GENERAL MEDICINE

Diabetes Mellitus
Definition
Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It's also your brain's main source of fuel.

Description
The underlying cause of diabetes varies by type. But, no matter what type of diabetes you have, it can lead to excess sugar in your blood. Too much sugar in your blood can lead to serious health problems.
Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes conditions include prediabetes and gestational diabetes. Prediabetes occurs when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes. And prediabetes is often the precursor of diabetes unless appropriate measures are taken to prevent progression. Gestational diabetes occurs during pregnancy but may resolve after the baby is delivered.
Symptoms
Diabetes symptoms vary depending on how much your blood sugar is elevated. Some people, especially those with prediabetes or type 2 diabetes, may sometimes not experience symptoms. In type 1 diabetes, symptoms tend to come on quickly and be more severe.
Some of the signs and symptoms of type 1 diabetes and type 2 diabetes are:

• Increased thirst
• Frequent urination
• Extreme hunger
• Unexplained weight loss
• Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin)
• Fatigue
• Irritability
• Blurred vision
• Slow-healing sores
• Frequent infections, such as gums or skin infections and vaginal infections

Type 1 diabetes can develop at any age, though it often appears during childhood or adolescence. Type 2 diabetes, the more common type, can develop at any age, though it's more common in people older than 40.
When to see a doctor
If you suspect you or your child may have diabetes. If you notice any possible diabetes symptoms, contact your doctor. The earlier the condition is diagnosed, the sooner treatment can begin.
If you've already been diagnosed with diabetes. After you receive your diagnosis, you'll need close medical follow-up until your blood sugar levels stabilize
Causes
To understand diabetes, first you must understand how glucose is normally processed in the body.
How insulin works
Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas).

• The pancreas secretes insulin into the bloodstream.
• The insulin circulates, enabling sugar to enter your cells.
• Insulin lowers the amount of sugar in your bloodstream.
• As your blood sugar level drops, so does the secretion of insulin from your pancreas.

The role of glucose
Glucose — a sugar — is a source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources: food and your liver.
• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
• Your liver stores and makes glucose.
• When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range.

Causes of type 1 diabetes
The exact cause of type 1 diabetes is unknown. What is known is that your immune system — which normally fights harmful bacteria or viruses — attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.
Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what those factors are is still unclear. Weight is not believed to be a factor in type 1 diabetes.
Causes of prediabetes and type 2 diabetes
In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream.
Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of type 2 diabetes too. Being overweight is strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight.
Causes of gestational diabetes
During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin.
Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your cells and too much stays in your blood, resulting in gestational diabetes.Risk factors for diabetes depend on the type of diabetes.
Risk factors for type 1 diabetes
Although the exact cause of type 1 diabetes is unknown, factors that may signal an increased risk include:

• Family history. Your risk increases if a parent or sibling has type 1 diabetes.
• Environmental factors. Circumstances such as exposure to a viral illness likely play some role in type 1 diabetes.
• The presence of damaging immune system cells (autoantibodies). Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes autoantibodies. If you have these autoantibodies, you have an increased risk of developing type 1 diabetes. But not everyone who has these autoantibodies develops diabetes.
• Geography. Certain countries, such as Finland and Sweden, have higher rates of type 1 diabetes.

Risk factors for prediabetes and type 2 diabetes
Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and others don't. It's clear that certain factors increase the risk, however, including:

• Weight. The more fatty tissue you have, the more resistant your cells become to insulin.
• Inactivity. The less active you are, the greater your risk. Physical activity helps you control your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
• Family history. Your risk increases if a parent or sibling has type 2 diabetes.
• Race or ethnicity. Although it's unclear why, certain people — including Black, Hispanic, American Indian and Asian American people — are at higher risk.
• Age. Your risk increases as you get older. This may be because you tend to exercise less, lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing among children, adolescents and younger adults.
• Gestational diabetes. If you developed gestational diabetes when you were pregnant, your risk of developing prediabetes and type 2 diabetes increases. If you gave birth to a baby weighing more than 9 pounds (4 kilograms), you're also at risk of type 2 diabetes.
• Polycystic ovary syndrome. For women, having polycystic ovary syndrome — a common condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.
• High blood pressure. Having blood pressure over 140/90 millimeters of mercury (mm Hg) is linked to an increased risk of type 2 diabetes.
• Abnormal cholesterol and triglyceride levels. If you have low levels of high-density lipoprotein (HDL), or "good," cholesterol, your risk of type 2 diabetes is higher. Triglycerides are another type of fat carried in the blood. People with high levels of triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know what your cholesterol and triglyceride levels are.

Risk factors for gestational diabetes
Pregnant women can develop gestational diabetes. Some women are at greater risk than are others. Risk factors for gestational diabetes include:

• Age. Women older than age 25 are at increased risk.
• Family or personal history. Your risk increases if you have prediabetes — a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You're also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.
• Weight. Being overweight before pregnancy increases your risk.
• Race or ethnicity. For reasons that aren't clear, women who are Black, Hispanic, American Indian or Asian American are more likely to develop gestational diabetes.

Complications
Long-term complications of diabetes develop gradually. The longer you have diabetes — and the less controlled your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening. Possible complications include:

• Cardiovascular disease. Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you're more likely to have heart disease or stroke.
• Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in your legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward.
• Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.
• Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant.
• Eye damage (retinopathy). Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
• Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can develop serious infections, which often heal poorly. These infections may ultimately require toe, foot or leg amputation.
• Skin conditions. Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
• Hearing impairment. Hearing problems are more common in people with diabetes.
• Alzheimer's disease. Type 2 diabetes may increase the risk of dementia, such as Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears to be. Although there are theories as to how these disorders might be connected, none has yet been proved.
• Depression. Depression symptoms are common in people with type 1 and type 2 diabetes. Depression can affect diabetes management.

Complications of gestational diabetes
Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby.
Complications in your baby can occur as a result of gestational diabetes, including:

• Excess growth. Extra glucose can cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth.
• Low blood sugar. Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
• Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
• Death. Untreated gestational diabetes can result in a baby's death either before or shortly after birth.

Complications in the mother also can occur as a result of gestational diabetes, including:

• Preeclampsia. This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
• Subsequent gestational diabetes. Once you've had gestational diabetes in one pregnancy, you're more likely to have it again with the next pregnancy. You're also more likely to develop diabetes — typically type 2 diabetes — as you get older.

Complications of prediabetes
Prediabetes may develop into type 2 diabetes.
Prevention
Type 1 diabetes can't be prevented. However, the same healthy lifestyle choices that help treat prediabetes, type 2 diabetes and gestational diabetes can also help prevent them:

• Eat healthy foods. Choose foods lower in fat and calories and higher in fiber. Focus on fruits, vegetables and whole grains. Strive for variety to prevent boredom.
• Get more physical activity. Aim for about 30 minutes of moderate aerobic activity on most days of the week, or at least 150 minutes of moderate aerobic activity a week.
• Lose excess pounds. If you're overweight, losing even 7% of your body weight — for example, 14 pounds (6.4 kilograms) if you weigh 200 pounds (90.7 kilograms) — can reduce the risk of diabetes.

Don't try to lose weight during pregnancy, however. Talk to your doctor about how much weight is healthy for you to gain during pregnancy.

To keep your weight in a healthy range, focus on permanent changes to your eating and exercise habits. Motivate yourself by remembering the benefits of losing weight, such as a healthier heart, more energy and improved self-esteem.

Sometimes medication is an option as well. Oral diabetes drugs such as metformin (Glumetza, Fortamet, others) may reduce the risk of type 2 diabetes — but healthy lifestyle choices remain essential. Have your blood sugar checked at least once a year to check that you haven't developed type 2 diabetes.
Diagnosis
Symptoms of type 1 diabetes often appear suddenly and are often the reason for checking blood sugar levels. Because symptoms of other types of diabetes and prediabetes come on more gradually or may not be evident, the American Diabetes Association (ADA) has recommended screening guidelines. The ADA recommends that the following people be screened for diabetes:

• Anyone with a body mass index higher than 25 (23 for Asian Americans), regardless of age, who has additional risk factors, such as high blood pressure, abnormal cholesterol levels, a sedentary lifestyle, a history of polycystic ovary syndrome or heart disease, and who has a close relative with diabetes.
• Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, to be screened every three years thereafter.
• Women who have had gestational diabetes are advised to be screened for diabetes every three years.
• Anyone who has been diagnosed with prediabetes is advised to be tested every year.

