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The color of the flowers remain the same whether cultivated in one country or another while the leaves may grow larger or smaller according to the system of cultivation adopted. Those varieties of the plant with heart-shaped leaves have paniculated flowers with unequal cups.
The flower stems on the American varieties are much longer than those of European tobaccos and also larger. The season has much to do with the size of the flowers; as if very dry they are usually smaller and not as numerous as if grown under more favorable circumstances. As soon as the flowers drop from the fruit bud the capsules grow very rapidly until they have attained full size—which occurs only in those plants which have been left for seed and remain untopped.
When topped they are not usually full grown—as some growers top the plants when just coming into blossom, while others prefer to top the plants when in full bloom and others still when the blossoms begin to fall. The fruit is described by Wheeler.
There is a line on each side of it, and it contains two cells, and opens at the top. The receptacles one of a half-oval figure, punctuated and affixed to the separating body.
The seeds are numerous, kidney-shaped, and rugose. Most growers of the plant would describe the fruit bud as follows: In form resembling an acorn though more pointed at the top; in some species, of a dark brown in others of a light brown color, containing two cells filled with seeds similar in shape to the fruit bud, but not rugose as described by some botanists.
Some writers state that each cell contains about one thousand seeds. The fruit buds of Connecticut, Virginia, Kentucky and Ohio Tobacco as well as of most of the varieties grown within the limits of the United States are much larger than those of Havana, Yara, Syrian, and numerous other species of the plant, while the color of these last named varieties is a lighter shade of brown.
The color p. The seeds of some species are of a dark brown while others are of a lighter shade. The seeds, however, are so small that the variety to which they belong cannot be determined except by planting or sowing them.
The plants selected for seed are usually left growing until late in the season, and at night should be protected from the cold and frost by a light covering of some kind—this may not be absolutely necessary, as most growers of tobacco have often noticed young plants growing around the base or roots of the seed stalk—the seeds of which germinated although remaining in the ground during the winter.
Strong, healthy plants generally produce large, well filled capsules the only ones to be selected by the grower if large, fine plants are desired. Many growers of tobacco have doubtless examined the capsules of some species of the plant and frequently observed that the capsules or fruit buds are often scarcely more than half-filled while others contain but a few seeds.
The largest and finest capsules on the plant mature first, while the smaller ones grow much slower and are frequently several weeks changing from green to brown. Many of the capsules do not contain any seed at all. The offshoots or suckers as they are termed, make their appearance at the junction of the leaves and stalk, about the roots of the plant, the result of that vigorous growth caused by topping. The suckers can hardly be seen until after the p. Tatham describing the sucker says:.
The planter is therefore careful to destroy these intruders with the thumb nail, as in the act of topping. This superfluity of vegetation, like that of the top, has been often the subject of legislative care; and the policy of supporting the good name of the Virginia produce has dictated the wisdom of penal laws to maintain her good faith against imposition upon strangers who trade with her.
The ripening of the suckers not only proves injurious to the quality of the leaf but retards their size and maturity and if allowed to continue, prevents them from attaining their largest possible growth.
On large, strong, growing plants the growth of suckers is very rank after attaining a length of from six to ten inches, and when fully grown bearing flowers like the parent stalk. After growing for a length of time they become tough and attached so firmly to the stem of the leaf and stalk that they p.
The growth of the suckers, however, determines the quality as well as the maturity of the plants. Weak, spindling plants rarely produce large, vigorous shoots, the leaves of such suckers are generally small and of a yellowish color.
When the plants are fully ripe and ready to harvest the suckers will be found to be growing vigorously around the root of the plant.
This is doubtless the best evidence of its maturity, more reliable by far than any other as it denotes the ripening of the entire plant. Suckering the plants hastens the ripening of the leaves, and gives a lighter shade of color, no matter on what soil the plants are grown. Having treated at some length of the various parts of the tobacco plant—stalk, leaves, flowers, capsules and suckers we come now to its nicotine properties. The tobacco plant, as is well known, produces a virulent poison known as Nicotine.
This property, however, as well as others as violent is found in many articles of food, including the potato together with its stalk and leaves; the effects of which may be experienced by chewing a small quantity of the latter. The New Edinburgh Encyclopedia says:. Chemistry has taught us that nicotine is only one among many principles which are contained in the plant. It is supposed by many but not substantiated by chemical research that nicotine is not the flavoring agent which gives tobacco its essential and peculiar varieties of odor.
Such are most probably given by the essential oils, which vary in amount in different species of the plant. The late Dr. Blotin tested by numerous experiments the effects of nicotine on the various parts of the organization of p. While the physiological effects of nicotine may be interesting to the medical practitioner, they will hardly interest the general reader unless it can be shown that the effects of nicotine and tobacco should be proved to be identical.
We are loth to leave this subject, however, as it is so intimately connected with the history of the plant, without treating somewhat of its medicinal properties which to many are of more interest than its social qualities. The Indians not only used the plant socially, religiously, but medicinally. Their Medicine men prescribed its use in various ways for most diseases common among them.
The use thus made of the plant attracted the attention of the Spanish and English, far more than its use either as a means of enjoyment or as a religious act. When introduced to the Old World, its claims as a remedy for most diseases gave it its popularity and served to increase its use.
Edmund Gardiner, “Practitioner of Physicke,” issued in a volume entitled, “The Triall of Tobacco,” setting forth its curative powers. Speaking of its use he says:. Thus then you plainly see that all medicines, and especially tobacco, being rightly and rationally used, is a noble medicine and contrariwise not in his due time with other circumstances considered, it doth no more than a nobleman’s shooe doth in healing the gout in the foot.
Verner of Bath, in his Treatise concerning the taking the fume of tobacco says that when “taken moderately and at fixed times with its proper adjunct, which as they doe p. William Barclay in his work on Tobacco, declares “that it worketh wonderous cures. When first exported to Spain and Portugal from the West Indies and South America, and even by the English from Virginia, the leaf was dark in color and strong and rank in flavor.
This, however, seems to have been the standard in regard to some varieties while others are spoken of by some of the early writers upon tobacco as “sweet. The tobacco uppowoc grown by the Indians in America, at the time of its discovery, and more particularly in North America, would compare better with the suckers of the largest varieties of the plant rather than with even the smallest species of the plant now cultivated. At the present time tobacco culture is considered a science in order to secure the colors in demand, and that are fashionable, and also the right texture of leaf now so desirable in all tobaccos designed for wrappers.
