Tuesday, October 06, 2009


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This article is about the disorder. For other uses, see Migraine (disambiguation).
Classification & external resources







Migraine is a neurological syndrome that can cause a wide range of symptoms during an attack. The most commonly thought of symptom is headache.[1][2][3]
It is widespread in the population. In the U.S., 18% of women and 6% of men report having had at least one migraine episode in the previous year,[4] with seriousness ranging from an annoyance to a life-threatening and/or daily experience.[citation needed]

• 1 Overview
• 2 Classification
• 2.1 Defining severity of pain
• 2.2 Migraine without aura
• 2.3 Migraine with aura
• 2.4 Basilar type migraine
• 2.5 Familial hemiplegic migraine
• 2.6 Abdominal migraine
• 2.7 Acephalgic migraine
• 2.8 Menstrual migraine
• 3 Signs and symptoms
• 3.1 Prodrome phase
• 3.2 Aura phase
• 3.3 Pain phase
• 3.4 Postdrome phase
• 4 Diagnosis
• 5 Pathophysiology
• 6 Epidemiology
• 7 Triggers
• 7.1 Food
• 7.2 Weather
• 7.3 Hair wash headache
• 8 Treatment
• 8.1 Abortive treatment
• 8.1.1 Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
• 8.1.2 Serotonin agonists
• 8.1.3 Ergot alkaloids
• 8.1.4 Other agents
• 8.1.5 Comparative studies
• 8.2 Preventative treatment
• 8.2.1 Prescription drugs
• 8.2.2 Trigger avoidance
• 8.2.3 Herbal and nutritional supplements
• 8.2.4 Surgical treatments
• 8.2.5 Noninvasive medical treatments
• 8.2.6 Behavioral treatments
• 8.2.7 Alternative medicine
• 9 History
• 10 Economic impact
• 11 Migraine and cardiovascular risks
• 12 References
• 12.1 Migraine triggers
• 12.2 Treatment
• 12.2.1 Triptans
• 12.3 General
• 12.4 Economic impact
• 12.5 Clinical picture
• 13 Footnotes
• 14 External links

[edit] Overview
Usually migraine causes episodes of severe or moderate headache (which is often one-sided and pulsating) lasting from four to 72 hours,[5] accompanied by gastrointestinal upsets, such as nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (phonophobia). Approximately one third of people who experience migraine get a preceding aura, in which a patient senses a strange light or unpleasant smell.[6]
The word migraine is French in origin and comes from the Greek hemicrania, as does the Old English term megrim. Literally, hemicrania means "half (the) head".
Migraines' secondary characteristics are inconsistent. Triggers precipitating a particular episode of migraine vary widely. The efficacy of the simplest treatment, applying warmth or coolness to the affected area of the head, varies between persons, sometimes worsening the migraine.[7] A particular migraine rescue drug may sometimes work and sometimes not work in the same patient. Some migraine types don't have pain or may manifest symptoms in parts of the body other than the head.
Available evidence suggests that migraine pain is one symptom of several to many disorders of the serotonergic control system, a dual hormone-neurotransmitter with numerous types of receptors. Two disorders — classic migraine with aura (MA, STG) and common migraine without aura (MO, STG) — have been shown to have a genetic factor.[8] Studies on twins show that genes have a 60 to 65% influence on the development of migraine (PMID 10496258 and PMID 10204850 ). Additional migraine types are suspected and could be proven to be genetic. Migraine understood as several or many disorders could explain the inconsistencies, especially if a single patient has more than one genetic type.
However, still other migraine types might be functionally acquired due to hormone organ disease or injury. Three quarters of adult migraine patients are female, although pre-pubertal migraine affects approximately equal numbers of boys and girls. This reveals the strong correlation to hormonal cycling and hormonal-related causes or triggers.[citation needed] Hormonal migraine is a likely consequence of periodically falling hormone levels causing reduction in protein biosynthesis of metabolic components including intestinal tract serotonin.
[edit] Classification
Migraines have been classified by the International Headache Society which periodically revises their classification.[9]
[edit] Defining severity of pain
In addition to classifying the type of headache, the International Headache Society defines intensity of pain on a verbal 4 point scale:[10]
• 0 no pain
• 1 mild pain 'does not interfere with usual activities'
• 2 moderate pain 'inhibits, but does not wholly prevent usual activities'
• 3 severe pain 'prevents all activities'
[edit] Migraine without aura
This is the most commonly seen form of migraine; patients who primarily suffer from migraine without aura may also have attacks of migraine with aura. According to the International Classification of Headache Disorders[9] it is a recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.
In order to diagnose migraine without aura, there must have been at least five attacks not attributable to another cause that fulfill the following criteria:
1. Headache attacks lasting 4–72 hours when untreated
2. At least two of the following characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity
3. During the headache there must be at least one of the following associated symptom clusters:
• Nausea and/or vomiting
• Photophobia and phonophobia
Where these criteria are not fully met, the problem may be classified as "probable migraine without aura" but other diagnoses such as "episodic tension type headache" must also be excluded.
[edit] Migraine with aura
This is the second most commonly seen form of migraine: patients who primarily suffer from migraine with aura may also have attacks of migraine without aura. According to the International Classification of Headache Disorders[9] it is a recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, the aura may occur without a subsequent headache or the headache may be non-migrainous in type.
In order to diagnose migraine with aura, there must have been at least two attacks not attributable to another cause that fulfill the following criteria:
1. Aura consisting of at least one of the following, but no muscle weakness or paralysis:
• Fully reversible visual symptoms (e.g. flickering lights, spots, lines, loss of vision)
• Fully reversible sensory symptoms (e.g. pins and needles, numbness)
• Fully reversible dysphasia (speech disturbance)
2. Aura has at least two of the following characteristics:
• Visual symptoms affecting just one side of the field of vision and/or sensory symptoms affecting just one side of the body
• At least one aura symptom develops gradually over more than 5 minutes and/or different aura symptoms occur one after the other over more than 5 minutes
• Each symptom lasts from 5–60 minutes
Where these criteria are not fully met, a diagnosis of "probable migraine with aura" may be considered, although other neurological causes must also be excluded. If the picture complies with the criteria but includes one-sided muscular weakness or paralysis, a diagnosis of "sporadic hemiplegic migraine" or "familial hemiplegic migraine" should be considered.
[edit] Basilar type migraine
Basilar type migraine (BTM), formerly known as basilar artery migraine (BAM) or basilar migraine (BM), is an uncommon type of complicated migraine with symptoms that result from brainstem dysfunction. Serious episodes of BTM can lead to stroke, coma, or even death. The use of triptans and other vasoconstrictors as abortive treatments in BTM is contraindicated. Abortive treatments for BTM often focus on vasodilation and restoration of normal blood flow to the vertebrobasilar territory and subsequent return of normal brainstem function.
[edit] Familial hemiplegic migraine
Main article: Familial hemiplegic migraine
Familial hemiplegic migraine 'FHM' is a type of migraine with a possible polygenetic component. These migraine attacks may last 4–72 hours[9] and are apparently caused by ion channel mutations, three types of which have been identified to date. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties. A non-familial form exists as well, "sporadic hemiplegic migraine" (SHM). It is often difficult to make the diagnosis between basilar-type migraine and hemiplegic migraine. When making the differential diagnosis is difficult, the deciding symptom is often the motor weakness or unilateral paralysis which can occur in FHM or SHM. While basilar-type migraine can present with tingling or numbness, true motor weakness and/or paralysis occur only in hemiplegic migraine.
[edit] Abdominal migraine
According to the International Classification of Headache Disorders[9] abdominal migraine is a recurrent disorder of unknown origin which occurs mainly in children. It is characterised by episodes of moderate to severe central abdominal pain lasting 1–72 hours. There is usually associated nausea and vomiting but the child is entirely well between attacks.
In order to diagnose abdominal migraine, there must be at least five attacks, not attributable to another cause, fulfilling the following criteria:
1. Attacks lasting 1–72 hours when untreated
2. Pain must have ALL of the following characteristics:
• Location in the midline, around the umbilicus or poorly localised
• Dull or 'just sore' quality
• Moderate or severe intensity
3. During an attack there must be at least two of the following:
• Loss of appetite
• Nausea
• Vomiting
• Pallor
Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.
[edit] Acephalgic migraine
Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemiparesis and other migraine symptoms but does not experience headache. Acephalgic migraine is also referred to as amigrainous migraine, ocular migraine, or optical migraine.
Sufferers of acephalgic migraine are more likely than the general population to develop classical migraine with headache.
The prevention and treatment of acephalgic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of acephalgic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.
Visual snow might be a form of acephalgic migraine.
If symptoms are primarily visual, it may be necessary to consult an ophthalmologist to rule out potential eye disease before considering this diagnosis.
[edit] Menstrual migraine
Menstrual migraine is distinct from other migraines. Approximately 21 million women in the US suffer from migraines,[11] and about 60% of them suffer from menstrual migraines.[12]

• There are two types of menstrual migraine – Menstrually Related Migraine (MRM) and Pure Menstrual Migraine (PMM)
• MRM is a headache of moderate-to-severe pain intensity that happens around the time of a woman’s period and at other times of the month as well.
• PMM is similar in every respect but only occurs around the time of a woman’s period.[13]
• The exact causes of menstrual migraine are uncertain but evidence suggest there may be a link between menstruation and migraine due to the drop in estrogen levels that normally occurs right before the period starts.[14]
• Menstrual migraine has been reported to be more likely to occur during a five-day window, from two days before to two days after menstruation.[15]

