Medical conference 24 March 2016

1. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Primary headache:
You don’t want to missed
Migraine
Medication overused issues
24 March 2016

2. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Outline
• Issue 1 : Concept
• Issue 2 : Diagnosis criteria
• Issue 3 : Prevention
• Issue 4 : Emergency and inpatient
management

3. Headache
Unilatateral
Secondary
: side-lock Intracranial *
Primary
side- shift
Localized small
area
primary
Secondary Paracranial
Diffuse
Primary
Secondary Sysetemic, Meningeal,IICP
Practical approach
Reference: Prof.Kummant Punthumjinda
Plusothertools
1.Redflags
2.Headachesyndromes
3.Historicaldetails

4. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Concept :Classification
ICHD 3 beta
Primary:
Pain modulating
system
1. Migraine
2.Tension type
3.Trigeminal Autonomic
Cephalgia
4. Others
Secondary:
Pain sensitive
structure
Headache attribute to…
1.Injury
2.Vascular
3.Non vascular
4. Substance/withdraw
5. Infection
6. Homeostasis
7. Paracranial structure
8.Psychiatric disorder
Cranial Neuralgia
: Nerve fiber

5. Cortex hyperexitability
• Cortical spreading
depression (-> aura)
• Subcortical wave (no aura)
Modulating factors
Gene
Gender/hormone
Drug/metabolic
Environment
Brain stem
Dorsolateral pons
Hypothalamus
(->premonitory)
Peripheral sensitization
Trigeminovascular
5-HT,CGRP
Neurogenic inflamation
AED
Betablocker
Ergot
Triptan
NSAIDs
Central
sensitazaion
-> allodynia
Chronic pain
Maassenvandenbrink A. Eur J Pharmacol. 2008;585(2-3):313-9

6. 12-24 hrs 0.5-1
hrs
4-72 hrs 12-24 hrs

7. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Cortical spreading : Aura

8. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Visual aura :
Scintillating (spark) scotoma (dark)

9. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Sensory aura: Cheiro-oral numbness

10. 1.Migraine
1.4 Complication of migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.5 Probable migraine
1.6 Episodic syndrome that may associatie
with migraiine
1.3 Chronic migraine
• Status migranosus
• Persistent aura without infarction
• Migranous infarction
• Migralepsy
• Migraine with typical aura
• Migraine with brain stem aura
• Hemiplegic migraine (sporadic, FHM)
• Retinal migraine

11. Medication overused
Episodic migraine
• Migraine without aura
• Migraine with aura
Chronic migraine
Status migranosus
High frequency
episodic migraine
Migranous infarction?
Probable
migraine

12. 5 attacks
4 hrs to 72 hrs without treatment
Severe
Throbbling
Unilateral
Disabling *
Intestinal symptoms: Nausea or Vomiting
Oto&Oph symptoms: Phonophobia & Photophobia
Migraine without aura
54 STUDIO
60%
90%
70%
1
1
2/4
1/2

13. 2 attacks
Type of aura
- Typical : Visual , Sensory, speech
- Hemiplegic
- Brainstem
- Retinal
Character of aura
- spread gradually >5 min
- unilateral
- last 5-60 min
- accompanie
or ‘follow by’ headache within 60 min
Exclude Seizure, TIA
Migraine with aura
1
1/6
2/4
1/1
Note: No need ‘headache’
< 5 min suspect seizure
> 60 min suspect TIA

14. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Chronic migraine
• Headache may be migraine-like
or tension-type like ( Transformed migraine)
• >= 15 days / month of headache
with 8 days/month = migraine-like (aura / without aura /
response to migraine specific medication)

15. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Medication overused
• Triptans, Ergots, Opioids > 10 days/mo
• Simple analgesic > 15 days/mo
• Regular used of above medication >3months
Medication overused headache
• Headache resolved or reverts to previous pattern
within 2 mo after cessation

16. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
MOH common presentation
• Using combination of acute medication
• Morning headache – nocturnal withdraw
• Predominant neck pain
• Autonomic and vasomotor symptom
• Comorbidity depression and anxiety
• Sleep disturbance
• Reduced effectiveness of alltreatments

17. 1. >= 4 times/ month or >= 8 days of headache
2. Overuse of acute medication
3. Troublesome side effect of acute medication
4. Types of Migraine
- Hemiplegic , Brain stem
- Frequent prolong uncomfortable aura
- Migraine with complication ie. Migranous infarction
5. Patient’s preference
When to use migraine
prevention

18. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Preventive medication
(AAN’s Level A)
• Propranolol 40-120 mg twice daily
• Metoprolol 25-100 mg twice daily
• Valporate 400-600 mg twice daily
• Topiramate 50-200 mg daily

19. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Approach MOH
Overused
agent
Tapering Bridging order
Triptan
Ergot
Abrupt or
Gradual
Long acting
NSAIDs
Stearoid taper
Naproxen 500
twice daily
Prednisolone6
0 mg day 1-2
taper over
week
Opioid Gradual taper Add triptan
or long acting
NSAIDs
NSAIDs Abrup or
gradual
Add triptan

20. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Approach status
migranousus
• IV hydration
• Dopaminergic antagonist
• Metoclopramide 20 mg IV
• Chlorpromazine 12.5 -37.5mg IV
• Haloperidol 5 mgIV in 500 mg NSSover20-30 min
• Valorate 300 -500 mg IV
• Dexamethasone 10-24 mg IV

21. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Take home message
Concept : Primary headache : pain modulating abnormal
Migraine = Hyperexitabitatory trigeminovascular
Prevention : Avoid acute medication overused is important
Diagnosis : Follow ICHD 3 beta criteria
Emergency : AED, Dopamine antagonist, Steroid
Not opioid
appropriate for status migranosus

22. NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
Reference
• ตำรำประสำทวิทยำคลินิก . สมำคมประสำทวิทยำแห่ง
ประเทศไทย 2557
• Continuum 2012;18(4)
• Continuum 2015;21(4)