ࡱ> @=-ѦY\hnP!Ix]k[u5ZMG<%v#Ŗ:/LXIvwmmF)4,cǪČi-b+59s;]gg'k\of33cAw. "H| (޴CA )^A> pB~o+ x<.OFV6-Ƶ^kwC_6%Es+o`P~g YyD5Mph\}?r8E'y|VWeN|H}ɿ9ȟ /!-[ōܩZ_)|lo=61^D6y<>a9N1e=ʋ,*1'm37s|Bo3/07ZC7nC? ߸ wNƞ)kEwH֥sc2'hȕ}ޓK֡\rSFOrpC]_ 8tpU(πx(*&픚(fixf~4B̧a~EG2p` a,} DCZ02/oPaIW)Lӌ/"y u 8t Eu~I5*z@r":DG+C[ _HLJoj{ڷPv#ܫtQz97?8xt%I&b6=E'3̿ȑ̤.PDM廭rnlxH9n=yOb _G~$u2W]Q yؿ`,%epӬʟ4`  .yvAOm D;s?d[tek>+1˓ƮoX:Ǯڧey-72}O}Oq;?c͑5c=_qI̺5_u'HQICErX'2_-c6ׂv&ۥˮd%˨}j&Bt?օWI>ߣV sJqؖ*'byhQyc2c iIi5}^yYkњ0AܧdYYfBKrh9,ڛmM^mǃ«xUޅ8<,+3=gkTJ;8+ۖ8ed3sFDzav+-rm\pHشOWx62׾kv\;_d\Ý8Wrӎuh?A:۹$]noX;fj\Rx$bjs}p$љu ϶>^3)o&mhl.1ur5>\ ֶe5ϋ|4[cu͂c\7<88l.sF.ŃNL1Dz@;o8mNl.+1l9ًGa>{&"OŜi9d8>~:rIyPsL?º=RCZ^u)ʓeoa.F^4 O/zzETtgNko|7?gV ~^R˱ghVKe53ۂoq6ϫ=Gp򫖼ʲ9T=0_%e3u9Y{Q!9^Y\%c< Bko>t*w|9-?}\=P !̙^Qxu365y4%2i?|RhP՚h :Z~Ɣc!mΧvul.s=WyˏwՙUٳKsƲ<۬~sʞ/__M({c}x2wYH}݇Trϙ׭gE?>sg<~%RW{.p%eovri\oZz.miGnԸe;ZZ,wjnϒ5L9sq?;/.mgfaiOmbeqn 8\>papq:wr鸠å?n!mdK_>N;vxtviB;&bW_ |&՗Ou&vWk]c5+&qkymt\/\㫶 r~qw8K_ Sp=e&2}Lx_Fޗ  ˄e}ٰ}Lx_Fޗ  ˄e}ٰגQ`LcThڬۇVVDUjհ}ihJZEV ۗVVDUjհ}ihJZEV W31Nx_GS ui}}𾎼7m_3בuu:޴}IxD7MM&iؾxdx$o"MM&iؾxdx$o"}!sa.v뙛3fm6jMlZm3ZmQm66j6l_Zm3ZmQm66j6l_1Ĩ.}y%ww a}}𾋼/ww a}}𾋼Q˜ 3F3ƨ>j'VվajjhZ/VվajjhZ5dbԐ~< Cа}~~Hx?D  Cа}~~Hx?D  DŽc>x?fx?&#džcc1~lؾx?fx?&#džcc1~l27+( &Ͷl\gbq|5mZM{}i5 Km_ZMZ5qkKi@&.}+x^۾bTIǨ} y^ޗޗKm_/1/ޗ%۾x_bx_"/!K"}Dx_BޗDl}}xcx#!{"}GxCDl}}𾇼}y}!c?aL:-&Q1j@:@mĤCFju bۗVVD@Ķ/VՁm_Z0ZP۾bԈQ#|$&m1ޏ#۾x?bx?"!G"}~~Dx?BޏDl~ؾP1;/eX<'ĺC{-6{kG]/`]/y x {kG]p|弘*uN.me6r_kk`4G\4\Pҟ @iå?׹0qg}z{C׏I_BqjƐ\\6yu%J+=*3\enepuG\UWՁWUw{dp5q`pp:Wvj{epuq=zƁ W#!k5k;p= qm< - -\[<*1J\%* W#= =\{<1j\5 W#a\{apu:q\=G\\N{5`p q\#G\\ί1. ?dG~o\5qk+X?6_K[t3l@( !  0%Worksheet Excel.Sheet.802Microsoft Excel Worksheet/ 0DTimes New RomanȷȷԳ0 0DArialNew RomanȷȷԳ0 0" DSymbolew RomanȷȷԳ0 0   @n?" dd@  @@`` d\5y    /X$"$-ѦY\hnPc $@8&'Mg42d2d 0 ppp@ <4!d!dȷ\  <4BdBdȷȷf\ 2*___PPT9 z? %9MIGRAINEGavin Torr LGI A&E   MIGRAINE^Diagnosis 4000yrs Old Word  Migraine introduced by Galen approx AD150 Defn: Familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Assoc. with anorexia nausea and vomiting. Often preceded by associated neurologic or mood disturbances. *0J ,G  DIAGNOSISL60% Undiagnosed   chronic headaches A&E review study  Only 45-51% receive the correct diagnosis 1988 International Headache Society established diagnostic criteria  Migrane Without Aura S evere U ni L ateral T hrobbing A ctivity N ausea S ensitive to light and sound Diagnosis Two of 1st four.One of 2nd two (+ lasts 4-72hours)QZZ=Z$$$$ (((/    R DIFFERENTIAL DIAGNOSIS   MANAGEMENTNo ideal universally consistent and successful treatment Wide variety of agents Many have high success rates Many have side effects Dependence Problems Often safer agent is less ideal treatment&PrPrTHE