches, and as we all point out, some or many of these variables must align for the worst to happen. I find exercise early in an attack will abort, others find not.
I do look forward in years to come more research about the role of the optic nerve, etc.
My girlfriend has been around me for this entire cycle being an absolute angel, and she gives me a third person perspective I sometimes lack.
She pointed out that watching movies in a theater projected on film would almost always lead to an attack. This is really interesting to me.
Films projected from celluloid cycle through the projector with a shutter mechanism, creating flicker. If you spend two hours in a cinema, you are actually spending an hour in darkness. For every concurrent frame you see a frame of darkness.
Likewise, watching things on a non progressive scan tv during this cycle seems to trigger. This is an image which flickers.
Watching things deinterlaced on an LCD monitor, however, is not triggering. Reading is causing (and normally i'm a voracious reader).
I am intensely bored at the moment, btw.
There could be something there, or maybe I just see patterns. But I think the best thing we can do is isolate the mechanism of cause before all, as the medications we are given do not specifically target that mechanism and have side effects.
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otakuhouse
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Re: CH episode triggered by emotional stress
« Reply #17 on: Feb 5th, 2008, 6:19pm » |
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Oh one last thing -
This current cycle began while I have very little emotional stress. I'm very happy with my personal life, feel good in my relationships, and just accomplished some good stuff at work.
All my reading suggests that the triggers are many. But the mechanism is hypothalamus / vascular in origin.
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Kevin_M
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Re: CH episode triggered by emotional stress
« Reply #18 on: Feb 5th, 2008, 6:42pm » |
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on Feb 4th, 2008, 10:36pm, Annette wrote:| Several cases of cluster headache triggered by, or secondary to, lesions localised in the trigeminal territory, such as those caused by head injury, dental extraction, impacted superior wisdom tooth, and ocular enucleation, have been published. |
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Individual cases have been published of diagnosed clusters triggered by or secondary to the above incidents, also noting one for orgasm. Experiencing one first episode that started at a time of severe stress is now published.
Quote:| we propose a causal relationship between the extreme emotional stress in our patient and the onset of his cluster headaches. Clinical or imaging hints for a secondary origin of the new type of headache were absent. |
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More individual causal relationships are being designated as a primary origin.
It could also be understood that these being singular case incidents of "lesions localised in the trigeminal territory, such as those caused by head injury, dental extraction, impacted superior wisdom tooth, and ocular enucleation" orgasm, and severe stress (another study, a six-year latency from a lightning strike) that there may be something else in common happening in these individuals, which seems to be the affecting primary origin if such a diverse array of head and brain causal relationships are being proposed. Each incident alone hasn't had much standing yet.
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| « Last Edit: Feb 5th, 2008, 6:42pm by Kevin_M » |
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Annette
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Re: CH episode triggered by emotional stress
« Reply #19 on: Feb 5th, 2008, 6:58pm » |
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on Feb 5th, 2008, 6:19pm, otakuhouse wrote:
All my reading suggests that the triggers are many. But the mechanism is hypothalamus / vascular in origin. |
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No one knows what is the true mechanism or origin of CH yet. There maybe several.
Prof Goadsby found some structural abnormality in the hypothalamus of several CHers but until ALL CHers are scanned and found to have the same abnormality, it is not conclusive that this is the origin of the condition.
Cranial vascular dilatation occurs in a hit if triggered by alcohol or glycerin nitrate, but this doesnt happen in chronics or in out-of-cycle episodics. Therefore it cant be considered the origin either.
More and more evidences are actually pointing towards chemical imbalances in the brain, specifically neurotransmitters such as serotonins, dopamine, noradrenaline, melatonin, etc and hormones such as testosterone and cortisone.
Now what causes these chemical imbalances ? Ask this question and we are back to triggers !
If we look to other medical conditions for a pattern in pathophysiology, such as diabetes or migraines or schizophrenia, then there are risk factors which when coupled with susceptibility in a particular individual, lead to the development of the condition.
One could say a person is "prone" to CH due to whatever reasons : genetic, head injury, smoking, lifestyles, developmental anomalies .... when exposed to ( maybe repeated ) triggers over a certain amount of time will develop the symptoms ?
But then there are people who develop CH secondary to another known medical condition. The perfect example is our own beloved DJ. His CH was present alongside Moyamoya. When surgery fixed the moyamoya problem, it cured his CH too. However others with Moyamoya dont have CH !
The quest to knowledge continues ...
