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CLINICAL RESEARCH AND METHODSOnce the CSD is terminated,the brain cells synthesize manyvasodilators but most importantlynitric oxide (NO), which diffusesto the cortical area and stimulatesthe peripheral blood vessels at themeninges to swell. These vessels arehighly innervated by the peripheraltrigeminal nerves; also know as thetrigeminal afferents. Once the stretchreceptors found in the walls of themeningeal vessels are activatedupon the dilation of these vessels, thetrigeminal afferents will send specificsensory input to the trigeminal nucleusin the brain stem [13] . In a pseudo-reflexpathway, motor trigeminal nervesrelease at their axonal terminals manyneurotransmitters and neuropeptidesnear the dilated vessels. The mostimportant chemicals are substanceP, which is mainly responsible formediating the pain impulses to theappropriate nociceptors in the brain,and neurokinin A which promotesprotein extravasations from theblood plasma to the neighboringtissue. Both of the latter, with theneuropeptide calcitonin gene-relatedpeptide (CGRP) induce vasodilationof more peripheral arteries, worseningthe pain. Other chemicals like thevasoactive intestinal peptide (VIP),nitric oxide (NO), serotonin (5-HT),and dopamine (D) are also involved.This pool of chemicals will cause alocal inflammatory reaction, termedsterile neurogenic perivascularinflammation [13] .It is suggested as well that thethalamus plays an important role indirectly stimulating the cortical painareas situated in higher centersof the CNS, which produce painof the headache [11] . Note also thatseveral aminergic brain stem nucleiare directly involved in the migraineattack. Dorsal Raphe nucleus forinstance is involved in changing thelevels of serotonin in the brain [12] .This neurotransmitter is crucial formood control, pain sensation, sexualbehavior, sleep, as well as dilationand constriction of the blood vessels,which might trigger a migraine [14] .Locus Ceruleus causes changes inepinephrine level, which explains theactivation of the sympathetic nervoussystem in the body during or arounda migraine attack. This activity in theintestine causes nausea, vomiting,30and diarrhea. Sympathetic activityalso delays emptying of the stomachinto the small intestine and therebyprevents oral medications fromentering the intestine and beingabsorbed. The impaired absorption oforal medications is a common reasonfor the ineffectiveness of medicationstaken to treat migraine headaches.The increased sympathetic activityalso decreases the circulation ofblood, and this leads to pallor of theskin as well as cold hands and feet.The sensitivity to light and soundas well as blurred vision are alsoconsequences for the increasedsympathetic activity [15] .Till now, the complete phenomenonof migraine initiation was not wellunderstood. In fact more research andstudies are required in order to revealthe whole pathway triggering thisdisorder. Once this stage is reached,the “perfect” treatment for migrainewould be easily synthesized.Results1. 1. Migraine. Microsoft® Student 2008 [DVD]. Redmond,WA: Microsoft Corporation, 2007.2. 2. Sahai, S. (2007, April, 27). Pathophysiology andTreatment of Migraine and Related Headache.emedicine, Retrieved August 20, 2008, from http://www.emedicine.com/neuro/TOPIC517.HTM3. 3. Trigeminal nerve. In Medical Dictionary Online[Web]. Retrieved August 20, 2008, fromhttp://www.online-medical-dictionary.org/omd.asp?q=trigeminal+nerve4. 4. Migraine. (2006). In MedlinePlus [Web]. U.S.:Retrieved August 20, 2008, from http://www.nlm.nih.gov/medlineplus/ency/article/000709.htm5. 5. Ophoff RA, Terwindt GM, Vergouwe GM, et al.Familial hemiplegic migraine and episodic ataxiatype-2 are caused by mutations in the Ca2+ channelgene CACNL1A4. Cell.1996;87:543-552.6. 6. May A, Ophoff, RA, Terwindt GM, et al. Familialhemiplegic migraine locus on chromosome 19p13is involved in common forms of migraine with andwithout aura. Hum Genet. 1995;96(5):604-608.7. 7. Nyholt DR, Lea RA, Goadsby PJ, et al. Familialtypical migraine: linkage to chromosome 19p13and evidence for genetic heterogeneity. Neurology.1998;50:1428-1432.8. 8. De Fusco M, Marconi R, Silvestri L, et al. Haploinsufficiencyof ATP1A2 encoding the Na+/K+ pumpalpha2 subunit associated with familial hemiplegicmigraine type 2. Nat Genet. 2003;33(2):192-196.9. 9. Peroutka SJ, Wilhoit T, Jones K. Clinical susceptibilityto migraine with aura is modified by dopamineD2 receptor (DRD2) NcoI alleles. Neurology.1997;49:201-206.10. 10. Warner, J. (2008). Migraine Headaches WithAura Magnifies Risk of Heart Disease and Stroke inWomen. In WebMD [Web]. USA: Retrieved August20, 2008, from http://www.webmd.com/heart-disease/news/20080730/womens-migraines-mult11. 11. Retrieved August 23, 2008, from Migraine Associationof Ireland Web site: http://www.migraine.ie/index.cfm/loc/3-5-2.htm12. 