MARKET& ..Common Complaint Estimated 40% Americans suffer from severe headache Migraine effects 5-15% US population 2/3 people never see a doctor 1995  estimated market from world 7 major markets = 63 million people Global Market believed to be worth $2.3 billion Big spender in Drugs budget But : Lost earnings $6.5-17 billion annually USOZO &Emergency Medicine Report Guidelines: ''(American Health Consultants  (www.ahcpub.com/onlinehtml) First Line Prochlorperazine 5-10mg IV Metoclopramide 10mg IV Ketorolac 30-60mg IM Chlorpromazine 25mg IM Sumatriptan 6mg s/c or 25mg PO Second Line Dihydroergotamine Isometheptene Third Line Opioids Steriods:Z Z}Z Z Z ZZ: }     #   "    Sumatriptan FFirst introduced in 1993 Injection, tablet, nasal spray Not Cheap Tablet 50mg = 29.70 (6) Injection 12mg/ml = 41.14 (2) Nasal Spray 20mg/0.1ml = 12 (2) Denmark& .. Many METOO isomers Almotriptan, naratriptan, rizatriptan, zolmitriptan General consensus Sumatriptan is best /most potent zZ*ZdZZhZZ*di b     Sumatriptan (ii) Studies have shown efficacy Sumatriptan International Study Group (1991) s/c injection 6-8mg - 72% improvement at 60mins - 86-92% improvement at 120mins Matthew et al 1992 Oral efficacy with increasing dose 73% 6mg & 80% 8mg Numerous other studies Problems: Work best if take ASAP Doesn t work during auras Often require rescue medication also LZZ@ZZ6Z!ZVZZL@6  !  V$ <Sumatriptan (iii) Mech ?  Vasoconstriction via 5HT, Dopamine and Adrenaline Other Problems Cannot give with ergots Contraindications  Hypertension, CAD, Vascular insufficiency. (diabetes, asthma and angina) SEs  Arrhythmias, Arrest, MI, Stroke. <KK$' 0The Three Part Question& In [patients presenting to an A&E department] [with an acute migraine] [Should sumatripan be the obvious first line treatment].P ' Search Strategy`Medline 1966-12/01 using OVID (Migraine AND Sumatriptan) AND (Sumatriptan and NSAIDS OR tolfenamic acid OR metoclopramide OR prochlorperazine OR chlorpromazine OR opioids OR ergotamine or isometheptene OR steriods) LIMIT to human AND english AND randomised controlled trial Also Cochrane Database, ACP Journal Club and Database of reviews and reviews of effectiveness. Also: Most recent guidelines  Emergency Medicine Reports. $Z"Z,      % $TRIALS:kAll Randomised controlled trials 4 x NSAIDs 1 x Paracetamol + Isometheptene 1 x Chlorpromazine 2 x ERGOT kl,% Sumatripan vs NSAIDS"1. Diclofenac-K/Sumatriptan Migane Study Group (1999) 100mg Vs Diclofenac (Single oral dose 50mg and 100mg) N=156 Diclofenac performed better at 2h otherwise no diff SEs better with Diclofenac 2. Myllyla 1998 (Finland) Vs Tolfenamic Acid N=141 IHS criteria No significance in two groups x6ZZZZFZ6F  * )  8 