When compared with migraines that occur at other times of the month, menstrual migraines have been reported to
• Last longer—up to 72 hours[16]
• Be more severe[17][18]
• Occur more often with nausea and vomiting[19]
• Be more difficult to treat—occur more frequently[20]
[edit] Signs and symptoms
The signs and symptoms of migraine vary among patients. Therefore, what a patient experiences before, during and after an attack cannot be defined exactly. The four phases of a migraine attack listed below are common but not necessarily experienced by all migraine sufferers. Additionally, the phases experienced and the symptoms experienced during them can vary from one migraine attack to another in the same migraineur:
1. The prodrome, which occurs hours or days before the headache.
2. The aura, which immediately precedes the headache.
3. The pain phase, also known as headache phase.
4. The postdrome.
[edit] Prodrome phase
Prodromal symptoms occur in 40 to 60% of migraineurs. This phase may consist of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), constipation or diarrhea, increased urination, and other vegetative symptoms. These symptoms usually precede the headache phase of the migraine attack by several hours or days, and experience teaches the patient or observant family how to detect that a migraine attack is near.
[edit] Aura phase
For the 20–30%[21][22] of migraineurs who suffer migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. They appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes. The headache phase of the migraine attack usually begins within 60 minutes of the end of the aura phase, but it is sometimes delayed up to several hours, and it can be missing entirely. Symptoms of migraine aura can be visual, sensory, or motor in nature.[23]
Visual aura is the most common of the neurological events. There is a disturbance of vision consisting usually of unformed flashes of white and/or black or rarely of multicolored lights (photopsia) or forma¬tions of dazzling zigzag lines (scintillating scotoma; often arranged like the battlements of a castle, hence the alternative terms "fortification spectra" or "teichopsia"). Some patients complain of blurred or shimmering or cloudy vision, as though they were look¬ing through thick or smoked glass, or, in some cases, tunnel vision and hemianopsia. The somatosensory aura of migraine consists of digitolingual or cheiro-oral paresthesias, a feeling of pins-and-needles experienced in the hand and arm as well as in the ipsilateral nose-mouth area. Paresthesia migrate up the arm and then extend to involve the face, lips and tongue.
Other symptoms of the aura phase can include auditory or olfactory hallucinations, temporary dysphasia, vertigo, tingling or numbness of the face and extremities, and hypersensitivity to touch.
[edit] Pain phase
The typical migraine headache is unilateral, throbbing, moderate to severe and can be aggravated by physical activity. Not all of these features are necessary. The pain may be bilateral at the onset or start on one side and become generalized, and usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 and 48 hours in children. The frequency of attacks is extremely variable, from a few in a lifetime to several times a week, and the average migraineur experiences from one to three headaches a month. The head pain varies greatly in intensity. The pain of migraine is invariably accompanied by other features. Nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients. Many patients experience sensory hyperexcitability manifested by photophobia, phonophobia, osmophobia and seek a dark and quiet room. Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor or sweating may be noted during the headache phase. There may be localized edema of the scalp or face, scalp tenderness, prominence of a vein or artery in the temple, or stiffness and tenderness of the neck. Impairment of concentration and mood are common. Lightheadedness, rather than true vertigo and a feeling of faintness may occur. The extremities tend to be cold and moist.
[edit] Postdrome phase
The patient may feel tired, "washed out", irritable, or listless and may have impaired concentration, scalp tenderness or mood changes. Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise. Often, some of the minor headache phase symptoms may continue, such as loss of appetite, photophobia, and lightheadedness.
[edit] Diagnosis
Migraines are underdiagnosed[24] and misdiagnosed.[25] The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":
• 5 or more attacks
• 4 hours to 3 days in duration
• 2 or more of - unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
• 1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia
For migraine with aura, only two attacks are required to justify the diagnosis.
The mnemonic POUNDing (Pulsating, duration of 4–72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[26]
The presence of either disability, nausea or sensitivity, can diagnose migraine with:[27]
• sensitivity of 81%
• specificity of 75%
[edit] Pathophysiology
Migraine was once thought to be initiated by problems with blood vessels. This theory is now largely discredited.[28] Current thinking is that a phenomenon known as cortical spreading depression is responsible for the disorder.[29] In cortical spreading depression, neurological activity is depressed over an area of the cortex of the brain. This situation results in the release of inflammatory mediators leading to irritation of cranial nerve roots, most particularly the trigeminal nerve, which conveys the sensory information for the face and much of the head.
This view is supported by neuroimaging techniques, which appear to show that migraine is primarily a disorder of the brain (neurological), not of the blood vessels (vascular). A spreading depolarization (electrical change) may begin 24 hours before the attack, with onset of the headache occurring around the time when the largest area of the brain is depolarized. A French study in 2007, using the Positron Emission Tomography (PET) technique identified the hypothalamus as being critically involved in the early stages.[30] The effects of migraine may persist for some days after the main headache has ended. Many sufferers report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.
Migraine headaches can be a symptom of Hypothyroidism.
[edit] Epidemiology
Migraine is an extremely common condition which will affect 12–28% of people at some point in their lives.[31] However this figure — the lifetime prevalence — does not provide a very clear picture of how many patients there are with active migraine at any one time. Typically, therefore, the burden of migraine in a population is assessed by looking at the one-year prevalence — a figure that defines the number of patients who have had one or more attacks in the previous year. The third figure, which helps to clarify the picture, is the incidence — this relates to the number of first attacks occurring at any given age and helps understanding of how the disease grows and shrinks over time.
Based on the results of a number of studies, one year prevalence of migraine ranges from 6–15% in adult men and from 14–35% in adult women.[31] These figures vary substantially with age: approximately 4–5% of children aged under 12 suffer from migraine, with little apparent difference between boys and girls.[32] There is then a rapid growth in incidence amongst girls occurring after puberty,[33][34][35] which continues throughout early adult life.[36] By early middle age, around 25% of women experience a migraine at least once a year, compared with fewer than 10% of men.[31][37] After menopause, attacks in women tend to decline dramatically, so that in the over 70s there are approximately equal numbers of male and female sufferers, with prevalence returning to around 5%.[31][37]
At all ages, migraine without aura is more common than migraine with aura, with a ratio of between 1.5:1 and 2:1.[38][39] Incidence figures show that the excess of migraine seen in women of reproductive age is mainly due to migraine without aura.[40] Thus in pre-pubertal and post-menopausal populations, migraine with aura is somewhat more common than amongst 15–50 year olds[41][42]

Age-Gender Incidence
There is a strong relationship between age, gender and type of migraine,[43] illustrated here.

