Neurology: Migraine throughout the life cycle: Treatment through the ages Bailey’s
utd online pathogen Clinical otolaryngology and allied sciences
Neurology: Migraine throughout the life cycle: Treatment through the ages
1. Migraine  UTMB Department of Otolaryngology  Grand Rounds March 2005  Jeffrey Buyten, MD  David C. Teller, MD  Francis B. Quinn, MD
2. Prevalence Familial Young, healthy women; F>M: 3:1 – 17 – 18.2% of adult females – 6 – 6.5% adult males 2-3rd decade onset… can occur sooner Peaks ages 22-55. ½ migraine sufferers not diagnosed. 94% pt’s seen in primary care settings for HA have migraines
3.  Common misdiagnoses for migraine: – Sinus HA – Stress HA Referral to ENT for sinus disease and facial pain.
4.  Migraineurs more likely to have motion sickness. Half of Meniere’s patients claim to have migrainous symptoms. BPPV
5.  $13 billion/year in lost productivity 1/3 participants in American Migraine Study II missed work in prior 3 months
6. Migraine Definition IHS criteria: Migraine/aura (3 out of 4)  IHS Diagnostic criteria: migraine w/o – One or more fully reversible aura aura symptoms indicates focal cerebral – HA lasting for 4-72 hrs cortical or brainstem dysfunction. – HA w/2+ of following: – At least one aura symptom  Unilateral develops gradually over more than  Pulsating 4 minutes.  Mod/severe intensity. – No aura symptom lasts more than one hour.  Aggravated by routine – HA follows aura w/free interval of physical activity. less than one hour and may begin – During HA at least 1 of following before or w/aura.  N/V  Photophobia  Phonophobia History, PE, Neuro exam show no other organic disease. At least five attacks occur
7. Migraine Subtypes  Basilar type migraine – Dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, bilateral paresthesias, altered consciousness. – Simultaneous bilateral visual symptoms. – No muscular weakness.  Retinal or ocular migraine – Repeated monocular scotomata or blindness < 1 hr – Associated with or followed by a HA
8. Migraine Subtypes Menstrual migraine Hemiplegic migraine – Unilateral motor and sensory symptoms that may persist after the headache. – Complete recover Familial hemiplegic migraine
9. Migrainous vertigo  Vertigo – sole or prevailing symptom.  Benign paroxysmal vertigo of childhood.  Prevalence 7-9% of pts in referral dizzy and migraine clinics.  Not recognized by the IHS  Diagnosis (proposed criteria) – Recurrent episodic vestibular symptoms of at least moderate severity. – One of the following:  Current of previous history of IHS migraine.  Migrainous symptoms during two or more attacks of vertigo.  Migraine-precipitants before vertigo in more than 50% of attacks. – Response to migraine medications in more than 50% of attacks
11.  Important role in migraine pathogenesis. Mechanism of action in migraines not well established. Main target of pharmacotherapy.
12. Aura Mechanism Cortical spreading depression – Self propagating wave of neuronal and glial depolarization across the cortex  Activates trigeminal afferents – Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.  Alters blood-brain barrier. – Associated with a low flow state in the dural sinuses.
13.  Auras – Vision – most common neurologic symptom – Paresthesia of lips, lower face and fingers… 2nd most common – Typical aura  Flickering uncolored zigzag line in center and then periphery  Motor – hand and arm on one side  Auras (visual, sensory, aphasia) – 1 hr Prodrome – Lasts hours to days…
14. Clinical manifestations  Clinical manifestations – Lateralized in severe attacks – 60-70% – Bifrontal/global HA – 30% – Gradual onset with crescendo pattern. – Limits activity due to its intensity. – Worsened by rapid head motion, sneezing, straining, constant motion or exertion. – Focal facial pain, cutaneous allodynia, GI dysfunction, facial flushing, lacrimation, rhinorrhea, nasal congestion and vertigo…
18. Abortive care strategies Stepped – Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.  Analgesics – Tylenol, NSAIDs…  Vasoconstrictors – sympathomimetics…  Opioids (try to avoid) - Butorphanol  Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan, zomatriptan. – Limited by patient compliance. Stratified – Adjusts treatment according to symptom intensity.  Mild – analgesics, NSAIDs  Moderate – analgesic plus caffeine/sympathomimetic  Severe – opioids, triptans, ergots… – Severe sx treatment limited due to concomitant GI sx’s. Staged – Bases treatment on intensity and time of attacks. – HA diary reviewed with patient. – Medication plan and backup plans.
19. Preventive therapy Consider if pt has more than 3-4 episodes/month. Reduces frequency by 40 – 60%. Breakthrough headaches easier to abort. Beta blockers Amitriptyline Calcium channel blockers Lifestyle modification. Biofeedback.
20. Botox51% migraineurs treated had complete prophylaxis for 4.1 months.38% had prophylaxis for 2.7 months.Randomized trial showed significant improvement in headache frequency with multiple treatments.
21. Conclusions Migraine is common but unrecognized. Keep migraine and its variants in the differential diagnosis.
22. References1. Landy, S. Migraine throughout the Life Cycle: Treatment through the Ages. Neurology. 2004; 62 (5) Supplement 2: S2-S8.2. Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.3. Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of Migraine in Adults. Up To Date online. 2005.4. Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the labels that headache sufferers apply to their headaches. Neurology. 2002; 58(9) Supplement 6: S21-S26.5. Cady, RK, Schreiber, CP. Sinus headache or migraine?: Considerations in making a differential diagnosis. Neurology. 2002; 58 (9) Supplement 6: S10-S14.6. Perry, BF, Login, IS, Kountakis, SE. Nonrhinologic headache in a tertiary rhinology practice. Otolaryngology – Head and Neck Surg 2004; 130: 449-452.7. Daudia, AT, Jones, NS. Facial migraine in a rhinological setting. Clinical Otolaryngology and Allied Sciences. 2002; 27(6): 521-525.8. Spierings, EL. Migraine mechanism and management. Otolarynogol Clin N Am 36 (2003): 1063 – 1078.9. Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-1670.10. Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Textbook of Otolaryngology Grand Rounds Archive. 2001. http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc11. Ondo, WG, Vuong KD, Derman, HS. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel design study. Cephalalgia 2004 (24): 60-65.