Could the Indians, who cultivated the plant on the banks of the James, the Amazon and other rivers of America, now look upon the plant growing in rare luxuriance upon the same fields where they first raised it, they could hardly realize them to be the same varieties that they had previously planted. Nearly four hundred years have passed away since the tobacco plant and its use was introduced to the civilized world.
It was in the month of November, , that the sailors of Columbus in exploring the island of Cuba first noted the mode of using tobacco. They found the Indians carrying lighted firebrands as they at first supposed and puffed the smoke inhaled from their mouths and nostrils.
The Spaniards concluded that this was a method common with them of perfuming themselves; but its frequent use soon taught them that it was the dried leaves of a plant which they burned inhaling and exhaling the smoke. It attracted the attention of the Spaniards no less from its novelty than from the effect produced by the indulgence.
The use of tobacco by the Indians was entirely new to the Spanish discoverers and when in they landed in various parts of South America they found that both chewing and smoking the herb was a common custom with the natives. But while the Indians and their habits attracted the attention of the Spanish sailors Columbus was more deeply interested in the great continent and the luxuriant tropical growth to be seen on every hand.
Columbus himself says of it:—. The beauty of the streams, the clearness of the water, through which I could see the sandy bottom; the multitude of palm-trees of different kinds, the tallest and finest I had ever seen; and an infinite number of other large and flourishing trees; the p. He made himself acquainted with the uses and supposed virtues of the plant and the manner of cultivating it, and sent plants to Spain, as part of the spoils and treasures of his new-found World.
Oviedo [4] is the first author who gives a clear account of smoking among the Indians of Hispaniola [5]. He alludes to it as one of their evil customs and used by them to produce insensibility.
Their mode of using it was by inhalation and expelling the smoke through the nostrils by means of a hollow forked cane or hollow reed. Oviedo describes them as. He gave it the name of Cohoba Cohobba, Gioia. In , the negroes had already habituated themselves to the use of tobacco, and cultivated it in the plantations of their masters.
Europeans likewise already smoked it. Others derive it from Tabasco, a province of Mexico; others from the island of Tobago one of the Caribbees; and others from Tobasco in the gulf of Florida. The more probable derivation of the word is from a place called Tobaco in Yucatan from which the herb was first sent to the New World. It did not properly denote the herb, but the tube through which the smoke was inhaled. It seems surprising that a vegetable production so universally spread should have different names among neighboring people.
The pete-ma of the Omaguas is, no doubt, the pety of the Guaranos; but the analogy between the Cabre and Algonkin or Lenni-Lennope words which denote tobacco may be merely accidental. The following are the synonymes in five languages: Aztec or Mexican, yetl ; Huron, oyngona ; Peruvian, sayri ; Brazil, piecelt ; Moxo, sabare.
Roman Pane who accompanied Columbus on his second voyage alludes to another method of using the herb. They p. This is doubtless the first account that we have of snuff-taking; Fairholt says concerning its use:—. This may be accounted for from the fact of the imperfect method of curing tobacco adopted by them and all of the natives up to the period of the settlement of Virginia by the English.
As nearly all of the early voyagers allude to the plant and especially to its use it would seem probable that it had been cultivated from time immemorial by all the native people of the Orinoco; and at the period of the conquest the habit of smoking was found to be alike spread over both North and South America. The Tamanacs and the Maypures of Guiana wrap maize leaves round their cigars as the Mexicans did at the time of the arrival of Cortez.
The Spaniards since have substituted paper for the leaves of maize, in imitation of them. Tobacco at this period was also rolled up in the leaves of the Palm and smoked. Columbus found the natives of San Salvador smoking after this manner. Lobel in his History of Plants [6] gives an engraving p. But not only was snuff taking and the use of tobacco rolls or cigars noted by European voyagers, but the use of the pipe also in some parts of America, seemed to be a common custom especially among the chiefs.
Be Bry in his History of Brazil describes its use and also some interesting particulars concerning the plant. Their method of curing the leaves was to air-dry them and then packing them until wanted for use. In smoking he says:—.
This statement is not entirely correct—the mode of using tobacco in Norway by plugging the nostrils with small pieces of tobacco seems to have been unknown among the Indians of America as it is now with all other nationalities, excepting the Norwegians.
When Cortez made conquest of Mexico in smoking seemed to be a common as well as an ancient custom among the natives. Benzoni in his History of the New World [7] describing his travels in America gives a detailed account of the plant and their method of curing and using it. In both North and South America the use of tobacco seemed to be universal among all the tribes and beyond all question the custom of using the herb had its origin among them. The traditions of the Indians all confirm its ancient source; they considered the plant as a gift from the Great Spirit for their p.
The use of tobacco in sufficient quantities to produce intoxication seemed to be a favorite remedy for most diseases among them and was administered by their doctors or medicine-men in large quantities. Benzoni gives an engraving of their mode of inhaling the smoke and says of its use:—. On returning to his senses he told a thousand stories of his having been at the council of the gods, and other high visions.
It can hardly be supposed that while the custom of using tobacco among the Indians in both North and South America was very general and the mode of use the same, that the plant grown was of the same quality in one part as in another. While the rude culture of the natives would hardly tend to an improvement in quality; the climate being varied would no doubt have much to do with the size and quality of the plant.
This would seem the more probable for as soon as its cultivation began in Virginia by the English colonists it had successful rivals in the tobacco of the West Indies and South America. Robertson says:—. But not only has the name tobacco and the implements employed in its use caused much discussion but also the origin of the plant.
Some writers affirm that it came from Asia and that it was first grown in China having been used by the Chinese long before the narcotic properties of opium were known. Tatham in his work on Tobacco says of its origin in substantial agreement with La Bott:—.
I have been thirty years ago, and the greatest part of my time during that period, intimately acquainted with the interior parts of America; and have been much in the unsettled parts of the country, among those kinds of soil which are favorable to the cultivation of tobacco; but I do not recollect one single instance where I have met with tobacco growing wild in the woods, although I have often found a few spontaneous plants about the arable and trodden grounds of deserted habitations.
This circumstance, as well as that of its being now, and having been, cultivated by the natives at the period of European discoveries, inclines towards a supposition that this plant is not a native of North America, but may possibly have found its way thither with the earliest migrations from some distant land. This might, indeed, have easily been the case from South America, by way of the Isthmus of Panama; and the foundation of the Choctaw and Chickasaw nations who we have reasons to consider as descendants from the Tloseolians, and to have migrated to the eastward of the river Mississippi, about the time of the Spanish conquest of Mexico by Cortez , seems to have afforded one fair opportunity for its dissemination.