Geographical differences in migraine prevalence are not marked. Studies in Asia and South America suggest that the rates there are relatively low,[44][45] but they do not fall outside the range of values seen in European and North American studies.[31][46]
The incidence of migraine is related to the incidence of epilepsy in families, with migraine twice as prevalent in family members of epilepsy sufferers, and more common in epilepsy sufferers themselves.[47]
[edit] Triggers
A migraine trigger is any factor that, on exposure or withdrawal, leads to the development of an acute migraine headache. Triggers may be categorized as behavioral, environmental, infectious, dietary, chemical, or hormonal. In the medical literature, these factors are known as 'precipitants.'
According to the National Library of Medicine's Medical Encyclopedia, migraine attacks may be triggered by:
• Allergic reactions
• Bright lights, loud noises, and certain odors or perfumes
• Physical or emotional stress
• Changes in sleep patterns
• Smoking or exposure to smoke
• Skipping meals
• Lack of Water or dehydration
• Alcohol or caffeine
• Menstrual cycle fluctuations, birth control pills
• Tension headaches
• Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG), or nitrates (like bacon, hot dogs, and salami)
• Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products, and fermented or pickled foods.[48]
Many people report that one or more dietary, physical, hormonal, emotional, or environmental factors precipitate their migraines. The most-often reported triggers include: pesticides (sprayed fruits/vegetables), perfumes or fragrances (30% of sufferers), stress, over-illumination or glare, alcohol, foods, too much or too little sleep, and weather. Some women experience migraines in conjunction with monthly menstrual cycles.
Sometimes the migraine occurs with no apparent "cause". The trigger theory supposes that exposure to various environmental factors precipitates, or triggers, individual migraine episodes. Migraine patients have long been advised to try to identify personal headache triggers by looking for associations between their headaches and various suspected trigger factors. Patients are urged to keep a "headache diary" in which to note what they eat and when they get a headache, to look for correlations, and to try to avoid headache by avoiding factors they identify as triggers. Typically this advice is accompanied by a list of trigger factors.
[edit] Food
In 2005, authors who reviewed the medical literature[49] found that the available information about dietary trigger factors relies mostly on the subjective assessments of patients. Some suspected dietary trigger factors appear to genuinely promote or precipitate migraine episodes, but many other suspected dietary triggers have never been demonstrated to trigger migraines. The review authors found that alcohol, caffeine withdrawal, and missing meals are the most important dietary migraine precipitants. The authors say dehydration deserves more attention, and that some patients report sensitivity to red wine. The authors found little or no demonstrated evidence that notorious suspected triggers chocolate, cheese, or that histamine, tyramine, nitrates, or nitrites normally present in foods trigger headaches. The artificial sweetener aspartame (NutraSweet®) has not been shown to trigger headache, but in a large and definitive study monosodium glutamate (MSG) in large doses (2.5 grams) was associated with adverse symptoms including headache more often than was placebo. The review authors also note that while general dietary restriction has not been demonstrated to be an effective migraine therapy, it is beneficial for the individual to avoid what has been a definite cause of the migraine.
On the other hand, several headache clinics have had good results with individually tailored dietary restriction as a therapy. Dr. Ian Livingstone, director of the Princeton Headache Clinic, recommends eliminating the following common headache triggers from the diet: aged cheese, monosodium glutamate, processed fish and meats containing nitrates (such as hot dogs), dark chocolate, aspartame, certain alcoholic beverages (including red wine), citrus fruits, and caffeine. After a period of one to two months, these foods can be reintroduced one at a time to determine their trigger potential for that individual. Adding large amounts of the suspected trigger in a short time may generate a response that is easy to observe.[citation needed]
Dr. David Buchholz, a neurologist who treats headaches at Johns Hopkins Hospital, has a longer list of suspected migraine triggers. He also recommends eliminating the triggers from the diet altogether, and then reintroducing them slowly after many weeks to measure the effects. His list includes: coffee (including decaf), chocolate, monosodium glutamate, processed meats and fish (aged, canned, preserved, processed with nitrates, and some meats that contain tyramine), cheese and dairy products (the more aged, the worse), nuts, citrus and some other fruits, certain vegetables (especially onions), fresh risen yeast baked goods, dietary sources of tyramine (including the foods listed above), and whatever gives you a headache.
The National Headache Foundation has a more specific list of triggers based on the tyramine theory, which differs slightly from David Buchholz's list. For example, it says that decaffeinated coffee is allowed. The list details "Allowed", "Use with caution", and "Avoid" triggers.[50]
[edit] Weather
Several studies have found some migraines are triggered by changes in weather. One study[51] noted that 62% of the subjects in the study thought that weather was a factor, in fact 51% were actually sensitive to weather changes. Among those whose migraines did occur during a change in weather, the subjects often picked a weather change other than the actual weather data recorded. Most likely to trigger a migraine were, in order:
1. Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
2. Significant changes in weather
3. Changes in barometric pressure (See Abortive Treatment)
Another study[52] researched whether chinook winds (warm westerly winds occurring along the Front Ranges of the Rocky Mountains) are a migraine trigger. Many patients had increased incidence of migraines immediately before and/or during the chinook winds. The number of people reporting migrainous episodes during the chinook winds was higher on high-wind chinook days. The probable cause is "through increased air positive ion concentrations."
[edit] Hair wash headache
Another trigger for migraine has been proposed by Dr.K.Ravishankar, a neurologist and headache specialist from India. He reported an unusual trigger for migraine seen among women, Hair Wash Headache. It is described as a migraine headache that originates with a head bath while sitting on the floor, or hanging the head downwards for an extended period of time.[53] (Ravishankar, 2006)
[edit] Treatment
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs. Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.
Children and adolescents, are often first given drug treatment, but the value of diet modification should not be overlooked. The simple task of starting a diet journal to help modify the intake of trigger foods like hot dogs, chocolate, cheese and ice cream could help alleviate symptoms[54]
[edit] Abortive treatment
Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. A cold or hot shower directed at the head, a hot or cold wet washcloth, a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed.[citation needed]
Some headache sufferers are surprised to learn that a simple cup of coffee is used daily around the world to control minor vascular headaches that are not quite migraines.[citation needed] Minor vascular headaches are frequently associated with the hormonal fluctuations of menstrual periods, irregular eating, and unusually hard work. For migraineurs, a well-timed cup of coffee can prevent outright migraine under the same conditions.
For patients who have been diagnosed with recurring migraines, doctors recommend taking migraine abortive medicines to treat the attack as soon as possible. Migraine without aura presenting without prodrome or nausea can present with sudden onset. Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However, in many cases once an attack is underway, it can become intensely painful, last for a long time (sometimes even for several days), and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.
[edit] Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
The first line of treatment is over-the-counter abortive medication.
• Regarding non-steroidal anti-inflammatory drugs, a randomized controlled trial found that naproxen can abort about one third of migraine attacks, which was 5% less than the benefit of sumatriptan.[55]
• Paracetamol, at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a randomized controlled trial.[56]
• Simple analgesics combined with caffeine may help.[57] During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit.[citation needed] Excedrin is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an OTC treatment for migraine[citation needed].
Patients themselves often start off with paracetamol (known as acetaminophen in the USA), aspirin, ibuprofen, or other simple analgesics that are useful for tension headaches. Some patients find relief from taking Benadryl[citation needed], an over-the-counter sedative antihistamine, or anti-nausea agents. OTC drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".[citation needed]
[edit] Serotonin agonists
Main article: triptans
Sumatriptan and related selective serotonin receptor agonists are excellent for severe migraines or those that do not respond to NSAIDs[55] or other over-the-counter drugs.[56] Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.
[edit] Ergot alkaloids
Until the introduction of sumatriptan in 1991, ergot derivatives (see ergoline) were the primary oral drugs available to abort a migraine once it is established.
Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine. However, ergotamine tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favour due to the problem of ergotism. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository (or Ergostat sublingual tablets made until circa 1992). Ergotamine-caffeine 1/100 mg fixed ratio tablets (like Cafergot, Ercaf, etc.) are much less expensive per headache than triptans, and are commonly available in Asia. They are difficult to obtain in the USA. Ergotamine-caffeine can't be regularly used to abort evening or night onset migraines due to debilitating caffeine interference with sleep. Pure ergotamine tartrate is highly effective for evening-night migraines, but is rarely or never available in the USA. Dihydroergotamine (DHE), which must be injected or inhaled, can be as effective as ergotamine tartrate, but is much more expensive than $2 USD Cafergot tablets.
[edit] Other agents
If over-the-counter medications do not work, or if triptans are unaffordable, the next step for many doctors is to prescribe Fioricet or Fiorinal, which is a combination of butalbital (a barbiturate), Paracetamol (in Fioricet) or acetylsalicylic acid (more commonly known as aspirin and present in Fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches. Barbiturate-containing medications are not available in many European countries.
Narcotic pain killers (for example, codeine, morphine or other opiates) provide variable relief, but their side effects, the possibility of causing rebound headaches or analgesic overuse headache, and the risk of addiction contraindicates their general use.
Amidrine (a cocktail of a pain reliever, a sedative, and a vasoconstrictor) is sometimes prescribed for migraine headaches.
Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms. The earlier these drugs are taken in the attack, the better their effect.
Intravenous chlorpromazine has proven very effective in treating status migrainosus — intractable and unremitting migraine.[citation needed]
Status migrainosus is an extremely rare life-threatening condition.[citation needed] In otherwise uncomplicated, non-nauseated cases, it can be treated with 20 mg of prednisone tablets every eight hours until the migraine ends, followed by mandatory tapering off doses (the classic steroid taper). Prednisone is a cortisol-like semi-synthetic adrenal hormone, a non-anabolic steroid, which strongly stimulates biosynthesis of proteins from DNA. The replicated proteins include enzymes that cure the migraine through numerous metabolic boosts, including molecular construction of more natural serotonin to be stored in blood platelets.
Prednisone risks include immune system suppression, adrenal axis suppression, non-addictive dependence, and long-term osteoporosis. Vitamin antioxidants taken with calcium and magnesium may reduce the damage caused by the extra free radicals released, and the bone lost, during long term prednisone use.[citation needed]
The herbal supplement feverfew (more commonly used for migraine prevention, see below) is marketed by the GelStat Corporation as an OTC migraine abortive, administered sublingually (under the tongue) in a mixture with ginger.[58] An open-label study (funded by GelStat) found some tentative evidence of the treatment's effectiveness,[59] but no scientifically sound study has been done.
[edit] Comparative studies
Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial[60] reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain. Acetylsalicylic acid is OTC aspirin, ibuprofen is OTC Advil, and since migraineurs know they don't provide much relief, the results of this study are unexpected. They may be partly related to the dosage of acetylsalicylic acid used, which was considerably higher than the one or two 300 mg tablets normally recommended for OTC use. High doses of aspirin and ibuprofen may cause ringing of the ears, which is a sign of drug toxicity to the inner ear.
Another randomized controlled trial, funded by the manufacturer of the study drug, found that a combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone.[55]
[edit] Preventative treatment
Preventative (also called prophylactic) treatment of migraines can be an important component of migraine management. Such treatments can take many forms, including everything from taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy.[61] Another reason to pursue these goals is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which is a common problem among migraneurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache.[62]
[edit] Prescription drugs
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered.
...Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.[61]
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes:
• beta blockers such as propranolol and atenolol. A meta-analysis by the Cochrane Collaboration of nine randomized controlled trials or crossover studies, which together included 668 patients, found that propranolol had an "overall relative risk of response to treatment (here called the 'responder ratio')" was 1.94.[63]
• anticonvulsants such as valproic acid and topiramate. A meta-analysis by the Cochrane Collaboration of ten randomized controlled trials or crossover studies, which together included 1341 patients, found anticonvulsants had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a number needed to treat of 3.8.[64] However, concerns have been raised about the marketing of gabapentin.[65]
• antidepressants include tricyclic antidepressants (TCAs) such as amitriptyline and the newer selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine. A meta-analysis by the Cochrane Collaboration found selective serotonin reuptake inhibitors are no more effective than placebo.[66] Another meta-analysis found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.[67] A randomized controlled trial found that amitriptyline was better than placebo and similar to propranolol.[68]
Other drugs:
• Sansert was withdrawn from the US market by Novartis, but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including retroperitoneal fibrosis.
• Namenda, memantine HCI tablets, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
• ASA or Asprin can be taken daily in low doses such as 80 to 81 mg, the blood thinners in ASA has been shown to help some migrainures, especially those who have an aura.
[edit] Trigger avoidance
Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. Beyond an often pronounced placebo effect, general dietary restriction has not been demonstrated to be an effective approach to treating migraine.[2]
Nonetheless, some people fervently claim that they have successfully identified foods that are likely to result in migraines, and by avoiding them, can decrease the likelihood of an episode.
[edit] Herbal and nutritional supplements
50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex®, does not.[3]
Cannabis was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted. Some migraine sufferers report that cannabis increases throbbing and pain, especially if smoked. A pharmaceutical company is currently conducting trials of a whole cannabis extract spray for migraine[4]
Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In an open-label trial,[69] Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.[70]
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive.[71] However, since then, more studies have been carried out.[72] As well as its prophylactic properties, feverfew is also touted as a migraine abortative; see above.
Kudzu root (Pueraria lobata) has been demonstrated to help with menstrual migraine headaches and cluster headaches. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors. Kudzu Monograph at Med-Owl.
Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9–12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.[73]
The supplement Riboflavin (also called Vitamin B2) has been shown (in a placebo-controlled trial)[74] to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months.[75][76]
There is tentative evidence that Vitamin B12 may be effective in preventing migraines.[75] In particular, in an open-label pilot study, 1 mg of intranasal hydroxocobalamin (a form of Vitamin B12), taken daily for three months, was shown to reduce migraine frequency by 50% or more in 10 of 19 participants.[77] Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.[78]
[edit] Surgical treatments
In 2005, research[79] was published indicating that in some people with a patent foramen ovale (PFO), a hole between the upper chambers of the heart, suffer from migraines which may have been caused by the PFO. The migraines reduce in frequency if the hole is patched. Several clinical trials are currently under way in an effort to determine if a causal link between PFO and migraine can be found. Early speculation as to this relationship has centered on the idea that the lungs detoxify blood as it passes through. The PFO allows uncleaned blood to go directly from the right side of the heart to the left without passing through the lungs.
Botox is being used by many headache specialists for patients with frequent or chronic migraines with encouraging results.[80]
Spinal cord stimulators are an implanted medical device sometimes used for those who suffer severe migraines several days each month.[81]
[edit] Noninvasive medical treatments
Transcranial Magnetic Stimulation (TMS): At the 49th Annual meeting of the American Headache Society in June 2006, scientists from Ohio State University Medical Center presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression, obsessive compulsive disorder and tinnitus, among other ailments — helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.[5] In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[6] Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.[82]
Biofeedback has been used successfully by some to control migraine symptoms through training and practice.[83]
Hyperbaric oxygen therapy has been used successfully in treating migraines.[84] This suggests that sufferers might be treated during an attack with a hyperbaric chamber of some sort, such as a Gamow bag (as is done in the treatment of "The Bends" and altitude sickness).
Bruxism, clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.
There is a speculative connection between vision correction (particular with prism eyeglasses) and migraines. Two British studies, one from 1934[85] and another from 1956[86] claimed that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism. However, both studies are subject to criticism because of sample bias, sample size, and the lack of a control group. A more recent study [7] found that precision tinted lenses may be an effective migraine treatment. (Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.)
[edit] Behavioral treatments
Many physicians believe that exercise for 15–20 minutes per day is helpful for reducing the frequency of migraines.[87]
Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.
Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches.
Sexual activity has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases.[8]
In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
[edit] Alternative medicine
A number of forms of alternative medicine, particularly bodywork, are used in preventing migraines.
Massage therapy and physical therapy are often very effective forms of treatment to reduce the frequency and intensity of migraines. However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can 'trigger' a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments.
Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that Myofascial Release can relieve this tension and in doing so reduce or eliminate the stress headache element.[citation needed]
Some migraine sufferers find relief through acupuncture, which is usually used to help prevent headaches from developing.[88] Sometimes acupuncture is used to relieve the pain of an active migraine headache.[89] In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.[citation needed]
Additionally acupressure is used by some for relief. For instance pressure between the thumbs and index finger to help subside headaches if the headache or migraine isn't too severe.[citation needed]
Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents.[90] However, some scents can be a trigger factor.
[edit] History
9000 year old skulls exist with evidence of trepanation. It is hypothesized that this drastic step was taken in response to headaches, though there is no clear evidence proving this.[citation needed]. Headache with neuralgia was recorded in the medical documents of the ancient Egyptians as early as 1200 BC. In 400 BC Hippocrates described the visual aura that can precede the migraine headache and the relief which can occur through vomiting. Aretaeus of Cappadocia is credited as the "discoverer" of migraines because of his second century description of the symptoms of a unilateral headache associated with vomiting, with headache-free intervals in between attacks. Galenus of Pergamon used the term "hemicrania" (half-head), from which the word "migraine" was derived. He thought there was a connection between the stomach and the brain because of the nausea and vomiting that often accompany an attack. For relief of migraine, Andalusian-born physician Abulcasis, also known as Abu El Quasim, suggested application of a hot iron to the head or insertion of garlic into an incision made in the temple. In the Medieval Ages migraine was recognized as a discrete medical disorder with treatment ranging from hot irons to blood letting and even witchcraft[citation needed]. Followers of Galenus explained migraine as caused by aggressive yellow bile. Ebn Sina (Avicenna) described migraine in his textbook "El Qanoon fel teb" as "... small movements, drinking and eating, and sounds provoke the pain... the patient cannot tolerate the sound of speaking and light. He would like to rest in darkness alone." Abu Bakr Mohamed Ibn Zakariya Râzi noted the association of headache with different events in the lives of women, "...And such a headache may be observed after delivery and abortion or during menopause and dysmenorrhea."
In Bibliotheca Anatomica, Medic, Chirurgica, published in London in 1712, five major types of headaches are described, including the "Megrim", recognizable as classic migraine. Graham and Wolff (1938) published their paper advocating ergotamine tart for relieving migraine. Later in the 20th century, Harold Wolff (1950) developed the experimental approach to the study of headache and elaborated the vascular theory of migraine, which has come under attack as the pendulum again swings to the neurogenic theory.
[edit] Economic impact
In addition to being a major cause of pain and suffering, chronic migraine attacks are a significant source of both medical costs and lost productivity. Medical costs per migraine sufferer (mostly physician and emergency room visits) averaged $107 USD over six months in one 1988 study,[citation needed] with total costs including lost productivity averaging $313. Annual employer cost of lost productivity due to migraines was estimated at $3,309 per sufferer. Total medical costs associated with migraines in the United States amounted to one billion dollars in 1994, in addition to lost productivity estimated at thirteen to seventeen billion dollars per year. Employers may benefit from educating themselves on the effects of migraines in order to facilitate a better understanding in the workplace. The workplace model of 9–5, 5 days a week may not be viable for a migraine sufferer. With education and understanding an employer could compromise with an employee to create a workable solution for both.
[edit] Migraine and cardiovascular risks
The risk of stroke may be increased two- to threefold in migraine sufferers. Young adult sufferers and women using hormonal contraception appear to be at particular risk.[91] The mechanism of any association is unclear, but chronic abnormalities of cerebral blood vessel tone may be involved. Women who experience auras have been found to have twice the risk of strokes and heart attacks over non-aura migraine sufferers and women who do not have migraines.[92][91] Migraine sufferers seem to be at risk for both thrombotic and hemorrhagic stroke as well as transient ischemic attacks.[93] Death from cardiovascular causes was higher in people with migraine with aura in a Women's Health Initiative study, but more research is needed to confirm this.[94][95]

