Comparison of carotid artery ultrasound and manual method for pulse check in cardiopulmonary resuscitation.

OBJECTIVES: The success of the manual pulse check method frequently employed during cardiopulmonary resuscitation (CPR) is controversial due to its subjective, patient- and operator-dependent, and time-consuming nature. Carotid ultrasound (c-USG) has recently emerged as an alternative, although there are still insufficient studies on the subject. The purpose of the present study was to compare the success of the manual and c-USG pulse check methods during CPR. METHODS: This prospective observational study was conducted in the critical care area of a university hospital emergency medicine clinic. Pulse checks in patients with non-traumatic cardiopulmonary arrest (CPA) undergoing CPR were performed using the c-USG method from one carotid artery and the manual method from the other. The gold standard in the decision regarding return of spontaneous circulation (ROSC) was the clinical judgment made using the rhythm on the monitor, manual femoral pulse check, end tidal carbon dioxide (ETCO2), and cardiac USG instruments. The success in predicting ROSC and measurement times of the manual and c-USG methods were compared. The success of both methods was calculated as sensitivity and specificity, and the clinical significance of the difference between the methods' sensitivity and specificity was evaluated Newcombe's method. RESULTS: A total of 568 pulse measurements were performed on 49 CPA cases using both c-USG and the manual method. The manual method exhibited 80% sensitivity and 91% specificity in predicting ROSC (+PV: 35%, -PV: 64%), while c-USG exhibited 100% sensitivity and 98% specificity (+PV: 84%, -PV: 100%). The difference in sensitivities between the c-USG and manual methods was -0.0704 (95% CI: -0.0965; -0.0466), and the difference between their specificities was 0.0106 (95% CI: 0.0006; 0.0222). The difference between the specificities and sensitivities was statistically significant at analysis performed adopting the clinical judgment of the team leader using multiple instruments as the gold standard. The manual method yielded an ROSC decision in 3 ± 0.17 s and c-USG in 2.8 ± 0.15 s, the difference being statistically significant. CONCLUSION: According to the results of this study, the pulse check method with c-USG may be superior to the manual method in terms of fast and accurate decision making in CPR.

A rare complication of cardiopulmonary resuscitation applied during transportation by ambulance: A case report of flail chest.

Cardiopulmonary resuscitation (CPR) to be applied during patient transfer by ambulance differs from CPR applied in the field or in the hospital in terms of physical condition. Especially the deeper and faster chest compressions recommended in the latest CPR guidelines, when administered during ambulance transport, may result in a further increase in traumatic CPR complications. However, in the current CPR guidelines, there are no clear recommendations regarding additional measures that can be taken to reduce the complications and increase the efficiency of CPR during patient transport. In this study, a case of flail chest that developed after short-term CPR application during ambulance transport is presented. The aim of this study was to evaluate the flail chest complication and solution suggestions that may occur due to chest compressions applied during transportation.

The effect of calcium gluconate in the treatment of hyperkalemia.

OBJECTIVES: Intravenous (IV) calcium salts are routinely recommended as a cardio-protective therapy in the emergency treatment of severe hyperkalemia. However, this recommendation is supported by a low level of evidence and is anecdotal. The aim of this study is to determine the effectiveness of IV Calcium (Ca) gluconate in the treatment of hyperkalemia. MATERIALS AND METHODS: Patients with hyperkalemia and with the electrocardiogram (ECG) changes due to hyperkalemia over a 1 year period were included in this prospective observational study. Patients' ECGs were measured, before and after IV Ca-gluconate treatment and after normalization of potassium levels. Wilcoxon test and McNemar's test were used to compare the ECG parameters before and after Ca-gluconate therapy. RESULTS: The mean potassium value of 111 patients who met the inclusion criteria was 7.1 ± 0.6 mmol/l. In this study, a total of 243 ECG pathology related to hyperkalemia, 79 of which included main rhythm disorders, and the remaining 164 were nonrhythm disorders in ECG parameters, were analyzed. No statistically significant changes were determined in patients' nonrhythm ECG disorders with IV Ca-gluconate treatment (P = 0.125). However, nine of the 79 main rhythm disorders due to hyperkalemia improved with calcium gluconate treatment and this change was statistically significant (P < 0.004). CONCLUSION: IV Ca-gluconate therapy was found to be effective, albeit to a limited degree, in main rhythm ECG disorders due to hyperkalemia, but it was not found to be effective in nonrhythm ECG disorders due to hyperkalemia. Therefore, Ca-gluconate may be effective only in the main rhythm disorders due to hyperkalemia.

