s David R. Greeley, MD, FAAN Northwest Neurological, PLLC October 23, 2015
Why is Headache Important? 36,000,000 people have migraine - more than asthma and diabetes combined 13,000,000 have chronic daily headache 4,000,000 have > 15 migraines per month
Common family history of: - chronic pain - chronic headache - psychiatric concerns - abuse Learned behavior on medication use/abuse
The Cycle chronic pain poor sleep depression
Adverse Childhood Experiences
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
Exercise - regular, not excessive - simple, cheap and enjoyable - Yoga, T ai Chi, water aerobics...
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
Sleep hygiene - sleep consolidation - avoidance of stimulants - regular and consistent behavior - light box - overnight oximetry - Belsomra
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
Physical Modalities - physical therapy - chiropractic - therapeutic massage - acupuncture - craniosacral therapy - Rolfing / Structural Integration
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
Behavioral / Psychological / Psychiatric - Counseling - Listening - Support - Biofeedback / Meditation - Limited medicines
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
- a multifactorial approach - A contract for therapy - Education - Exercise - Sleep - Physical modalities - Psychiatric management - Avoidance of ER s and Urgent Care - Dietary changes - Medication
Dietary changes - hydration -- half your weight in oz/d - eating healthy foods - supplements as necessary -? allergies -- IgG from US Biotek - elimination diets - gluten-free - Naturopathic medicine
US Biotek Most common IgG markers in migraine patients: dairy and chicken egg In one study dietary elimination of these two improved migraine by >80% in >80% of patients
Rx -- acute care medications - steroid tapers - trigger point injections - Midrin (isometheptene mucate, dichloralphenazone and acetaminophen) - triptans - opioids
Rx -- chronic preventive medications - AED s - Tricyclics - Beta Blockers - Calcium Channel Blockers - others - research
AED s (anti-epileptic drugs) - topiramate (Topamax ) - divalproex (Depakote ) - lamotrigine (Lamictal ) - gabapentin (Neurontin ) - pregabalin (Lyrica )
TCA s (tricyclic antidepressants) - amitriptyline - imitriptyline - notriptyline - despiramine
Beta Blockers - propranolol - timolol - atenolol - metoprolol - nadolol
Calcium Channel Blockers - verapamil - diltiazem - amlodipine - nimodipine
Non-Prescription Agents Migrelief Petadolex Gliacin Zira Nourished Mind turmeric melatonin
Other Rx for Headache ACE inhibitors acetazolamide angiotensin II receptor antagonists (ARBs candesartan) clonidine indomethacin Namenda neuroleptics opioids oxytocin prazosin SSRI/SNRI
Botox in Migraine Botox has been used for neurological diseases for >20 years Treatment for spasticity led to: - improvement in hyperhidrosis Treatment for blepharospasm led to improvement in: - wrinkles - migraine
Botox in Migraine FDA-approved protocol 80+% reduction in headache 31 injections x5 units every 10-12 weeks: - 7: corrugator, procerus, frontalis - 8: temporalis - 6: occipitalis - 4: paracervical - 6: trapezius
Calcitonin Gene-Related Peptide Member of the calcitonin family α and β forms 37 amino acids derived from cell bodies of spinal cord motor neurons helps with regeneration derived from dorsal root ganglia linked to transmission of pain derived from trigeminal ganglion involved in migraine involved in cardiovascular homeostasis
CGRP in Migraine Meningeal nociceptors from the trigeminal ganglion release CGRP CGRP binds to CGRP receptors on meningeal vessels potent neurogenic vasodilator Triptans block CGRP acutely Botox prevents release of CGRP by cleavage of SNAP-25 protein monoclonal antibodies block CGRP after monthly infusion
CGRP Research Phase III study 825 patients nationwide Northwest Neurological is local site Patients with acute and chronic migraine Once a month infusion vs placebo Beginning enrollment in November 2015
Why is Headache Important? 36,000,000 people have migraine - more than asthma and diabetes combined 13,000,000 have chronic daily headache 4,000,000 have > 15 migraines per month
s QUESTIONS? David R. Greeley, MD Northwest Neurological, PLLC 509.458.7720 www.nwn4me.com
Northwest Neurological, PLLC Jason Aldred, MD Anne-Marie Bergeleen, ARNP David Duba, MD Jeff Emery, DO Tim Gilreath, LMP David Greeley, MD Jamie Mark, ARNP 509.458.7720 www.nwn4me.com