Tests for type 1 and type 2 diabetes and prediabetes

Glycated hemoglobin (A1C) test. This blood test, which doesn't require fasting, indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells.

The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5% or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 % indicates prediabetes. Below 5.7 is considered normal.

If the A1C test results aren't consistent, the test isn't available, or you have certain conditions that can make the A1C test inaccurate — such as if you are pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:

• Random blood sugar test. A blood sample will be taken at a random time. Regardless of when you last ate, a blood sugar level of 200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L) — or higher suggests diabetes.
• Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
• Oral glucose tolerance test. For this test, you fast overnight, and the fasting blood sugar level is measured. Then you drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours.

A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.

If type 1 diabetes is suspected, your urine will be tested to look for the presence of a byproduct produced when muscle and fat tissue are used for energy because the body doesn't have enough insulin to use the available glucose (ketones). Your doctor will also likely run a test to see if you have the destructive immune system cells associated with type 1 diabetes called autoantibodies.
Tests for gestational diabetes
Your doctor will likely evaluate your risk factors for gestational diabetes early in your pregnancy:

• If you're at high risk of gestational diabetes — for example, if you were obese at the start of your pregnancy; you had gestational diabetes during a previous pregnancy; or you have a mother, father, sibling or child with diabetes — your doctor may test for diabetes at your first prenatal visit.
• If you're at average risk of gestational diabetes, you'll likely have a screening test for gestational diabetes sometime during your second trimester — typically between 24 and 28 weeks of pregnancy.

Your doctor may use the following screening tests:

Initial glucose challenge test. You'll begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level. A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered normal on a glucose challenge test, although this may vary at specific clinics or labs.
If your blood sugar level is higher than normal, it only means you have a higher risk of gestational diabetes. Your doctor will order a follow-up test to determine if you have gestational diabetes.
Follow-up glucose tolerance testing. For the follow-up test, you'll be asked to fast overnight and then have your fasting blood sugar level measured. Then you'll drink another sweet solution — this one containing a higher concentration of glucose — and your blood sugar level will be checked every hour for a period of three hours.
If at least two of the blood sugar readings are higher than the normal values established for each of the three hours of the test, you'll be diagnosed with gestational diabetes.

Treatment
Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral medications may play a role in your treatment. Eating a healthy diet, maintaining a healthy weight and participating in regular activity also are important factors in managing diabetes.
Treatments for all types of diabetes
An important part of managing diabetes — as well as your overall health — is maintaining a healthy weight through a healthy diet and exercise plan:

Healthy eating. Contrary to popular perception, there's no specific diabetes diet. You'll need to center your diet on more fruits, vegetables, lean proteins and whole grains — foods that are high in nutrition and fiber and low in fat and calories — and cut down on saturated fats, refined carbohydrates and sweets. In fact, it's the best eating plan for the entire family. Sugary foods are OK once in a while, as long as they're counted as part of your meal plan.
Yet, understanding what and how much to eat can be a challenge. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle. This will likely include carbohydrate counting, especially if you have type 1 diabetes or use insulin as part of your treatment.
Physical activity. Everyone needs regular aerobic exercise, and people who have diabetes are no exception. Exercise lowers your blood sugar level by moving sugar into your cells, where it's used for energy. Exercise also increases your sensitivity to insulin, which means your body needs less insulin to transport sugar to your cells.
Get your doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. What's most important is making physical activity part of your daily routine.
Aim for at least 30 minutes or more of aerobic exercise most days of the week, or at least 150 minutes of moderate physical activity a week. Bouts of activity can be as brief as 10 minutes, three times a day. If you haven't been active for a while, start slowly and build up gradually. It's also a good idea to avoid sitting for too long — aim to get up and move if you've been sitting for more than 30 minutes.

Treatments for type 1 and type 2 diabetes
Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent blood sugar checks, and carbohydrate counting. Treatment of type 2 diabetes primarily involves lifestyle changes, monitoring of your blood sugar, along with diabetes medications, insulin or both.

Monitoring your blood sugar. Depending on your treatment plan, you may check and record your blood sugar as many as four times a day or more often if you're taking insulin. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. People with type 2 diabetes who aren't taking insulin generally check their blood sugar much less frequently.
People who receive insulin therapy also may choose to monitor their blood sugar levels with a continuous glucose monitor. Although this technology hasn't yet completely replaced the glucose meter, it can significantly reduce the number of fingersticks necessary to check blood sugar and provide important information about trends in blood sugar levels.
Even with careful management, blood sugar levels can sometimes change unpredictably. With help from your diabetes treatment team, you'll learn how your blood sugar level changes in response to food, physical activity, medications, illness, alcohol, stress — and for women, fluctuations in hormone levels.
In addition to daily blood sugar monitoring, your doctor will likely recommend regular A1C testing to measure your average blood sugar level for the past two to three months.
Compared with repeated daily blood sugar tests, A1C testing better indicates how well your diabetes treatment plan is working overall. An elevated A1C level may signal the need for a change in your oral medication, insulin regimen or meal plan.
Your target A1C goal may vary depending on your age and various other factors, such as other medical conditions you may have. However, for most people with diabetes, the American Diabetes Association recommends an A1C of below 7%. Ask your doctor what your A1C target is.
Insulin. People with type 1 diabetes need insulin therapy to survive. Many people with type 2 diabetes or gestational diabetes also need insulin therapy.
Many types of insulin are available, including short-acting (regular insulin), rapid-acting insulin, long-acting insulin and intermediate options. Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night.
Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action. Often insulin is injected using a fine needle and syringe or an insulin pen — a device that looks like a large ink pen.
An insulin pump also may be an option. The pump is a device about the size of a small cellphone worn on the outside of your body. A tube connects the reservoir of insulin to a catheter that's inserted under the skin of your abdomen
A tubeless pump that works wirelessly is also now available. You program an insulin pump to dispense specific amounts of insulin. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.
In September 2016, the Food and Drug Administration approved the first artificial pancreas for people with type 1 diabetes who are age 14 and older. A second artificial pancreas was approved in December 2019. Since then systems have been approved for children older than 2 years old.
An artificial pancreas is also called closed-loop insulin delivery. The implanted device links a continuous glucose monitor, which checks blood sugar levels every five minutes, to an insulin pump. The device automatically delivers the correct amount of insulin when the monitor indicates it's needed.
There are more artificial pancreas (closed loop) systems currently in clinical trials.
Oral or other medications. Sometimes other oral or injected medications are prescribed as well. Some diabetes medications stimulate your pancreas to produce and release more insulin. Others inhibit the production and release of glucose from your liver, which means you need less insulin to transport sugar into your cells.
Still others block the action of stomach or intestinal enzymes that break down carbohydrates or make your tissues more sensitive to insulin. Metformin (Glumetza, Fortamet, others) is generally the first medication prescribed for type 2 diabetes.
Another class of medication called SGLT2 inhibitors may be used. They work by preventing the kidneys from reabsorbing sugar into the blood. Instead, the sugar is excreted in the urine.
Transplantation. In some people who have type 1 diabetes, a pancreas transplant may be an option. Islet transplants are being studied as well. With a successful pancreas transplant, you would no longer need insulin therapy.
But transplants aren't always successful — and these procedures pose serious risks. You need a lifetime of immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, which is why transplants are usually reserved for people whose diabetes can't be controlled or those who also need a kidney transplant.

Bariatric surgery. Although it is not specifically considered a treatment for type 2 diabetes, people with type 2 diabetes who are obese and have a body mass index higher than 35 may benefit from this type of surgery. People who've undergone gastric bypass have seen significant improvements in their blood sugar levels. However, this procedure's long-term risks and benefits for type 2 diabetes aren't yet known.

