My Flight Surgeon
Sr. Aviation Medical Examiner
[FONT="]This is another in the series of condition for which the FAA grants Special Issuance certificates.
As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissunace.com can assist you in preparing your records for submission.
The topic today is Migraine Headaches. Be aware as you read this post that some of the medications used to manage migraine headaches may not by “approved” by the FAA and are therefore disqualifying for a medical certificate.[/FONT]
A migraine can be disabling — with symptoms so severe, all you can think about is finding a dark, quiet place to lie down. Up to 17 percent of women and 6 percent of men have experienced a migraine.
In some cases, these painful headaches are preceded or accompanied by a sensory warning sign (aura), such as flashes of light, blind spots or tingling in your arm or leg. A migraine is also often accompanied by other signs and symptoms, such as nausea, vomiting, and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.
[FONT="]Signs and symptoms[/FONT]
[FONT="]A typical migraine attack produces some or all of these signs and symptoms:[/FONT]
[FONT="]Not all migraines are the same. Most people experience migraines without auras, which were previously called common migraines. Some, however, have migraines with auras, which were previously called classic migraines. If you're in the second group, you'll likely have an aura about 15 to 30 minutes before your headache begins. Auras may continue after your headache starts or even occur after your headache begins. When you're experiencing an aura, you may:[/FONT]
[FONT="]Although much about headaches still isn't understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your nervous system, and by imbalances in brain chemicals, including serotonin, which plays a regulatory role for pain messages going through this pathway.[/FONT]
[FONT="]During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering (meninges). There they cause blood vessels to become dilated and inflamed. The result is headache pain.[/FONT]
[FONT="]Migraine triggers[/FONT][FONT="]
Whatever the exact mechanism of headaches, a number of things may trigger them. Common migraine triggers include:[/FONT]
Many people with migraines have a family history of migraine. If both your parents have migraines, there's a good chance you will too. Even if only one of your parents has migraines, you're still at increased risk of developing migraines.
You also have a relatively higher risk of migraines if you're young and female. In fact, women are three times as likely to have migraines as men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.
If you're a woman with migraines, you may find that your headaches begin just before or shortly after onset of menstruation. They may also change during pregnancy or menopause. Many women report improvement in their migraines later in pregnancy, but others report that their migraines worsened during the first trimester. If pregnancy or menstruation affects your migraines, your headaches are also likely to worsen if you take birth control pills or hormone replacement therapy (HRT).
Screening and diagnosis
If you have typical migraines or a family history of migraines, your doctor will likely diagnose the condition on the basis of your medical history and a physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend a variety of tests to rule out other possible causes for your pain.
Complications
Sometimes your efforts to control your pain cause problems. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin, may cause abdominal pain, bleeding and ulcers — especially if taken in large doses or for a long period of time.
In addition, if you take over-the-counter or prescription headache medications more than two or three times a week or in excessive amounts, you may be setting yourself up for a serious complication known as rebound headaches. Rebound headaches occur when medications not only stop relieving pain, but actually begin to cause headaches. You then use more pain medication, which traps you in a vicious cycle.
Serotonin syndrome
A potentially life-threatening drug interaction — called serotonin syndrome — can occur if you take migraine medicines called triptans, such as sumatriptan (Imitrex) or zolmitriptan (Zomig), along with antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs). Some common SSRIs include Zoloft, Prozac and Paxil. SNRIs include Cymbalta and Effexor. Fortunately, serotonin syndrome is exceedingly uncommon.
[FONT="]Treatment[/FONT]
[FONT="]A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:[/FONT]
[FONT="]Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help find the right medication for you.[/FONT]
[FONT="]Pain-relieving medications[/FONT][FONT="]
For best results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them:[/FONT]
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.[/FONT]
[FONT="]In most cases, preventive medications don't eliminate headaches completely, and some can have serious side effects. For best results, take these medications as your doctor recommends:[/FONT]
[FONT="]Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:[/FONT]
[FONT="]Self-care measures can help ease the pain of a migraine. Try these headache helpers:[/FONT]
[FONT="]Nontraditional therapies may be helpful if you have chronic headache pain:[/FONT]
[FONT="]FAA Special Issuance[/FONT][FONT="]
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.
An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.
Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following: [/FONT]
As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissunace.com can assist you in preparing your records for submission.
The topic today is Migraine Headaches. Be aware as you read this post that some of the medications used to manage migraine headaches may not by “approved” by the FAA and are therefore disqualifying for a medical certificate.[/FONT]
A migraine can be disabling — with symptoms so severe, all you can think about is finding a dark, quiet place to lie down. Up to 17 percent of women and 6 percent of men have experienced a migraine.