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Annette
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Re: CH episode triggered by emotional stress
« Reply #20 on: Feb 5th, 2008, 7:06pm » |
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on Feb 5th, 2008, 6:42pm, Kevin_M wrote:
.... that there may be something else in common happening in these individuals, which seems to be the affecting primary origin if such a diverse array of head and brain causal relationships are being proposed. . |
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Yep, that is the missing link, I believe
Maybe its a recess gene that CHers possess, which will be activated when exposed to a magic formula of events both biological and mental in a persons life time. To complicate matters more, this magic formula seems to be specific to unique individuals.
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Pinkfloyd
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Re: CH episode triggered by emotional stress
« Reply #21 on: Feb 5th, 2008, 10:04pm » |
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on Feb 5th, 2008, 6:15pm, Annette wrote:
This knowledge should lead to a more comprehensive treatment plan for CH, where emotional/psychological stresses need to be addressed/treated more aggressively, which is something not yet seen happening.
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It's not happening yet because this is ONE case report.
It means absolutely nothing....or very little at best.
What it means is that it was an interesting story and the authors thought they could get it published, adding to their list of published articles.
Get published or perish, as they say.
I'm not sure what you're saying here. You think all cluster patients should be treated by a psychiatrist?
Based upon one case report, you think doctors should change the way they treat clusters?
BTW, being a professional and all, don't you think it a bit unprofessional to cut and paste a copyrighted article in it's entirety? Even though it's a free article (for registered members) it's still copyrighted. I think that having to become a member to read it, makes it actually, not "free" anyway.
Bobw
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Annette
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Re: CH episode triggered by emotional stress
« Reply #22 on: Feb 5th, 2008, 10:57pm » |
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on Feb 5th, 2008, 10:04pm, Pinkfloyd wrote:
BTW, being a professional and all, don't you think it a bit unprofessional to cut and paste a copyrighted article in it's entirety? Even though it's a free article (for registered members) it's still copyrighted. I think that having to become a member to read it, makes it actually, not "free" anyway.
Bobw
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Its free to register as member and article that are more than 12 months old are free for all members.
What is your problem Bob ?
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starlight
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Re: CH episode triggered by emotional stress
« Reply #23 on: Feb 5th, 2008, 11:39pm » |
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Annette,
I think that what you have written here is very intelligent. I rambled a lot earlier (apologize for that btw)--I've had these for 20 years--I will say that I believe for me emotional stress has played a role--I am open to the idea in fact that it (stress) could even trigger the whole condition...my guess though is that there is some other abnormality going on, and I do not believe it to be the hypothalamus. I understand why others do, but I do not believe that. I understand it makes "sense" in a vague, unsatisfying kind of way, but I do not believe it.
I hope they figure out these HAs...keep thinking.
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pattik
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Re: CH episode triggered by emotional stress
« Reply #24 on: Feb 5th, 2008, 11:58pm » |
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on Feb 5th, 2008, 10:57pm, Annette wrote:
Its free to register as member and article that are more than 12 months old are free for all members. |
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You have essentially stolen a copyrighted article without even crediting the site from which you stole it...bad manners and unprofessional. I'm assuming that you got it from the BMJ group. Here is part of their license agreement which may be too difficult for you to understand:
Quote:Intellectual property rights
The content, layout, design, data, databases and graphics on this website are protected by UK and other international intellectual property laws and are owned by the BMJ Group or is Licensors. Unless expressly permitted in writing a licence agreement[ and other than printing a small proportion of content or displaying this on your screen or both, (strictly for your personal non-commercial use), no part of the website may be reproduced, stored in any medium, including but not limited to a retrieval system or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, broadcasting nor,shown in public. You may not create any derivative work or make any other adaptation, without our prior written consent. You must not modify the copies you have displayed or printed in any way and you may not use any illustrations, photographs, videos or audio sequences or any graphics separately from any accompanying text. Any permitted use of our material is subject to ensuring that our copyright notices and trade marks appear as they do on all copies online and customary bibliographical citations including author attribution, date article title (where applicable) and the URL to the relevant BMJ Group website are included. If you print off or download any material from our website(s) in breach of thes terms of use, your right to use our site(s) will cease immediately and you must at our option return or destroy any copies of the materials you have made. All rights not expressly granted in these terms or any express written licence, are reserved. |
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Technically, I shouldn't have even quoted this agreement here, but you should know that just because you signed up for the free look, you don't have the right to paste it wherever you feel like it.
Pat
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