Treatment for gestational diabetes
Controlling your blood sugar level is essential to keeping your baby healthy and avoiding complications during delivery. In addition to maintaining a healthy diet and exercising, your treatment plan may include monitoring your blood sugar and, in some cases, using insulin or oral medications.
Your doctor also will monitor your blood sugar level during labor. If your blood sugar rises, your baby may release high levels of insulin — which can lead to low blood sugar right after birth.
Treatment for prediabetes
If you have prediabetes, healthy lifestyle choices can help you bring your blood sugar level back to normal or at least keep it from rising toward the levels seen in type 2 diabetes. Maintaining a healthy weight through exercise and healthy eating can help. Exercising at least 150 minutes a week and losing about 7% of your body weight may prevent or delay type 2 diabetes.
Sometimes medications — such as metformin (Glucophage, Glumetza, others) — also are an option if you're at high risk of diabetes, including when your prediabetes is worsening or if you have cardiovascular disease, fatty liver disease or polycystic ovary syndrome.
In other cases, medications to control cholesterol — statins, in particular — and high blood pressure medications are needed. Your doctor might prescribe low-dose aspirin therapy to help prevent cardiovascular disease if you're at high risk. However, healthy lifestyle choices remain key.
Signs of trouble in any type of diabetes
Because so many factors can affect your blood sugar, problems may sometimes arise that require immediate care, such as:

High blood sugar (hyperglycemia). Your blood sugar level can rise for many reasons, including eating too much, being sick or not taking enough glucose-lowering medication. Check your blood sugar level as directed by your doctor, and watch for signs and symptoms of high blood sugar — frequent urination, increased thirst, dry mouth, blurred vision, fatigue and nausea. If you have hyperglycemia, you'll need to adjust your meal plan, medications or both.
Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat. This produces toxic acids known as ketones. Watch for loss of appetite, weakness, vomiting, fever, stomach pain and a sweet, fruity breath.
You can check your urine for excess ketones with an over-the-counter ketones test kit. If you have excess ketones in your urine, consult your doctor right away or seek emergency care. This condition is more common in people with type 1 diabetes.
Hyperglycemic hyperosmolar nonketotic syndrome. Signs and symptoms of this life-threatening condition include a blood sugar reading over 600 mg/dL (33.3 mmol/L), dry mouth, extreme thirst, fever, drowsiness, confusion, vision loss and hallucinations. Hyperosmolar syndrome is caused by sky-high blood sugar that turns blood thick and syrupy.
It is seen in people with type 2 diabetes, and it's often preceded by an illness. Call your doctor or seek immediate medical care if you have signs or symptoms of this condition.
Low blood sugar (hypoglycemia). If your blood sugar level drops below your target range, it's known as low blood sugar (hypoglycemia). If you're taking medication that lowers your blood sugar, including insulin, your blood sugar level can drop for many reasons, including skipping a meal and getting more physical activity than normal. Low blood sugar also occurs if you take too much insulin or an excess of a glucose-lowering medication that promotes the secretion of insulin by your pancreas.
Check your blood sugar level regularly, and watch for signs and symptoms of low blood sugar — sweating, shakiness, weakness, hunger, dizziness, headache, blurred vision, heart palpitations, irritability, slurred speech, drowsiness, confusion, fainting and seizures. Low blood sugar is treated with quickly absorbed carbohydrates, such as fruit juice or glucose tablets.

Hypertension
Definition
a.High blood pressure (hypertension) is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease.
Short Description
Blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. A blood pressure reading is given in millimeters of mercury (mm Hg). It has two numbers.

• Top number (systolic pressure). The first, or upper, number measures the pressure in your arteries when your heart beats.
• Bottom number (diastolic pressure). The second, or lower, number measures the pressure in your arteries between beats.

You can have high blood pressure for years without any symptoms. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.
Symptoms
Most people with high blood pressure have no signs or symptoms, even if blood pressure readings reach dangerously high levels.
A few people with high blood pressure may have headaches, shortness of breath or nosebleeds, but these signs and symptoms aren't specific and usually don't occur until high blood pressure has reached a severe or life-threatening stage.
When to see a doctor
You'll likely have your blood pressure taken as part of a routine doctor's appointment.
Ask your doctor for a blood pressure reading at least every two years starting at age 18. If you're age 40 or older, or you're 18 to 39 with a high risk of high blood pressure, ask your doctor for a blood pressure reading every year.
Blood pressure generally should be checked in both arms to determine if there's a difference. It's important to use an appropriate-sized arm cuff.
Your doctor will likely recommend more-frequent readings if you've already been diagnosed with high blood pressure or have other risk factors for cardiovascular disease. Children age 3 and older will usually have blood pressure measured as a part of their yearly checkups.
If you don't regularly see your doctor, you may be able to get a free blood pressure screening at a health resource fair or other locations in your community. You can also find machines in some stores that will measure your blood pressure for free.
Public blood pressure machines, such as those found in pharmacies, may provide helpful information about your blood pressure, but they may have some limitations. The accuracy of these machines depends on several factors, such as a correct cuff size and proper use of the machines. Ask your doctor for advice on using public blood pressure machines.
Causes
There are two types of high blood pressure.
Primary (essential) hypertension
For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years.
Secondary hypertension
Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Obstructive sleep apnea
• Kidney disease
• Adrenal gland tumors
• Thyroid problems
• Certain defects you're born with (congenital) in blood vessels
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines

Risk factors
High blood pressure has many risk factors, including:

• Age. The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Race. High blood pressure is particularly common among people of African heritage, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in people of African heritage.
• Family history. High blood pressure tends to run in families.
• Being overweight or obese. The more you weigh, the more blood you need to supply oxygen and nutrients to your tissues. As the amount of blood flow through your blood vessels increases, so does the pressure on your artery walls.
• Not being physically active. People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• Using tobacco. Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow and increase your risk of heart disease. Secondhand smoke also can increase your heart disease risk.
• Too much salt (sodium) in your diet. Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet. Potassium helps balance the amount of sodium in your cells. A proper balance of potassium is critical for good heart health. If you don't get enough potassium in your diet, or you lose too much potassium due to dehydration or other health conditions, sodium can build up in your blood.
• Drinking too much alcohol. Over time, heavy drinking can damage your heart. Having more than one drink a day for women and more than two drinks a day for men may affect your blood pressure.
• If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Stress. High levels of stress can lead to a temporary increase in blood pressure. Stress-related habits such as eating more, using tobacco or drinking alcohol can lead to further increases in blood pressure.
• Certain chronic conditions. Certain chronic conditions also may increase your risk of high blood pressure, including kidney disease, diabetes and sleep apnea.

Sometimes pregnancy contributes to high blood pressure as well.
Although high blood pressure is most common in adults, children may be at risk, too. For some children, high blood pressure is caused by problems with the kidneys or heart. But for a growing number of kids, poor lifestyle habits — such as an unhealthy diet and lack of exercise — contribute to high blood pressure.
Complications
The excessive pressure on your artery walls caused by high blood pressure can damage your blood vessels as well as your organs. The higher your blood pressure and the longer it goes uncontrolled, the greater the damage.
Uncontrolled high blood pressure can lead to complications including:

• Heart attack or stroke. High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
• Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure. To pump blood against the higher pressure in your vessels, the heart has to work harder. This causes the walls of the heart's pumping chamber to thicken (left ventricular hypertrophy). Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body's needs, which can lead to heart failure.
• Weakened and narrowed blood vessels in your kidneys. This can prevent these organs from functioning normally.
• Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
• Metabolic syndrome. This syndrome is a group of disorders of your body's metabolism, including increased waist size, high triglycerides, decreased high-density lipoprotein (HDL) cholesterol (the "good" cholesterol), high blood pressure and high insulin levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
• Trouble with memory or understanding. Uncontrolled high blood pressure may also affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people with high blood pressure.
• Dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading to a certain type of dementia (vascular dementia). A stroke that interrupts blood flow to the brain also can cause vascular dementia.

Your doctor will ask questions about your medical history and do a physical examination. The doctor, nurse or other medical assistant will place an inflatable arm cuff around your arm and measure your blood pressure using a pressure-measuring gauge.
Your blood pressure generally should be measured in both arms to determine if there is a difference. It's important to use an appropriate-sized arm cuff.
Blood pressure measurements fall into several categories:

• Normal blood pressure. Your blood pressure is normal if it's below 120/80 mm Hg.
• Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from 120 to 129 mm Hg and a diastolic pressure below (not above) 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure. Elevated blood pressure may also be called prehypertension.
• Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
• Stage 2 hypertension. More-severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.
• Hypertensive crisis. A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care. If you get this result when you take your blood pressure at home, wait five minutes and retest. If your blood pressure is still this high, contact your doctor immediately. If you also have chest pain, vision problems, numbness or weakness, breathing difficulty, or any other signs and symptoms of a stroke or heart attack, call 911 or your local emergency medical number.