The first knowledge which the English discoverers had of the plant was in when they found it growing in Florida, one hundred and seventy-three years after it was first discovered by Columbus on the island of Cuba. Sir John Hawkins says of its use in Florida:—. This preparation might not have been tobacco as the Indians smoke a kind of bark which they scrape from the killiconick, an aromatic shrub, in form resembling the willow; p. Lionel Wafer in his travels upon the Isthmus of Darien in saw the plant growing and cultivated by the natives.
He says:—. It grows as the tobacco in Virginia, but is not so strong, perhaps for want of transplanting and manuring, which the Indians do not well understand, for they only raise it from the seed in their plantations.
When it is dried and cured they strip it from the stalks, and laying two or three leaves upon one another, they roll up all together sideways into a long roll, yet leaving a little hollow. Round this they roll other leaves one after another, in the same manner, but close and hard, till the roll be as big as one’s wrist, and two or three feet in length. Their way of smoking when they are in company is thus: a boy lights one end of a roll and burns it to a coal, wetting the part next it to keep it from wasting too fast.
The end so lighted he puts into his mouth, and blows the smoke through the whole length of the roll into the face of every one of the company or council, though there be two or three hundred of them.
Then they, sitting in their usual posture upon forms, make with their hands held together a kind of funnel round their mouths and noses. Into this they receive the smoke as it is blown upon them, snuffing it up greedily and strongly as long as ever they are able to hold their breath, and seeming to bless themselves, as it were, with the refreshment it gives them.
In the year James Cartier a Frenchman was commissioned to explore the coast of North America, with a view to find a place for a colony. He observed that the natives of Canada used the leaves of an herb which they preserved in pouches made of skins and smoked in stone pipes. It being offensive to the French, they took none of it with them on their return.
But writing more particularly concerning the plant he says:—. They say that this doth keepe them warme and in health, they never goe without some of this about them. Be Bry in his History of Brazil gives an engraving of a native smoking a pipe and a female offering him a handful of tobacco leaves. The pipe has a modern look and is altogether unlike those found by the English in use among the Indians in Virginia.
Father Francisco Creuxio states that the Jesuit missionaries found the weed extensively used by the Indians of the Seventeenth Century. In he found the Hurons smoking the dried leaves and stalks of the Tobacco plant or petune. Many tribes of Indians consider that Tobacco is a gift bestowed by the Great Spirit as a means of enjoyment. In consequence of this belief the pipe became sacred, and smoking became a moral if not a religious act, amongst the North American Indians.
The Iroquois are of opinion that by burning Tobacco they could send up their prayers to the Great Spirit with the ascending incense, thus maintaining p. Daniel Wilson suggests that. When an Indian goes on an expedition, whether of peace or war, his pipe is his constant companion; it is to him what salt is among Arabs: the pledge of fidelity and the seal of treaties.
In the words of a Review :. While the presence, and use of tobacco by the natives of America are among the most interesting features connected with its history, it can hardly be more so than is its early cultivation by the Spaniards, English and Dutch, and afterward by the French.
In Cuba its culture commenced in , and from this and the other islands large quantities were shipped to Europe. It was also cultivated near Varina in Columbia, while Amazonian tobacco had acquired an enviable reputation as well as Varinian, long before its cultivation began in Virginia by the English.
At this period of its culture in America the entire product was sent to Spain and Portugal, and from thence to France and Great Britain and other countries of Europe. The plant and its use attracted at once the attention as well as aroused the cupidity of the Spaniards, who prized it as one of their greatest discoveries. As soon as Tobacco was introduced into Europe by the Spaniards, and its use became a general custom, its sale increased as extensively as its cultivation.
At this period it brought enormous prices, the finest selling at from fifteen to eighteen shillings per pound. Its cultivation by the Spaniards in various portions of the New World proved to them not only its real value as an article of commerce, but also that several varieties of the plant existed; as on removal from one island or province to another it changed in size and quality of leaf. Varinas tobacco at this time was p.
The early voyagers little dreamed, however, of the vast proportions to be assumed by the trade in the plant which they had discovered, and which in time proved a source of the greatest profit not only to the European colonies, but to the dealers in the Old World. The importance, financially and commercially speaking, of this discovery of tobacco—a discovery which in the end proved more productive to the Spanish crown than that of the gold mines of the Indies.
Spain and Portugal in all their colonies fostered and encouraged its cultivation and then at once ranked as the best producers and dealers in tobacco. The varieties grown by them in the West Indies and South America were highly esteemed and commanded much higher prices than that grown by the English and Dutch colonies. In , however, the Dutch merchants were the largest wholesale tobacconists in Europe, and the people of Holland, generally, the greatest consumers of the weed.
The expedition of , under the auspices of Sir Walter Raleigh, which resulted in the discovery of Virginia, also introduced the tobacco plant, among other novelties, to the attention of the English. Hariot, [11] who sailed with this expedition, says of the plant:. In the West Indies it hath divers names, according to the severall places and countries where it groweth and is used; the Spaniards generally call it Tobacco. The leaves thereof being dried and brought into powder, they use to take the fume or smoke thereof by sucking it through pipes made of clay into their stomacke and heade, from whence it purgeth superfluous fleame and other grosse humors; openeth all the pores and passages of the body; by which means the use thereof not only preserveth the body from obstructions, but also if any be so that they have not beene of too long continuance, in short time breaketh them; whereby their bodies are notably preserved in health, and know not many grievous diseases wherewithall we in England are oftentimes affected.
This uppowoc is of so precious estimation amongest them that they thinke their gods are marvellously delighted therewith; whereupon sometime they make halowed fires, and cast some of the powder therein for a sacrifise. Being in a storme uppon the waters, to pacifie their gods, they cast some up into the aire and into the water: so a weave for fish being newly set up, they cast some therein and into the aire; also after an escape of danger they cast some into the aire likewise; but all done with strange gestures, stamping, sometimes dancing, clapping of hands, holding up of hands, and staring up into the heavens, uttering there withal and chattering strange wordes, and noises.
The natives also when Drake [12] landed in Virginia, “brought a little basket made of rushes, and filled with an herbe which they called Tobah;” they “came also the second time to us bringing with them as before had been done, feathers and bags of Tobah for presents, or rather indeed for sacrifices, upon this persuasion that we were gods. William Strachey [13] says of tobacco and its cultivation by the Indians:.
It would seem then, if the account given by Strachey be correct, that the tobacco cultivated by the Indians of North America was of inferior growth and quality to that grown in many portions of South America, and more particularly in the West India islands.
As there are still many varieties of the plant grown in America, so there doubtless was when cultivated by the Indians.
