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Gatterer H, Villafuerte FC, Ulrich S, Bhandari SS, Keyes LE, Burtscher M. Altitude illnesses. Nat Rev Dis Primers 2024; 10:43. [PMID: 38902312 DOI: 10.1038/s41572-024-00526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/22/2024]
Abstract
Millions of people visit high-altitude regions annually and more than 80 million live permanently above 2,500 m. Acute high-altitude exposure can trigger high-altitude illnesses (HAIs), including acute mountain sickness (AMS), high-altitude cerebral oedema (HACE) and high-altitude pulmonary oedema (HAPE). Chronic mountain sickness (CMS) can affect high-altitude resident populations worldwide. The prevalence of acute HAIs varies according to acclimatization status, rate of ascent and individual susceptibility. AMS, characterized by headache, nausea, dizziness and fatigue, is usually benign and self-limiting, and has been linked to hypoxia-induced cerebral blood volume increases, inflammation and related trigeminovascular system activation. Disruption of the blood-brain barrier leads to HACE, characterized by altered mental status and ataxia, and increased pulmonary capillary pressure, and related stress failure induces HAPE, characterized by dyspnoea, cough and exercise intolerance. Both conditions are progressive and life-threatening, requiring immediate medical intervention. Treatment includes supplemental oxygen and descent with appropriate pharmacological therapy. Preventive measures include slow ascent, pre-acclimatization and, in some instances, medications. CMS is characterized by excessive erythrocytosis and related clinical symptoms. In severe CMS, temporary or permanent relocation to low altitude is recommended. Future research should focus on more objective diagnostic tools to enable prompt treatment, improved identification of individual susceptibilities and effective acclimatization and prevention options.
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Affiliation(s)
- Hannes Gatterer
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.
- Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT TIROL-Private University for Health Sciences and Health Technology, Hall in Tirol, Austria.
| | - Francisco C Villafuerte
- Laboratorio de Fisiología del Transporte de Oxígeno y Adaptación a la Altura - LID, Departamento de Ciencias Biológicas y Fisiológicas, Facultad de Ciencias e Ingeniería, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sanjeeb S Bhandari
- Mountain Medicine Society of Nepal, Kathmandu, Nepal
- Emergency Department, UPMC Western Maryland Health, Cumberland, MD, USA
| | - Linda E Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Martin Burtscher
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
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Horiuchi M, Mitsui S, Uno T. Influence of Smoking and Alcohol Habits on Symptoms of Acute Mountain Sickness on Mount Fuji: A Questionnaire Survey-Based Pilot Study. High Alt Med Biol 2024; 25:140-148. [PMID: 38416507 DOI: 10.1089/ham.2023.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Horiuchi, Masahiro, Satomi Mitsui, and Tadashi Uno. Influence of smoking and alcohol habits on symptoms of acute mountain sickness on Mount Fuji: a questionnaire survey-based pilot study. High Alt Med Biol 00:000-000, 2024. Background: Acute cigarette smoking or alcohol intake would cause opposing vasculature effects that may influence acute mountain sickness (AMS). The present study aimed to investigate the effects of smoking and alcohol consumption behaviors, and acute smoking and consuming alcohol during ascent on AMS on Mount Fuji. Methods: This questionnaire survey study included 887 participants who climbed Mount Fuji and obtained information regarding sex, age, and smoking and alcohol habits, including behavior during ascent. Results: AMS prevalence was 45% for all participants. A univariate analysis revealed that younger participants (20-29 years) were associated with increased AMS prevalence (effect size [ES] = 0.102, p = 0.057) and severity (ES = 0.18, p = 0.01). A prediction model using multiple logistic regression indicated that several factors influenced AMS risk: younger age (p = 0.001), daily smoking habits (p = 0.021), no smoking (p = 0.033), or alcohol consumption during ascent (p = 0.096). Alcohol consumption during ascent had no effect on the increased AMS risk in younger participants (20-29 years), while alcohol consumption during ascent increased AMS risk for middle-age participants (50-59 years). Conclusion: Younger individuals are more likely to experience AMS. Smoking habits are associated with an increased AMS risk. It may be recommended that middle-aged climbers should ascend without consuming alcohol.