3. Oral Sumatriptan and Aspirin plus metoclopramide comparative study group 1992 Vs Aspirin 900mg and Metoclopramide 10mg N=358 Sumatriptan produced faster results in headache relief Relief of Nausea, vomiting and photophobia and phenophobia similar in both groups&QQb 3 Z  4. Tfelt-Hansen 1995 (Denmark) 100mg Vs Lysine acetylsalicylate (=900mg aspirin) and metoclopramide 10mg N=421 No difference in groups (57% vs 53%) Nausea improvement with aspirin/metoclopramide&PM)%Sumatriptan vs Combination Freitag et al 2001 (USA) Isometheptene + dichloralphenazone +paracetamol N=126 IHS criteria No significant difference Combination had better early response&6 bSumatriptan vs Chlorpromazine $Kelly et al 1997 (Australia) Sub-Cut 6mg Vs Chlorpromazine (IM) 12.5mg-37.5mg No difference seen in results (78% vs 63%) Less use of rescue medicine in Sumatriptan group Cross over in trial  Patients preferred Sumatriptan&>q$ / Sumatriptan vs ErgotamineZWinner et al 1996 (USA) N=295 using nasal spray (equal dosages) Good results with both but recurrence worse with sumatriptan (45% vs 17%) Multinational Oral Sumatriptan & Cafergot Study Group (1991) 580 Pax (100mg vs 2mg Ergot 200mg caffeine) Sumatriptan statistically significant in reducing headache and nausea, vomiting. SEs worse on Cafergot\ZrZ>ZZr>q    E #Sumatriptan or not to Sumatriptan ?$  Evidence seems to suggest other options equally as good. More comparative and bigger trials needed Side Effects ? Good Evidence for simple analgesia and antiemetics. Role of Opioids ? >  PLAN of ACTION:ZHx and exam Confirm diagnosis of migraine  exclude differential diagnosis ASK PATIENT WHAT HAS WORKED BEFORE Anti-emetic and simple analgesia ? Role of NSAIDs Don t underestimate Antiemtics Consider Triptans as second line  care with contraindications Advice re Triggers and GP follow up +Z#ZEZ1Z"Z Z$ZZZZNE1jH  YPROCHLORPERAZINEWhy ? - N&V Action ?  Dopamine modulation Studies: IV 10mg 74% complete relief, no returns to A&E in one study 82% effective within 30 minutes no recurrence in 24hrs Can be given rectally 25mg Vs Metoclopramide: nausea reduction more pronounced and headache recurrence less common. No significant difference between two in another study t7ZZZZ METOCLOPRAMIDE WHY ?  N&V Action ?  Dopamine modulation Studies : IM no better than placebo IV 67% reduction in relief (placebo 19%) &7D7D* ` ff33f` ffD3f` MMM` f3fD"Yf` f3f6f3f` 3f̙f>?" dd@,|?" dd@   " @ ` n?" dd@   @@``@n?" dd@  @@``PR    @ ` ` p>> &&o&(    H2,$@  0>   0e0e     ?B)CDElFt @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||c $)6N_i> _4% #j +  y  p  d(78@ #  3 0e0e     ?BCnDEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||//  MoK0YVS_^tT, [v] T5  G r C  ]smm#h g:Y/x|!  