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The mystery of migraines
 

The mystery of migraines

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  • Primary vs Secondary headaches
  • Coded to as many as 4 digits
  • Migraine is 2 nd most common cause in U.S. Prevalence increases from 1% at age 6 yrs to 5% at ll years; in males, prevalnece remains about 5-10% during adult life; in females, may increase to 20% during reproductive years; 90% have first attack before age 50 years 50% migraneurs have one or both parents with migraine
  • Recurrent, periodic headache of mild to moderate to severe intensity Begins gradually and maximizes in 30-60 minutes Cutaneous allodynia or osmophobia may develop
  • 75% report at least one trigger
  • For severe, frequent headaches that interfere with the patients daily routines Contraindicaton to or failure or overuse of acute therapies Adverse events to acute therapies Patient preference Also if: hemiplegic migraine, basilar type migraine, migraine with prolonged aura, migrainour infarction

The mystery of migraines The mystery of migraines Presentation Transcript

  • The Mystery ofMigrainesAndrew Massey, M.D. UKSM-WMay 14, 2013
  • Classification of Headaches(circa 1977)1. Vascular headachea. Classic migraineb. Common migraine2. Muscle tension headache3. Traction and inflammatory headache
  • Classification of HeadachesInternational Headache Society 1988• 14 major categories• 195 separate, individually defined headaches• 19 migraine types
  • Classification of HeadacheInternational Headache Society 2005• Part I: The Primary Headaches• 1. Migraine• 2. Tension-type headache• 3. Cluster headache and other trigeminal autonomic cephalalgias• 4. Other primary headaches• Part II: The Secondary Headaches• 5. Headache attributed to head and/or neck trauma• 6. Headache attributed to cranial or cervical vascular disorder• 7. Headache attributed to non-vascular intracranial disorder• 8. Headache attributed to a substance or its withdrawal• 9. Headache attributed to infection• 10. Headache attributed to disorder of homoeostasis• 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or• other facial or cranial structures• 12. Headache attributed to psychiatric disorder• Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches• 13. Cranial neuralgias and central causes of facial pain• 14. Other headache, cranial neuralgia, central or primary facial pain
  • Migraine: Subtypes1.1 Migraine without aura1.2 Migraine with aura1.2.1 Typical aura with migraine headache1.2.2 Typical aura with nonmigraine headache1.2.3 Typical aura without headache1.2.4 Familial hemiplegic migraine1.2.5 Sporadic hemiplegic migraine1.2.6 Basilar-type migraine1.3 Childhood periodic syndromes1.3.1 cyclic vomiting1.3.2 abdominal migraine1.3.3 benign paroxysmal vertigo of childhood
  • Migraine: Subtypes(continued)1.4 Retinal migraine1.5 Complications of migraine1.5.1 Chronic migraine1.5.2 Status migrainosus1.5.3 Persistent aura without stroke1.5.4 Migrainous stroke1.5.5 Migraine-triggered seizure1.6 Probable migraine1.6.1 Probable migraine without aura1.6.2 Probable migraine with aura1.6.3 Probable chronic migraine
  • 8. HA attributed to a substance or its withdrawal8.1 HA induced by acute substance exposure8.1.4 Alcohol induced headache8.1.4.1 Immediately induced8.1.4.2 Delayed induced headache
  • Migraine• 90% of all headache due to one of 3 disorders:– Tension-type headache– Migraine headache– Cluster headache• 15% of people in U.S. experience migraine– 17% of women, 6% of men
  • Migraine: Symptoms• Pain– Dull, deep, steady when mild to moderate– Throbbing or pulsatile when severe– Worsened by light, noise, motion, sneezing,straining– 70% with pain only on one side of the head• Other symptoms– Nausea, vomiting, photophobia, phonophobia– 20% with auras
  • Migraine: Symptoms• Migraine Aura– Preceeds or accompanies the headache– May be sensory, visual, motor, or speech– Last 5 to 20 minutes (uncommonly 60 minutes)• Headache may last a few hours to several days– Usually resolve in sleep• Postdrome phase– Patient feels “drained” or exhausted
  • Migraine: Triggers• Emotional stress, worry• Medications & chemicals– Nitroglycerin, hydralazine, estrogens– Strong perfumes, smoke, organic solvents• Certain foods or additives– Nitrites, monosodium glutamate, aspartate, alcohol• Other triggers– Fasting, sleep deprivation, physical exertion, weather,lights, caffeine withdrawal, menstruation
  • Migraine: Diagnostic CriteriaA. At least 5 attacks fulfilling B-DB. HA lasting 4-72 hoursC. HA has at least two of the following1. Unilateral location2. Pulsating quality3. Moderate or severe intensity4. Aggravation by walking stairs or similar routinephysical activityD. Headache not explained by another disorder
  • Diagnosis of headache1. Take a careful history2. Do a careful examination
  • History:30 y.o. British soldier with two year history ofheadache and trouble fitting his helmetExam:See next slide 
  • Migraine: Treatment1. Recognize & avoid triggers2. Preventive treatment to reduce frequency &intensity of headaches3. Acute treatment of migraine
  • Preventive Treatment 1/4• Medications for control of hypertension– Beta blockers:• propranolol, metoprolol, timolol, nadolol, atenolol– Calcium channel blockers:• verapamil, nifedipine, nimodipine– ACE inhibitors or ARBs:• lisinopril, candesartan
  • Preventive Treatment 2/4• Antidepressants– Tricyclics:• amitriptyline, nortriptyline, protriptyline, doxepin– Serotonin/norepinephrine reuptake inhibitors:• venlafaxine
  • Preventive Treatment 3/4• Anti-Epileptic medications:– Valproate,– topiramate,– gabapentin• Other agents:– Botulinum toxin– Coenzyme Q10– Nonsteroidal antiinflammatory drugs:• Naproxen, indomethacin– Narcotics– Riboflavin (vitamin B2)
  • Preventive Treatment 4/4• Nonpharmacologic therapy– Relaxation training– Behavioral therapy– Hypnosis– Occipital nerve electrical stimulation– Acupuncture– Surgery (eg., removal of glabellar muscle)– Closure of patent foramen ovale (PFO)– Exercise
  • Acute Treatment of Migraine• Mild analgesics– Nonsteroidals: ibuprofen, diclofenac, naproxen– Acetaminophen– Aspirin• Triptans– Sumatriptan, zolmitriptan, naratriptan, rizatriptan,almotriptan, eletriptan, frovatriptan• Ergots– Ergotamine, dihydroergotamine (DHE)
  • Acute Treatment of Migraine• Anti-nausea medications– Metoclopramide, chlorpromazine,prochlorperazine• Others– Benzodiazepines, narcotics, barbiturates– Steroids (eg., dexamethasone)• Investigational drugs– CGRP receptor antagonists– lasmiditan
  • Acute Treatment of Migraine• General principles for preventive medications1. Take early in the attack2. Non-oral med if prominent nausea &vomiting3. Consider anti-nausea medication4. Consider caffeinated beverage5. Guard against medication overuse headachea. Expecially with barbiturates or narcoticsb. Increase risk with >2-3 acute treatments per week