The term "sick building syndrome" (SBS) is used to describe situations in which building occupants experience acute health and comfort effects that appear to be linked to time spent in a building, but no specific illness or cause can be identified. The complaints may be localized in a particular room or zone, or may be widespread throughout the building. In contrast, the term "building related illness" (BRI) is used when symptoms of diagnosable illness are identified and can be attributed directly to airborne building contaminants.
A 1984 World Health Organization Committee report suggested that up to 30 percent of new and remodeled buildings worldwide may be the subject of excessive complaints related to indoor air quality (IAQ). Often this condition is temporary, but some buildings have long-term problems. Frequently, problems result when a building is operated or maintained in a manner that is inconsistent with its original design or prescribed operating procedures. Sometimes indoor air problems are a result of poor building design or occupant activities.
Indicators of SBS include:
• Building occupants complain of symptoms associated with acute discomfort, e.g., headache; eye, nose, or throat irritation; dry cough; dry or itchy skin; dizziness and nausea; difficulty in concentrating; fatigue; and sensitivity to odors.
• The cause of the symptoms is not known.
• Most of the complainants report relief soon after leaving the building.
Indicators of BRI include:
• Building occupants complain of symptoms such as cough; chest tightness; fever, chills; and muscle aches
• The symptoms can be clinically defined and have clearly identifiable causes.
• Complainants may require prolonged recovery times after leaving the building.
It is important to note that complaints may result from other causes. These may include an illness contracted outside the building, acute sensitivity (e.g., allergies), job related stress or dissatisfaction, and other psychosocial factors. Nevertheless, studies show that symptoms may be caused or exacerbated by indoor air quality problems.
Causes of Sick Building Syndrome
A Word About Radon and Asbestos...
SBS and BRI are associated with acute or immediate health problems; radon and asbestos cause long-term diseases which occur years after exposure, and are therefore not considered to be among the causes of sick buildings. This is not to say that the latter are not serious health risks; both should be included in any comprehensive evaluation of a building's IAQ.
See and
The following have been cited causes of or contributing factors to sick building syndrome:
Inadequate ventilation: In the early and mid 1900's, building ventilation standards called for approximately 15 cubic feet per minute (cfm) of outside air for each building occupant, primarily to dilute and remove body odors. As a result of the 1973 oil embargo, however, national energy conservation measures called for a reduction in the amount of outdoor air provided for ventilation to 5 cfm per occupant. In many cases these reduced outdoor air ventilation rates were found to be inadequate to maintain the health and comfort of building occupants. Inadequate ventilation, which may also occur if heating, ventilating, and air conditioning (HVAC) systems do not effectively distribute air to people in the building, is thought to be an important factor in SBS. In an effort to achieve acceptable IAQ while minimizing energy consumption, the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recently revised its ventilation standard to provide a minimum of 15 cfm of outdoor air per person (20 cfm/person in office spaces). Up to 60 cfm/person may be required in some spaces (such as smoking lounges) depending on the activities that normally occur in that space (see ASHRAE Standard 62-1989).
Chemical contaminants from indoor sources: Most indoor air pollution comes from sources inside the building. For example, adhesives, carpeting, upholstery, manufactured wood products, copy machines, pesticides, and cleaning agents may emit volatile organic compounds (VOCs), including formaldehyde. Environmental tobacco smoke contributes high levels of VOCs, other toxic compounds, and respirable particulate matter. Research shows that some VOCs can cause chronic and acute health effects at high concentrations, and some are known carcinogens. Low to moderate levels of multiple VOCs may also produce acute reactions. Combustion products such as carbon monoxide, nitrogen dioxide, as well as respirable particles, can come from unvented kerosene and gas space heaters, woodstoves, fireplaces and gas stoves. For more information, see VOCs; Carbon Monoxide; Formaldehyde; Nitrogen Dioxide; Respirable Particles.
Chemical contaminants from outdoor sources: The outdoor air that enters a building can be a source of indoor air pollution. For example, pollutants from motor vehicle exhausts; plumbing vents, and building exhausts (e.g., bathrooms and kitchens) can enter the building through poorly located air intake vents, windows, and other openings. In addition, combustion products can enter a building from a nearby garage.
Biological contaminants: Bacteria, molds, pollen, and viruses are types of biological contaminants. These contaminants may breed in stagnant water that has accumulated in ducts, humidifiers and drain pans, or where water has collected on ceiling tiles, carpeting, or insulation. Sometimes insects or bird droppings can be a source of biological contaminants. Physical symptoms related to biological contamination include cough, chest tightness, fever, chills, muscle aches, and allergic responses such as mucous membrane irritation and upper respiratory congestion. One indoor bacterium, Legionella, has caused both Legionnaire's Disease and Pontiac Fever. For more information, see Biologicals and Mold.
These elements may act in combination, and may supplement other complaints such as inadequate temperature, humidity, or lighting. Even after a building investigation, however, the specific causes of the complaints may remain unknown.
Top of page
Building Investigation Procedures
The goal of a building investigation is to identify and solve indoor air quality complaints in a way that prevents them from recurring and which avoids the creation of other problems. To achieve this goal, it is necessary for the investigator(s) to discover whether a complaint is actually related to indoor air quality, identify the cause of the complaint, and determine the most appropriate corrective actions.
An indoor air quality investigation procedure is best characterized as a cycle of information gathering, hypothesis formation, and hypothesis testing. It generally begins with a walkthrough inspection of the problem area to provide information about the four basic factors that influence indoor air quality:
• the occupants
• the HVAC system
• possible pollutant pathways
• possible contaminant sources.
Preparation for a walkthrough should include documenting easily obtainable information about the history of the building and of the complaints; identifying known HVAC zones and complaint areas; notifying occupants of the upcoming investigation; and, identifying key individuals needed for information and access. The walkthrough itself entails visual inspection of critical building areas and consultation with occupants and staff.
The initial walkthrough should allow the investigator to develop some possible explanations for the complaint. At this point, the investigator may have sufficient information to formulate a hypothesis, test the hypothesis, and see if the problem is solved. If it is, steps should be taken to ensure that it does not recur. However, if insufficient information is obtained from the walk through to construct a hypothesis, or if initial tests fail to reveal the problem, the investigator should move on to collect additional information to allow formulation of additional hypotheses. The process of formulating hypotheses, testing them, and evaluating them continues until the problem is solved.
Although air sampling for contaminants might seem to be the logical response to occupant complaints, it seldom provides information about possible causes. While certain basic measurements, e.g., temperature, relative humidity, CO2, and air movement, can provide a useful "snapshot" of current building conditions, sampling for specific pollutant concentrations is often not required to solve the problem and can even be misleading. Contaminant concentration levels rarely exceed existing standards and guidelines even when occupants continue to report health complaints. Air sampling should not be undertaken until considerable information on the factors listed above has been collected, and any sampling strategy should be based on a comprehensive understanding of how the building operates and the nature of the complaints.
Top of page
Solutions to Sick Building Syndrome
Solutions to sick building syndrome usually include combinations of the following:
Pollutant source removal or modification is an effective approach to resolving an IAQ problem when sources are known and control is feasible. Examples include routine maintenance of HVAC systems, e.g., periodic cleaning or replacement of filters; replacement of water-stained ceiling tile and carpeting; institution of smoking restrictions; venting contaminant source emissions to the outdoors; storage and use of paints, adhesives, solvents, and pesticides in well ventilated areas, and use of these pollutant sources during periods of non-occupancy; and allowing time for building materials in new or remodeled areas to off-gas pollutants before occupancy. Several of these options may be exercised at one time.
Increasing ventilation rates and air distribution often can be a cost effective means of reducing indoor pollutant levels. HVAC systems should be designed, at a minimum, to meet ventilation standards in local building codes; however, many systems are not operated or maintained to ensure that these design ventilation rates are provided. In many buildings, IAQ can be improved by operating the HVAC system to at least its design standard, and to ASHRAE Standard 62-1989 if possible. When there are strong pollutant sources, local exhaust ventilation may be appropriate to exhaust contaminated air directly from the building. Local exhaust ventilation is particularly recommended to remove pollutants that accumulate in specific areas such as rest rooms, copy rooms, and printing facilities. (For a more detailed discussion of ventilation, read Fact Sheet: Ventilation and Air Quality in Offices)
Air cleaning can be a useful adjunct to source control and ventilation but has certain limitations. Particle control devices such as the typical furnace filter are inexpensive but do not effectively capture small particles; high performance air filters capture the smaller, respirable particles but are relatively expensive to install and operate. Mechanical filters do not remove gaseous pollutants. Some specific gaseous pollutants may be removed by adsorbent beds, but these devices can be expensive and require frequent replacement of the adsorbent material. In sum, air cleaners can be useful, but have limited application.
Education and communication are important elements in both remedial and preventive indoor air quality management programs. When building occupants, management, and maintenance personnel fully communicate and understand the causes and consequences of IAQ problems, they can work more effectively together to prevent problems from occurring, or to solve them if they do.