While most probably the quality of leaf remained the same from generation to generation, still in some portions of America, owing more to the soil and climate than the mode of cultivating by them, they cured very good tobacco.
We can readily see how this might have been, from numerous experiments made with both American and European varieties. Nearly all of the early Spanish, French and English voyagers who landed in America were attracted by the beauty of the country.
Ponce De Leon, who sailed from Spain to the Floridas, was charmed by the plants and flowers, and doubtless the first sight of them strengthened his belief in the existence somewhere in this tropical region of the fountain of youth. The discovery of tobacco proved of the greatest advantage p. As Spain, however, has fallen from the high place she once held, her colonial system has also gone down.
And while England, thanks to her more liberal policy, still retains a large share of the territory which she possessed at first, Spain, which once held sway over a vast portion of America, has been deprived of nearly all of her colonies, and ere long may lose control of the island on which the discoverer of America first saw the plant. It is an historical fact that wherever in the English and Spanish colonies civilization has taken the deepest root, so has also the plant which has become as famous as any of the great tropical products of the earth.
The relation existing between the balmy plant and the commerce of the world is of the strongest kind. Fairholt has well said, that “the revenue brought to our present Sovereign Lady from this source alone is greater than that Queen Elizabeth received from the entire customs of the country. The narrow view of commercial policy held by her successors, the Stuarts, induced them to hamper the colonists of America with restrictions; because they were alarmed lest the ground should be entirely devoted to tobacco.
Had not this Indian plant been discovered, the whole history of some portions of America would have been far different. In the West Indies three great products—Coffee, Sugar-Cane, and Tobacco,—have proved sources of the greatest wealth—and wherever introduced, have developed to a great extent the resources of the islands. Thus it may be seen that while the Spaniards by the discovery and colonization p. An English writer has truthfully observed that “Tobacco is like Elias’ cloud, which was no bigger than a man’s hand, that hath suddenly covered the face of the earth; the low countries, Germany, Poland, Arabia, Persia, Turkey, almost all countries, drive a trade of it; and there is no commodity that hath advanced so many from small fortunes to gain great estates in the world.
Sailors will be supplied with it for their long voyages. Soldiers cannot but want it when they keep guard all night, or upon other hard duties in cold and tempestuous weather. Farmers, ploughmen, and almost all labouring men, plead for it. If we reflect upon our forefathers, and that within the time of less than one hundred years, before the use of tobacco came to be known amongst us, we cannot but wonder how they did to subsist without it; for were the planting or traffick of tobacco now hindered, millions of this nation in all probability must perish for the want of food, their whole livelihood almost depending upon it.
When first discovered in America, and particularly by the English in Virginia, the plant was cultivated only by the females of the tribes, the chiefs and warriors engaging only in the chase or following the warpath. They cultivated a few plants around their wigwams, and cured a few pounds for their own use. The smoke, as it ascended from their pipes and circled around their rude huts and out into the air, seemed typical of the race—the original cultivators and smokers of the plant.
But, unlike the great herb which they cherished and gave to civilization, they have gradually grown weak in numbers and faded away, while the great plant has gone on its way, ever assuming more and more sway over the commercial and social world, until it now takes high rank among the leading elements of mercantile and agricultural greatness. We do not find in any accounts of the English voyagers made previous to , any mention of the discovery of tobacco, or its use among the Indians. This may appear a little strange, as Captains Amidas and Barlow, who sailed from England under the auspices of Sir Walter Raleigh in , on returning from Virginia, had brought home with them pearls and tobacco among other curiosities.
But while we have no account of those who returned from the voyage made in taking any tobacco with them, it is altogether probable that those who remained took a lively interest in the plant and the Indian mode of use; for we find that in nine years after they landed at Jamestown tobacco had become quite an article of culture and commerce.
Hamo in alluding to the early cultivation of tobacco by the colony, says, that John Rolfe was the pioneer tobacco planter. In his words:. John Rolfe, Anno Domini , partly for the love he hath a long time borne unto it, and partly to raise commodities to the adventurers, in whose behalfe I intercede and vouchsafe to hold my testimony in beleefe that during the time of his aboade there, which draweth neere sixe years p. This was in , when the colony numbered only three hundred and fifty-one persons.
Rolfe, in his relation of the state of Virginia, written and addressed to the King, gives the following description of the condition of the colony in The generall mayne body of the planters are divided into Officers, Laborers, Farmors.
These officers are bound to maintayne themselves and families with food and rayment by their owne and their servant’s industrie. The laborers are of two sorts. They are bound by covenant, both for themselves and servants, to maintaine your Ma’ties right and title in that kingdom, against all foreigne and domestique enemies.
To watch and ward in the townes where they are resident. To do thirty-one dayes service for the colony, when they shalbe called thereunto—yet not at all tymes, but when their owne busines can best spare them. To maintayne themselves and families with food and rayment—and every farmor to pay yearlie into the magazine for himself and every man servant, two barrells and a halfe of English measure.
For an easie laborer will keepe and tend two acres of corne, and cure a good store of tobacco—being yet the principall commoditie the colony for the present yieldeth. This magazine shalbe yearelie supplied to furnish them, if they will endeavor, by their labor, to maintayne it—which wilbe much beneficiall to the planters and adventurers, by interchanging their commodities, and will add much encouragement to them and others to preserve and follow the action with a constant resolution to uphold the same.
The colony at this time was engaged in planting corn and tobacco, “making pitch and tarr, potashes, charcole, salt,” and in fishing. Of Jamestown he says:. Lawarre,—whereof thirty-one are farmors; all theis maintayne themselves with food and rayment.
Richard Buck minister there—a verie good preacher. What wood they have occasion for they carry off, and burn the rest, or let it lie and rot upon the ground. The land between the logs and stumps they hoe up, planting tobacco there in the spring, inclosing it with a slight fence of cleft rails. Accommodations are provided, and Persons admitted in their masquing Habits. Any Person may agree by the Great, and be kept in Repair by the Year.
The Doctor draws Teeth without pulling off your Mask. James’s Coffee-house, either by miscalling the Servants, or requiring such things from them as are not properly within their respective Provinces; this is to give Notice, that Kidney, Keeper of the Book-Debts of the outlying Customers, and Observer of those who go off without paying, having resigned that Employment, is succeeded by John Sowton; to whose Place of Enterer of Messages and first Coffee-Grinder, William Bird is promoted; and Samuel Burdock comes as Shooe-Cleaner in the Room of the said Bird.