Rapid Shallow Breathing Index as a Predictor for Intubation and Mortality in Acute Respiratory Failure.

BACKGROUND: Noninvasive ventilation (NIV) is one of the most important therapeutic tools in patients with acute respiratory failure. However, in case of incorrect patient selection it can delay necessary intubation and is associated with complications and even mortality. Patient selection, therefore, plays a key role in therapeutic success. The purpose of this study was to determine the value of the rapid shallow breathing index (RSBI) in predicting the failure of NIV. METHODS: This prospective observational study was conducted in the emergency department (ED) of a tertiary hospital. Adults presenting to the ED with acute respiratory failure were included in the study. The success of RSBI values measured initially (RSBI 1) and at 30 min (RSBI 2) and the difference between these 2 values (Δ RSBI) in predicting subjects' intubation requirement and survival was tested using multivariate logistic regression analysis. RESULTS: Two hundred sixty-seven subjects were included in the study. RSBI 1, RSBI 2, and Δ RSBI values differed significantly between the intubated and non-intubated subjects. According to the multivariate model, RSBI 1 and RSBI 2 > 105, Δ RSBI < 19, heart rate > 100 beats/min, and SpO2 < 92% were significantly associated with intubation requirement. RSBI 1, RSBI 2, and Δ RSBI values also differed significantly between subjects with a fatal course and surviving individuals. According to the multivariate model, RSBI 2 > 105, Δ RSBI < 19, heart rate > 100, and increasing age were associated with in-hospital mortality. CONCLUSIONS: RSBI can be a successful marker in predicting the failure of NIV and predicting in-hospital mortality in patients admitted to the ED with acute respiratory failure.

Diagnostic Accuracy of Early Systolic Notching in Pulmonary Embolism.

OBJECTIVE: Recently, a cardiac sonography finding, early systolic notching (ESN), was reported with high sensitivity and specificity for the diagnosis of pulmonary embolism (PE) in a limited population. The aim of this study was to determine the diagnostic accuracy of ESN finding for PE in emergency department (ED) patients. METHOD: This prospective multicenter study was conducted in 4 academic EDs. All patients who underwent computed tomography angiography for suspected PE were included in the study. After inclusion, cardiac ultrasound including the right ventricular outflow tract Doppler signal was performed. The diagnostic tests of ESN finding were used for PE and its subgroups. RESULTS: In the study, 183 of 201 patients met the study criteria. Of all patients, 52.5% had PE (n = 96), and 19.7% (n = 36) had ESN finding. In all ED patients, the sensitivity of ESN for PE was 34% (95% CI 25-45), and the specificity was 97% (95% CI 90-99). In the subgroup analysis, the sensitivity of ESN for PE with high or intermediate-high risk was 69% (95% CI 49-85), and the specificity was 90% (95% CI 84-94). Inter-rater reliability for ESN finding between the cardiologist and emergency physician was strong with a kappa statistic of 0.87. CONCLUSION: The pulmonary Doppler flow of ESN was moderate to high specific but low sensitive for PE in all ED patients. In the subgroup analysis, this finding was moderate specific and low sensitive.

The effects of synthetic cannabinoids on the cardiovascular system: A case-control study.

OBJECTIVES: Limited clinical studies have investigated the effects of synthetic cannabinoids (SCs) on the cardiovascular system (CVS). The aim of this study was to evaluate the effects of SCs on the CVS. METHODS: The patient group of this single-center, prospective, case-control study consisted of adult patients presenting to the emergency department (ED) with symptoms of SC use. Vital signs and electrocardiogram (ECG) after use of SC of patients were followed. A control group with a similar number of patients and patient demographics were formed following the patient admission process. Pulse rate, arterial blood pressure (ABP), and ECG of patient and control groups were compared using Mann-Whitney U and Chi-squared tests. RESULTS: A total of 148 people were included in the study, 74 in the patient group and 74 in the control group. Systolic and diastolic ABPs of patient group were statistically significantly lower than those of the control group (P < 0.001). P-wave width and amplitude in the patient group were significantly higher compared to the control group (P: 0.027 and P: 0.004, respectively). QRS width on patient group ECGs was significantly higher than in the control group, while T-wave amplitude was significantly lower (P: 0.045 and P < 0.001, respectively). ST elevation was seen in 12 (16.2%) subjects in the patient group, while no ST elevation was seen in the control group (P < 0.001). CONCLUSION: SCs can reduce systemic tension and SCs may cause changes in ECG, especially P wave, ST segment, T wave, and QRS. Further large-scale studies are needed to show whether these changes are associated with fatal arrhythmias or myocardial infarction.

