Avoidance Of Triggers Research Articles

Treatment for moderate to severe atopic dermatitis in alpine and moderate maritime climates differentially affects helper T cells and memory B cells in children.

Treatment of atopic dermatitis (AD) is focused on topical anti-inflammatory therapy, epidermal barrier repair and trigger avoidance. Multidisciplinary treatment in both moderate maritime and alpine climates can successfully reduce disease activity in children with AD. However, it remains unclear whether abnormalities in B cell and T cell memory normalize and whether this differs between treatment strategies. To determine whether successful treatment in maritime and alpine climates normalizes B- and T lymphocytes in children with moderate to severe AD. The study was performed in the context of a trial (DAVOS trial, registered at Current Controlled Trials ISCRTN88136485) in which eighty-eight children with moderate to severe AD were randomized to 6weeks of treatment in moderate maritime climate (outpatient setting) or in the alpine climate (inpatient setting). Before and directly after treatment, disease activity was determined with SA-EASI and serum TARC, and T cell and B cell subsets were quantified in blood. Both treatment protocols achieved a significant decrease in disease activity, which was accompanied by a reduction in circulating memory Treg, transitional B cell and plasmablast numbers. Alpine climate treatment had a significantly greater effect on disease activity and was accompanied by a reduction in blood eosinophils and increases in memory B cells, CD8+ TemRO, CD4+ Tcm and CCR7+ Th2 subsets. Clinically successful treatment of AD induces changes in blood B- and T cell subsets reflecting reduced chronic inflammation. In addition, multidisciplinary inpatient treatment in the alpine climate specifically affects memory B cells, CD8+ T cells and Th2 cells. These cell types could represent good markers for treatment efficacy.

Autoimmune Progesterone Dermatitis Mistaken for Stevens-Johnson Syndrome.

Autoimmune progesterone dermatitis is an uncommon disease presenting with cyclical skin eruptions corresponding with the menstrual cycle luteal phase. Because symptoms are precipitated by rising progesterone levels, treatment relies on hormone suppression. A 22-year-old nulligravid woman presented with symptoms mistaken for Stevens-Johnson syndrome. A cyclic recurrence of symptoms occurred, and the diagnosis of autoimmune progesterone dermatitis was made by an intradermal progesterone challenge. After 48 months, her disease remained refractory to medical management, and definitive surgical treatment with bilateral oophorectomy was performed. Autoimmune progesterone dermatitis is a challenging diagnosis as a result of its rarity and variety of clinical presentations. Treatment centers on suppression of endogenous progesterone and avoidance of exogenous triggers. When these modalities fail, surgical management must be undertaken.

Pediatric abdominal migraine: current perspectives on a lesser known entity.

BackgroundAbdominal migraine (AM) is a common cause of chronic and recurrent abdominal pain in children. It is characterized by paroxysms of moderate to severe abdominal pain that is midline, periumbilical, or diffuse in location and accompanied by other symptoms including headache, anorexia, nausea, vomiting, or pallor. Despite the presence of comprehensive diagnostic criteria under Rome IV classification of functional gastrointestinal disorders (FGIDs) and International Classification of Headache Disorders, it continues to be an underdiagnosed entity.OverviewThe average age of diagnosis is 3–10 years with peak incidence at 7 years. Most of the patients have a personal or family history of migraine. Pathophysiology of the condition is believed to be similar to that of other FGIDs and cephalic migraine. It is also well recognized as a type of pediatric migraine variant. A careful history, thorough physical examination, and use of well-defined, symptom-based guidelines are needed to make a diagnosis. Selective or no testing is required to support a positive diagnosis. It resolves completely in most of the patients. However, these patients have a strong propensity to develop migraine later in life. Explanation and reassurance should be the first step once the diagnosis is made. Nonpharmacologic treatment options including avoidance of triggers, behavior therapy, and dietary modifications should be the initial line of management. Drug therapy should be considered only if symptoms are refractory to these primary interventions.ConclusionMore research focused on pathophysiology and management of AM needs to be carried out to improve outcomes in affected children.