They are not only instructed to pronounce Words distinctly, and in a proper Tone and Accent, but to speak the Language with great Purity and Volubility of Tongue, together with all the fashionable Phrases and Compliments now in use either at Tea-Tables or visiting Days.
Those that have good Voices may be taught to sing the newest Opera-Airs, and, if requir’d, to speak either Italian or French, paying something extraordinary above the common Rates. They whose Friends are not able to pay the full Prices may be taken as Half-boarders. She teaches such as are design’d for the Diversion of the Publick, and to act in enchanted Woods on the Theatres, by the Great.
As she has often observ’d with much Concern how indecent an Education is usually given these innocent Creatures, which in some Measure is owing to their being plac’d in Rooms next the Street, where, to the great Offence of chaste and tender Ears, they learn Ribaldry, obscene Songs, and immodest Expressions from Passengers and idle People, and also to cry Fish and Card-matches, with other useless Parts of Learning to Birds who have rich Friends, she has fitted up proper and neat Apartments for them in the back Part of her said House; where she suffers none to approach them but her self, and a Servant Maid who is deaf and dumb, and whom she provided on purpose to prepare their Food and cleanse their Cages; having found by long Experience how hard a thing it is for those to keep Silence who have the Use of Speech, and the Dangers her Scholars are expos’d to by the strong Impressions that are made by harsh Sounds and vulgar Dialects.
In short, if they are Birds of any Parts or Capacity, she will undertake to render them so accomplish’d in the Compass of a Twelve-month, that they shall be fit Conversation for such Ladies as love to chuse their Friends and Companions out of this Species.
Powell, as sometimes raising himself Applause from the ill Taste of an Audience; I must do him the Justice to own, that he is excellently formed for a Tragoedian, and, when he pleases, deserves the Admiration of the best Judges; as I doubt not but he will in the Conquest of Mexico, which is acted for his own Benefit To-morrow Night.
She is also well-skilled in the Drapery-part, and puts on Hoods and mixes Ribbons so as to suit the Colours of the Face with great Art and Success. This Day is publish’d An Essay on Criticism. A magnetic resonance imaging MRI angiographic study demonstrated that PACAPinduced headache was associated with prolonged dilatation of the middle meningeal arteries, but not of the middle cerebral arteries in healthy volunteers [4].
The recent functional imaging study pointed that intravenous PACAPinduced migraine attacks was associated with alterations in brain network connectivity [6]. Clinical investigation provided evidence of a clear association between migraine phases during a spontaneous migraine attack versus pain-free period and the alteration of plasma PACAP level [7].
The activation and sensitization of the trigeminovascular system by vasoactive neuropeptides might be crucial factors of the migraine pathogenesis [8]. The recent preclinical and clinical studies suggest the importance of PACAP as a future biomarker of migraine headache. Schytz, H. PACAP38 induces migraine-like attacks in patients with migraine without aura. Tuka, B. Peripheral and central alterations of pituitary adenylate cyclase activating polypeptide-like immunoreactivity in the rat in response to activation of the trigeminovascular system.
Peptides ; Amin, F. Cephalalgia ; Investigation of the pathophysiological mechanisms of migraine attacks induced by pituitary adenylate cyclase-activating polypeptide Brain ; Neurology ; Alterations in PACAPlike immunoreactivity in the plasma during ictal and interictal periods of migraine patients.
Several studies are found a relationship between headache and psychiatric comorbidity in both children and adolescents []. The most frequently described comorbidities include anxiety, mood disorders [1], sleep disorder [2] and attention hyperactive disorder [3]. The association between headache and comorbidities has been interpreted in the light of different possible causal pathways.
Psychiatric comorbidity may represent the consequence of a link between neurotransmitter systems involved in migraine and psychiatric disorder, such as depression and anxiety [4].
A central role is thought to be played by serotonergic receptors, adrenergic and dopaminergic D2 receptor genotype, that seem to be associated with migraine, major depression, generalized anxiety disorder, panic attacks and phobia [5]. It has been suggested that the patient’s vulnerability to anxiety disorders and affective disorders as well as migraine might be attributed to the dysregulation of the serotonergic system [6].
Furthermore, it is possible that each disorder increases the risk of the other [4;7]. Therefore, the relevance of other mediating factors for the co-occurrence of headache and psychiatric comorbidity has to be taken into consideration. Recent research found that an insecure attachment may be a risk factor for an outcome of poor adaptation that includes chronic pain [9] and that pain perception may change in relation with specific attachment styles.
The ambivalent attachment seems to be the most common style among patients reporting high attack frequency and severe pain intensity and in children with this attachment style there is a relationship between high attack frequency and high anxiety levels [10]. Barone et al. Although more studies are needed in order to detect the biological, genetic and environmental mechanisms underlying the relationship between headache and comorbidities, attachment styles can be regarded as one of the factors mediating this association [12].
Anxiety, depression and behavioral problems among adolescents with recurrent headache: the Young-HUNT study. The relationship between sleep and headache in children: implications for treatment. Headache and attention deficit and hyperactivity disorder in children: common condition with complex relation and disabling consequences. Epilepsy Behav. Migraine and psychiatric comorbidity: a review of clinical findings. Mol Med. Association of 5-HTT gene polymorphisms with migraine: a systematic review and meta-analysis.
J Neurol Sci ; : Headache and comorbidity in children and adolescents. J Headache Pain ; Genetic and environmental influences on migraine: a twin study across six countries.
Twin Res. Pain and emotion: a biopsychological review of recent research. J Clin Psychol ; 67 9 : Attachment styles in children affected by migraine without aura. Neuropsychiatr Dis Treat. Behavioural problems in children with headache and maternal stress: is children’s attachment security a protective factor?
Dev ; DOI: The role of attachment insecurity in the emergence of anxiety symptoms in children and adolescents with migraine: an empirical study. J Headache Pain In Press. Metabolic syndrome and overweight are highly prevalent among migraineurs and the weight-loss was suggested as a useful strategy to improve both migraine and metabolic syndrome. Recently, we have observed that a particular version of VLCD characterized by very low-carbohydrate intake and Ketone bodies KBs production, named very low-calorie ketogenic diet VLCKD , was able to induce a rapid improvement of headache in migraineurs.
To assess if the favorable outcome on migraine was due to the caloric restriction, instead of KBs, we performed a double blind crossover study to compare headache modifications during a VLCD and a VLCKD in a population of overweighed and obese migraineurs.
Among patients referred to the Sapienza University Obesity Clinic, a neurologist specializing in headache recruited 35 migraineurs. To verify variations in headache frequency, we used as baseline the month before the first VLCD and the first transition diet.