Sick building syndrome
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Sick building syndrome (SBS) is a combination of ailments (a syndrome) associated with an individual's place of work (office building) or residence. A 1984 World Health Organization report into the syndrome suggested up to 30% of new and remodelled buildings worldwide may be linked to symptoms of SBS. Most of the sick building syndrome is related to poor indoor air quality.[1]
Sick building causes are frequently pinned down to flaws in the heating, ventilation, and air conditioning (HVAC) systems. Other causes have been attributed to contaminants produced by outgassing of some types of building materials, volatile organic compounds, molds (see mold health issues), improper exhaust ventilation of light industrial chemicals used within, or fresh-air intake location / lack of adequate air filtration (see Minimum Efficiency Reporting Value).
Symptoms are often dealt with after-the-fact by boosting the overall turn-over rate of fresh air exchange with the outside air, but the new green building design goal should be to avoid most of the SBS problem sources in the first place, minimize the ongoing use of VOC cleaning compounds, and eliminate conditions that encourage allergenic, potentially-deadly[2] mold growth.

• 1 Symptoms
• 2 Causes
• 3 Prevention
• 4 See also
• 5 Notes
• 6 References
• 7 External links

[edit] Symptoms
Building occupants complain of symptoms such as:
• Headache
• Eye, nose, or throat irritation
• Dry cough; dry or itchy skin
• Dizziness and nausea
• Difficulty in concentrating
• Fatigue
• Sensitivity to odors
• Increased incidence of asthma attacks/appearance of asthma in non-asthmatics
• Personality changes such as rage/weeping/paranoia/depression
• Putative cases of bronchitis or pneumonia which do not respond to antibiotic treatment
• Symptoms resembling Irritable Bowel Syndrome (IBS)
This is a shortened list, as over 50 possible symptoms are known. It is possible for a dozen sick occupants to report a surprising array of individual symptoms which may be dismissed as unconnected. The key to discovery is the increased incidence of illnesses in general with onset or exacerbation within a fairly close time frame - usually within a period of weeks. Some sources will insist that for SBS to exist, these symptoms must disappear soon after the occupants go outside. However, this view discounts the lingering effects of various neurotoxins, which may not clear up when the occupant leaves the building. In particularly sensitive individuals, the potential for long-term health effects cannot be overlooked.
[edit] Causes
The contributing factors often relate to the design of the built environment, and may include combinations of some or all of the following:
• Indoor air pollution
• Toxic mold
• Artificial fragrance, such as dryer sheets
• Poor or inappropriate lighting (including absence of or only limited access to natural sunlight)
• Poor heating or ventilation
• Microbial or mite contamination of HVAC systems.
• Bad acoustics
• Poorly designed furnishings, furniture and equipment (e.g. computer monitors, photocopiers, etc.).
• Poor ergonomics.
• Chemical contamination.
• Biological contamination.
To the owner or operator of a "sick building", the symptoms may include high levels of employee sickness or absenteeism, lower productivity, low job satisfaction and high employee turnover.
[edit] Prevention
• Pollutant source removal or modification to storage of sources.
• Replacement of water-stained ceiling tiles and carpeting.
• Institution of smoking restrictions.
• Use paints, adhesives, solvents, and pesticides in well ventilated areas, and use of these pollutant sources during periods of non-occupancy.
• Increase the number of air exchanges, The American Society of Heating, Refrigeration & Air Conditioning Engineers recommend a minimum of 8.4 air exchanges per 24 hour period.
• Proper and Frequent Maintenance of [1]HVAC systems
[edit] See also
• Aspergillus
• Building biology
• Indoor air pollution in developing nations
• Multiple chemical sensitivity
• New car smell
• Ventilation
• Mold health issues
• Mold growth, assessment, and remediation
• Bioaerosol
• Indoor air quality
• Volatile organic compounds

Di bawah ini adalah gelar-gelar dokter spesialis di Indonesia:
• Sp.A - spesialis anak
• Sp.An - spesialis anastesi
• Sp.And - spesialis andrologi
• Sp.B - spesialis bedah umum
• Sp.B KBD - spesialis bedah (Konsultan Digestif/Pencernaan)
• Sp.B.Onk - spesialis bedah onkologi
• Sp.BA - spesialis bedah anak
• Sp.BO - spesialis bedah orthopedi
• Sp.BM - spesialis bedah mulut (dokter gigi)
• Sp.BP - spesialis bedah plastik
• Sp.BS - spesialis bedah syaraf
• Sp.BU - spesialis bedah urologi
• Sp.F - spesialis kedokteran forensik
• Sp.G - spesialis gizi
• Sp.GK - spesialis gizi klinik
• Sp.JP - spesialis jantung dan pembuluh darah
• Sp.KG - spesialis konservasi gigi (termasuk penambalan dan perawatan urat saraf gigi)(dokter gigi)
• Sp.KGA- spesialis kedokteran gigi anak (dokter gigi)
• Sp.KJ - spesialis kedokteran jiwa atau Psikiater
• Sp.KK - spesialis penyakit kulit dan kelamin (dermatologi)
• Sp.KN - spesialis kedokteran nuklir
• Sp.KO - spesialis kedokteran olahraga
• Sp.KP - spesialis kedokteran penerbangan
• Sp.M - spesialis mata
• Sp.MK - spesialis mikrobiologi klinik
• Sp.Ort - spesialis orthodonti (meratakan gigi)(dokter gigi)
• Sp.OG - spesialis obstetri ginekologi (kebidanan dan kandungan)
• Sp.Ok - spesialis kedokteran okupasi (kerja)
• Sp.OT - spesialis bedah orthopaedi dan traumatologi
• Sp.P - spesialis paru (pulmonologi)
• Sp.Perio - spesialis periodonsia (jaringan gusi dan penyangga gigi)(dokter gigi)
• Sp.PA - spesialis patologi anatomi
• Sp.PD - spesialis penyakit dalam
• Sp.PK - spesialis patologi klinik
• Sp.R - spesialis radiologi
• Sp.RM - spesialis rehabilitasi medik
• Sp.S - spesialis saraf (neurologi)
• Sp.THT-KL - spesialis Telinga Hidung Tenggorok-Bedah Kepala Leher
• Sp.U - Spesialis urologi
[sunting] Tambahan gelar
Gelar yang bisa ditambahkan:
• K diakhir gelar spesialisasi berarti Konsultan/Spesialis 2/Sub Spesialis
• KAI - "Konsulen Alergi dan Imunologi" (biasanya dimiliki oleh spesialis penyakit dalam)
• KGEH - "Konsulen Gastro Entero Hepatologi" (biasanya dimiliki oleh spesialis penyakit dalam)
• KHOM - "Konsulen Hematologi Onkologi Medik" (biasanya dimiliki oleh spesialis penyakit dalam)
• KKV - khusus kardiovaskuler, misalnya Sp.BTKV (spesialis bedah thorax dan kardiovaskuler)
• KFER - "Konsulen Fertilitilty Endokrinologi Reproduksi" (biasanya dimiliki oleh spesialis kebidanan)
• KFM - "Konsulen Feto Maternal" (dimiliki oleh spesialis kebidanan-kandungan)
• Gelar yang bisa ditambahkan pada spesialis jantung dan spesialis bedah:
• FACC - "Fellow of the American College of Cardiologists"
• FACP - "Fellow of the American College of Physicians"
• FACS - "Fellow of the American College of Surgeons", menandakan anggota dari "American College of Surgeons"
• FESC - "Fellow of the European Society of Cardiology"
• FICS - "Fellow Of the International College Of Surgious"
• FIHA - "Fellows Indonesian Heart Association"
• Tambahan gelar lainnya:
• DPM - "Doctor of Podiatric Medicine"
• FAAEM - "Fellow of the American Academy of Emergency Medicine"
• FAAFP - "Fellow of the American Academy of Family Physicians"
• FACE - "Fellow of the American College of Endocrinology"
• FACEP - "Fellow of the American College of Emergency Physicians"
• FACFAS - "Fellow of the American College of Foot and Ankle Surgeons"
• FACOG - "Fellow of the American College of Obstetrics and Gynecologists"
• FCCP - "Fellow of the American College of Chest Physicians"
Sampai sekarang, pendidikan dokter spesialis masih dalam posisi dilematis:
* jumlah lulusannya belum mencukupi kebutuhan, tetapi tidak bisa juga
memperbesar kapasitas pendidikan.
* memperpendek lama pendidikan spesialis dan tetap menjaga mutu lulusan
sesuai standar.
* menetapkan standar dan mendapatkan mutu pendidikan spesialis yang mencapai
standar yang dapat dicapai oleh semua program pendidikan spesialis yang ada.
* kompensasi peserta pendidikan spesialis yang tidak seimbang dengan jumlah
waktu 'kerja'.