The value of conventional manometry in the identification of normal esophageal manometry.

ABSTRACT: In the last decade, high-resolution esophageal manometry (HREM) is the main device for the management of dysphagia replacing conventional manometry (CM). Conventional manometry still seems to have some space to diagnose major motility disorders and differentiate normal from abnormal esophageal motility. The long term outcomes of patients with normal CM were analyzed in our study.Participants (patients with dysphagia and normal CM) took a questionnaire via a phone call in February 2021. Impact Dysphagia Questionnaire (IDQ) was used as an assessment tool.Only 55% (83/151) the individuals with previous normal manometric findings were reached via telephone. The group who have completed the survey was representative of the cohort. 66.2% of the participants were female (P = .40). The mean age was 57.21, mean weight was 70.69 kg, mean height was 163.74 cm and mean body mass index was 26.41. More than 40% of patients were completely asymptomatic at follow up, reflected by an IDQ score of 0. Only 28 out of 83 (33.7%) patients reported significant symptoms as reflected by an IDQ score greater than or equal to 7. The rest of responders admitted as having moderate to mild symptoms.HREM is a valid technique with comparable precision to CM. HREM measurements differ considerably to CM. The identification of normal motor function in CM is not likely a positive prognostic indicator and must be interpreted precautiously.

A rare complication of continuous positive airway pressure treatment - rectus sheath hematoma: a case report.

Noninvasive mechanical ventilation (NIMV) has a relevant role in the treatment of critically ill patients displaying severe dyspnea. Continuous positive airway pressure (CPAP), a method of NIMV, is also widely used in the management of acute heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, and symptomatic sleep apnea. However, numerous traumatic complications of CPAP treatment in the face region, head, and thorax have been reported and may be related to the application of a continuous positive high pressure to the airway. Conversely, we have observed no complications due to CPAP-related increased intra-abdominal pressure. In this article, we describe a clinical case of a patient with an acute rectus sheath hematoma during CPAP treatment. This previously unreported complication demonstrates that CPAP should be carefully used in patients with exacerbated COPD with difficulty in expiration.

A Rare Ultrasonographic Finding of Emphysematous Cholecystitis: The Champagne Sign.

BACKGROUND: Emphysematous cholecystitis (EC) is a form of cholecystitis with high mortality rates more commonly seen in patients with medical histories such as diabetes, hypertension, and peripheral vascular disease. The common features of these medical diseases are impaired pain perception, particularly abdominal pain, due to advanced age and peripheral neuropathies. Accurate evaluation of characteristics observed at ultrasonography, the method of first choice in the diagnosis of EC, is therefore highly important in these patients. CASE REPORT: This study reports a case of the champagne sign, rarely seen in EC, together with other EC findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The champagne sign is a little-known sonographic finding that is evidence of the presence of gas in the gallbladder. The champagne sign that will be detected while evaluating the hepatobiliary system on bedside ultrasound is one of the valuable findings in the diagnosis of emphysematous cholecystitis with high mortality.

The value of the inferior vena cava ultrasound in the decision to hospitalise in patients with acute decompensated heart failure; the best sonographic measurement method?

OBJECTIVES: The primary aim of this study was to determine the value of the inferior vena cava (IVC) ultrasound in the decision to hospitalise acute decompensated heart failure (ADHF) patients. Our secondary aim was to find the most successful IVC measurement method in monitoring volume status. METHODS: ADHF patients were accepted over a 1-year period in this study. Patients' vital signs, laboratory tests and IVC measurements measured by six methods (in B- and M-mode; maximum, minimum diameter and caval index) performed on an hourly basis were recorded. The presence of any statistically significant difference between the IVC measurement methods, laboratory tests and vital parameters between the hospitalised and discharged patients was calculated. ROC curves were produced in order to determine the ability of parameters to differentiate two groups. Spearman's correlation test was used to investigate correlation between the IVC measurement methods and patients' urine outputs. RESULTS: A total of 71 patients were included in the study; 42 of these were hospitalised and 29 were discharged. Potassium, brain natriuretic peptide, respiration rate, urine output, maximum and minimum IVC diameters differed significantly between the two groups. Minimum IVC diameter measured in M-mode was identified as a weak marker with 65% sensitivity and 64% specificity (+PPV: 73%; -NPV:54%) for hospitalisation. Change in maximum IVC diameter measured in B-mode exhibited a high degree of correlation with change in body fluid (cc: 0.802). CONCLUSION: IVC ultrasound may have a limited value in the decision to hospitalise ADHF patients. But Maximum IVC diameter may be an ideal method for monitoring hypervolemic patients' volume status. CLINICAL TRIALS IDENTIFIER: NCT02725151.