L  _`@e   3 0e0e     ?BC DEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||44S.e'w : v   E n OV?5^B<Shjv  _UEf"X( w 8  lQ<e$<. il@  3 0e0e     ?BC%DEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||11_eskw$ h % U  m`*W`/kcy$yu:^V]I\& iWB0' cd@3   3 0e0e     ?BCDE`Fh @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||S>VO\Nb2h"n?}w; I i  Ij KtN14@j4(  3 0e0e     ?BC$DEpFx @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||##6Th DXncq u Cm ^w yr ^ho|9<@  3 0e0e     ?BCDEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||,,n/vg^L : "X B   ]_>^ 8ZI* 9 l ] )@8nJVbhncqnY\@X   0BD CDE@FH@? C u, <C !$@D   0 P  V Click to edit Master title style! !   s *   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S   s * ``  Y*    s *4 `   [*    s *Ժ `   [*  T  <޽h? ffD3f  Pulse'  &&0:&(    H2,$@  0   3 0e0e     ?B)CDElFt @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||c $)6N_i> _4% #j +  y  p  d(78@ #  3 0e0e     ?BCnDEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||//  MoK0YVS_^tT, [v] T5  G r C  ]smm#h g:Y/x|!  L  _`@e   3 0e0e     ?BC DEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||44S.e'w : v   E n OV?5^B<Shjv  _UEf"X( w 8  lQ<e$<. il@  3 0e0e     ?BC%DEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||11_eskw$ h % U  m`*W`/kcy$yu:^V]I\& iWB0' cd@3   3 0e0e     ?BCDE`Fh @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||S>VO\Nb2h"n?}w; I i  Ij KtN14@j4(  3 0e0e     ?BC$DEpFx @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||##6Th DXncq u Cm ^w yr ^ho|9<@  3 0e0e     ?BCDEF @ 5% 8c8c     ?1 0u0@Ty2 NP'p<'p @A)BCD|E?||,,n/vg^L : "X B   ]_>^ 8ZI* 9 l ] )@8nJVbhncqnY\@X   0BD CDE@FH@? C u, <C !$@D   HT? ??p  V Click to edit Master title style! !   BT? ?? `    Y#Click to edit Master subtitle style$ $   s * ``  Y*    s * `   [*    s * `   [*  T  <޽h? ffD3f @4(    0T P    =*   0     ?*   6 `P   =*   6 `   ?* H  0޽h ? ̙33  $(  r  S t p  r  S   `    H  0޽h ? ̙33  P \(   x  c $ P     c $ <$ 0  H  0޽h ?   `P(  r  S $i P     S c <$ 0  H  0޽h ?    p0E (  0v 0 6de` >MIGRAINE WITHOUT AURA (COMMON MIGRAINE) A. Duration 4-72 hours B. Two or more of the following: 1. Unilateral location 2. Pulsating quality 3. Moderate to severe intensity 4. Aggravated by routine physical activity C. At least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia D. Five or more attacks fitting the above criteria E. Exclusion of secondary cause of headache MIGRAINE WITH AURA (CLASSIC MIGRAINE) A. At least three of the following: 1. One or more fully reversible aura symptoms indicating brain dysfunction 2. One aura symptom developing in at least 4 mins,or two or more symptoms in succession 3. No aura symptom lasting over one hour 4. Headache follows aura within one hour B. At least two attacks fitting the above criteria C. Exclusion of secondary cause of headache ( *#####[##1##,#(###0##*#'        + !     