OK, segitu dulu.

PS: Thanks to bea that brought this topic to my attention---T

Jalan Mahal Mengubah Nasib Dokter

Sejak 1996, saat dimulainya semester baru Program Pendidikan Dokter
Spesialis (PPDS), beredar berita bahwa SPP akan dinaikkan sehingga memancing
pro dan kontra pihak-pihak terkait. Beberapa orang calon peserta pendidikan,
bahkan orang tua calon peserta, sempat menuliskan keprihatinannya pada
rubrik surat pembaca di sejumlah surat kabar.

Pendidikan kedokteran mencakup rentang yang panjang dan terdiri atas tiga
jenjang, yakni pendidikan dokter umum, doter spesialis, dan subspesialis.
Sesungguhnya, pendidikan kedokteran itu bersifat seumur hidup. Dengan
demikian, setelah mahasiswa menyelesaikan pendidikan formalnya, dia
diwajibkan mengikuti pendidikan kedokteran berkelanjutan.

Peranan pendidikan kedokteran dalam kehidupan profesi menjadi amat vital.
Bila pendidikan kedokteran diselenggarakan dengan baik, menghasilkan dokter
yang berilmu, terampil, dan beretika, tentu kehidupan profesi dokter akan
baik pula.

Tujuan pendidikan yang dicapai tidaklah sama antarberbagai negara. Hal ini
amat ditentukan kebijakan pemerintah, terutama yang menyangkut program dan
sistem kesehatan yang dianut, kebutuhan dan tuntutan kesehatan masyarakat,
serta perkembangan ilmu dan teknologi kedokteran.

Rumusan yang disusun harus mencakup tiga aspek pokok program pendidikan,
yakni pengetahuan (kognitif), keterampilan (psikomotor), dan sikap (afektif)
lulusan yang dihasilkan. Pendidikan dokter spesialis sangat unik. RS (rumah
sakit) memberikan kesempatan kepada peserta PPDS untuk mengamati dan
mengobati kasus yang beraneka macam.

Bila akan menjadi seorang ahli bedah, secara berangsur-angsur dia akan
menjalankan operasi-operasi yang makin sukar di bawah pengawasan seorang
ahli bedah senior dan dapat mengambil alih pembedahan bila diperlukan.
Singkatnya, seorang peserta PPDS belajar dengan cara magang, berlatih
menerapkan ilmu yang dipelajarinya dalam pengawasan dokter spesialis sebagai

Jumlah Terbatas

Dari sudut jumlahnya, tempat untuk pendidikan spesialis sangat terbatas.
Misalnya, dokter spesialis urologi. Untuk jumlah penduduk Indonesia yang di
atas 200 juta, baru ada 90 orang, sementara lulusan yang dihasilkan tiap
tahun hanya 1-2 orang.

Tenaga dokter spesialis di RS daerah masih kurang dan penyebarannya tidak
merata. Penempatan dokter spesialis di daerah sangat dibutuhkan agar
pelayanan kesehatan di daerah optimal. Saat ini, baru 40 persen rumah sakit
daerah tingkat II yang memiliki empat jenis dokter spesialis dasar, yakni
spesialis kebidanan, kesehatan anak, penyakit dalam, dan bedah umum.

Kendala yang ditemukan, antara lain, jumlah lulusan dokter spesialis sedikit
dibandingkan dengan kebutuhan, kesulitan proses penempatan, khususnya untuk
rumah sakit di daerah terpencil. Depkes akan memberlakukan sanksi tegas bagi
dokter spesialis yang menolak mengabdi di tempat terpencil.

Memang, semua dokter yang mengambil spesialisasi berdasarkan ketentuan
pegawai negeri otomatis mendapat bantuan dana Rp 6,5 juta per tahun ditambah
uang saku Rp 300 ribu per bulan. Tampaknya, upaya penjatuhan sanksi memang
perlu karena ditengarai jumlah dokter spesialis yang enggan bertugas ke
daerah mencapai 40 persen di antara 250 dokter yang baru lulus setiap

Keberatan yang mereka ajukan sebenarnya cukup beralasan, yakni di daerah tak
bisa berpraktik. Depkes juga akan memberikan beasiswa kepada dokter umum
yang telah menyelesaikan tugas PTT-nya untuk menempuh pendidikan
spesialisasi dengan syarat mereka bersedia ditempatkan di rumah sakit daerah
tingkat II.

Lama Pendidikan

Lama pendidikan untuk menjadi spesialis tidak seragam, tergantung bagian
keilmuan yang dipilih. Untuk menjadi seorang dokter spesialis kebidanan,
misalnya, dibutuhkan 4-5 tahun. Masa pendidikan ini akan molor jika
kurikulum belum jelas dan pendidiknya bergaya feodal.

Tidak mengherankan bila sebagian besar dokter spesialis di Indonesia berusia
tua. Hal ini disebabkan keharusan menjalani PTT dan mengikuti proses
pendidikan yang lama. Kondisi ini berbeda jauh dengan negara maju yang
sistem pendidikannya memungkinkan dokter baru untuk menjadi dokter spesialis
secara cepat.

Model pendidikan spesialis di sini terlalu lama dan merugikan. Tugas WKS
(wajib kerja sarjana) -baik I dan II, maupun PTT- yang harus dijalani para
dokter yang baru lulus mau tak mau membuat calon spesialis (dokter umum yang
baru lulus) menjadi kehilangan waktu yang sangat banyak. Tamat dokter di
usia 25 tahun, PTT selama tiga tahun (minimal), kalau diterima, langsung
pendidikan spesialis selama 4-6 tahun. Setelah itu, WKS II lagi selama 3-5

Alhasil, pada umur 40 tahun, baru seorang dokter spesialis bisa kembali ke
pinggir kota karena di tengah kota dirajai dokter spesialis senior yang
jumlahnya 5 persen populasi dokter. Apa yang bisa diharapkan dari seorang
spesialis berusia 40 tahun?

Seharusnya, para spesialis juga mulai mengembangkan diri ke arah penelitian.
Tetapi, usia spesialis sudah 40 tahun dan harus mengembalikan modal untuk
menghidupi keluarganya.

Hasilnya menjadi sangat berbeda jika dibandingkan dengan spesialis di luar
negeri yang rata-rata berusia dua puluhan tahun serta mereka meneliti pada
usia muda. Mau tak mau, perkembangan ilmu pengetahuan dan teknologi
kedokteran di Indonesia stagnan.

Kesempatan dan Mutu

Persaingan pendidikan spesialis memang tidak dapat dihindari. Harus diakui,
terdapat perbedaan mutu antara lulusan pendidikan di kota-kota besar dan
daerah. Untuk itu, perlu diadakan ujian nasional. Beberapa spesialisasi
telah melakukan ujian nasional dan internasional agar mereka siap menghadapi
era globalisasi.

Peranan organisasi profesi sangat penting untuk pendidikan spesialis dan
subspesialis. Selain menyusun standar pendidikan profesi, memantau
pelaksanan pendidikan dalam bentuk umpan balik, juga mencakup penilaian
hasil program pendidikan.

Karena itu, di negara-negara yang telah maju, ujian bagi dokter spesialis
dan subspesialis diselenggarakan organisasi profesi. Di AS, sesudah masa
pendidikannya, dokter asisten ahli menempuh sejumlah ujian yang
diselenggarakan dewan spesialis kedokteran.

Dewasa ini, terdapat dewan untuk setiap cabang spesialisasi dan dewan itu
bukanlah usaha pemerintah, melainkan organisasi yang didirikan para
spesialis ternama untuk memajukan standar ilmu kedokteran. Meskipun dewan
itu tidak memiliki kekuasaan resmi untuk memberikan izin sebagaimana
pemerintah, mereka memiliki kekuatan luar biasa besar karena dijunjung
begitu tinggi oleh rumah sakit maupun para dokter praktik.

Biaya Pendidikan

Dulu pendidikan spesialisasi terbuka untuk PNS dari DepKes sehingga peserta
tidak membayar, malah mendapat gaji. Tetapi, sekarang, dengan adanya dokter
PTT yang tidak otomatis PNS, peserta calon spesialis kebidanan, misalnya,
harus membayar SPP antara Rp 1, 2 juta hingga Rp 3 juta per semester, biaya
operasional Rp 5 juta, dan sumbangan bervariasi dari 50 juta-200 juta yang
ditentukan saat calon spesialis tes wawancara.