Bedside ultrasound in the management of critically ill patients; Echocardiographic signs of acute respiratory distress syndrome and pulmonary embolism can be very similar, and lung ultrasound can act as a key: A case report.

Right-sided heart failure (RHF) diagnosed at point-of-care-ultrasonography examination of critical patients may reveal an acute disease, such as pulmonary embolism (PE), requiring emergency thrombolytic treatment. However, acute respiratory distress syndrome (ARDS) and PE leading to acute RHF may exhibit very similar echocardiographic features. We report the case of a 27-year-old pregnant woman diagnosed with ARDS due to septic abortion, and in whom ARDS mimicked PE both clinically and on echocardiography. Such similarity may lead to inappropriate administration of thrombolytic therapy and/or delay the correct treatment. Lung ultrasonography may help avoiding this pitfall.

How would you like your COVID-19? From a host with mild course disease, or from a severe one?

The clinical course of COVID-19 presents a broad spectrum, being asymptomatic in some individuals while following a severe course and resulting in mortality in others. It is known that such factors as age and chronic diseases can result in a different clinical courses in individuals, however, variable clinical courses among the similar individuals in terms of age and chronic diseases are also seen. Other possible factors affecting the course of the disease that are mostly speculative or under investigation are genetic factors and the origin of transmission or possible subtype of novel coronavirus. Whether the source of transmission is important in the clinical course of the disease is unknown. A case series composed of seven individuals in a similar age group, with different lines of descent and different genetic structures, but who were infected from the same source is presented here. The similar and different clinical, laboratory and radiological findings of the cases residing in the same nursing home, who presented to the hospital altogether, were evaluated. The aim of the study was to analyze whether the source of transmission is influential in the clinical course of the disease.

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures.

BACKGROUND: The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. OBJECTIVES: The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. METHODS: Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. RESULTS: Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. CONCLUSIONS: The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.

Effect of Changes in Intravascular Volume on Inferior Vena Cava and Aorta Diameters and the Caval/Aorta Index in Healthy Volunteers.

OBJECTIVES: Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring. METHODS: This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests. RESULTS: Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059). CONCLUSIONS: The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.

A comparison of noninvasive methods for early detection of hemorrhage: Inferior vena cava ultrasonography and spectrophotometric hemoglobin levels.

OBJECTIVES: Blood hemoglobin concentration measurements using a spectrophotometric method (SpHb), and inferior vena cava ultrasonography (IVC-US) are noninvasive methods used to follow-up hemorrhages. We compared their efficacy using voluntary blood donation as a model of moderate (approx. 500 mL) blood loss. METHODS: In this prospective observational study enrolling blood-donor volunteers (BD) and matched controls, we recorded SpHb, IVC diameters, and vital signs. Changes in variables from baseline were compared between BD and controls using the paired t test and Wilcoxon signed rank test. RESULTS: We included 118 subjects in the BD group and 95 healthy subjects in the control group. Changes in IVC maximum diameter, IVC minimum diameter, pulse rate, mean arterial pressure, pulse pressure, and shock index, but not in other variables, were significantly different in the BD and the control group (P < 0.05). IVCmax ≥1.1 mm yielded a 74% sensitivity and 77% specificity (PPV 79.8%, NPV 70.2%) in detecting early hemorrhage. With these cutoff values, IVCmax or PR reached a 90% sensitivity, while IVCmin and PR reached 98% specificity. CONCLUSIONS: IVC ultrasound may be superior to SpHb in predicting blood loss and may be useful in addition to vital signs for its follow-up.

Estimation of Cardiac Systolic Function Based on Mitral Valve Movements: An Accurate Bedside Tool for Emergency Physicians in Dyspneic Patients.

