Brain attack as a word, a close cousin of heart attack, might just do the trick of awakening the lay public to the need to be on the alert when pain in the head comes like a bolt from the blue with the intensity never felt before. Headaches are so common that if one did not get any headache at all he is either lying or has probably no head at all! Very severe headache coming on very suddenly is sure to be the beginning of a major problem and may be the harbinger of a future stroke.

Any stroke needs urgent medical attention to minimise, if not totally rectify, the neurologic deficit. One of the early symptoms of a stroke is severe headache, in addition to the other symptoms. I must hasten to add that minor headaches, or headaches one is accustomed to over a long period, are of no consequence in this context. Your doctor should be the best person to either treat you or refer you to the neurologist when the need arises. So always consult your doctor without losing precious time, when in doubt. Going directly to a specialist with minor aches and pains may, at times, land you in trouble; as the great medical teacher of yore, William Harvey, wrote in the early part of this century: " Specialists have an inevitable tendency to a narrow and perverted vision in which the life of the ant-hill is mistaken for the world at large."

One of the causes of brain attack is what the doctors call sub-arachnoid leak or haemorrhage. Here the diagnosis in the early curable phase depends only on the correct history of the attack got from the patient. This was recently proved in a study in England where a team of neurologists and surgeons reviewed prospectively the efficacy of this early approach to management of subarachnoid haemorrhage. It is very important to note from this study that the proper history from the patient is the best way to make a diagnosis of the first leak, which even a CT scan may not pick up in the early stages. The only sign of this malady is a sudden severe headache like a bolt from the blue, the like of which the sufferer never had in the past. This may or may not be accompanied by vomiting. Every living human being has had headache sometime or the other, and many of us have headaches almost daily and a few of us are a headache to others. But the headache of a stroke is very severe and can never be missed. It is mandatory that one sees his own doctor forthwith lest he should miss the best opportunity for an early diagnosis and correct management.

A good history, coupled with a thorough clinical examination of the patient with, may be a simple examination of the spinal fluid got after lumbar puncture, should yield the diagnosis. The first bleed is rarely ever fatal; if not diagnosed and treated properly, the second bleed is almost always dangerous and many times fatal. The usual cause of the bleed is a congenital malformation of the blood vessel inside the cranial cavity, called by doctors as congenital berry aneurysms. In this situation the question of prevention does not arise as no one knows who has the malformation as also the risk of the first bleed. The second bleed is a certainty and so requires surgical correction of the abnormality: the latter is a very simple procedure these days.

There is a lot of talk about preventing strokes by treating mildly elevated blood pressures in the population these days. In this area the largest study has been the MRC ( Medical Research Council of UK) study published in 1985 after studying a very large number of people. This study has the largest patient-years of experience of any study to date, of 85,000 patient-years of experience! Do not get shocked! These are all statistical terms and it does not mean that the study observed patients for 85,000 years. The study, however, did show that to save one man from stroke we need to treat 850 apparently healthy people with marginally elevated blood pressures with drugs that do not help them might harm. It is also true that the largest stroke centre in the UK in Glasgow kept its records of the stroke patient admitted in an year, of which around 18% were high blood pressure patients untreated, another 12% were well controlled hypertensives, and the remaining 70% were normotensives.

Strokes could be due to many causes, but all of them need emergency medical attention as many of them could benefit from modern medical advances. It is high time that we, in this part of the world, stopped thinking that strokes do not have treatment in modern medicine and our best bet is to give the patient oil massage and folk medicines. Far from it. Even some of the haemorrhagic strokes could be very well treated with surgical methods and many of the thrombotic strokes, where blood clots inside the blood vessels of the brain, could be helped with the present drug regimen. Newer clot busters are also being tried with fair degree of success. The future holds lot of promise in the area.

It is always a good dictum to live well and eat healthy diet and take regular exercise for the well being and comfortable living. To think that by doing all that and having regular check-ups ( Executive Check-ups sold these days) will prevent one from getting diseases and postpone death is only a myth. In this area we have opinions and very few facts. It is time for doctors to shed their dogmatic attachment and work with compassionate pragmatism for the good of their patients and society at large. The idea that healthy long life results from regular check ups to detect diseases in their pre-symptomatic stage has also not stood the test of time. Our best bet is to see our doctor with the least deviation in our otherwise healthy living. There are two situations where this dictum will fail. Alcohol and tobacco will blunt our body signals. It may not be a bad idea for alcoholics and smokers to have regular check ups, lest they should miss the early warning signals from their bodies.

There was a recent symposium on this last issue in memory of Petr Skrabanek, who along with McCormick had done a lot of work in this field, at the Trinity College Dublin, wherein the speakers brought out many interesting data which will have relevance here.

1. The gains of a life time spent in the pursuit of health care are not large where longevity is concerned in people with average risk.

2. By computer modeling it was determined that a life long cholesterol awareness and correction might lead to an average of three weeks of extra life.

3. In all screening programmes most individuals never contract the disease of interest.

4. Disciplined subjects who comply with life long ingestion or non-ingestion of certain substances "forever" will seldom live to reap the benefit of their compliance.

5. Instead they die of something unrelated.

The moral of the story is to live well only to enjoy healthy life: to avoid premature death do see your doctor immediately when in trouble or in doubt, and only when in trouble and not before!