Proses penerimaan tersebut bergantung pada bagian spesialis yang dipilih.
Umumnya, seleksi meliputi beberapa tahap, yaitu tes tertulis, lisan, dan
wawancara. Di Unair, misalnya, sistem penerimaan seorang peserta PPDS
meliputi psikotes untuk IQ, kepribadian dan sikap, wawancara dan tes
keilmuan, serta hasil S1 menjadi pertimbangan.

Di negara lain, misalnya Singapura, calon spesialis otomatis menjadi pegawai
di rumah sakit pendidikan tempat dia bekerja dan mendapatkan gaji. Sementara
di Indonesia, dengan sistem yang berlaku saat ini, kehidupan calon dokter
spesialis cukup sulit.

Sebagai gambaran, seorang peserta PPDS dengan status PNS di UI digaji
sekitar Rp 300 ribu sebulan dan diwajibkan membayar SPP Rp 850 ribu per
semester. Tentu, dia harus menyisihkan uang untuk biaya keluarga,
pengeluaran untuk buku-buku, serta pembuatan makalah dan penelitian.

Di sini, terjadi ketimpangan antara pemasukan dan pengeluaran. Tidak heran
jika banyak keluarga yang tidak sanggup menghadapinya sehingga perceraian
pun tak terelakkan.

Pro dan Kontra

Biaya pendidikan spesialis yang akan dinaikkan dirasa tidak adil. Dengan
biaya yang ada sekarang saja, beberapa peserta PPDS sudah mengeluh.
Mendengar berita kenaikan biaya spesialis itu, sudah banyak calon peserta
yang mulai bingung. Sebab, praktis, selama PTT dia tidak bisa praktik
sehingga sukar mengumpulkan uang, kecuali gaji yang Rp 900 ribu-Rp 1 juta
per bulan.

Dengan biaya pendidikan yang tinggi, pemerataan pendidikan tidak akan
tercapai. Sebab, yang bisa masuk sudah hampir pasti adalah dokter yang sudah
punya uang dari keluarganya. Sedangkan yang mulai dari nol harus cukup puas
dengan gigit jari dan terpuruk di klinik-klinik 24 jam.

Pihak Depdikbud dan CHS sendiri belum tahu perincian yang jelas, berapa
sebetulnya biaya untuk pendidikan spesialis. Terasa aneh jika kemudian
ditetapkan biaya pendidikan spesialis dengan jumlah sekian. Padahal, tidak
bisa dijelaskan, biaya pendidikan tersebut untuk apa.

Selain itu, tidak adil jika biaya pendidikan spesialis dokter dikaitkan
biaya pendidikan program S2 bidang lain. Untuk program Magister Manajemen,
memang mereka mengeluarkan uang yang banyak selama pendidikan, tetapi itu
hanya selama dua tahun. Setelah itu, mereka dapat langsung bekerja dengan
kedudukan dan pendapatan yang jauh lebih tinggi.
* dr Sardjana SpOG, kandidat doktor ilmu kedokteran di Unair.

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Fakultas Kedokteran Universitas Indonesia
Penerimaan Calon Peserta Program
Waktu : bulan Januari dan bulan Juli
Persyaratan peserta program
Persyaratan akademik
- Syarat wajib (keharusan)
- Memiliki ijazah dokter yang diakui
- TOEFL > 500 (LPUI)
- Lulus seleksi masuk: ujian tulis dan wawancara
- Syarat tambahan (lebih disukai) - Pertimbangan
- Satu tahun pengalaman klinis (pelayanan masyarakat)
- Potensi akademik baik - IPK min 3,0 - Nilai IKA baik
- Prestasi kerja yang baik (masyarakat dan kesehatan)
- Karya ilmiah bidang kedokteran
- Rekomendasi 􀃆 mengenal kemampuan akademik
Penerimaan Calon Peserta Program
• Persyaratan pendaftaran
- Formulir pendaftaran Program Pendidikan Dokter Spesialis
- Kelengkapan formulir pendaftaran – melampirkan:
• Foto kopi ijazah dokter dan transkrip akademik
• Surat izin atasan (bila telah bekerja)
• Surat rekomendasi IDI (tdk malpraktek - pelanggaran kode
• Surat keterangan berkelakuan baik - tidak tersangkut
pelanggaran hukum dari kepolisian
• Foto kopi tanda penghargaan (bila ada)
• Pasfoto 4 x 6 sebanyak 6 lembar
• Bukti pembayaran biaya seleksi, dll yang berkaitan
Penerimaan Calon Peserta Program
• Persyaratan administratif
- Ditentukan oleh Fakultas
- Dana pengembangan : Rp. 25.000.000,- / Rp. 40.000.000,-
- SPP per semester
- Rp. 3.000.000,- (Regular : PTT, usia <35 tahun) - Rp. 15.000.000,- (Mandiri) 2 Prosedur dan Proses seleksi Di Pusat Pendidikan Dokter Spesialis Anak FKUI •Diselenggarakan oleh Panitia Seleksi masuk calon PPDS IKA •Ujian yang harus diikuti : • Ujian tulis MCQ (batas lulus 75) menilai pengetahuan kedokteran umum & IKA • Ujian TOEFL (LP-UI) (min 500) • Wawancara (min 700) - kemampuan/kompetensi kedokteran umum dan IKA - penampilan/perilaku profesional - motivasi, pandangan dan sikap terhadap bidang IKA - pengalaman dan upaya mengembangkan ilmunya - Kesiapan keluarga selama proses pendidikan - kemampuan berbahasa Inggris • Keputusan penerimaan peserta - Panitia seleksi calon PPDS - Calon PPDS 50-60 orang 􀃆 diterima 12 􀃆 20 orang (?) - Hasil seleksi dilaporkan ke FKUI 􀃆 calon peserta • Pendaftaran ulang - Peserta yg diterima harus mendaftar ulang ~ prosedur dan jadwal yang telah ditentukan - Menyelesaikan persyaratan administratif - Membayar biaya pendidikan • Biaya pendidikan - biaya pendidikan selama masa studi harus dibayar sesuai ketentuan FKUI Prosedur dan Proses seleksi Di Pusat Pendidikan Dokter Spesialis Anak FKUI Kegiatan Akademik dan Pelatihan Keprofesian PENGAYAAN ( Semester I) P-1 P-2 I NI PGD PERI M A D Y A ( S III – IV+ ) Mo-1 Mo-2 Mo-3 Mo-4 Mo-5 Mo-6 Mo-7 Mo-8 Mo-9 Mo-10 Mo-11 Mo-12 Mo-13 Mo-14 Mo-15 S E N I O R ( S V – VIII ) I NI PGD PERI TK-PS POLI-RRS RSM RSM EN Sari Pustaka, Sajian kasus (SK) Proposal, SK, Journal reading, lap jaga LJ, KK, SK, SK Longitudinal, tesis Tugas Jaga Tugas Jaga Tugas Jaga JUNIOR (S II) PROGRAM MAGISTER KEDOKTERAN PROFESI DOKTER SPESIALIS-1 PMKPDSp-1 3 Tahapan Pembekalan Magang Mandiri Jumlah SKS 15 17 17 14 14 14 16 14 121 MPA2 1 1 3 2 2 2 MPK 9 10 11 12 14 12 Profesi 79 MPA1 2 3 3 MKK 11 4 MKU 2 4 MDK 6 42 MDU 7 Magister 1 2 3 4 5 6 7 8 Total SKS Semester Substansi/ Kelompok STRUKTUR KURIKULUM PMKDSp-1 MDU : Materi Dasar Umum : Filsafat IP, etika profesi, metode penelitian, biostatitka MDK : Materi Dasar Khusus : Biologi molekuler, farmakologi klinik, Epidemiologi klinik, EBM MKU : Materi Keahlian Umum : Teknologi pendidikan, Dokumen medik, Tumbuh kembang, Nutrisi-PM, Genetika, Elektroli-asam basa MKK : Materi Keahlian Khusus : 15 subdisiplin IKA MPA : Materi Penerapan Akademik : MPA-1 : Sari Pustaka, Proposal penelitian, Tesis MPA-2 : Jurnal reading, SKL, Sajian kasus, laporan jaga, kuliah pasca sarjana, dl MPK : Materi Penerapan Keprofesian : Tata laksanapasien gawat darurat, rawat inap, rawat jalan, kasus jangka panjang, prosedur spesialistik, pediatrik subspesialistik, TK-Pedsos • Jumlah kebutuhan dokter Sp. anak (1:30.000) = 6.000 SpA • Jumlah dokter Sp. Anak saat ini : 2059 orang • Regulasi pendistribusian lulusan PPDS Anak • Departemen Kesehatan – IDAI (Pegawai Negeri Sipil) • Saat ini (>> non PNS) ?

Friday, April 13, 2007
Pendidikan Dokter Spesialis di Indonesia
Topik ini lagi hangat-hangatnya dibicarain di milis salemba6. Herannya, anggota milis yang senior dan berpangkat staf pengajar memilih diam dan bungkam tanpa komentar. Buat yang kebetulan membaca, harus saya ketengahkan disclaimer berikut: blog ini milik saya pribadi, kalau tidak setuju silahkan tinggalkan komen. komen yang menurut saya tidak suportif atau hanya menjelekjelekkan adalah preogratif saya untuk menghapusnya. Ini blog saya, bukan negara demokrasi.

Kalau pernah baca tulisan saya di multiply tentang pasien yang banyak kabur keluar negeri untuk berobat, maka sedikit banyak tulisan ini bisa mengungkap sebabnya. Agak sulit dan sakit hati sebenernya, seperti membuka borok sendiri...