Behaviour change strategies for internet, pornography and gaming addiction: A taxonomy and content analysis of professional and consumer websites

There is a growing body of literature on internet-related behaviours and their associated problems, including Internet Addiction (IA). Although evidence suggests most people self-treat, little is known about the type, or efficacy, of the methods they implement. The current study sought to identify and describe the change strategies used to limit or reduce IA (including internet gaming and internet pornography). The study explored the content of 79 websites containing behaviour change advice provided by experts and consumers. A total of 4459 change strategies were identified. Through pragmatic content analysis, they were classified into 19 categories and organised into four phases of goal achievement. Across the entire sample, the most frequently promoted or discussed change strategy was seeking alternatives to internet usage (20% of total strategies), followed by maintaining readiness to change (10%), and avoidance of triggers of internet usage (10%). We found the frequency and content of 16 out of the 19 change strategies differs according to the type of internet problem (i.e., general, gaming, or pornography). This research provides detailed information for the development of tailored interventions. It indicates that interventions for IA could contain the same types of change strategies, but that the specific detail of strategies needs to be tailored towards the specific type of internet problem.

Eosinophilic Esophagitis: an Important Comorbid Condition of Asthma?

Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.

Cyclic vomiting syndrome: diagnostic approach and current management strategies.

Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1–5 days followed by asymptomatic periods. The etiology of CVS is unknown, but it shares similar characteristics to migraine headaches. CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic. Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care. The goal of therapy for the remission phase is prophylaxis of further episodes. Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients. This article provides a summary of diagnostic strategies and reviews current management strategies for CVS.

School-Based Interprofessional Asthma Self-Management Education Program for Middle School Students: A Feasibility Trial.

Asthma is the most common chronic disease among school-aged children under 18 years of age and is a major cause of morbidity, loss of school days, and increased hospitalizations. Asthma disproportionately affects low-income, minority youth in Alabama. The benefits of improving asthma control and self-management have significance for improving health, preventing disease, and reducing health disparities by addressing social, behavioral, environmental, economic, and medical determinants of health. This collaborative community partnership between the Mobile County Public School System, University of South Alabama (USA), and USA Children's and Women's Hospital involved nursing students, respiratory therapy students, and medical residents from three colleges and the hospital. The research question was whether a school-based asthma self-management education program presented by an interprofessional team was feasible for teens with asthma in a medically underserved area (MUA). Middle school students with a diagnosis of asthma participated in this institutional review board-approved study. Asthma assessments, one-on-one coaching, and group education were done over five sessions, using Power Breathing for teens curriculum. Instruments were the Childhood Asthma Control Test (ACT), the Asthma Responsibility Questionnaire (ARQ), the Self-Efficacy Scale, the Pediatric Asthma Quality of Life Questionnaire (PAQLQ), peak flow monitoring, and spirometry. Eighteen students with moderate to severe persistent asthma completed the program with reduced asthma symptoms and increased asthma control, medication knowledge/skills, self-efficacy, and asthma responsibility. Adolescents with asthma need education in medication management, spacer use, peak flow, trigger avoidance, and coaching to take on the responsibility of asthma care. This multidimensional, interprofessional approach can strengthen asthma self-management in a middle school medically underserved community population.

Paroxysmal sympathetic hyperactivity syndrome caused by fat embolism syndrome

Paroxysmal sympathetic hyperactivity represents an uncommon and potentially life-threatening complication of severe brain injuries, which are most commonly traumatic. This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. Underdiagnosis is common, and delayed recognition may increase morbidity and long-term disability. Trigger avoidance and pharmacological therapy can be very successful in controlling this complication. Fat embolism syndrome is a rare but serious complication of long bone fractures. Neurologic signs, petechial hemorrhages and acute respiratory failure constitute the characteristic presenting triad. The term cerebral fat embolism is used when the neurological involvement predominates. The diagnosis is clinical, but specific neuroimaging findings can be supportive. The neurologic manifestations include different degrees of alteration of consciousness, focal deficits or seizures. Management is supportive, but good outcomes are possible even in cases with very severe presentation. We report two cases of paroxysmal sympathetic hyperactivity after cerebral fat embolism, which is a very uncommon association.

What is the role of bronchial thermoplasty in the management of severe asthma?

Asthma is a common chronic inflammatory condition of the airways. Conventional therapy comprises inhaled corticosteroid and bronchodilators as well as trigger avoidance and management of comorbid conditions. A small group remain symptomatic despite these strategies and novel therapies have been developed. Bronchial thermoplasty is a nonpharmacological therapy which targets airway smooth muscle to improve asthma control. Clinical trials to date have shown the efficacy and safety of bronchial thermoplasty with a persistent effect on extended follow up. Questions remain regarding the exact mechanism of action of bronchial thermoplasty, the cost effectiveness of the procedure and the ideal criteria for patient selection.