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Affiliation(s)
- Masahiro Horiuchi
- Faculty of Sports and Life Science, National Institute of Fitness and Sports in KANOYA, Kanoya-City, Japan
- Division of Human Environmental Science, Mount Fuji Research Institute, Fujiyoshida City, Japan
| | - Satomi Mitsui
- Division of Human Environmental Science, Mount Fuji Research Institute, Fujiyoshida City, Japan
| | - Tadashi Uno
- Division of Human Environmental Science, Mount Fuji Research Institute, Fujiyoshida City, Japan
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Pacheco-Barrios K, Velasquez-Rimachi V, Navarro-Flores A, Huerta-Rosario A, Morán-Mariños C, Molina RA, Farroñay-García C, Metcalf T, Fregni F, Alva-Díaz C. Primary headache disorders in Latin America and the Caribbean: A meta-analysis of population-based studies. Cephalalgia 2023; 43:3331024221128265. [PMID: 36606574 DOI: 10.1177/03331024221128265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND In this manuscript, we aim to systematically estimate the pooled prevalence and incidence of primary headaches and its subtypes (migraine, tension-type headache, and chronic headaches) in Latin America and the Caribbean, describing its epidemiological profile and associated factors. METHODS We systematically searched PubMed/MEDLINE, Scopus, and LILACS (From conception to March 2021), for populational studies reporting the epidemiology of primary headaches and their associated factors in Latin America and the Caribbean. The data extraction was conducted independently. We performed random-effect model meta-analysis of prevalence (overall primary headaches and by subtypes) and associated factors, assessed potential sources of heterogeneity, the risk of bias, publication bias, and the evidence certainty (GRADE methodology). RESULTS We included 32 populational studies (38 subpopulations, n = 63,813). The prevalence of primary headaches was 41.4% (95% CI 31.1-52.2%; n = 54,357), 15% for migraine (95% CI 12.0-18.3; n = 53,658 individuals), 20.6% for tension-type headache (95% CI 12.4-30.2; n = 25,840), and 6% for chronic headaches (95% CI 3.3-9.6; n = 21,720), with high between-study heterogeneity. No incidence data was found. Female sex, white ethnicity, high BMI, comorbid mental health disorders, and low-back pain were associated with higher prevalence of primary headaches. The prevalence was less in rural areas. CONCLUSION In Latin America and the Caribbean, primary headaches are highly prevalent affecting young females disproportionally. The prevalence of chronic headaches is higher than in other systematic global and regional estimations. The presence of comorbidities as modifiable risk factors should encourage their integration as targets for community-based preventive and therapeutic interventions. PROTOCOL REGISTRATION NUMBER CRD42018105116.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.,SYNAPSIS Mental Health and Neurology, Lima, Peru.,Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Victor Velasquez-Rimachi
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru.,Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Alba Navarro-Flores
- Georg-August-University Göttingen, International Max Planck Research School for Neurosciences, Göttingen, Germany
| | | | - Cristian Morán-Mariños
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru.,Unidad de Investigación en Bibliometría, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | | | - Chandel Farroñay-García
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru.,Instituto Nacional de Salud, INS, Lima, Peru
| | - Tatiana Metcalf
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru.,Servicio de Neurología, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigación, Hospital Daniel Alcides Carrión, Callao, Peru
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA.,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Carlos Alva-Díaz
- Unidad de Investigación en Bibliometría, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
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Abouzari M, Tawk K, Nguyen CHH, Risbud A, Djalilian HR. Tympanostomy tube placement for pressure-sensitive vertigo. Laryngoscope Investig Otolaryngol 2022; 7:1987-1991. [PMID: 36544944 PMCID: PMC9764749 DOI: 10.1002/lio2.860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To evaluate tympanostomy tube placement in patients with pressure-sensitive vertigo. Methods Retrospective case series. Results Six patients with pressure-sensitive vertigo reported resolution of their vertigo and other vestibular symptoms after placement of the tympanostomy tubes. All recurrences of symptoms were due to either extrusion or plugging of the tubes. All patients fulfilled the criteria for vestibular migraine. None of the patients had superior canal dehiscence on imaging or precedent event that triggered the problem, and all had a negative fistula test. Conclusion Tympanostomy tube placement should be considered in selected patients with vertigo exacerbated by seemingly small changes in atmospheric pressure (e.g., just prior to thunderstorms, air travel, or travel to the mountains). By eliminating the capability of the tympanic membrane to sense changes in pressure with a tube, patients with pressure-induced vertigo (in the absence of perilymph fistula or superior canal dehiscence) may have relief of their symptoms. Level of Evidence IV