2 +  % # M /  & ) ) 2 +  0 6dz AURAS " Positive scotomas " Negative scotomas " Teichopsia/fortification spectra " Photopsia (flashing lights) " Homonymous visual disturbance " Unilateral paresthesias/numbness " Unilateral weakness " Aphasia/unclassifiable speech difficulty " Visual or auditory hallucinations " Diplopia " Ataxia " Vertigo " Syncope " Hyperosmia nI #" (#" A#" #" "#" #" *#" ##" #" #" #" #" # h                       * #            0 S e  P   %IHS CRITERIA 1988H 0 0޽h ?   @$(  @r @ S $f ` P   r @ S Dg   H @ 0޽h ?    y q 8 (  8 8 <k@ m ?NONMIGRAINOUS VASCULAR HEADACHE Fever Hypoxia/hypercarbia Carbon monoxide poisoning Hypertensive headache Anemia Altitude headache Stroke Effort/coital headache Hypoglycemia Hypothyroidism/hyperthyroidism Hypoadrenalism Menopausal hormone cessation TRACTION HEADACHE Tumor Arteriovenous malformation Cerebral aneurysm/subarachnoid hemorrhage Pseudotumor cerebri Brain abscess Subdural hematoma/epidural hematoma Postspinal puncture headache p   ##"#"#"#"#"#"#"#" #"#"#"#"#"#"#"#")#"#" #"##"#"#"%                                          8 6n@  >INFLAMMATORY HEADACHE Temporal arteritis INFECTIOUS CAUSES Meningitis Encephalitis Abscess (brain, dental) Sinus headache MISCELLANEOUS Trigeminal neuralgia Glaucoma Temporomandibular joint (TMJ) syndrome Post-traumatic (post-concussive) headache Ventricular shunt headache Cervical headache (rheumatoid arthritis, spondylosis, trauma) Postictal headache Muscle contraction headache m #"#"#"#" #" #"#"#"# #"#"#"&#")#"#"5#"#"#"#"                     )  )          r 8 S m    H 8 0޽h ?   DP(  Dr D S l P    D S dh <$ 0  H D 0޽h ?   P(  r  S l P     S dk <$ 0  H  0޽h ?   XP(  Xr X S k P    X S j <$ 0  H X 0޽h ?   xP(  xr x S b P    x S i <$ 0  H x 0޽h ?   P(  r  S g      S db <$ 0  H  0޽h ?   |P(  |r | S Dd P    | S Dj <$ 0  H | 0޽h ? 4 H\(  Hx H c $$ڗ `   H c $ؗ `  <$ 0  H H 0޽h ?   PP(  Pr P S ݗ P    P S $ݗ <$ 0  H P 0޽h ?    P(  r  S Dۗ P     S ܗ <$ 0  H  0޽h ?   0dP(  dr d S Dޗ `    d S ٗ `<$ 0  H d 0޽h ?   @h$(  hr h S dٗ P   r h S 4V   H h 0޽h ?   Pl$(  lr l S X P   r l S tX   H l 0޽h ?   ``$(  `r ` S 4Y P   r ` S Y   H ` 0޽h ?   pp$(  pr p S TZ P   r p S Z   H p 0޽h ?   tP(  tr t S \ P    t S \ <$ 0  H t 0޽h ?   P(  r  S ^ P     S t^ <$ 0  H  0޽h ?   P(  r  S _      S T` ` <$ 0  H  0޽h ?  H(    <A ??PW 0N  6޽h޽h ?   0(  x  c $` P   x  c $a   H  0޽h ?   0(  x  c $ta P   x  c $a   H  0޽h ?  .xZ{pUvII&mz6iѴ4mBXwewo!HP:2΀ /8 > Vu`Ff<ʀ#ړٻg9|ɾ|Gk.VPYL .