Factors and Issues on Treatment Adherence among Filipino Patients with Epilepsy and their Caregivers

Background. Non-adherence to treatment in epilepsy is considered as a worldwide problem ranging from 30-50% of patients. Despite its striking magnitude, only a few studies tried to explain the factors affecting it. Moreover, a standard method to measure adherence to treatment among patients is still lacking. An in-depth analysis on adherence to treatment of patients with epilepsy, taking into factor their values, beliefs, and culture, is deemed necessary. Objectives. The purpose of this qualitative study is to investigate the contributory factors and issues on treatment adherence faced by Filipino patients with epilepsy and their caregivers. This study also aimed to serve as a catalyst to further stimulate local researches on treatment adherence in epilepsy. Methods. Four focus group discussions were conducted with patients and caregivers who voluntarily agreed to participate and share their experiences on dealing with epilepsy. A total of 39 participants were included. The focus group discussions, facilitated by skilled moderators, were composed of an ice breaker and a discussion on the experiences and issues faced by the participants. The discussions were transcribed and analyzed using thematic coding. Results. Three main content categories were identified from the focus group discussions, namely, 1) accepting a life with epilepsy, 2) dealing with the disease, and 3) ensuring freedom from seizure attacks, which were further sub-categorized. From these, a number of factors affecting treatment adherence were identified and a conceptual framework was developed by the investigators. Conclusion. This study was able to demonstrate that conducting a focus group discussion was an effective means of eliciting the experiences and issues in patients and their caregivers. Several factors affecting treatment adherence such as patient-doctor relationship, financial resources, government support, adverse medication effects, religious belief, trigger avoidance, frequent reminders, and safety precautions were elucidated in this study.

Paroxysmal Dyskinesias

Paroxysmal dyskinesias (PD) are hyperkinetic movement disorders where patients usually retain consciousness. Paroxysmal dyskinesias can be kinesigenic (PKD), nonkinesigenic (PNKD), and exercise induced (PED). These are usually differentiated from each other based on their phenotypic and genotypic characteristics. Genetic causes of PD are continuing to be discovered. Genes found to be involved in the pathogenesis of PD include MR-1, PRRT2, SLC2A1, and KCNMA1. The differential diagnosis is broad as PDs can mimic psychogenic events, seizure, or other movement disorders. This review also includes secondary causes of PDs, which can range from infections, metabolic, structural malformations to malignancies. Treatment is usually based on the correct identification of type of PD. PKD responds well to antiepileptic medications, whereas PNKD and PED respond to avoidance of triggers and exercise, respectively. In this article, we review the classification, clinical features, genetics, differential diagnosis, and management of PD.

Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study.

BackgroundReducing near‐fatal asthma exacerbations is a critical problem in asthma management.ObjectivesTo determine patterns of factors preceding asthma exacerbations in a real‐world setting.MethodsIn a nationwide prospective study of 190 patients who had experienced near‐fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2‐week period before admission.ResultsThree distinct clusters of symptoms were defined employing the self‐reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle‐aged patients with low Body mass index and tendency to depression who had stopped anti‐asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle‐aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long‐acting beta‐agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild‐moderate symptoms. There were no differences in overuse of short‐acting beta‐agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters.ConclusionTo reduce severe or life‐threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti‐type 2 response‐targeted therapies should be considered for cluster C.

Review of the Diagnosis and Treatment of Periodic Paralysis.

ABSTRACTPeriodic paralyses (PPs) are rare neuromuscular disorders caused by mutations in skeletal muscle sodium, calcium, and potassium channel genes. PPs include hypokalemic paralysis, hyperkalemic paralysis, and Andersen‐Tawil syndrome. Common features of PP include autosomal dominant inheritance, onset typically in the first or second decades, episodic attacks of flaccid weakness, which are often triggered by diet or rest after exercise. Diagnosis is based on the characteristic clinic presentation then confirmed by genetic testing. In the absence of an identified genetic mutation, documented low or high potassium levels during attacks or a decrement on long exercise testing support diagnosis. The treatment approach should include both management of acute attacks and prevention of attacks. Treatments include behavioral interventions directed at avoidance of triggers, modification of potassium levels, diuretics, and carbonic anhydrase inhibitors. Muscle Nerve 57: 522–530, 2018

Re-educating immunity in respiratory allergies: the potential for hematopoietic stem cell-mediated gene therapy.