In some cases, these painful headaches are preceded or accompanied by a sensory warning sign (aura), such as flashes of light, blind spots or tingling in your arm or leg. A migraine is also often accompanied by other signs and symptoms, such as nausea, vomiting, and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.
[FONT="]Signs and symptoms[/FONT]
[FONT="]A typical migraine attack produces some or all of these signs and symptoms:[/FONT]
- [FONT="]Moderate to severe pain, which may be confined to one side of the head or may affect both sides[/FONT]
- [FONT="]Head pain with a pulsating or throbbing quality[/FONT]
- [FONT="]Pain that worsens with physical activity[/FONT]
- [FONT="]Pain that interferes with your regular activities[/FONT]
- [FONT="]Nausea with or without vomiting[/FONT]
- [FONT="]Sensitivity to light and sound[/FONT]
[FONT="]Not all migraines are the same. Most people experience migraines without auras, which were previously called common migraines. Some, however, have migraines with auras, which were previously called classic migraines. If you're in the second group, you'll likely have an aura about 15 to 30 minutes before your headache begins. Auras may continue after your headache starts or even occur after your headache begins. When you're experiencing an aura, you may:[/FONT]
- [FONT="]See sparkling flashes of light[/FONT]
- [FONT="]Perceive dazzling zigzag lines in your field of vision[/FONT]
- [FONT="]Experience slowly spreading blind spots in your vision[/FONT]
- [FONT="]Feel tingling, pins and needles sensations in one arm or leg[/FONT]
- [FONT="]Rarely, experience weakness or language and speech problems[/FONT]
- [FONT="]Feelings of elation or intense energy[/FONT]
- [FONT="]Cravings for sweets[/FONT]
- [FONT="]Thirst[/FONT]
- [FONT="]Drowsiness[/FONT]
- [FONT="]Irritability or depression[/FONT]
[FONT="]Although much about headaches still isn't understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your nervous system, and by imbalances in brain chemicals, including serotonin, which plays a regulatory role for pain messages going through this pathway.[/FONT]
[FONT="]During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering (meninges). There they cause blood vessels to become dilated and inflamed. The result is headache pain.[/FONT]
[FONT="]Migraine triggers[/FONT][FONT="]
Whatever the exact mechanism of headaches, a number of things may trigger them. Common migraine triggers include:[/FONT]
- [FONT="]Hormonal changes.[/FONT][FONT="] Although the exact relationship between hormones and headaches isn't clear, fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, and this corresponds to a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications, such as contraceptives and hormone replacement therapy, also may worsen migraines.[/FONT]
- [FONT="]Foods.[/FONT][FONT="] Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; aspartame; overuse of caffeine; monosodium glutamate — a key ingredient in some Asian foods; certain seasonings; and many canned and processed foods. Skipping meals or fasting also can trigger migraines.[/FONT]
- [FONT="]Stress.[/FONT][FONT="] A hard week at work followed by relaxation may lead to a weekend migraine. Stress at work or home also can instigate migraines.[/FONT]
- [FONT="]Sensory stimuli.[/FONT][FONT="] Bright lights and sun glare can produce head pain. So can unusual smells — including pleasant scents, such as perfume and flowers, and unpleasant odors, such as paint thinner and secondhand smoke.[/FONT]
- [FONT="]Changes in wake-sleep pattern.[/FONT][FONT="] Either missing sleep or getting too much sleep may serve as a trigger for migraine attacks in some individuals.[/FONT]
- [FONT="]Physical factors.[/FONT][FONT="] Intense physical exertion, including sexual activity, may provoke migraines.[/FONT]
- [FONT="]Changes in the environment.[/FONT][FONT="] A change of weather, season, altitude level, barometric pressure or time zone can prompt a migraine.[/FONT]
- [FONT="]Medications.[/FONT][FONT="] Certain medications can aggravate migraines.[/FONT]
Many people with migraines have a family history of migraine. If both your parents have migraines, there's a good chance you will too. Even if only one of your parents has migraines, you're still at increased risk of developing migraines.
You also have a relatively higher risk of migraines if you're young and female. In fact, women are three times as likely to have migraines as men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.
If you're a woman with migraines, you may find that your headaches begin just before or shortly after onset of menstruation. They may also change during pregnancy or menopause. Many women report improvement in their migraines later in pregnancy, but others report that their migraines worsened during the first trimester. If pregnancy or menstruation affects your migraines, your headaches are also likely to worsen if you take birth control pills or hormone replacement therapy (HRT).
Screening and diagnosis
If you have typical migraines or a family history of migraines, your doctor will likely diagnose the condition on the basis of your medical history and a physical exam. But if your headaches are unusual, severe or sudden, your doctor may recommend a variety of tests to rule out other possible causes for your pain.