12. Migraine. (2001). In Merckmedicus [Web]. USA:Merck & Co.. Retrieved August 20, 2008, fromhttp://www.merckmedicus.com/pp/us/hcp/diseasemodules/migraine/path13. 13. Boyd, J. Pathophysiology of Migraine and ra-MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6tionale for a targeted approach of prevention. RetrievedAugust 23, 2008, from Migraine preventionWeb site: http://www.migraineprevention.com/14. 14. Alexander Mauskop; Fox, Barry (2001). WhatYour Doctor May Not Tell You About(TM): Migraines: The Breakthrough Program That Can Help EndYour Pain (What Your Doctor May Not Tell YouAbout...(Paperback)). New York: Warner Books.ISBN 0-446-67826-0.15. 15. Dennis, L. Migraine Headache. Retrieved August20, 2008, from MedicineNet Web site: http://www.medicinenet.com/migraine_headache/article.htm
CASE REPORTSThe Etiology and Patterns of Maxillofacial Injuries At AMilitary Hospital in JordanABSTRACTObjective: To describe the cases ofmaxillofacial injuries that attendedthe Emergency Department at QueenAlia Military Hospital.Methods: A descriptive study of 85cases representing patients withmaxillofacial injuries who attendedthe emergency department at QueenAlia military hospital during a 3year period (January 2002 till January2005) were analyzed in relationto age, gender, cause of injury andneed for referral to other specialtiesfor better management.Results: Out of the total 85 casesthat were reviewed, there were 65(76.4%) males and 20 (23.6%) females.The mean age of the patientswas (24.5) and their age range wasbetween (3-50) years. The majorityof the maxillofacial injuries weredue to car accidents 69 (81.17%).Regarding the need for referral, 14(16.4%) cases had associated serioushead and eye injuries, thereforethey were referred to Neurosurgeryand Ophthalmology Departments.The majority of cases 71 (83.6%) hadmaxillary and mandibular fractures,which required referral to the departmentof maxillofacial surgery.Conclusion: The number of documentedcases of maxillofacial injuriesduring the study period may reflectunder-reporting of the problem.This may necessitate the need for anobligatory special form to be used atthe Emergency Department to overcomethis problem.Keywords: Oral Injuries, Maxillofacialinjuries, Mandibular fracture.Muntaha Y.Jerius MDKing Hussain Medical centerOut patient DepartmentRoyal Medical ServicesAmman-JordanCorrespondence to:Muntaha Y.JeriusP.O.Box 921004Amman 11192JordanE-mail: dr.muntaha@hotmail.comIntroductionMaxillofacial trauma is presented inAccident and Emergency Departmentof the hospital either as isolated injuryor part of multiple injuries to the head,neck, chest and abdomen (1) . Theetiology of these injuries is variablefrom one country to another and evenwithin the same country dependingon prevailing socioeconomic culturaland environmental factors (2) . Theseinjuries not only affect the functionof the patient but also cause seriouspsychological, physical and cosmeticdisabilities. Most of our patients wereinvolved in road traffic accidents (2) ,while in developed countries like theUnited Kingdom it was found thatviolence is the commonest causeof maxillofacial injuries, while caraccident injuries were declining,maybe because of improvement incar design and safety equipment andrapid management of the patients (5) .Epidemiologically, studies ofmaxillofacial trauma have classicallyshown that young adults are the mainvictims (3,4,5) . The aim of this study wasto investigate the incidence, etiology,management, age and sex distributionof maxillofacial injuries.Materials and MethodsThis descriptive study wasconducted at Emergency Departmentat Queen Alia Military Hospital duringa 3year period from January 2002till January 2005. The data werecollected by reviewing 85 medicalrecords representing patients withmaxillofacial injuries who attendedthe Emergency department at thatperiod, analyzed in relation to age,sex, cause of injury and need forreferral to other specialties for bettermanagement. The managementstarted with (ATLS) AdvancedTrauma Life Support including themaintenance of airway control ofbleeding, antibiotic coverage andhead elevation. Regular mouthwashwas advised. In all cases plain x-rays and CT scan were obtainedwhen possible. Patients who neededsurgical intervention were referredfor admission to be managedaccordingly.ResultsOut of the total 85 cases that werereviewed, there were 65 (76.4%)males and 20 (23.5%) females.More than 90% were between theage of 5 years and 35 years, meanage was (24.5). 69 cases (81%) weredue to car accidents and the restwere either due to quarrels or othertypes of trauma as seen in Table 1and Table 2.Regarding the need for referral, 14(16.4%) cases wereassociated withserious head and eye injuries; thereforethey were referred to neurosurgeryand ophthalmology departments, andthe rest were referred to the oral andmaxillofacial surgery department forfurther management.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 31
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