Both numbers in a blood pressure reading are important. But after age 50, the systolic reading is even more important. Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 80 mm Hg) but systolic pressure is high (greater than or equal to 130 mm Hg). This is a common type of high blood pressure among people older than 65.
Because blood pressure normally varies during the day and may increase during a doctor visit (white coat hypertension), your doctor will likely take several blood pressure readings at three or more separate appointments before diagnosing you with high blood pressure.
Taking your blood pressure at home
Your doctor may ask you to record your blood pressure at home to provide additional information and confirm if you have high blood pressure.
Home monitoring is an important way to confirm if you have high blood pressure, to check if your blood pressure treatment is working or to diagnose worsening high blood pressure.
Home blood pressure monitors are widely available and inexpensive, and you don't need a prescription to buy one. Home blood pressure monitoring isn't a substitute for visits to your doctor, and home blood pressure monitors may have some limitations.
Make sure to use a validated device, and check that the cuff fits. Bring the monitor with you to your doctor's office to check its accuracy once a year. Talk to your doctor about how to start checking your blood pressure at home.
Devices that measure your blood pressure at your wrist or finger aren't recommended by the American Heart Association because they can provide less reliable results.
Tests
If you have high blood pressure, your doctor may recommend tests to confirm the diagnosis and check for underlying conditions that can cause hypertension.

• Ambulatory monitoring. This 24-hour blood pressure monitoring test is used to confirm if you have high blood pressure. The device used for this test measures your blood pressure at regular intervals over a 24-hour period and provides a more accurate picture of blood pressure changes over an average day and night. However, these devices aren't available in all medical centers, and they may not be reimbursed.
• Lab tests. Your doctor may recommend a urine test (urinalysis) and blood tests, including a cholesterol test.
• Electrocardiogram (ECG or EKG). This quick and painless test measures your heart's electrical activity.
• Echocardiogram. Depending on your signs and symptoms and test results, your doctor may order an echocardiogram to check for more signs of heart disease. An echocardiogram uses sound waves to produce images of the heart.

Treatment
Changing your lifestyle can help control and manage high blood pressure. Your doctor may recommend that you make lifestyle changes including:

• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if you're overweight or obese
• Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren't enough. If diet and exercise don't help, your doctor may recommend medication to lower your blood pressure.
Medications
The type of medication your doctor prescribes for high blood pressure depends on your blood pressure measurements and overall health. Two or more blood pressure drugs often work better than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.
You should aim for a blood pressure treatment goal of less than 130/80 mm Hg if:

• You're a healthy adult age 65 or older
• You're a healthy adult younger than age 65 with a 10% or higher risk of developing cardiovascular disease in the next 10 years
• You have chronic kidney disease, diabetes or coronary artery disease

Ask your doctor what your blood pressure treatment goal should be. Also, the ideal blood pressure treatment goal can vary with age and health conditions, particularly if you're older than age 65.
Medications used to treat high blood pressure include:

• Diuretics. Diuretics, sometimes called water pills, are medications that help your kidneys eliminate sodium and water from the body. These drugs are often the first medications tried to treat high blood pressure.
• There are different classes of diuretics, including thiazide, loop and potassium sparing. Which one your doctor recommends depends on your blood pressure measurements and other health conditions, such a kidney disease or heart failure. Diuretics commonly used to treat blood pressure include chlorthalidone, hydrochlorothiazide (Microzide) and others.
• A common side effect of diuretics is increased urination, which could reduce potassium levels. If you have a low potassium level, your doctor may add a potassium-sparing diuretic — such as triamterene (Dyazide, Maxide) or spironolactone (Aldactone) — to your treatment.
• Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Prinivil, Zestril), benazepril (Lotensin), captopril and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.
• Angiotensin II receptor blockers (ARBs). These medications relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others.
• Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.
• Don't eat or drink grapefruit products when taking calcium channel blockers. Grapefruit increases blood levels of certain calcium channel blockers, which can be dangerous. Talk to your doctor or pharmacist if you're concerned about interactions.

Additional medications sometimes used to treat high blood pressure
If you're having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:

• Alpha blockers. These medications reduce nerve signals to blood vessels, lowering the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
• Alpha-beta blockers. Alpha-beta blockers block nerve signals to blood vessels and slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
• Beta blockers. These medications reduce the workload on your heart and widen your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol, atenolol (Tenormin) and others.
• Beta blockers aren't usually recommended as the only medication you're prescribed, but they may be effective when combined with other blood pressure medications.
• Aldosterone antagonists. These drugs also are considered diuretics. Examples are spironolactone and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid buildup, which can contribute to high blood pressure. They may be used to treat resistant hypertension.
• Renin inhibitors. Aliskiren (Tekturna) slows the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.
• Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.
• Vasodilators. These medications include hydralazine and minoxidil. They work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.
• Central-acting agents. These medications prevent your brain from telling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv) and methyldopa.

Treating resistant hypertension
If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension.
You're also considered to have resistant hypertension if you have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control. If you do, your doctor should investigate the possibility of a secondary cause of the high blood pressure.
Having resistant hypertension doesn't mean your blood pressure will never get lower. If you and your doctor can determine the cause, a more effective treatment plan can be created to help you meet your goal blood pressure.
Treating resistant hypertension may involve many steps, including:

• Changing your high blood pressure medications to determine which combinations and doses work best
• Reviewing all the medications you take, including those that you take for other conditions or buy without a prescription
• Monitoring your blood pressure at home to see if going to the doctor causes your blood pressure to increase (white coat hypertension)
• Making healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting alcohol

You should always take blood pressure medications as prescribed. Never skip a dose or abruptly stop taking your blood pressure medication. Suddenly stopping certain blood pressure drugs, such as beta blockers, can cause a sharp increase in blood pressure (rebound hypertension).
If you skip doses because you can't afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don't change your treatment without your doctor's guidance.
Potential future treatments
Researchers continue to study catheter-based ultrasound and radiofrequency ablation of the kidney's sympathetic nerves (renal denervation) as a treatment for resistant hypertension. Early studies showed some benefit, but more-robust studies found that the therapy does not significantly lower blood pressure in people with resistant hypertension. More research is underway to determine what role, if any, this therapy may have in treating hypertension.
Lifestyle and home remedies
Lifestyle changes can help you control and prevent high blood pressure, even if you're taking blood pressure medication. Here's what you can do:

• Eat healthy foods. Eat a heart-healthy diet. Try the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains, poultry, fish and low-fat dairy foods. Get plenty of potassium, which can help prevent and control high blood pressure. Eat less saturated fat and trans fat.
• Decrease the salt in your diet. Aim to limit sodium to less than 2,300 milligrams (mg) a day or less. However, a lower sodium intake — 1,500 mg a day or less — is ideal for most adults.
• While you can reduce the amount of salt you eat by putting down the saltshaker, you generally should also pay attention to the amount of salt that's in the processed foods you eat, such as canned soups or frozen dinners.
• Maintain a healthy weight. Keeping a healthy weight, or losing weight if you're overweight or obese, can help you control your high blood pressure and lower your risk of related health problems. In general, you may reduce your blood pressure by about 1 mm Hg with each kilogram (about 2.2 pounds) of weight you lose.
• Increase physical activity. Regular physical activity can help lower your blood pressure, manage stress, keep your weight under control and reduce your risk of many health conditions. If you have high blood pressure, consistent moderate- to high-intensity workouts can lower your top blood pressure reading by about 11 mm Hg and the bottom number by about 5 mm Hg.
• Aim for at least 150 minutes a week of moderate aerobic activity or 75 minutes a week of vigorous aerobic activity, or a combination of moderate and vigorous activity. For example, try brisk walking for about 30 minutes most days of the week. Or try interval training, in which you alternate short bursts of intense activity with short recovery periods of lighter activity. Aim to do muscle-strengthening exercises at least two days a week.
• Limit alcohol. Even if you're healthy, alcohol can raise your blood pressure. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women, and up to two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Don't smoke. Tobacco can injure blood vessel walls and speed up the process of buildup of plaque in the arteries. If you smoke, ask your doctor to help you quit.
• Manage stress. Reduce stress as much as possible. Practice healthy coping techniques, such as muscle relaxation, deep breathing or mindfulness. Getting regular physical activity and plenty of sleep can help, too.
• Monitor your blood pressure at home. Home blood pressure monitoring allows you to keep a daily log of blood pressure measurements. Your doctor can review the information to determine if your medication is working or if you're having complications. Home blood pressure monitoring isn't a substitute for visits to your doctor. Even if you get normal readings, don't stop or change your medications or alter your diet without talking to your doctor first.
• If your blood pressure is under control, ask your doctor about how often you     need to check it.
• Practice relaxation or slow, deep breathing. Practice taking deep, slow breaths to help relax. Some research shows that slow, paced breathing (five to seven deep breaths per minute) combined with mindfulness techniques can reduce blood pressure. There also are some devices available that promote slow, deep breathing. According to the American Heart Association, device-guided breathing may be a reasonable nondrug option for lowering blood pressure, especially if you have anxiety with high blood pressure or can't tolerate standard treatments well.
• Control blood pressure during pregnancy. Women with high blood pressure should discuss with their doctors how to control their blood pressure during pregnancy.