Headaches are one of the most disabling disorders [1]. Moreover, recent knowledge have suggested that physical examination for provocative procedures should be done on each patient with side- locked headaches as many of these headaches may closely mimic primary headaches [4]. There have been identified eleven physical tests to properly assess cervical disorders.
When these dysfunctions are present, they support a reciprocal interaction between the trigeminal and the cervical systems as a trait symptom in migraine [6, 7]. In this presentation, an evidence based physical protocol of specific tests it will be provided by a physiotherapist to assess musculoskeletal disorders in the most common primary headaches as Migraine and Tension Type Headache.
Moreover, the integration of this examination in a multidisciplinary team it will be discussed. Stovner LJ.
Migraine prophylaxis with drugs influencing the renin- angiotensin system. Eur J Neurol. Prevalence of neck pain in migraine and tension-type headache: a population study. Temporomandibular disorders is more prevalent among patients with primary headaches in a tertiary outpatient clinic. Arq Neuropsiquiatr. Prakash S, Rathore C. Side-locked headache: an algorithm based approach.
The Journal of Headache and Pain ; doi International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Man Ther. Musculoskeletal dysfunction in migraine patients. The International Classification of Headache Disorders, 3rd edition beta version Jul;33 9 Headache represents the most common neurological symptom in pediatric age. Among the primary headaches, migraine is far more prevalent than tension-type headache and cluster headache.
Though extremely rare at this age, also trigeminal autonomic cephalgias have been reported. The most frequent causes of pediatric secondary headaches are represented by respiratory tract infections, while potentially life-threatening diseases, such as brain tumors, are less common.
However, especially in the emergency setting, the possibility that a headache attack is due to a brain tumor must be always considered. To avoid missing these cases, some headache characteristics red flags have been identified [1].
However, while the most recent ICHD criteria improved the possibility to classify some patients, such as children with migraine with aura [2], they turned out to be unsuitable for others, such as young patients with primary headache. Several studies have shown the primary role played by psychological factors in determining the severity of migraine in children [4]. Therefore, a psychological examination is often mandatory, as part of the initial assessment of the patient.
Lastly, when assessing a child with primary headache, possible comorbidities should be never forgotten, since addressing them can represent a crucial point for the treatment [5]. Headache as an emergency in children and adolescents. Curr Pain Headache Rep ; Cephalalgia, submitted.
Diagnosis of primary headache in children younger than 6 years: A clinical challenge. Cephalalgia ; Chronic Migraine in Children and Adolescents. Headache and comorbidities in childhood and adolescence. Springer, Whether medication-overuse headache MOH represents a distinct biological entity within the concept of chronic daily headache with specific neurobiological and genetic background is still a matter of debate.
A great deal of interest has been directed at understanding the neurophysiological mechanisms that underlie MOH pathogenesis. Currently, two main, non-mutually exclusive hypotheses have been proposed.
The first, stems from the apparent compulsive use of headache medications by MOH patients, and considers this disorder a sort of addiction to symptomatic remedies. The second shifts the focus from drug addiction to neural sensitization, claiming that triptan overuse triggers adaptations of the trigeminovascular system, thereby facilitating pain transmission and leading to a state of latent sensitization.
Answering these questions might be relevant to better understand the neurochemical mechanisms prompted by acute headache medications that underlie the pathophysiology of MOH and of chronic headache in general.
In this presentation, preclinical data will be presented showing that chronic exposure to eletriptan or indomethacin alter trigeminal ganglion gene expression patterns broadly and to a similar extend. Remarkably, qualitative transcriptomic analysis reveals that prolonged exposure to the two different symptomatic drugs triggers almost identical, increased expression of various genes coding for proteins involved in headache pathogenesis such as neuropeptides, their cognate receptors, TRP channels, prostanoid and NO synthesizing enzymes.
These findings will be correlated with the clinical aspects of MOH. The dramatic caloric restriction promotes the fat metabolism, mimicking the starvation, even if meals replacements ad hoc developed accounts for essential nutrients, avoiding the malnutrition. Because of the extreme caloric restriction, this type of diet is very effective in weight loss, however, that characteristic also is the main limit of VLCD, since it is possible to follow this kind of dietetic regimen for a very limited period usually weeks.
Salads are allowed ad libitum dressed with a spoonful of olive oil. Also in this kind of diet, there are meals per day, mainly consisting in meal replacement products. There is a growing interest in the ketogenic form of the VLCD because several studies have shown a higher compliance of patients with this diet. The reason of this higher adherence to the diet is still under scrutiny but several reasons are called in cause: an appetite suppression induced by proteins and maybe by ketone bodies KBs , or a modification in hormone secretion insulin, glucagon, ghrelin, adipokines.
The real impact of ketogenic diets in weight loss is still disputed; in fact, on the long period there are not differences between low-carb and low-fat diets in terms of weight reduction and regain of lost weight after the diet.
However, thanks to the higher compliance and the drastic caloric restriction, the VLCKDs seem to be a promising approach in the early management of obesity and in the preparation phase for patients that must undergo to bariatric or other types of surgical procedures.
Temporomandibular disorders TMD represent the main cause of orofacial pain of non-dental origin and comprehend several disturbances of the masticatory system characterized by myofascial pain of masticatory muscles or articular pain localized in the pre-auricular area.
Moreover, TMD patients show temporomandibular joint sounds and deviation or limitation of the opening of the mouth. Myofascial pain is a probable consequence of central nervous system mechanisms of convergence and activation of second order neurons with enlargement of the receptive field, reduced pain threshold and allodinia.
Often there are accompanying symptoms like facial pain and headaches. Headache is the most prevalent neurologic disorder, third most diffused health disturbance and the seventh cause of disability in the world.
It can be primary, without apparent organic cause, or secondary to other pathologies. Some epidemiological studies indicates that headache is more prevalent in TMD patients and TMD is more prevalent in subjects affected by headache. A stronger association exists between TMD and chronic migraine in comparison with other types of headache. Nevertheless the methodological quality of the available studies is not optimal and many of them classify patients with anamnestic questionnaire that tend to overestimate the values of prevalence.
A growing body of literature suggests that the association between headache and TMD may be a manifestation of a central sensitization mechanism. Temporomandibular joint and muscles receive the sensitive innervation of the trigeminal nerve that supply also the cranial vascular structures likely involved in the etiology of the headache.
