MIGRAINE. Denise Cambier M.D. Delaware Neurology, Ohio Health March 2013

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1 MIGRAINE Denise Cambier M.D. Delaware Neurology, Ohio Health March 2013

2 HISTORY: Graham and Wolff 1938: decreased amplitude of arterial pulsations coincided with reduction of headache with IV ergotamine. Theory of vasodilatation Leao 1944: cortical spreading depression Wave of neuronal depolarization followed by suppression of neuronal activity with corresponding changes in cerebral blood flow

Theory of vasodilatation Leao 1944: cortical spreading depression Wave of

3 PREVALANCE: Cumulative lifetime prevalence: 43% women and 18% men Equal until puberty at 4% boys and 5% girls

4 DIAGNOSIS: International Classification of Headache Disorders: Migraine = primary headache disorder With or without aura Aura 20% Hemi cranial vs. bilateral Episodic < 15 days month vs. Chronic > 15 days/month Sensory symptoms: the phobias, n/v, and disability

20% Hemi cranial vs. bilateral Episodic < 15 days month vs.

5 TRIGGERS: Polygenic inheritance Head trauma Estrogen/hormonal Exertion Dietary Sleep disturbances Medications

6 IMAGING: MRI brain/ct brain typically normal/ubos PET and fmri show increased activity in deep gray matter and brainstem which control cerebral blood flow Patent foramen ovale 50% migraine Closure shows no clear clinical benefit

brainstem which control cerebral blood flow Patent

7 MENSTRAUL MIGRAINE: 11 % onset at menarche 14% only have migraines with menses Defined as migraine occurring in 2 of 3 menstrual cycles (usually without aura) Due to a drop in estrogen levels Long-acting triptans, NSAIDs Hormonal manipulation: estrogen patches, progesterone, oral contraceptives

without aura) Due to a drop in estrogen levels Long-acting triptans,

8 PREGNANCY: Improves in 55-90% No change in 5-30% Small number worsen Medication options are limited

9 GOALS OF TREATMENT: Restoration of function Reduction of disability/pain Reduction of headache progression Optimal: quickly restore person to normal functioning in a safe, side effect-free, costeffective manner that minimizes the need for additional medication exposure or resource use.

restore person to normal functioning in a safe, side effect-free,

10 PRINCIPLES OF TREATMENT: Identifying prodrome and early treatment 50% patients delay treatment To determine if migraine To avoid medication unless severe attack Limit acute medication for cost or supply reasons Limit for fear of overuse

migraine To avoid medication unless severe attack Limit

11 NSAIDs: Nonsteroidal Anti- Inflammatory Drugs Aspirin, Tylenol, Ibuprofen, Naproxen OTC Indomethocin, Diclofenac, Ketoprofen, Ketorolac by prescription Combined with nausea medication can be very effective Limited if on blood thinners and liver/kidney disease

Ketorolac by prescription Combined with nausea medication can be

12 ANTIEMETICS Often combined with other therapies Compazine, Phenergan Reglan Zofran Drowsy and dizziness

13 PREVENTION MEDICATIONS: No single unified mechanistic theory of action Reduce frequency, severity and duration Potential improved response to acute therapy Two to three per month, disability, acute medications ineffective or overused Start low and go slow 2-3 month trial

response to acute therapy Two to three per month, disability, acute

14 CLASSES OF PREVENTION MEDICATONS: Antiepileptic drugs Anti-depressants Beta-adrenergic blockers Calcium channel blocker NSAIDs Serotonin 5-hydroxytryptamine antagonists Neurotoxins (Botox) Other

Calcium channel blocker NSAIDs Serotonin

15 ACUTE TREATMENTS: Triptans: 5-hydroxytryptamine 1B and 1D receptor agonists Vasoconstrictors Peripheral inhibition Brainstem inhibition 7 different options Cost, onset, duration Oral, injectable, nasal

Peripheral inhibition Brainstem inhibition 7

16 TRIPTANS: Onset 20 to 60 minutes, repeat in 1-4 hours if needed Pain recurs in 1/3 Often combined with NSAIDs and/or antiemetics Max of two doses per day, 2-3 days per week Cannot use in coronary artery disease or pregnancy Chest tightness and shortness of breath common

Max of two doses per day, 2-3 days per week Cannot use in coronary

17 ERGOTS: Less receptor specific than triptans = more side effects, nausea Pretreat with antiemetic Avoid in vascular disease, hypertension, renal or hepatic failure, and pregnancy DHE (Dihydroergotamine) nasal spray or injectable

vascular disease, hypertension, renal or hepatic

18 RESCUE THERAPIES: Sumatriptan SQ DHE + antiemetic Neuroleptics Ketorolac Magnesium Valproate IV Steroids Metoclopramide Benadryl

19 OPOIDS: Ideally short-term and intermittent use Potential tolerance, dependence and addiction Overuse may worsen primary headache disorders Max of 2 days per week

20 BOTOX: OnabotulinumtoxinA FDA approved for chronic migraine Specific criteria 31 small injections every 3 months done in office Few potential risks

21 Alternative and Complementary Therapy

22 BIOFEEDBACK: Learning to control body functions not normally under conscious control State of deep relaxation Success highest with daily practice 10 weekly sessions Meditation for 20 minutes daily

23 CBT AND ACT: Cognitive-Behavioral Therapy (CBT) Focus of control and experience, life values, cognitive diffusion, mindfulness, committed action and moving forward Acceptance Commitment Therapy Uses CBT with relaxation training, pain monitoring, identifying and challenging negative thoughts, problem solving, review and practice and relapse prevention

24 PHYSICAL METHODS: Aerobic exercise = 40 min three x per week Isometric neck exercise Physical therapy Massage therapy

25 DIETARY: Caffeine Gluten Skipping meals High carbohydrate meals, reactive hypoglycemia Tyramine-rich food, fermented foods, alcohol, aspartame, nitrates

26 ALTERNATIVE MEDICATIONS: Magnesium mg daily Coenzyme Q10 100mg three times daily Riboflavin 400mg daily Butterbur 150mg daily Feverfew one daily (products vary) Folic acid 1-4 mg daily Vitamin B12 400ug daily Vitamin B6 25mg daily

27 ACCUPUNCTURE: Evidence is controversial Largest study (11,874 patients) did not specify migraine Showed a 45% reduction in headaches over 6 months

HEADACHES IN CHILDREN AND ADOLESCENTS. Brian D. Ryals, M.D.

HEADACHES IN CHILDREN AND ADOLESCENTS Brian D. Ryals, M.D. Frequency and Type of Headaches in Schoolchildren 8993 children age 7-15 in Sweden Migraine in 4% Frequent Nonmigrainous in 7% Infrequent Nonmigrainous