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Affiliation(s)
- Mehdi Abouzari
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaIrvineCaliforniaUSA
| | - Karen Tawk
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaIrvineCaliforniaUSA
| | - Cecilia H. H. Nguyen
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaIrvineCaliforniaUSA
| | - Adwight Risbud
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaIrvineCaliforniaUSA
| | - Hamid R. Djalilian
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaIrvineCaliforniaUSA,Department of Biomedical EngineeringUniversity of CaliforniaIrvineCaliforniaUSA
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Falla M, Giardini G, Angelini C. Recommendations for traveling to altitude with neurological disorders. J Cent Nerv Syst Dis 2021; 13:11795735211053448. [PMID: 34955663 PMCID: PMC8695750 DOI: 10.1177/11795735211053448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 09/02/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Several neurological conditions might worsen with the exposure to high altitude (HA). The aim of this review was to summarize the available knowledge on the neurological HA illnesses and the risk for people with neurological disorders to attend HA locations. METHODS A search of literature was conducted for several neurological disorders in PubMed and other databases since 1970. The neurological conditions searched were migraine, different cerebrovascular disease, intracranial space occupying mass, multiple sclerosis, peripheral neuropathies, neuromuscular disorders, epileptic seizures, delirium, dementia, and Parkinson's disease (PD). RESULTS Attempts were made to classify the risk posed by each condition and to provide recommendations regarding medical evaluation and advice for or against traveling to altitude. Individual cases should be advised after careful examination and risk evaluation performed either in an outpatient mountain medicine service or by a physician with knowledge of HA risks. Preliminary diagnostic methods and anticipation of neurological complications are needed. CONCLUSIONS Our recommendations suggest absolute contraindications to HA exposure for the following neurological conditions: (1) Unstable conditions-such as recent strokes, (2) Diabetic neuropathy, (3) Transient ischemic attack in the last month, (4) Brain tumors, and 5. Neuromuscular disorders with a decrease of forced vital capacity >60%. We consider the following relative contraindications where decision has to be made case by case: (1) Epilepsy based on recurrence of seizure and stabilization with the therapy, (2) PD (± obstructive sleep apnea syndrome-OSAS), (3) Mild Cognitive Impairment (± OSAS), and (4) Patent foramen ovale and migraine have to be considered risk factors for acute mountain sickness.
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Affiliation(s)
- Marika Falla
- Institute of Mountain Emergency
Medicine, Eurac Research, Bolzano, Italy
- Center for Mind/Brain Sciences,
CIMeC, University of Trento, Rovereto, Italy
| | - Guido Giardini
- Mountain Medicine and Neurology
Centre, Valle D’Aosta Regional
Hospital, Aosta, Italy
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Garrido E, Botella de Maglia J, Castillo O. Acute, subacute and chronic mountain sickness. Rev Clin Esp 2021; 221:481-490. [PMID: 34583826 DOI: 10.1016/j.rceng.2019.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/16/2019] [Indexed: 11/29/2022]
Abstract
More than 100 million people ascend to high mountainous areas worldwide every year. At nonextreme altitudes (<5500m), 10-85% of these individuals are affected by acute mountain sickness, the most common disease induced by mild-moderate hypobaric hypoxia. Approximately 140 million individuals live permanently at heights of 2500-5500m, and up to 10% of them are affected by the subacute form of mountain sickness (high-altitude pulmonary hypertension) or the chronic form (Monge's disease), the latter of which is especially common in Andean ethnicities. This review presents the most relevant general concepts of these 3 clinical variants, which can be incapacitating and can result in complications and become life-threatening. Proper prevention, diagnosis, treatment and management of these conditions in a hostile environment such as high mountains are therefore essential.