The sensitization of the trigeminal caudate nucleus by the TMD symptoms can favor the triggering of migraine episode. Beside the epidemiological studies and the neurophysiologic hypothesis, there are some initial clinical evidence that show how severity of TMD symptoms parallels an increase of frequency and intensity of migraine and the simultaneous treatment of both conditions results in better outcomes. From a clinical perspective, a comprehensive assessment based on a biopsychosocial approach can provide relevant information to plan a contemporaneous treatment of TMD and headache, together with an intervention targeted to the reduction of psychosocial conditions that can elicit and maintain mechanisms of central sensitization likely responsible of the comorbidity of TMD and headache.
The exact pathophysiology is still unknown, but evidence supporting both peripheral and central mechanisms i. In fact, the frequency of headache attacks has found to be related to the level of central sensitization [4]. However, not all TTH patients present with the same level of central sensitization and clinical presentation, but subgroups need to be identified in order to offer specific therapeutic programs [5].
Prolonged peripheral nociceptive input from the pericranial, neck, and shoulder regions e. In fact, it has been found that sustained stimulation of TrPs may induce central sensitization in healthy participants [7]. The number of TrPs seems to be associated with the degree of widespread pressure pain hypersensitivity in TTH patients, supporting the role of TrPs on central sensitization: however the cross-sectional nature of the study does not allow to establish a cause and effect relationship between TrPs and central sensitization, as other variables may influence this association [9].
Physical therapy may be helpful for the management of TTH patients [10,11], as it may decrese the peripheral nociceptive input. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia ;— Tension type headache. Curr Rheumatol Rev ; — Pressure pain thresholds assessed over temporalis, masseter, and frontalis muscles in healthy individuals, patients with tension- type headache, and those with migraine: A systematic review.
Pain ; — Frequency of headache is related to sensitization: a population study. Pain ; Identification of subgroups of patients with tension type headache with higher widespread pressure pain hyperalgesia.
J Headache Pain ; 18 1 The role of muscles in tension-type headache. Curr Pain Headache Rep. Sustained nociceptive mechanical stimulation of latent myofascial trigger point induces central sensitization in healthy subjects. J Pain. Myofascial trigger points and sensitization: An updated pain model for tension-type headache.
Trigger Points are associated with widespread pressure pain sensitivity in people with tension-type headache. Cephalalgia [Epub ahead of print]. Muscle trigger point therapy in tension-type headache. Expert Rev Neurother ; 12 3 Effectiveneess of physical therapy in patients with tension-type headache: literature review.
J Jpn Phys Ther Assoc ; 17 1 Migraine is related to the highest disability among headaches. Great efforts are faced to improve the outcome of forthcoming treatments. However, still now, many patients regard as unsatisfactory the low responder rate about the half of patients and adverse effects that current treatments account. Therefore, waiting for innovative, more tolerated and effective treatments, there is a large request for non-pharmacological approaches that in many cases have specific pathophysiological targets.
Among these treatments, nutraceuticals has a leading role. Several nutraceutical products are proposed for migraine and sold around the world, but researchers adequately study only few compounds. Among studied nutraceuticals compounds, only few of them have studies of good quality in support. Moreover, also interactions among different molecules are not studied. We have reviewed literature data in order to find researches that support the use of nutraceutical molecules in migraine management.
Available good quality data support the use of certain nutraceuticals, in particular riboflavin, coenzyme Q10, magnesium, butterbur, feverfew, and omega-3 polyunsaturated fatty acids. Even if not supported by double blind studies, recently some prospective observational studies about fixed combination of nutraceuticals were performed. For instance, it is the case of a combination of coenzyme Q10, feverfew and magnesium for migraine prophylaxis: a prospective observational study.
A double blind versus placebo study about the effect of a fixed combination of riboflavin, coenzyme Q10, feverfew, andrographis and magnesium for migraine prophylaxis is currently in progress. Usually patients appreciate nutraceuticals more than traditional drugs, since they are regarded as safe and of efficacy not inferior to other pharmacological products.
Available data seem to support this widespread belief, but some concerns about the regulation of nutraceuticals and quality of some products, still remain. Contrary to what is generally thought of, headaches and algology pain therapy share many aspects. Headaches and chronic non-oncological pain are two paradigms of chronic illness capable of generating enormous individual and social impact by disabling the sick person not only in the biological, but also in the psychological, professional, social and relational spheres.
Both cause alterations in psychological equilibrium, secondary depression, loss of social and professional roles, which, in the most serious cases, can cause loss of work. Literature documents in both cases, headaches and chronic pain, a rise in direct costs but above all of the indirect ones with a huge burden of disease.
Both are capable of generating a marked drop in the quality of life associated with a serious bio-psycho-social disability. Headaches and chronic pain, although distinct according to a topographical criterion, share many mechanisms and physiopathogenetic steps. One of the most current fields in which neurologists and pain therapists converge is the focus on neuroinflammation [3] and central sensitization[4], two key mechanism for triggering, maintaining, and subsequent perpetuation of pain: the pain as a symptom, filogenetically responsible for maintaining homeostasis of the organism against actual or potential damage, becomes unnecessary illness without any protective meaning.
Another important shared pathogenetic passage is that of neuroimmune mechanisms, which interlink the immune system with the central nervous system[4]. Furthermore, numerous contribution to the scientific international literature highlight the need to modify the therapeutic approach, directing it towards a semeiotic criterion pain phenothype: specific sign and symptoms of a certain type of pain in a specific moment , which is an epiphenomenon of underlyng pathogenetic mechanism, instead of basing it on a etiologic criterion[5].
This would enable a more appropriate prescription and greater efficiency, taking into primary consideration the possibility of getting back to everyday life rather than obtaining complete analgesia.
All the above mentioned aspects are equally important but one of them can prevail over the others depending on patient characteristics and background.
In conclusion it can be stated that the aspects of sharing between headaches and chronic non-oncological pain are significantly greater than those that clearly divide them.
World Health Organization. International classification of functioning, disability and health ICF. Geneva, World Health Organization, Steiner T. J Lifting the burden: The global campaign against headache. Ru-Rong Ji Emerging targets in neuroinflammation-driven chronic pain. Nat Rev Drug Discov. Baron R Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol. Headache is a common clinical feature in neurological patients.
Usually, neuroimaging is unnecessary in patients with episodic migraine or tension type headache with typical headache features and with a normal neurological examination. These patients do not have a higher probability of a relevant brain pathology compared to the general population.
A recent study, however, reported that neuroimaging is routinely ordered in outpatient headache even if guidelines specifically recommend against their use. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all trigeminal autonomic cephalalgias TACs. Neuroimaging should be considered in patients presenting with atypical headache features, a new onset headache, change in previously headache pattern, headache abruptly reaching the peak level, headache changing with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre and abnormal neurological examination.