Complications
Sometimes your efforts to control your pain cause problems. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) and aspirin, may cause abdominal pain, bleeding and ulcers — especially if taken in large doses or for a long period of time.
In addition, if you take over-the-counter or prescription headache medications more than two or three times a week or in excessive amounts, you may be setting yourself up for a serious complication known as rebound headaches. Rebound headaches occur when medications not only stop relieving pain, but actually begin to cause headaches. You then use more pain medication, which traps you in a vicious cycle.
Serotonin syndrome
A potentially life-threatening drug interaction — called serotonin syndrome — can occur if you take migraine medicines called triptans, such as sumatriptan (Imitrex) or zolmitriptan (Zomig), along with antidepressants known as selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs). Some common SSRIs include Zoloft, Prozac and Paxil. SNRIs include Cymbalta and Effexor. Fortunately, serotonin syndrome is exceedingly uncommon.
[FONT="]Treatment[/FONT]
[FONT="]A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:[/FONT]
- [FONT="]Pain-relieving medications.[/FONT][FONT="] Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.[/FONT]
- [FONT="]Preventive medications.[/FONT][FONT="] These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.[/FONT]
[FONT="]Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help find the right medication for you.[/FONT]
[FONT="]Pain-relieving medications[/FONT][FONT="]
For best results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them:[/FONT]
- [FONT="]Nonsteroidal anti-inflammatory drugs (NSAIDs).[/FONT][FONT="] These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines, but aren't effective alone for severe migraines. If over-the-counter medications don't help, your doctor may suggest a stronger, prescription-only version of the same drug. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches.[/FONT]
- [FONT="]Triptans.[/FONT][FONT="] For many people with severe migraine attacks, triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines. Sumatriptan (Imitrex) was the first drug specifically developed to treat migraines. Related medications include rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of triptans include nausea, dizziness, muscle weakness and, rarely, stroke and heart attack. In recent studies, a single-tablet combination of sumatriptan and naproxen sodium relieved migraine symptoms more effectively than did either individual medication. This combination tablet will likely be marketed soon.[/FONT]
- [FONT="]Ergots.[/FONT][FONT="] Ergotamine (Ergomar) has been in use for more than 60 years and was a common prescription for migraine before triptans were introduced. Ergotamine is much less expensive, but also less effective, than triptans. Dihydroergotamine is an ergot derivative that is more effective and has fewer side effects than ergotamine.[/FONT]
- [FONT="]Anti-nausea medications.[/FONT][FONT="] Since migraine attacks are often accompanied by nausea with or without vomiting, medication for treatment of these symptoms is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or rectal suppository).[/FONT]
- [FONT="]Butalbital combinations.[/FONT][FONT="] Medications that combine the sedative butalbital with aspirin or acetaminophen are sometimes used to treat migraine attacks. Some combinations also include caffeine or codeine. These medications, however, have a high risk of rebound headaches and withdrawal symptoms and accordingly should be used infrequently.[/FONT]
- [FONT="]Opiates.[/FONT][FONT="] Medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can't take triptans or ergots. These drugs are habit-forming and are usually used only as a last resort.[/FONT]
Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.[/FONT]
[FONT="]In most cases, preventive medications don't eliminate headaches completely, and some can have serious side effects. For best results, take these medications as your doctor recommends:[/FONT]
- [FONT="]Cardiovascular drugs.[/FONT][FONT="] Beta blockers — which are commonly used to treat high blood pressure and coronary artery disease — can reduce the frequency and severity of migraines. These drugs are considered among first-line treatment agents. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful. In addition, the antihypertensive medications lisinopril (Prinivil, Zestril) and candesartan (Atacand) are useful migraine prevention medications. Researchers don't understand exactly why all of these cardiovascular drugs prevent migraines. Side effects can include dizziness, drowsiness or lightheadedness.[/FONT]
- [FONT="]Antidepressants.[/FONT][FONT="] Certain antidepressants are good at helping prevent all types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and protriptyline (Vivactil). These medications are considered among first-line treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals. You don't have to have depression to benefit from these drugs. Newer antidepressants, however, generally aren't as effective for migraine prevention.[/FONT]
- [FONT="]Anti-seizure drugs.[/FONT][FONT="] Although the reason is unclear, some anti-seizure drugs, such as divalproex sodium (Depakote) and topiramate (Topamax), which are used to treat epilepsy and bipolar disease, seem to prevent migraines. Gabapentin (Neurontin), another anti-seizure medication, is considered a second-line treatment agent. In high doses, however, these anti-seizure drugs may cause side effects, such as nausea and vomiting, diarrhea, cramps, hair loss and dizziness.[/FONT]