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Affiliation(s)
- E Garrido
- Servicio de Hipobaria y Fisiología Biomédica, Universidad de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, Spain.
| | - J Botella de Maglia
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, Spain
| | - O Castillo
- Instituto Nacional de Biología Andina, Universidad Nacional Mayor de San Marcos, Lima, Peru
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Yang SL, Ibrahim NA, Jenarun G, Liew HB. Incidence and Determinants of Acute Mountain Sickness in Mount Kinabalu, Malaysia. High Alt Med Biol 2020; 21:265-272. [PMID: 32614265 PMCID: PMC7482124 DOI: 10.1089/ham.2020.0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/22/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Acute mountain sickness (AMS) is the most common type of high-altitude sickness. The incidence of AMS varies by mountain location, trail characteristics, and study design. The lack of local epidemiology data has driven us to investigate the incidence and severity of AMS and its associated factors at Mount Kinabalu, Malaysia. Methods: A cohort study was conducted to collect data from climbers after days 1 (3272 m) and 2 (4095 m) of ascent. A self-administered questionnaire was used to explore climbers' demographic and climb characteristics, history of AMS, alcohol exposure, and AMS prevention measures. The Lake Louis score 2018 was used to assess the presence and severity of AMS (cutoff ≥3). Univariate and multivariable logistic regressions were performed to determine the factors associated with the development of AMS on day 2. Results: Data from 345 climbers were analyzed. The incidence of AMS was 23.9% (95% confidence interval [CI] 19.5%-28.7%) and 21.7% (95% CI 17.5%-26.3%) on days 1 and 2, respectively. The majority were mild cases. Experiencing AMS on day 1 (odds ratio [OR] = 12.88; 95% CI 6.71-24.75), alcohol consumption (OR = 3.73; 95% CI 1.66-8.39), receiving guide advice on day 1 (OR = 0.49; 95% CI 0.26-0.93), and age (OR = 0.96; 95% CI 0.93-0.99) were significant determinants of AMS at Mount Kinabalu. Gender, history of AMS, past exposure to high altitude, ascending time, water intake, acetazolamide use, physical fitness, pulse rate, and peripheral capillary oxygen saturation (SpO2) were not associated with AMS at Mount Kinabalu. Conclusion: Future analysis with age strata is required to ascertain the association of age with AMS. Our research has signposted a strong call for collaborative efforts to improve the provision of hiking advice and discourage alcohol sales to mitigate the risk of AMS among Mount Kinabalu climbers.
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Affiliation(s)
- Su Lan Yang
- Centre for Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health Malaysia, Shah Alam, Malaysia
| | | | - Grazele Jenarun
- Clinical Research Centre, Hospital Queen Elizabeth II, Kota Kinabalu, Malaysia
| | - Houng Bang Liew
- Clinical Research Centre, Hospital Queen Elizabeth II, Kota Kinabalu, Malaysia
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Garrido E, Botella de Maglia J, Castillo O. Acute, subacute and chronic mountain sickness. Rev Clin Esp 2020; 221:S0014-2565(20)30064-3. [PMID: 32197780 DOI: 10.1016/j.rce.2019.12.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022]
Abstract
More than 100 million people ascend to high mountainous areas worldwide every year. At nonextreme altitudes (<5500 m), 10-85% of these individuals are affected by acute mountain sickness, the most common disease induced by mild-moderate hypobaric hypoxia. Approximately 140 million individuals live permanently at heights of 2500-5500 m, and up to 10% of them are affected by the subacute form of mountain sickness (high-altitude pulmonary hypertension) or the chronic form (Monge's disease), the latter of which is especially common in Andean ethnicities. This review presents the most relevant general concepts of these 3 clinical variants, which can be incapacitating and can result in complications and become life-threatening. Proper prevention, diagnosis, treatment and management of these conditions in a hostile environment such as high mountains are therefore essential.