Respiratory allergies represent a significant disease burden worldwide affecting up to 300 million people globally. Medication and avoidance of known triggers do not address the underlying pathology. Traditional immunotherapies for allergy aim to reinstate immune homeostasis but require years of treatment and have poor long-term efficacy. Novel approaches, such as gene-engineered hematopoietic stem cell transplantation, induce profound antigen-specific tolerance in autoimmunity. Recent evidence shows this approach may also have therapeutic utility for allergy. Here, we review the mechanisms of antigen-specific tolerance and the potential of stem cell-mediated gene therapy to induce tolerance in allergic respiratory diseases.

Lichen planus pigmentosus and its variants: review and update.

Lichen planus pigmentosus (LPP) is considered a rare variant of lichen planus (LP). It is characterized by acquired dark brown to gray macular pigmentation located on sun-exposed areas of the face, neck, and flexures, commonly found in dark-skinned patients. In patients with LPP, an inflammatory lichenoid response results in marked pigmentary incontinence. It has been associated with hepatitis C virus, sun exposure, and contactants such as mustard oil and nickel. LPP-inversus affects fair and dark skin, predominantly involving flexural and intertriginous areas, while sun-exposed areas are spared; friction is an associated trigger. LPP along Blaschko's lines has been associated with susceptibility to genetic mosaicisms. LPP can present concomitantly with other variants of LP such as frontal fibrosing alopecia, as well as endocrinopathies, and autoimmune diseases. Treatment is difficult and consists of avoidance of triggers and topical and systemic medications in order to stop the inflammatory reaction and reduce pigmentation, improving aesthetic appearance and quality of life.

Treatable inherited rare movement disorders.

There are many rare movement disorders, and new ones are described every year. Because they are not well recognized, they often go undiagnosed for long periods of time. However, early diagnosis is becoming increasingly important. Rapid advances in our understanding of the biological mechanisms responsible for many rare disorders have enabled the development of specific treatments for some of them. Well-known historical examples include Wilson disease and dopa-responsive dystonia, for which specific and highly effective treatments have life-altering effects. In recent years, similarly specific and effective treatments have been developed for more than 30 rare inherited movement disorders. These treatments include specific medications, dietary changes, avoidance or management of certain triggers, enzyme replacement therapy, and others. This list of treatable rare movement disorders is likely to grow during the next few years because a number of additional promising treatments are actively being developed or evaluated in clinical trials. © 2017 International Parkinson and Movement Disorder Society.

Sleep and headaches: Relationships between migraine and non‐migraine headaches and sleep duration, sleep quality, chronotype, and obstructive sleep apnoea risk

ObjectivesPrimary headache disorders affect a large proportion of the world's population, and sleep factors have been increasingly implicated in their aetiology. This study aimed to assess the relationships between a number of sleep factors, sleep duration, sleep quality, and chronotype, and migraine and non‐migraine headache. The approach was multifaceted which included assessing correlations with headache frequency, mediation effects of headache triggers, and diagnostic prediction modelling.MethodA total of 378 participants retained in the dataset (85.2% female) completed a battery of online self‐report tests measuring headache diagnosis and triggers, sleep factors, psychological distress, and demographic factors.ResultsPoor sleep quality was the strongest correlate of both migraine and non‐migraine headache. Poor sleep quality also was found to mediate the effect of sensitivity to headaches triggered by lack of sleep, in the order of 10% of the effect. The predictive modelling showed that morning chronotype was a significant predictor of chronic migraine, and that evening chronotype and anxiety significantly predicted chronic non‐migraine headache diagnosis.ConclusionsThe results indicate the importance of sleep quality in the headache relationship, and how it may impact on headaches triggered by other sleep factors, namely, lack of sleep. Further investigation into the role of chronotype in headache aetiology is needed, particularly, based on two theories. The first being the Trigger Avoidance Model of Headaches, and the second being a stress‐based model related to social and occupational incompatibilities with the rhythms of more extreme morning or evening chronotypes.

Evidence-based focused approach for fulfillment of aims: Experiences of an asthma clinic