Alternative medicine
Although diet and exercise are the most appropriate tactics to lower your blood pressure, some supplements also may help lower it. However, more research is needed to determine the potential benefits. These supplements include:

• Fiber, such as blond psyllium and wheat bran
• Minerals, such as magnesium, calcium and potassium
• Folic acid
• Supplements or products that increase nitric oxide or widen blood vessels (vasodilators), such as cocoa, coenzyme Q10, L-arginine and garlic
• Omega-3 fatty acids, found in fatty fish, high-dose fish oil supplements and flaxseed

Researchers are also studying whether vitamin D can reduce blood pressure, but evidence is conflicting. More research is needed.
While it's best to include these supplements in your diet as foods, you can also take supplement pills or capsules. Talk to your doctor before adding any of these supplements to your blood pressure treatment. Some supplements can interact with medications, causing harmful side effects, such as an increased bleeding risk that could be life-threatening.
You can also practice relaxation techniques, such as deep breathing or mindfulness, to help you relax and reduce your stress level. These practices may temporarily reduce your blood pressure.
Coping and support
High blood pressure isn't a problem that you can treat and then ignore. It's a condition you need to manage for the rest of your life. To keep your blood pressure under control:

• Take your medications properly. If side effects or costs pose problems, don't stop taking your medications. Ask your doctor about other options.
• Schedule regular doctor visits. It takes a team effort to treat high blood pressure successfully. Your doctor can't do it alone, and neither can you. Work with your doctor to bring your blood pressure to a safe level and keep it there.
• Adopt healthy habits. Eat healthy foods, lose excess weight and get regular physical activity. Limit alcohol. If you smoke, quit.
• Manage stress. Say no to extra tasks, release negative thoughts, maintain good relationships, and remain patient and optimistic.

Sticking to lifestyle changes can be difficult, especially if you don't see or feel any symptoms of high blood pressure. If you need motivation, remember the risks associated with uncontrolled high blood pressure. It may help to enlist the support of your family and friends as well.
Preparing for your appointment
If you think you may have high blood pressure, make an appointment with your doctor to have your blood pressure checked.
No special preparations are necessary to have your blood pressure checked. You might want to wear a short-sleeved shirt to your appointment so that the blood pressure cuff can fit around your arm properly. Avoid eating, drinking caffeinated beverages and smoking right before your test. Plan to use the toilet before having your blood pressure measured.
Because some medications, such as over-the-counter cold medicines, pain medications, antidepressants, birth control pills and others, can raise your blood pressure, it might be a good idea to bring a list of medications and supplements you take to your doctor's appointment. Don't stop taking any prescription medications that you think may affect your blood pressure without your doctor's advice.
Because appointments can be brief, and because there's often a lot to discuss, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do

• Write down any symptoms that you're having. High blood pressure rarely has symptoms, but it's a risk factor for heart disease. Letting your doctor know if you have symptoms such as chest pains or shortness of breath can help your doctor decide how aggressively to treat your high blood pressure.
• Write down key personal information, including a family history of high blood pressure, high cholesterol, heart disease, stroke, kidney disease or diabetes, and any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements that you're taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For high blood pressure, some basic questions to ask your doctor include:

• What kinds of tests will I need?
• Do I need any medications?
• What foods should I eat or avoid?
• What's an appropriate level of physical activity?
• How often do I need to schedule appointments to check my blood pressure?
• Should I monitor my blood pressure at home?
• What are the alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist?
• Is there a generic alternative to the medicine you're prescribing for me?
• Are there any brochures or other printed material that I can take home with me?
• What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• Do you have a family history of high cholesterol, high blood pressure or heart disease?
• What are your diet and exercise habits like?
• Do you drink alcohol? How many drinks do you have in a week?
• Do you smoke?
• When did you last have your blood pressure checked? What was your blood pressure measurement then?

What you can do in the meantime
It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and getting more exercise. These are main ways to protect yourself against high blood pressure and its complications, including heart attack and stroke

Pneumonia:
Definition:Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.
Short description
Pneumonia can range in seriousness from mild to life-threatening. It is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.
Symptoms
The signs and symptoms of pneumonia vary from mild to severe, depending on factors such as the type of germ causing the infection, and your age and overall health. Mild signs and symptoms often are similar to those of a cold or flu, but they last longer.
Signs and symptoms of pneumonia may include:

• Chest pain when you breathe or cough
• Confusion or changes in mental awareness (in adults age 65 and older)
• Cough, which may produce phlegm
• Fatigue
• Fever, sweating and shaking chills
• Lower than normal body temperature (in adults older than age 65 and people with weak immune systems)
• Nausea, vomiting or diarrhea
• Shortness of breath

Newborns and infants may not show any sign of the infection. Or they may vomit, have a fever and cough, appear restless or tired and without energy, or have difficulty breathing and eating.
When to see a doctor
See your doctor if you have difficulty breathing, chest pain, persistent fever of 102 F (39 C) or higher, or persistent cough, especially if you're coughing up pus.
It's especially important that people in these high-risk groups see a doctor:

• Adults older than age 65
• Children younger than age 2 with signs and symptoms
• People with an underlying health condition or weakened immune system
• People receiving chemotherapy or taking medication that suppresses the immune system

For some older adults and people with heart failure or chronic lung problems, pneumonia can quickly become a life-threatening condition.
Causes
Many germs can cause pneumonia. The most common are bacteria and viruses in the air we breathe. Your body usually prevents these germs from infecting your lungs. But sometimes these germs can overpower your immune system, even if your health is generally good.
Pneumonia is classified according to the types of germs that cause it and where you got the infection.
Community-acquired pneumonia
Community-acquired pneumonia is the most common type of pneumonia. It occurs outside of hospitals or other health care facilities. It may be caused by:

• Bacteria. The most common cause of bacterial pneumonia in the U.S. is Streptococcus pneumoniae. This type of pneumonia can occur on its own or after you've had a cold or the flu. It may affect one part (lobe) of the lung, a condition called lobar pneumonia.
• Bacteria-like organisms. Mycoplasma pneumoniae also can cause pneumonia. It typically produces milder symptoms than do other types of pneumonia. Walking pneumonia is an informal name given to this type of pneumonia, which typically isn't severe enough to require bed rest.
• Fungi. This type of pneumonia is most common in people with chronic health problems or weakened immune systems, and in people who have inhaled large doses of the organisms. The fungi that cause it can be found in soil or bird droppings and vary depending upon geographic location.
• Viruses, including COVID-19. Some of the viruses that cause colds and the flu can cause pneumonia. Viruses are the most common cause of pneumonia in children younger than 5 years. Viral pneumonia is usually mild. But in some cases it can become very serious. Coronavirus 2019 (COVID-19) may cause pneumonia, which can become severe.