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Affiliation(s)
- E Garrido
- Servicio de Hipobaria y Fisiología Biomédica, Universidad de Barcelona, L'Hospitalet de Llobregat, Barcelona, España; Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, España.
| | - J Botella de Maglia
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, España; Instituto de Estudios de Medicina de Montaña (IEMM), Barcelona, España
| | - O Castillo
- Instituto Nacional de Biología Andina, Universidad Nacional Mayor de San Marcos, Lima, Perú
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Sherpas, Coca Leaves, and Planes: High Altitude and Airplane Headache Review with a Case of Post-LASIK Myopic Shift. Curr Neurol Neurosci Rep 2019; 19:104. [PMID: 31781974 DOI: 10.1007/s11910-019-1013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW High altitude headache is a common neurological symptom that is associated with ascent to high altitude. It is classified by the International Classification of Headache Disorders, 3rd Edition (ICHD-3) as a disorder of homeostasis. In this article, we review recent clinical and insights into the pathophysiological mechanisms of high altitude and airplane headache. We also report a second case of post-LASIK myopic shift at high altitude exposure secondary hypoxia. Headache attributed to airplane travel is a severe typically unilateral orbital headache that usually improves after landing. This was a relative recent introduction to the ICHD-3 diagnostic criteria. Headache pain with flight travel has long been known and may have been previously considered as a part of barotrauma. Recent studies have helped identify this as a distinct headache disorder. RECENT FINDINGS Physiologic, hematological, and biochemical biomarkers have been identified in recent high altitude studies. There have been recent advance in identification of molecular mechanisms underlying neurophysiologic changes secondary to hypoxia. Calcitonin gene-related peptide, a potent vasodilator, has been implicated in migraine pathophysiology. Recent epidemiological studies indicate that the prevalence of airplane headache may be more common than we think in the adult as well at the pediatric population. Simulated flight studies have identified potential biomarkers. Although research is limited, there have been advances in both clinical and pathophysiological mechanisms associated with high altitude and airplane headache.
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Schneider M, Bärtsch P. Characteristics of Headache and Relationship to Acute Mountain Sickness at 4559 Meters. High Alt Med Biol 2018; 19:321-328. [PMID: 30067102 DOI: 10.1089/ham.2018.0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The goals of this study were to characterize headache at high altitude in relation to the severity of acute mountain sickness (AMS), to investigate whether a history of migraine or nonmigrainous headache at low altitude is a risk factor for AMS and to estimate its effect size in relation to established major risk factors. We performed a secondary, extended analysis of data obtained from 1320 mountaineers staying overnight at the Capanna Margherita (4559 m). Headache at low and high altitude was classified according to the criteria of the International Headache Society. About 45% of the mountaineers suffered from headache in the evening of the arrival day at 4559 m. In those with headache, tension type headache decreased from 62% to 29% and 13% with no AMS (AMS-C <0.70), moderate AMS, and more severe AMS (AMS-C ≥1.5), while headache fulfilling the criteria of migraine increased correspondingly from 14% to 34% and 69%. A history of migraine or any type of headache at low altitude is a minor predictor of AMS that does not significantly contribute to AMS risk in a multivariate analysis including the major risk factors such as history of AMS, rate of ascent, and degree of preacclimatization in this population of alpine mountaineers. The association between more severe AMS and migrainous headache may be due to common nonspecific symptoms but a common underlying pathophysiology of AMS and migraine cannot be excluded. Despite this association a history of migraine or other headache at low altitude is not a major risk factor for AMS.
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Affiliation(s)
- Michael Schneider
- 1 Department of Internal Medicine, University Hospital Heidelberg , Heidelberg, Germany .,2 Department of Pediatric Hematology/Oncology, Justus-Liebig University of Giessen , Giessen, Germany
| | - Peter Bärtsch
- 1 Department of Internal Medicine, University Hospital Heidelberg , Heidelberg, Germany
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