٪l>T_j^u W9 \q*\qU*j\kp +FOR w$L? 0\ F?b¹8r]ϩׇEO=}^+~ISQ䶜t-pap4\k>@T[Ɵ'lOam)9KWy K$X+SsWr7sB{MSf׾e ^_ѯ7[@;z~O?E4[\~7sϙcVBpSޔeN1~=HoL7B3ϠKcy _.yzrWz>}_H^^R{WI{cQUr/D3}kC/ܫ^!z@?Ð,ȿs/=X;O2/>|WRzex^wOƳ :bC] {( Xz$v;Dv?2|K ,wݯFTۇ8gcIo`RIyozl~gnYQ+\&$E=d@0MHIn~K͕} 6w5ˇ]MF'V;*wH@@Z ]n۩Y0]0`܅`w}{VX9p-4~p?kʳC>sy9z.c\1|>]^<#Y"Bw ^陃C4TF $"!A0(8C47E߬y%pE9nPL,߫g}͌!kg;y)==A"!ń1ͦH}{ ,QU 4i+hġl7qaö5z); AV׺N&dħ鴅 k,4}NfJ|rk /O9.Q$|!ײ}sRXB_OOalҖԞ޾C_7&]۷06 xI)ᤰ[\ϞLvYq$~n-x$e X,nleU9Fқ뿊>V1̃ YX;fzN8Xr!& g OFi7 4bBט9xWiu{3o,*os\)#\_yh$q⡸X6M0>@<VE rh(o`i3r,"c|',P֗?A#  ,3nƦGwËXHJ,de`{LUg&82ߊi `Y~`E ^[NkTUWWխr+JٯYt~ޓM;%d&&Q.Ϻn9_Ab#:7+%O * O%O7>m=T xRIjfede41MSV<}jzpJs9:v*6SصgVx#]}sl"y@?60qao~.;5]X)JG}635n>|ѮI_-i\ G$30M‚GR [rW+-<">blC^clCXCݍTJ:QKQVn̸NM:W!ՠMM }4VA^)*K }+hbÐ2 K C_0(DXa^RK(xZ0,(zRy%U*k;c/L9 q͉夷s-Xœ% nuXhyhKZ^VYPc)H>k0kK>3zdЯY2CXhJJ}žJRN:b:uHGrP2^4V:VlǕRKֈ땡/^ 2Uyj UI]Je׮ ]*J^`j!+po,5EnEjVpk2R嬡ohjiU)pM94}ꤊZ:IM[Y(PMyB}',Z0 M/Y( YV¨F%ㆾ,T#7J-vFY"5J6J.Zsư!G*xo`yX GhLgh<~bzPQ4x55 }e7AQFlo2IS#ꔀkaP0coU-֮%w[)Qf {H:pM#/I;4X ˣg/mޟoUiz]kn'\ z` QP4owyUo8C68O(H[}YRߊC;HTQ/ 9sFݛ-> ݾlV7>";+ۿ5Pr@S?]c { PtEu1AYE !9Qg_w$@)Wt@ikpL'Oh+'0_ hp  $ 0 <HP MIGRAINE TORRINEKC:\Program Files\Microsoft Office\Templates\Presentation Designs\PULSE.POTpauligr32lMicrosoft PowerPointoso@AFth@@V@{jůWG<^oM  /l& &&#TNPPp0D ` & TNPP &&TNPP    &&--&&- $<<- $<xx<- $xx!- $*- $,,3- $,hh,;- $hhC- $K- $R- $XXW- $XX\- $`- $  b- $ HH d- $HHe- $&&&- & $&&-&& &&-&&&&- $<<- $<xx<- $xx!- $*- $,,3- $,hh,;- $hhC- $K- $R- $XXW- $XX\- $`- $  b- $ HH d- $HHe- $&- --&&&&--G- $N- $ Y- $f- $'t- $3- $>- $#F- $&L- $)S- $,X- $.\- $/_- $1b- $1c- $2e- $2e- $1c- $1b- $/_- $.\- $,X- $)S- $&L- $#F- $>- $3- $'t- $f- $ Y- $N- $G- $---&&&\&--&& - $\\- $\\- $\\!- $\\*- $\\%%3- $%\%\55;- $5\5\DDC- $D\D\TTL- $T\T\ddR- $d\d\ssW- $s\s\\- $\\`- $\\b- $\\d- $\\e- $\\&&&- &:$:Rk %9 Zs!2FZq*<J[X&&-&& &&-&&:$:Rk %9 Zs!2FZq*<J[X&& - $\\- $\\- $\\!- $\\*- $\\%%3- $%\%\55;- $5\5\DDC- $D\D\TTL- $T\T\ddR- $d\d\ssW- $s\s\\- $\\`- $\\b- $\\d- $\\e- $\\&- --&&&Z&--&&D- $66E- $6kk6F- $kkH- $J- $  N- $ BB Q- $BwwBT- $wwX- $[- $^- $NN`- $NNb- $d- $e- $$$ $$ZZ$&&&- &b$/oA|S)8e%Hi 1G[q.DZhYN<w\C-jF&&-&& &&-&&b$/oA|S)8e%Hi 1G[q.DZhYN<w\C-jF&&D- $66E- $6kk6F- $kkH- $J- $  N- $ BB Q- $BwwBT- $wwX- $[- $^- $NN`- $NNb- $d- $e- $$$ $$ZZ$&- --&&&J&--&&D- $J<J<E- $<JxJx<F- $xJJxH- $JJJ- $J,J,M- $,JhJh,Q- $hJJhT- $JJX- $JJ[- $JYJY^- $YJJY`- $JJb- $J J d- $ JIJI e- $IJJI $JJ&&&- &l$4J]*Z=b/EU l$<RicF+uR#~vngpaI\XTPN]L/KJ&&-&& &&-&&l$4J]*Z=b/EU l$<RicF+uR#~vngpaI\XTPN]L/KJ&&D- $J<J<E- $<JxJx<F- $xJJxH- $JJJ- $J,J,M- $,JhJh,Q- $hJJhT- $JJX- $JJ[- $JYJY^- $YJJY`- $JJb- $J J d- $ JIJI e- $IJJI $JJ&- --&&& &--&&D- $<<  E- $<xx < F- $x x H- $  J- $,,  M- $,hh , Q- $h h T- $  X- $  [- $YY  ^- $Y Y `- $  b- $    d- $ II   e- $I I  $  &&&- &f$1=/>h?ADG#KQOV^fnIxg2MllaeV9LD<3{,O&!O    wU(&&-&& &&-&&f$1=/>h?ADG#KQOV^fnIxg2MllaeV9LD<3{,O&!O    wU(&&D- $<<  E- $<xx < F- $x x H- $  J- $,,  M- $,hh , Q- $h h T- $  X- $  [- $YY  ^- $Y Y `- $  b- $    d- $ II   e- $I I  $  &- --&&&_&--&&D- $<<__E- $<xx_<_F- $x_x_H- $__J- $,,__M- $,hh_,_Q- $h_h_T- $__X- $__[- $YY__^- $Y_Y_`- $__b- $  __d- $ II_ _e- $I_I_ $__&&&- &4$5b >u G{#, 5>?nIY^&&-&& &&-&&4$5b >u G{#, 5>?nIY^&&D- $<<__E- $<xx_<_F- $x_x_H- $__J- $,,__M- $,hh_,_Q- $h_h_T- $__X- $__[- $YY__^- $Y_Y_`- $__b- $  __d- $ II_ _e- $I_I_ $__&- --&&&&--&&D- $<<E- $<xx<F- $xxH- $J- $,,M- $,hh,Q- $hhT- $X- $[- $YY^- $YY`- $b- $  d- $ II e- $II $&&&- &<${s X<#"*4;CLjR=X^cgken<qtvxyYz!{{&&-&& &&-&&<${s X<#"*4;CLjR=X^cgken<qtvxyYz!{{&&D- $<<E- $<xx<F- $xxH- $J- $,,M- $,hh,Q- $hhT- $X- $[- $YY^- $YY`- $b- $  d- $ II e- $II $&- --&&&qo&--&&D- $77ooE- $7nno7oF- $nonoH- $ooJ- $ooM- $JJooQ- $JoJoT- $ooX- $oo[- $''oo^- $'^^o'o`- $^o^ob- $ood- $ooe- $::oo $:qqo:o&&&- &\$,;n2nxlkig(dGcm`]YV Q*MMHnD>83,%4O apo!M&(+/257t9S:.;;;&&-&& &&-&&\$,;n2nxlkig(dGcm`]YV Q*MMHnD>83,%4O apo!M&(+/257t9S:.;;;&&D- $77ooE- $7nno7oF- $nonoH- $ooJ- $ooM- $JJooQ- $JoJoT- $ooX- $oo[- $''oo^- $'^^o'o`- $^o^ob- $ood- $ooe- $::oo $:qqo:o&- --&&&.&--&&D- $..E- $<<..F- $<ZZ.<.H- $Zxx.Z.J- $x.x.M- $..Q- $..T- $..X- $..[- $--..^- $-KK.-.`- $Kii.K.b- $i.i.d- $..e- $.. $..&&&- &$$- -@-`,*)'%#L&&-&& &&-&&$$- -@-`,*)'%#L&&D- $..E- $<<..F- $<ZZ.<.H- $Zxx.Z.J- $x.x.M- $..Q- $..T- $..X- $..[- $--..^- $-KK.-.`- $Kii.K.b- $i.i.d- $..e- $.. $..&- --&&&G&2 |w|wgw2 - &Gy& --iyH-- Times New Roman|wgw u - f.2 BNMIGRAINE4*'+*$.--Q1-- fTimes New Roman|wgw2 - .2 Gavin   . . 2 Torr. .2 LGI A&E !.--"Systemwf/  -&TNPP &՜.+,D՜.+,t0    On-screen Shown-s.j Times New RomanArialSymbolPulseMicrosoft Excel Worksheet MIGRAINE MIGRAINE DIAGNOSISIHS CRITERIA 1988Migrane Without Aura DIFFERENTIAL DIAGNOSIS MANAGEMENTTHE MARKET..'Emergency Medicine Report Guidelines: SumatriptanSumatriptan (ii)Sumatriptan (iii)The Three Part QuestionSearch StrategyTRIALS:Sumatripan vs NSAIDS No Slide TitleSumatriptan vs Combination Sumatriptan vs Chlorpromazine Sumatriptan vs Ergotamine$Sumatriptan or not to Sumatriptan ?PLAN of ACTION:No Slide TitlePROCHLORPERAZINEMETOCLOPRAMIDE  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles 6> _PID_GUIDAN{1C5E9F2D-1C9F-11D6-B009-00D0B7B51A9A}_pauli  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry dO)PicturesCurrent UserSummaryInformation(_PowerPoint DocumentuvwxyzABCDEF(OPQRSTUVWXYZ  DocumentSummaryInformation()*+8456789:;<=>?@ABCDEJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijktuvwxyz{|}~   & ! 0 `9 R}    "   "!a: S~x