Hospital-acquired pneumonia
Some people catch pneumonia during a hospital stay for another illness. Hospital-acquired pneumonia can be serious because the bacteria causing it may be more resistant to antibiotics and because the people who get it are already sick. People who are on breathing machines (ventilators), often used in intensive care units, are at higher risk of this type of pneumonia.
Health care-acquired pneumonia
Health care-acquired pneumonia is a bacterial infection that occurs in people who live in long-term care facilities or who receive care in outpatient clinics, including kidney dialysis centers. Like hospital-acquired pneumonia, health care-acquired pneumonia can be caused by bacteria that are more resistant to antibiotics.
Aspiration pneumonia
Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into your lungs. Aspiration is more likely if something disturbs your normal gag reflex, such as a brain injury or swallowing problem, or excessive use of alcohol or drugs.
Risk factors
Pneumonia can affect anyone. But the two age groups at highest risk are:

• Children who are 2 years old or younger
• People who are age 65 or older

Other risk factors include:

• Being hospitalized. You're at greater risk of pneumonia if you're in a hospital intensive care unit, especially if you're on a machine that helps you breathe (a ventilator).
• Chronic disease. You're more likely to get pneumonia if you have asthma, chronic obstructive pulmonary disease (COPD) or heart disease.
• Smoking. Smoking damages your body's natural defenses against the bacteria and viruses that cause pneumonia.
• Weakened or suppressed immune system. People who have HIV/AIDS, who've had an organ transplant, or who receive chemotherapy or long-term steroids are at risk.

Complications
Even with treatment, some people with pneumonia, especially those in high-risk groups, may experience complications, including:

• Bacteria in the bloodstream (bacteremia). Bacteria that enter the bloodstream from your lungs can spread the infection to other organs, potentially causing organ failure.

• Difficulty breathing. If your pneumonia is severe or you have chronic underlying lung diseases, you may have trouble breathing in enough oxygen. You may need to be hospitalized and use a breathing machine (ventilator) while your lung heals.

• Fluid accumulation around the lungs (pleural effusion). Pneumonia may cause fluid to build up in the thin space between layers of tissue that line the lungs and chest cavity (pleura). If the fluid becomes infected, you may need to have it drained through a chest tube or removed with surgery.

• Lung abscess. An abscess occurs if pus forms in a cavity in the lung. An abscess is usually treated with antibiotics. Sometimes, surgery or drainage with a long needle or tube placed into the abscess is needed to remove the pus.

Prevention
To help prevent pneumonia:

• Get vaccinated. Vaccines are available to prevent some types of pneumonia and the flu. Talk with your doctor about getting these shots. The vaccination guidelines have changed over time so make sure to review your vaccination status with your doctor even if you recall previously receiving a pneumonia vaccine.
• Make sure children get vaccinated. Doctors recommend a different pneumonia vaccine for children younger than age 2 and for children ages 2 to 5 years who are at particular risk of pneumococcal disease. Children who attend a group child care center should also get the vaccine. Doctors also recommend flu shots for children older than 6 months.
• Practice good hygiene. To protect yourself against respiratory infections that sometimes lead to pneumonia, wash your hands regularly or use an alcohol-based hand sanitizer.
• Don't smoke. Smoking damages your lungs' natural defenses against respiratory infections.
• Keep your immune system strong. Get enough sleep, exercise regularly and eat a healthy diet.

Your doctor will start by asking about your medical history and doing a physical exam, including listening to your lungs with a stethoscope to check for abnormal bubbling or crackling sounds that suggest pneumonia.
Diagnosis
If pneumonia is suspected, your doctor may recommend the following tests:

• Blood tests. Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection. However, precise identification isn't always possible.
• Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and location of the infection. However, it can't tell your doctor what kind of germ is causing the pneumonia.
• Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream.
• Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough and analyzed to help pinpoint the cause of the infection.

Your doctor might order additional tests if you're older than age 65, are in the hospital, or have serious symptoms or health conditions. These may include:

• CT scan. If your pneumonia isn't clearing as quickly as expected, your doctor may recommend a chest CT scan to obtain a more detailed image of your lungs.
• Pleural fluid culture. A fluid sample is taken by putting a needle between your ribs from the pleural area and analyzed to help determine the type of infection.

Treatment
Treatment for pneumonia involves curing the infection and preventing complications. People who have community-acquired pneumonia usually can be treated at home with medication. Although most symptoms ease in a few days or weeks, the feeling of tiredness can persist for a month or more.
Specific treatments depend on the type and severity of your pneumonia, your age and your overall health. The options include:

• Antibiotics. These medicines are used to treat bacterial pneumonia. It may take time to identify the type of bacteria causing your pneumonia and to choose the best antibiotic to treat it. If your symptoms don't improve, your doctor may recommend a different antibiotic.
• Cough medicine. This medicine may be used to calm your cough so that you can rest. Because coughing helps loosen and move fluid from your lungs, it's a good idea not to eliminate your cough completely. In addition, you should know that very few studies have looked at whether over-the-counter cough medicines lessen coughing caused by pneumonia. If you want to try a cough suppressant, use the lowest dose that helps you rest.
• Fever reducers/pain relievers. You may take these as needed for fever and discomfort. These include drugs such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others).

Hospitalization

You may need to be hospitalized if:

• You are older than age 65
• You are confused about time, people or places
• Your kidney function has declined
• Your systolic blood pressure is below 90 millimeters of mercury (mm Hg) or your diastolic blood pressure is 60 mm Hg or below
• Your breathing is rapid (30 breaths or more a minute)
• You need breathing assistance
• Your temperature is below normal
• Your heart rate is below 50 or above 100

You may be admitted to the intensive care unit if you need to be placed on a breathing machine (ventilator) or if your symptoms are severe.
Children may be hospitalized if:

• They are younger than age 2 months
• They are lethargic or excessively sleepy
• They have trouble breathing
• They have low blood oxygen levels
• They appear dehydrated

Lifestyle and home remedies
These tips can help you recover more quickly and decrease your risk of complications:

• Get plenty of rest. Don't go back to school or work until after your temperature returns to normal and you stop coughing up mucus. Even when you start to feel better, be careful not to overdo it. Because pneumonia can recur, it's better not to jump back into your routine until you are fully recovered. Ask your doctor if you're not sure.
• Stay hydrated. Drink plenty of fluids, especially water, to help loosen mucus in your lungs.
• Take your medicine as prescribed. Take the entire course of any medications your doctor prescribed for you. If you stop taking medication too soon, your lungs may continue to harbor bacteria that can multiply and cause your pneumonia to recur.

Preparing for your appointment
You may start by seeing a primary care doctor or an emergency care doctor, or you may be referred to a doctor who specializes in infectious diseases or in lung disease (pulmonologist).
Here's some information to help you get ready for your appointment and know what to expect.
What you can do

• Keep a record of any symptoms, including your temperature.
• Write down key medical information, including recent hospitalizations and any medical conditions you have.
• Write down key personal information, including exposure to any chemicals or toxins, or any recent travel.
• Make a list of all medications, vitamins and supplements that you're taking, especially an antibiotic left over from a previous infection, as this can lead to a drug-resistant pneumonia.
• Bring a family member or friend along, if possible, to help you remember questions to ask and what your doctor said.
• Write down questions to ask the doctor.

Some basic questions to ask the doctor include:

• What is likely causing my symptoms?
• What kinds of tests do I need?
• What treatment do you recommend?
• Will I need to be hospitalized?
• I have other health conditions. How will my pneumonia affect them?
• Are there any restrictions that I need to follow?

Don't hesitate to ask other questions.
What to expect from the doctor
Be ready to answer questions your doctor may ask:

• When did you first start having symptoms?
• Have you had pneumonia before? If so, in which lung?
• Have your symptoms been continuous or occasional? How severe are they?
• What, if anything, seems to improve or worsen your symptoms?
• Have you traveled or been exposed to chemicals or toxic substances?
• Have you been exposed to sick people at home, school or work?
• Do you smoke? Or have you ever smoked?
• How much alcohol do you consume in a week?
• Have you had flu or pneumonia vaccines?