A recent consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. According the same consensus, fFor primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required [3].
Particularly in emergency room it is mandatory to exclude a secondary headache that requires special attention and further diagnostic workup. CT scan is the first line neuroimaging examination. MRI offers a greater resolution and discrimination and might therefore be the preferred method of choice in non acute headache. In addition, radiation due to CT scanning may be avoided.
Neuroimaging non conventional techniques are of little or no value in the clinical setting. Headache neuroimaging: Routine testing when guidelines recommend against them. European Headache Federation consensus on technical investigation for primary headachedisorders. Migraine frequency fluctuates over time.
In the literature, the most important recognized factors associated to chronic migraine are overuse of acute migraine medication, ineffective acute treatment, obesity, depression, presence of allodynia and stressful life events. Other factors reported in studies are age, female sex and low educational status. Very recently, a large population study suggested that the presence of additional noncephalic pain site is a risk factor for migraine chronification. For many of these factors the relationship with migraine chronification may however be bi-directional.
For instance, in the case of depression, it is possible that depression may negatively affect the response of migraine to acute and prophylactic treatments, but it is also true the opposite: i.
In the case of obesity, the association with chronic migraine may simply be ascribed to the effect of fat tissue in drug distribution. Beside and beyond the putative biological factors that may cause a worsening of disease, several lines of evidence suggest that the progression from episodic to chronic migraine is associated to a progressive increase and stabilization of functional and anatomical changes associated to chronic sensitization.
In this frame, it appears obvious that an additional cause for chronic migraine is quite likely represented by the low rate of prescription of preventive medications. The underutilization of preventive drugs has several explanations ranging from drug-associated issues limited efficacy, poor tolerability profile to education of practitioners, pharmacists and patients, and it also involve the limited access to qualified care.
Underutilization of preventative drugs also translate into a higher recourse to acute drugs, thus feeding on a vicious cycle that leads to negative consequences. CT has participated in advisory boards for Allergan and electroCore; she has lectured at symposia sponsored by Allergan; she is PI or collaborator in clinical trials sponsored by Alder, electroCore, Eli-Lilly and Teva.
Prevalence of migraine sufferers who are candidates for preventive therapy: results from the American migraine study AMPP study. Headache ; — The added value of an electronic monitoring and alerting system in the management of medication-overuse headache: A controlled multicentre study.
To date, the majority of clinical studies concerning primary headaches and their comorbidities are focused on migraine. Comorbidities of migraine may include neurological and psychiatric conditions, as mood disorders depression, mania, anxiety, panic attacks , epilepsy, essential tremor, stroke, and the presence of white matter abnormalities [2]. Particularly, a complex and bidirectional relation between migraine and stroke has been described, including migraine as a risk factor for cerebral ischemia, migraine caused by cerebral ischemia, migraine mimicking cerebral ischemia, migraine and cerebral ischemia sharing a common cause, and migraine associated with subclinical vascular brain lesions [2].
A recent meta-analysis pointed out that migraine is associated with increased ischemic stroke risk [3], and according to a systematic review and meta-analysis [4] the risk of hemorrhagic stroke in migraineurs is increased with respect to non-migraineurs.
Besides, the risk of transient ischemic attack seems to be increased in migraineurs, although this issue has not been extensively investigated [5]. A recent systematic review and meta-analysis also describes an increased risk of myocardial infarction and angina in migraineurs compared to non-migraineurs [6]. Concerning the association between migraine and vascular risk factors arterial hypertension, diabetes mellitus, dyslipidemia, obesity, alcohol consumption, family history of cardiovascular disease , a recent review [7] showed no solid evidence of an increased burden of conventional vascular risk factors in migraineurs, with the only exceptions of dyslipidemia and cigarette smoking, while a systematic review and meta-analysis regarding migraine and body mass index categories [8] found an increased risk of having migraine in underweight subjects and in obese women as compared with normal-weight subjects.
Few studies investigated the comorbidities of tension-type headache TTH , despite the fact that tension-type headache TTH is highly prevalent, and may be as debilitating as migraine [9]. It is noteworthy that, according to a review, TTH is associated with increased rate of affective distress [9].
Furthermore, some medical disorders may worsen a preexisting TTH, and it has been described the comorbidity of TTH with psychiatric disorders and fibromyalgia [10].
The International Classification of Headache Disorders, 3 rd edition beta version. Comorbid neuropathologies in migraine. Migraine headache and ischemic stroke risk: an updated meta-analysis. Am J Med. Migraine and hemorrhagic stroke: a meta-analysis. Sacco S, Kurth T. Migraine and the risk for stroke and cardiovascular disease. Curr Cardiol Rep. Migraine and risk of ischaemic heart disease: a systematic review and meta-analysis of observational studies.
Conventional vascular risk factors: Their role in the association between migraine and cardiovascular diseases. Migraine and body mass index categories: a systematic review and meta-analysis of observational studies. Tension-type headache and psychiatric comorbidity. Tension-type headache and systemic medical disorders.
Differentiating patients with life-threatening headaches from the overwhelming majority with primary headaches eg migraine, tension or cluster headache is an important issue in emergency department ED. Patients with non-traumatic headaches are up to 4.
These numbers seem to remain constant in Western countries Ramirez-Lassepas, ; Kowalski, ; Cvetkovic, ; Gaughran, Primary headaches still pose an open challenge in the ED because the failure to recognize a secondary headache could cause potentially fatal consequences.
Unfortunately, to date, there is still no a standard diagnostic procedure for headache in emergency conditions; although according to the diagnostic guidelines there are red flags that could help in the process, the positive predictive value of each severity indicator is not yet determined.
The problem of poor diagnostic sensitivity was attributed to IHCD-3 criteria rigidity in relation to primary headache diagnosis in emergency setting Dutto, , Swadron, Alternatively, a different standardized work-up has been proposed for the most frequent headache scenarios in ED Cortelli, ; Dutto, A careful history and physical examination remain the most important part of the assessment of the headache patient; they enable the clinician to determine whether the patient is at significant risk for a dangerous cause of their symptoms and what additional workup is necessary.
This presentation will discuss how to approach adults with headache in ED with an emphasis on those features that characterize high-risk headaches. Thus, the muscolokeletal contribution in Primary Headaches is still debate in the literature [5]. Moreover, recent knowledge suggests that different clinical headache phenotypes arising from a common pathophysiology rather than an independent disorder [6].
That is, in the most prevalent headaches disorders i.
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