OBJECTIVES: The purpose of this study was to determine the success of mitral valve movements in the estimation of left ventricular ejection fraction (LVEF). METHODS: Adult patients whose principal symptom was dyspnea were included in this prospective observational study. The distance from the anterior mitral valve (AMV) to the interventricular septum (IVS) during early diastole was measured first in B-mode in the parasternal long axis (PLAX) named parasternal long axis-anterior leaflet septal separation. Second, the AMV-IVS distance was measured in M-mode in the PLAX named E-point septal separation. Third, AMV-IVS distance was measured in B-mode in the apical 4-chamber view named apical 4-chamber view-anterior leaflet septal separation. Finally, maximum distance between the 2 mitral leaflets in the apical 4-chamber view was measured and named mitral valve leaflet separation. Comprehensive echocardiography was performed by an experienced cardiologist. Correlation was calculated between mitral valve measurements and LVEF. Cutoff values were determined using receiver operating characteristic curves and the chi-square test. RESULTS: A total of 118 patients were included in the study. Parasternal long axis-anterior leaflet septal separation, E-point septal separation, and apical 4-chamber view-anterior leaflet septal separation were highly correlated with LVEF (correlation coefficient, -0.848, -0.833, and-0.822 [P < .001]). Parasternal long axis-anterior leaflet septal separation values less than 2.30 mm, E-point septal separation values less than 2 mm, and mitral valve leaflet separation values greater than 25.15 mm exhibited a 100% negative predictive value in excluding reduced LVEF. Parasternal long axis-anterior leaflet septal separation values less than 4.95 mm, EPSS values less than 5.85 mm, apical 4-chamber view-anterior leaflet septal separation values less than 6.95 mm, and mitral valve leaflet separation values greater than 24.05 mm exhibited a 100% negative predictive value in excluding severe reduced LVEF. CONCLUSIONS: Mitral valve measurement methods may be useful in predicting LVEF or values thereof as a complementary method of diagnosing challenging patients on echocardiographic images.

A new side effect of synthetic cannabinoid use by the bucket (waterpipe) method: Acute respiratory distress syndrome (ARDS).

The use and content of synthetic canibinden (SCs) has been rapidly increased in the last decades. The complex content of these substances bring along a wide spectrum of side effects. In addition to the expected neuropsychological side effects of pleasure-inducing substances such as agitation, anxiety, panic attack and hallucinations, rare cases of cerebrovascular diseases, seizures, acute renal injury, myocardial infarction and chronic lung injury have also been previously reported. Here we report a 19-year -old male who was presented with acute respiratory distress syndrome (ARDS) within hours of inhaled SC use with the rarely preferred bucket method. There is limited information in the literature about pulmonary effects of SCs and we could not detect any other ARDS case that develoed within hours after consumption of SC with the bucket method.

How much can synthetic cannabinoid damage the heart? A case of cardiogenic shock following resistant ventricular fibrillation after synthetic cannabinoid use.

New substances are constantly being added to the content of synthetic cannabinoids (SCs). SCs can affect the cardiovascular system and cause hypotension and bradycardia, myocardial infarction, atrial fibrillation, prolonged QTc, and Mobitz type II atrioventricular block. However, no cases associated with ventricular fibrillation (VF) have been reported to date. We report a case of a 26-year-old male patient admitted to the emergency department due to altered consciousness after SC use and requiring prolonged cardiopulmonary resuscitation due to resistant VF and cardiogenic shock.

Oxidative/antioxidative status, lymphocyte DNA damage, and urotensin-2 receptor level in patients with migraine attacks.

BACKGROUND: The present study investigated the potential roles of plasma lymphocyte DNA damage, the urotensin-2 receptor (UTS2R), and oxidative changes in patients with varying degrees of migraine-related disability who were in the ictal phase and presented to our emergency department. METHODS: This study enrolled 40 consecutive adult patients with migraine attack and 40 age- and sex-matched healthy controls. The same health care professional determined the headache-related disability of each patient's migraine attack using the Migraine Disability Assessment Scale (MIDAS); patients were divided into three groups based on MIDAS score. Plasma lymphocyte DNA damage; UTS2R, malondialdehyde (MDA), and catalase (CAT) levels; total oxidant status (TOS); total antioxidant status (TAS); and the oxidative stress index (OSI) were used as predictors of early oxidative changes. RESULTS: Plasma lymphocyte DNA damage, TOS, MDA levels, and OSI values were significantly higher in patients with migraine compared to controls. Conversely, TAS and CAT and UTS2R levels were markedly lower in patients with migraine compared to controls. Comparisons of the patient groups by MIDAS score revealed significant differences in plasma lymphocyte DNA damage and CAT levels but no differences in TOS, MDA levels, OSI, TAS, or UTS2R levels. MIDAS scores were positively correlated with the degree of lymphocyte DNA damage, but neither of these factors was significantly related to CAT levels. CONCLUSION: The present data suggest that lymphocyte DNA damage and changes in oxidative/antioxidative status may reflect an enhanced oxidative damage and an ineffective antioxidant defense system in migraineurs during headache attacks. In addition, lymphocyte DNA damage levels may be an indicator of the degree of migraine-related disability as assessed by MIDAS score.