What you can do in the meantime
To avoid making your condition worse:

• Don't smoke or be around smoke
• Drink plenty of fluids and get plenty of rest

Cellulitis
Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. The affected skin appears swollen and red and is typically painful and warm to the touch.
Short Description
Cellulitis usually affects the skin on the lower legs, but it can occur in the face, arms and other areas. It occurs when a crack or break in your skin allows bacteria to enter.
Left untreated, the infection can spread to your lymph nodes and bloodstream and rapidly become life-threatening. It isn't usually spread from person to person.
Symptoms
Possible signs and symptoms of cellulitis, which usually occur on one side of the body, include:

• Red area of skin that tends to expand
• Swelling
• Tenderness
• Pain
• Warmth
• Fever
• Red spots
• Blisters
• Skin dimpling

When to see a doctor
It's important to identify and treat cellulitis early because the condition can spread rapidly throughout your body.
Seek emergency care if:

• You have a red, swollen, tender rash or a rash that's changing rapidly
• You have a fever

See your doctor, preferably that day, if:

• You have a rash that's red, swollen, tender and warm — and it's expanding — but without fever

Causes
Cellulitis occurs when bacteria, most commonly streptococcus and staphylococcus, enter through a crack or break in your skin. The incidence of a more serious staphylococcus infection called methicillin-resistant Staphylococcus aureus (MRSA) is increasing.
Although cellulitis can occur anywhere on your body, the most common location is the lower leg. Bacteria are most likely to enter disrupted areas of skin, such as where you've had recent surgery, cuts, puncture wounds, an ulcer, athlete's foot or dermatitis.
Animal bites can cause cellulitis. Bacteria can also enter through areas of dry, flaky skin or swollen skin.
Risk factors
Several factors put you at increased risk of cellulitis:

• Injury. Any cut, fracture, burn or scrape gives bacteria an entry point.
• Weakened immune system. Conditions that weaken your immune system — such as diabetes, leukemia and HIV/AIDS — leave you more susceptible to infections. Certain medications also can weaken your immune system.
• Skin conditions. Conditions such as eczema, athlete's foot and shingles can cause breaks in the skin, which give bacteria an entry point.
• Chronic swelling of your arms or legs (lymphedema). This condition sometimes follows surgery.
• History of cellulitis. Having had cellulitis before makes you prone to develop it again.
• Obesity. Being overweight or obese increases your risk of developing cellulitis.

Complications
Recurrent episodes of cellulitis may damage the lymphatic drainage system and cause chronic swelling of the affected limb.
Rarely, the infection can spread to the deep layer of tissue called the fascial lining. Necrotizing fasciitis is an example of a deep-layer infection. It's an extreme emergency.
Prevention
If your cellulitis recurs, your doctor may recommend preventive antibiotics. To help prevent cellulitis and other infections, take these precautions when you have a skin wound:

• Wash your wound daily with soap and water. Do this gently as part of your normal bathing.
• Apply a protective cream or ointment. For most surface wounds, an over-the-counter ointment (Vaseline, Polysporin, others) provides adequate protection.
• Cover your wound with a bandage. Change bandages at least daily.
• Watch for signs of infection. Redness, pain and drainage all signal possible infection and the need for medical evaluation.

People with diabetes and those with poor circulation need to take extra precautions to prevent skin injury. Good skin care measures include the following:

• Inspect your feet daily. Regularly check your feet for signs of injury so you can catch infections early.
• Moisturize your skin regularly. Lubricating your skin helps prevent cracking and peeling. Do not apply moisturizer to open sores.
• Trim your fingernails and toenails carefully. Take care not to injure the surrounding skin.
• Protect your hands and feet. Wear appropriate footwear and gloves.
• Promptly treat infections on the skin's surface (superficial), such as athlete's foot. Superficial skin infections can easily spread from person to person. Don't wait to start treatment.

Diagnosis
Your doctor will likely be able to diagnose cellulitis by looking at your skin. In some cases, he or she may suggest blood tests or other tests to help rule out other conditions.
Treatment
Cellulitis treatment usually includes a prescription oral antibiotic. Within three days of starting an antibiotic, let your doctor know whether the infection is responding to treatment. You'll need to take the antibiotic for as long as your doctor directs, usually five to 10 days but possibly as long as 14 days.
In most cases, signs and symptoms of cellulitis disappear after a few days. You may need to be hospitalized and receive antibiotics through your veins (intravenously) if:

• Signs and symptoms don't respond to oral antibiotics
• Signs and symptoms are extensive
• You have a high fever

Usually, doctors prescribe a drug that's effective against both streptococci and staphylococci. It's important that you take the medication as directed and finish the entire course of medication, even after you feel better.
Your doctor also might recommend elevating the affected area, which may speed recovery.
Lifestyle and home remedies
Try these steps to help ease any pain and swelling:

• Place a cool, damp cloth on the affected area as often as needed for your comfort.
• Ask your doctor to suggest an over-the-counter pain medication to treat pain.
• Elevate the affected part of your body.
• Ask your doctor whether it might help to wear compression wraps or stockings.

Preparing for your appointment
You're likely to start by seeing your family doctor or a general practitioner, who may refer you to a doctor who specializes in skin disorders (dermatologist). If you have a severe infection, an emergency room doctor may examine you first. You may also be referred to an infectious disease specialist.
Here's some information to help you get ready for your appointment.
What you can do

• List your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
• List key personal information, such as if you've had any recent surgeries, injuries, animal bites or insect bites.
• List medications, vitamins and supplements you're taking and the dosage.
• List questions to ask your doctor.

Preparing a list of questions can help you make sure that you cover the points that are important to you. For cellulitis, some basic questions to ask your doctor include:

• How might I have gotten this infection?
• What tests do I need? Do these tests require special preparation?
• How is this treated?
• How long before the treatment starts working?
• What side effects are possible with this medication?
• I have other medical conditions. How do I manage them together?
• Are there alternatives to antibiotics?
• Is there a generic alternative to the medicine you're prescribing?
• How can I prevent this type of infection in the future?
• Do you have any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions you have.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:

• When did your symptoms start?
• Do you remember injuries or insect bites to that area?
• How severe is the pain?
• Does anything seem to improve your symptoms?
• Are you allergic to or intolerant of any antibiotics?
• Have you had this type of infection before?

What you can do in the meantime
You may need a prescription antibiotic to clear your infection. However, until you see your doctor, you can wash the injured area with soap and water and place a cool, damp cloth over the affected area for relief.
Migraine
Definition
A migraine is a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities.
Short Description:
For some people, a warning symptom known as an aura occurs before or with the headache. An aura can include visual disturbances, such as flashes of light or blind spots, or other disturbances, such as tingling on one side of the face or in an arm or leg and difficulty speaking.
Medications can help prevent some migraines and make them less painful. The right medicines, combined with self-help remedies and lifestyle changes, might help.
Symptoms
Migraines, which affect children and teenagers as well as adults, can progress through four stages: prodrome, aura, attack and post-drome. Not everyone who has migraines goes through all stages.
Prodrome
One or two days before a migraine, you might notice subtle changes that warn of an upcoming migraine, including:

• Constipation
• Mood changes, from depression to euphoria
• Food cravings
• Neck stiffness
• Increased urination
• Fluid retention
• Frequent yawning

Aura
For some people, an aura might occur before or during migraines. Auras are reversible symptoms of the nervous system. They're usually visual but can also include other disturbances. Each symptom usually begins gradually, builds up over several minutes and can last up to 60 minutes.
Examples of migraine auras include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Weakness or numbness in the face or one side of the body
• Difficulty speaking

Attack
A migraine usually lasts from 4 to 72 hours if untreated. How often migraines occur varies from person to person. Migraines might occur rarely or strike several times a month.
During a migraine, you might have:

• Pain usually on one side of your head, but often on both sides
• Pain that throbs or pulses
• Sensitivity to light, sound, and sometimes smell and touch
• Nausea and vomiting

Post-drome
After a migraine attack, you might feel drained, confused and washed out for up to a day. Some people report feeling elated. Sudden head movement might bring on the pain again briefly.
When to see a doctor
Migraines are often undiagnosed and untreated. If you regularly have signs and symptoms of migraine, keep a record of your attacks and how you treated them. Then make an appointment with your doctor to discuss your headaches.
Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different.
See your doctor immediately or go to the emergency room if you have any of the following signs and symptoms, which could indicate a more serious medical problem:

• An abrupt, severe headache like a thunderclap
• Headache with fever, stiff neck, confusion, seizures, double vision, numbness or weakness in any part of the body, which could be a sign of a stroke
• Headache after a head injury
• A chronic headache that is worse after coughing, exertion, straining or a sudden movement
• New headache pain after age 50

Causes
Though migraine causes aren't fully understood, genetics and environmental factors appear to play a role.
Changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway, might be involved. So might imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system.
Researchers are studying the role of serotonin in migraines. Other neurotransmitters play a role in the pain of migraine, including calcitonin gene-related peptide (CGRP).
Migraine triggers
There are a number of migraine triggers, including:

Hormonal changes in women. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy and menopause, seem to trigger headaches in many women.
Hormonal medications, such as oral contraceptives, also can worsen migraines. Some women, however, find that their migraines occur less often when taking these medications.