Waktu saya lulus SMA dulu, dengan hati sedikit mantap saya mendaftarkan diri, via UMPTN, ke fakultas kedokteran UI, walaupun hanya pilihan ke 2 (pilihan ke 1 salah satu fakultas teknik favorit di ITB). Namun apa daya, otak saya cuman mampu untuk bersekolah di FKUI. Toh saya masih mencoba berulangkali untuk mendapatkan tempat di ITB namun selalu gagal. Pernah suatu kali saya nekat mengirimkan pendaftaran ke Purdue University di Indiana, USA. Gilanya, diterima. Lebih gila lagi, saya harus mengurungkan niat karena krisis moneter yang pada waktu itu melanda negara kita. Gak tega untuk minta uang ke bokap/nyokap segitu banyak, lebih gak tega lagi ngasih tau kalau saya akan melepaskan impian mereka untuk salah satu anaknya menjadi dokter (melihat profil kakak dan adik saya, semua orang tahu mereka gak akan doyan sekolahnya). Mulai dari sini, saya mencoba menekuni dengan sungguh-sungguh sekolah yang tadinya saya jalani hanya setengah-setengah.
Keirian saya dengan teman-teman dari fakultas lain memang sudah terasa sejak menjejakkan kaki di fakultas kedokteran. tahun 1-2 sama rasanya seperti sma kelas 4 dan 5. Dengan pelajaran yang sama dan ujian-ujian yang berturut-turut dengan type hampir sama dengan sistem sma. Ditambah dengan sistem pendidikan dan pembelajaran mereka yang jelas. Baik waktu, kurikulum dan penjurusan. Semua diorientasi dengan baik dan mengikuti sistem yang telah ada. Melihat kakak saya dan teman-temannya terlihat mereka tidak kesulitan meneruskan ke jenjang pendidikan yang lebih tinggi lagi, cuma saja dana harus mendukung. Menurut saya, mereka telah dipersiapkan betul untuk tuntuntan profesi yang mereka akan isi setelah lulus kuliah nanti.
Kembali lagi setelah saya memutuskan untuk menekuni sekolah dokter sungguh-sungguh. Kejadian ini setelah masuk tahun ke 3. Agak terlambat memang, tapi belum terlambat sama sekali untuk berubah. Mulai terlihat nilai-nilai saya yang membaik dan pujian dosen-dosen (juga pimpinan fakultas) yang mengatakan bahwa ternyata saya ada kebisaan yang lain selain metik senar bass dan nongkrong di kantin. Masuk tahun ke 4, perkuliahan saya ternyata sangat menarik karena sudah menginjak fase klinik dan melihat kasus2 dengan mata kepala sendiri. Pada tahun ke 5 dan 6 keadaan lebih menarik lagi karena kita sudah mulai dikedepankan dalam pemeriksaan pasien dan penanganan dini (malah di RS Tangerang kita terkenal dengan sebutan malaikan maut). Kembali mental saya diguncang (di-nggoncang, kalo kata teman saya Erika dari solo..). Dengan jadwal pengajaran yang acak-acakan, dosen tidak pernah ada di tempat karena praktek ngalor ngidul serta paranoia mereka mengenai kualitas dokter lulusan masa kini dan selalu membanding-bandingkan apa yang kita punya dengan keadaan di luar negeri, cukup membuat saya kebingungan dan bertanya-tanya "apakah perjalanan panjang ini ternyata suatu kesalahan?". Sempat saya mengkonfrontasi seorang dosen yang saya tahu sering kali berpikir dan berkata seperti ini, tentu saja jawabannya sangat diplomatis dan sangat manis begitu dosen tersebut melihat nama belakang saya.
Well.. setelah 7 (dari seharusnya 6) saya lulus kuliah. Dapet lebih pula, menggaet seorang gadis paling cantik dan paling seksi di sekolah itu untuk mengandung anak-anak saya (anak saya cukup bulan dan usia pernikahan kami lebih lama dari kehamilan.. hehe, dan untuk istri saya kalau membaca, boleh nanti malam pijitin kaki saya sebagai balasan). Kembali saya bingung. Saya terlahir dari keluarga yang sangat perfeksionis, tak lupa obsesif kompulsif (orang tua saya 2-2nya dokter yang berkeahlian bedah.. pantas saja). Lalu, apakah saya? hanya dokter umum yang izin praktek pun gak punya. Mau meneruskan sekolah spesialis saya pun ragu.. Meneruskan apa.. di mana.. Lalu datanglah kesempatan baik, tawaran untuk residensi di singapura ini. Terima kasih tak pernah saya ucapkan setiap hari, diberikan kesempatan untuk belajar dan berkarya di rumah sakit tingkat dunia dengan bimbingan profesor yang sangat besar baik dalam keilmuan dan kebesaran hati-nya (juga ukuran badan - lihat food review multiply saya, kebanyakan sumbangan beliau).

Memang introduction di atas agak kepanjangan. Tapi sekali lagi.. ini blog saya, terserah kan saya mau tulis seberapa panjang.. hehe.. Lets cut to the chase.

Apa permasalahan pendidikan dokter spesialis di Indonesia??

Kalau saya tangkap dari masukan teman-teman di milis salemba6, concern mereka adalah :
1. biaya spp yang sangat tinggi yang tidak dibarengi dengan pengadaan fasilitas baik pengajaran dalam bentuk bimbingan profesi ataupun sarana-prasarana lain (seperti : buku2, jurnal dan akses2 online yang sangat terbatas)
2. biaya hidup yang tinggi sebagai seorang peserta pendidikan spesialis untuk hal yang tidak terkait langsung dengan pendidikan (seperti: menyediakan dana hiburan untuk senior2, dana konsumsi sehari2 untuk senior2).
3. tidak dipersiapkan untuk pangsa pasar setelah kelulusan.

Adalah perhitungan dibawah ini (yang tidak memerlukan komputasi rumit) sebagai alasannya :
untuk menjadi residen di bidang yang sangat diminati seperti obstetri-ginekologi, bedah, kulit calon peserta pendidikan diminta untuk membayarkan uang sebesar hampir Rp.200 juta sebagai uang pangkal. Untuk yang lainnya cukup Rp. 60-80 juta saja. Setiap bulannya mereka diminta untuk membayar SPP sebesar Rp. 5-15 juta tiap bulannya tergantung keberhasilan waktu tingkat penyaringan. Selama pendidikan mereka tidak diperbolehkan untuk bekerja di rumah sakit lain (untuk cari duit..) atau klinik lain. Jadi dari mana datangnya uang dalam jumlah besar tersebut..? saya pun masih bertanya-tanya. kekaguman saya untuk mereka yang sebagian hidupnya saja sudah sulit.
Fasilitas yang didapatkan? mungkin hanya jas putih dan name-tag. Selebihnya cari sendiri. Termasuk instrumen bedah, obat-obatan, dll. Terkadang obat-obatan untuk golongan pasien yang tidak mampu harus mereka talangi sendiri diantara mereka. Dan obat-obatan ini tergolong spesial, dengan kata lain: sangat mahal. Bimbingan dari profesor/konsulen juga mereka rasakan sangat kurang. Sangat sulit untuk bertemu dengan staf-staf ahli karena pada umumnya mereka sibuk berpraktek di tempat lain. Dan secara logika, tentu mereka akan lebih mementingkan uang daripada situasi pengajaran karena lebih mendatangkan uang, secara mereka sendiri tidak dibayar banyak untuk meluangkan waktu bersama residen.
Beberapa teman dari jakarta (pada umumnya mereka yang kepepet) seringkali meminta bantuan saya untuk dicarikan bahan bakal paper atau penelitian mereka. Seingat saya pun, buku2 di perpustakaan banyak yang sudah usang. Itupun sumbangan dari alumni, bukan bagian spesialis atau (terlebih tak mungkin lagi) fakultas yang membeli. Teringat saya akan perkataan salah satu perkataan bekas staf ahli di bagian strabismus yang mengharuskan beliau untuk membawa peralatan sendiri untuk operasi, padahal instrumentasi tersebut adalah sangat mendasar untuk pendidikan.
Pada akhirnya semua bertanya : kemanakah uang yang setiap bagian ambil dengan keuntungan hampir milyaran rupiah besarnya per tahun? tidak ada yang tahu. Pihak fakultas pun tidak ambil peduli dengan tidak menjawab pertanyaan tersebut.

Membaca apa yang terjadi baru-baru ini di IPDN/STPDN Bandung, dan setelah menyambungkannya dengan pengalaman saya belajar di fkui dulu ternyata 2 institusi ini tidak ada beda-nya. Baik dalam struktur organisasi kependidikan maupun ke-absurd-an tingkah polah manusia di dalamnya. Organisasi kependidikan peserta pendidikan dokter spesialis ini secara strata berada di dalam depdiknas, namun jebolannya harus mendaftarkan diri kemudian hari ke departemen kesehatan untuk penugasan. Sumpah dan segala serapah saya ucapakan kepada petinggi-petinggi 2 departemen ini, yang secara nyata tidak tahu bagaimana menyelenggarakan pendidikan (untuk depdiknas - buat sistem ujian nasional saja sangat tidak becus!!!) atau membuat hidup dokter lebih nyaman dan aman (ini buat ibu menteri dan menteri2 sebelumnya! - peraturan ptt yang sangat tidak menguntungkan dokter dan membuka kesempatan korupsi yang sangat besar). Dalam keseharian pun, manusia-manusia yang terlibat dalam pendidikan tak ubahnya suatu sosialisasi dalam tingkat hirarki kolonial yang sangat tidak harmonis. Semakin tinggi tingkat senioritas, maka semakin tinggi tingkat elevasi dagu, semakin aneh permintaan yang harus dituruti. Saya teringat sewaktu mejalani pendidikan profesi tk 6 di obstetri-ginekologi, dimana seorang residen junior tergopoh-gopoh pada waktu sebelum buka puasa untuk mendata menu yang diinginkan senior-senior bengisnya. Walapun ada 2 orang dari mereka yang sangat rendah hati dan memilih "apa saja dik.. yang penting kamu juga kebagian yah.." atau "gak usah lah buat gue, kalo juga loe nekat beli, loe kasih sama keluarga pasien yang butuh di depan".
Hikmah yang bisa ditarik di sini adalah : manusia yang mengatur dan berpartisipasi dalam pendidikan berada dalam lingkup keterbatasan yang sangat berbahaya untuk diberikan kapasitas sebagai pencetak dokter spesialis yang bisa bersaing di tingkat dunia. Masih, sumpah serapah saya untuk dua menteri yang saya sebutkan berikutnya.

Terima kasih dan Puji syukur tak pernah saya lupa ucapkan setiap hari atas kesempatan yang diberikan untuk saya berkarya di sini. Sebetulnya Indonesia adalah pasar yang sangat potensial, bagi fakultas kedokteran sendiri dan pasaran rumah sakit. Jika saja mereka sadar bahwa pendidikan kemudian dikembalikan kepada individu-individu untuk memacu diri sendiri untuk berkreasi dan menempatkan dirinya 2 langkah didepan, hal-hal yang seharusnya diperhatikan 2 menteri paling bodoh sepanjang sejarah dan pimpinan fakultas lebih membuka diri untuk suara-suara dari 'bawah'.

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