Background: A new health system for the 21st century should be based on the best scientific knowledge, according to the Institute of Medicine, US. Objective: We have evaluated the effectiveness of asthma clinic providing comprehensive care based on the best available scientific evidence. Materials and Methods: This intervention study was conducted in a tertiary care hospital having a devoted asthma clinic for the comprehensive management. All children diagnosed as having asthma were included, and data of cases managed from July 2014 to June 2016 were analyzed. Intervention - comprehensive management of asthma including assessment, monitoring, health education, avoidance of triggers, management of comorbid conditions, appropriate medications, written asthma action plan, and counseling for follow-up. Outcome measures were treatment direction, asthma control, emergency visits, and hospitalizations. Results: 260 children were treated over a 2-year period. The effects of focused approach with progressive expertise lead to statistically significant benefits over the two successive years from July 2014 to June 2015 and July 2015 to June2016. These were in: (i) Treatment direction: Cases requiring stepping up of treatment decreased from 36.49% to 17.24% (relative risk [RR]: 0.473 [95% confidence interval {CI}: 0.249-0.895]); p=0.01229, (ii) asthma control: Cases with not well-controlled asthma decreased from 16.44% to 7.02% (RR 0.427: [95% CI: 0.199-0.914]); p=0.045, (iii) emergency department visits decreased from 35.62% to 21.05% (RR 0.591: [95% CI: 0.39-0.897]), p=0.00766, (iv) hospitalizations decreased from 16.44% to 5.26% (RR 0.32: [95% CI: 0.135-0.757]), p=0.00462. Conclusion: Establishing an asthma clinic and progressive expertise leads to significant beneficial results.

Outcomes of middle fossa craniotomy for the repair of superior semicircular canal dehiscence

Superior semicircular canal dehiscence (SSCD) is a rare defect of the arcuate eminence that causes an abnormal connection between the superior semicircular canal and middle cranial fossa. Patients often present with a variety of auditory and vestibular symptoms. Trigger avoidance is the initial strategy, but surgery may be necessary in debilitating cases. We retrospectively reviewed SSCD patients undergoing repair via a middle fossa craniotomy between March 2011 and September 2015. Forty-nine patients undergoing 58 surgeries were identified. Autophony was the most common symptom at presentation (n=44; 90%). Mean follow-up was 10.9months, with 100% of patients reporting resolution of at least one symptom. Aural fullness was the most commonly resolved symptom following surgical repair (n=19/22; 86%). Hearing loss (n=11/25; 44%) and tinnitus (n=11/38; 29%) were the most common symptoms to persist following surgery. The most common symptom to develop after surgery was disequilibrium (n=4/18; 22%). Upon comparing the overall pre-operative and post-operative groups, the number of patients with autophony (p<0.0001), aural fullness (p=0.0006), hearing loss (p=0.0119), disequilibrium (p=0.0002), sound- and pressure-induced vertigo (p<0.0001), and tinnitus (p<0.0001) were significantly different. Improved clinical outcomes were demonstrated in patients undergoing SSCD repair through a middle cranial fossa approach. The most common presenting symptom (autophony) was also most likely to resolve after surgery. Hearing loss is less amenable to surgical correction. Disequilibrium developed in a small number of patients after repair.

In-Depth Review of Symptoms, Triggers, and Treatment of Occipital Migraine Headaches (Site IV).

This study reports the surgical technique and efficacy of deactivation of occipital-triggered migraine headaches. In addition, it reports the effect of surgical deactivation of occipital-triggered migraine headaches on migraine triggers and associated symptoms other than pain. One hundred ninety-five patients undergoing surgery for occipital-triggered migraine headaches performed by a single surgeon, and followed for at least 1 year, were analyzed. Median regression adjusted for age, sex, and follow-up time was used to determine postoperative reduction in occipital-specific Migraine Headache Index, which is the product of migraine duration, frequency, and severity. Reduction in migraine-days was also measured. The association between symptom or trigger resolution and occipital-specific Migraine Headache Index reduction was studied by logistic regression. Details of surgical treatment are discussed and complication rates reported. Eighty-two percent of patients (n = 160) reported successful surgery at least 12 months postoperatively (mean follow-up, 3.67 years). Eighty-six percent (n = 168) had successful surgery as measured by migraine-days. Fifty-two percent reported complete occipital-triggered migraine headaches elimination. Symptoms resolving with successful surgery beyond headache include being bothered by light and noise, feeling lightheaded, difficulty concentrating, vomiting, blurred/double vision, diarrhea, visual aura, numbness and tingling, speech difficulty, and limb weakness (p < 0.05). Triggers resolving with successful surgery include missed meals; bright sunshine; loud noise; fatigue; certain smells; stress; certain foods; coughing, straining, and bending over; letdown after stress; and weather change (p < 0.05). Surgical deactivation of occipital-triggered migraine headaches provides long-lasting migraine relief. Successful site IV surgery is associated with changes in specific symptoms and triggers. This can assist in trigger avoidance and aid occipital-triggered migraine headache trigger-site identification. Therapeutic, IV.