• Drinks. These include alcohol, especially wine, and too much caffeine, such as coffee.
• Stress. Stress at work or home can cause migraines.
• Sensory stimuli. Bright or flashing lights can induce migraines, as can loud sounds. Strong smells — such as perfume, paint thinner, secondhand smoke and others — trigger migraines in some people.
• Sleep changes. Missing sleep or getting too much sleep can trigger migraines in some people.
• Physical factors. Intense physical exertion, including sexual activity, might provoke migraines.
• Weather changes. A change of weather or barometric pressure can prompt a migraine.
• Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.
• Foods. Aged cheeses and salty and processed foods might trigger migraines. So might skipping meals.
• Food additives. These include the sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods.

Risk factors
Several factors make you more prone to having migraines, including:

• Family history. If you have a family member with migraines, then you have a good chance of developing them too.
• Age. Migraines can begin at any age, though the first often occurs during adolescence. Migraines tend to peak during your 30s, and gradually become less severe and less frequent in the following decades.
• Sex. Women are three times more likely than men to have migraines.
• Hormonal changes. For women who have migraines, headaches might begin just before or shortly after onset of menstruation. They might also change during pregnancy or menopause. Migraines generally improve after menopause.

Complications
Taking painkillers too often can trigger serious medication-overuse headaches. The risk seems to be highest with aspirin, acetaminophen and caffeine combinations. Overuse headaches may also occur if you take aspirin or ibuprofen (Advil, Motrin IB, others) for more than 14 days a month or triptans, sumatriptan (Imitrex, Tosymra) or rizatriptan (Maxalt, Maxalt-MLT) for more than nine days a month.
Medication-overuse headaches occur when medications stop relieving pain and begin to cause headaches. You then use more pain medication, which continues the cycle.
Diagnosis
If you have migraines or a family history of migraines, a doctor trained in treating headaches (neurologist) will likely diagnose migraines based on your medical history, symptoms, and a physical and neurological examination.
If your condition is unusual, complex or suddenly becomes severe, tests to rule out other causes for your pain might include:

• Magnetic resonance imaging (MRI). An MRI scan uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.
• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.

Treatment
Migraine treatment is aimed at stopping symptoms and preventing future attacks.
Many medications have been designed to treat migraines. Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.
• Preventive medications. These types of drugs are taken regularly, often daily, to reduce the severity or frequency of migraines.

Your treatment choices depend on the frequency and severity of your headaches, whether you have nausea and vomiting with your headaches, how disabling your headaches are, and other medical conditions you have.
Medications for relief
Medications used to relieve migraine pain work best when taken at the first sign of an oncoming migraine — as soon as signs and symptoms of a migraine begin. Medications that can be used to treat it include:

• Pain relievers. These over-the-counter or prescription pain relievers include aspirin or ibuprofen (Advil, Motrin IB, others). When taken too long, these might cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract.
• Migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain.
• Triptans. Prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt, Maxalt-MLT) are used to treat migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine. They might not be safe for those at risk of a stroke or heart attack.
• Dihydroergotamine (D.H.E. 45, Migranal). Available as a nasal spray or injection, this drug is most effective when taken shortly after the start of migraine symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea.
• People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.
• Lasmiditan (Reyvow). This newer oral tablet is approved for the treatment of migraine with or without aura. In drug trials, lasmiditan significantly improved headache pain. Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least eight hours.
• Ubrogepant (Ubrelvy). This oral calcitonin gene-related peptide receptor antagonist is approved for the treatment of acute migraine with or without aura in adults. It's the first drug of this type approved for migraine treatment. In drug trials, ubrogepant was more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant should not be taken with strong CYP3A4 inhibitor drugs.
• CGRP antagonists. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral CGRP antagonists recently approved for the treatment of acute migraine with or without aura in adults. In drug trials, drugs from this class were more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor drugs.
• Opioid medications. For people who can't take other migraine medications, narcotic opioid medications might help. Because they can be highly addictive, these are usually used only if no other treatments are effective.
• Anti-nausea drugs. These can help if your migraine with aura is accompanied by nausea and vomiting. Anti-nausea drugs include chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro). These are usually taken with pain medications.

Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.
Preventive medications
Medications can help prevent frequent migraines. Your doctor might recommend preventive medications if you have frequent, long-lasting or severe headaches that don't respond well to treatment.
Preventive medication is aimed at reducing how often you get a migraine, how severe the attacks are and how long they last. Options include:

• Blood pressure-lowering medications. These include beta blockers such as propranolol (Inderal, InnoPran XL, others) and metoprolol tartrate (Lopressor). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
• Antidepressants. A tricyclic antidepressant (amitriptyline) can prevent migraines. Because of the side effects of amitriptyline, such as sleepiness, other antidepressants might be prescribed instead.
• Anti-seizure drugs. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines, but can cause side effects such as dizziness, weight changes, nausea and more. These medications are not recommended for pregnant women or women trying to get pregnant.
• Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
• CGRP monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer drugs approved by the Food and Drug Administration to treat migraines. They're given monthly or quarterly by injection. The most common side effect is a reaction at the injection site.

Ask your doctor if these medications are right for you. Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.
Lifestyle and home remedies
When symptoms of migraine start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or ice pack wrapped in a towel or cloth on your forehead and drink lots of water.
These practices might also soothe migraine pain:

• Try relaxation techniques. Biofeedback and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.
• Develop a sleeping and eating routine. Don't sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.
• Drink plenty of fluids. Staying hydrated, particularly with water, might help.
• Keep a headache diary. Recording your symptoms in a headache diary will help you learn more about what triggers your migraines and what treatment is most effective. It will also help your doctor diagnose your condition and track your progress in between visits.
• Exercise regularly. Regular aerobic exercise reduces tension and can help prevent a migraine. If your doctor agrees, choose aerobic activity you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.

Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.
Alternative medicine
Nontraditional therapies might help with chronic migraine pain.

• Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
• Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
• Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
• Meditation and yoga. Meditation may relieve stress, which is a known trigger of migraines. Done on a regular basis, yoga may reduce the frequency and duration of migraines.
• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn't recommended because of safety concerns.

A high dose of riboflavin (vitamin B-2) may reduce the frequency and severity of headaches. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.
Magnesium supplements have been used to treat migraines, but with mixed results.
Ask your doctor if these treatments are right for you. If you're pregnant, don't use any of these treatments without first talking with your doctor.
Preparing for your appointment
You'll probably first see a primary care provider, who might then refer you to a doctor trained in evaluating and treating headaches (neurologist).
Here's some information to help you get ready for your appointment.
What you can do

• Keep track of your symptoms. Keep a headache diary by writing a description of each incident of visual disturbances or unusual sensations, including when they occurred, how long they lasted and what triggered them. A headache diary can help your doctor diagnose your condition.
• Write down key personal information, including major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you take, including doses. It's particularly important to list all medications you've used to treat your headaches.
• Write down questions to ask your doctor.

Take a family member or friend along, if possible, to help you remember the information you receive.
For migraines, questions to ask your doctor include:

• What is likely triggering my migraines?
• Are there other possible causes for my migraine symptoms?
• What tests do I need?
• Are my migraines likely temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• What changes to my lifestyle or diet do you suggest I make?
• I have these other health conditions. How can I best manage them together?
• Are there printed materials you can give me? What websites do you recommend?

Don't hesitate to ask other questions.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:

• How often do your headaches occur?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Does anyone else in your family have migraines?