- [FONT="]Cyproheptadine.[/FONT][FONT="] This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.[/FONT]
- [FONT="]Botulinum toxin type A (Botox).[/FONT][FONT="] Some people receiving Botox injections for their facial wrinkles have noted improvement of their headaches. The mechanism by which Botox might prevent migraines is unclear, although the drug may cause changes in your nervous system that modify your tendency to develop migraines. Studies using Botox injections for migraines have had mixed results. Additional research is necessary. Still, if several other preventive medications have failed to control your headaches, you might talk to your doctor about trying Botox.[/FONT]
[FONT="]Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:[/FONT]
- [FONT="]Avoid triggers.[/FONT][FONT="] If certain foods seem to have triggered your headaches in the past, eat something else. If certain scents are a problem, try to avoid them. In general, establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.[/FONT]
- [FONT="]Exercise regularly.[/FONT][FONT="] Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches.[/FONT]
- [FONT="]Reduce the effects of estrogen.[/FONT][FONT="] If you're a woman with migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the amount of medications you take that contain estrogen. These medications include birth control pills and hormone replacement therapy. [/FONT]
[FONT="]Self-care measures can help ease the pain of a migraine. Try these headache helpers:[/FONT]
- [FONT="]Keep a diary.[/FONT][FONT="] A diary can help you determine what triggers your migraines. Note when your headaches start, how long they last and what, if anything, provides relief. Be sure to record your response to any headache medications you take. Also pay special attention to foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you're doing when headaches strike. If you're under stress, tell your doctor.[/FONT]
- [FONT="]Try muscle relaxation exercises.[/FONT][FONT="] Progressive muscle relaxation, meditation and yoga don't require any equipment. You can learn them in classes or at home using books or tapes. Or spend at least a half-hour each day doing something you find relaxing — listening to music, gardening, taking a hot bath or reading.[/FONT]
- [FONT="]Get enough sleep, but don't oversleep.[/FONT][FONT="] The average adult needs seven to nine hours of sleep a night.[/FONT]
- [FONT="]Rest and relax.[/FONT][FONT="] If possible, rest in a dark, quiet room when you feel a headache coming on. Place an ice pack wrapped in a cloth on the back of your neck and apply gentle pressure to painful areas on your scalp.[/FONT]
[FONT="]Nontraditional therapies may be helpful if you have chronic headache pain:[/FONT]
- [FONT="]Acupuncture.[/FONT][FONT="] In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin. The penetration is so shallow and the needles are so thin that acupuncture generally causes little or no pain or discomfort. A number of clinical trials have found acupuncture may be helpful for headache pain, but evidence from these trials isn't strong enough for experts to routinely recommend this treatment.[/FONT]
- [FONT="]Biofeedback.[/FONT][FONT="] Biofeedback appears to be especially effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses, such as muscle tension. This technique can be combined with preventive medications.[/FONT]
- [FONT="]Massage.[/FONT][FONT="] Although massage is a wonderful way to reduce stress and relieve tension, its value in treating headaches hasn't been fully determined. For people who have tight, tender muscles in the back of the head, neck and shoulders, massage may help relieve headache pain.[/FONT]
- [FONT="]Herbs, vitamins and minerals.[/FONT][FONT="] There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in the brain cells. There is also some evidence that coenzyme Q10 supplements may be helpful in some individuals. Oral magnesium sulfate supplements may reduce the frequency of headaches in some people, although studies don't all agree on this issue. In addition, infusions of magnesium sulfate seem to help some people during an acute headache, and they seem to relieve migraine pain in people with magnesium deficiencies. Ask your doctor if these treatments are right for you. Don't use feverfew or butterbur if you're pregnant.[/FONT]
- [FONT="]Cervical manipulation.[/FONT][FONT="] There are no scientifically valid studies that prove that chiropractic or other spine-manipulation treatments are effective in the treatment of migraine.[/FONT]
[FONT="]FAA Special Issuance[/FONT][FONT="]
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.
An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.
Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following: [/FONT]
- [FONT="]An Authorization granted by the FAA;[/FONT]
- [FONT="]A statement regarding the frequency of headaches and/or other associated symptoms since last followup report;[/FONT]
- [FONT="]A statement regarding if the characteristics of the headaches changed; and[/FONT]
- [FONT="]The name and dosage of medication(s) used for treatment and/or prevention with comment regarding side effects.[/FONT]
- [FONT="]The frequency of headaches and/or other symptoms increase since the last followup report; or[/FONT]
- [FONT="]The applicant is placed on medication(s), such as isometheptene mucate, narcotic analgesic, tramadol, tricyclic-antidepressant medication, etc.[/FONT]
