This document discusses migraine headaches and provides information on their diagnosis, symptoms, prevalence, burden, and pathophysiology.
Some key points:
- Migraine is diagnosed based on recurrent headaches with specific characteristics like pulsating pain, sensitivity to light/sound, and nausea. It affects 10% of people and is more common in women.
- Chronic migraine occurs in 1.4-2.2% and is more disabling than episodic migraine, significantly impacting quality of life.
- Migraine places a huge economic burden costing over $20 billion annually in the US due to lost productivity and medical costs.
- Theories on the underlying cause of migraine aura include cortical spreading depression
Neuropathic pain is caused by damage or disease affecting the somatosensory nervous system and is characterized by abnormal sensations such as burning or stabbing pain. It is estimated to affect 7-8% of adults. Common causes include diabetes, shingles, HIV, cancer treatments and injuries. Diagnosis involves medical history, exams and tests to rule out other conditions. Treatment involves pharmacologic options like antidepressants, anticonvulsants and opioids as well as non-pharmacologic therapies. However, neuropathic pain is difficult to treat and a multidisciplinary approach combining several therapies is often needed to provide effective relief.
1. The document discusses treating migraine headaches with compounded medications. It provides an overview of migraines including symptoms, phases, and common drug treatments.
2. A variety of compounded formulas are presented for treating migraines through different routes of administration to improve compliance and effectiveness. Compounding allows customizing medications to address individual patient needs.
3. Precipitating factors that can trigger migraines are listed, including dietary, environmental, hormonal, lifestyle, medication-related, and psychological causes. Compounded treatments aim to manage migraines and improve patients' quality of life.
Neuropathic pain strategies to improve clinical outcomewebzforu
This document discusses strategies for improving outcomes for patients with neuropathic pain. It begins by describing common conditions associated with neuropathic pain such as diabetes and shingles. It then discusses diagnostic approaches and distinguishing characteristics of neuropathic pain. Key points covered include the pathogenesis of neuropathic pain and new treatment options that modulate underlying mechanisms. Major forms of neuropathic pain like post-herpetic neuralgia and diabetic neuropathy are examined in depth. The document concludes by outlining a stepwise approach to managing neuropathic pain.
The document lists the 10 leading causes of disability worldwide according to cost in disability-adjusted life years (DALYs). Unipolar major depression is the leading cause, accounting for 10.3% of total cost. The top 3 causes are unipolar major depression, tuberculosis, and road traffic accidents. Together the top 10 causes account for over 40% of the total cost of disability worldwide.
The document provides an overview of pain management for nurses. It discusses [1] the prevalence and impact of pain, common barriers to treatment, and types of pain experienced by patients. It also [2] outlines principles of effective pain management including thorough assessment, appropriate medication selection and dosing, and multidisciplinary treatment. [3] Barriers to treatment include patients' and clinicians' attitudes as well as institutional factors, and uncontrolled pain negatively impacts multiple aspects of patients' lives.
Delirium: The Next Proposed “Never Event.” Is This Realistic?hospira2010
This document discusses delirium, which has been proposed as a "never event" by CMS. It summarizes evidence that delirium is common in ICU patients, associated with worse outcomes, and risk factors include older age, medications like benzodiazepines and opioids. Multicomponent protocols including monitoring, mobility, and reducing modifiable risk factors can help prevent delirium. Daily interruption of sedation with spontaneous breathing trials may help reduce duration of mechanical ventilation and ICU stay. Alternative sedatives like dexmedetomidine that are less likely to cause delirium should be considered over benzodiazepines when possible.
Recent advances in the mangement of extra pyramidal basal ganglia disorders webzforu
This document discusses recent advances in the management of extrapyramidal (basal ganglia) disorders. It defines movement disorders and lists various conditions such as Parkinsonism, dystonia, tremor, tics, chorea, tardive syndrome, and myoclonus. It provides details on classification, causes, treatment of these disorders and differential diagnosis of tics. Guidelines for treating tardive syndromes are also mentioned.
Neuropathic pain is caused by damage or disease affecting the somatosensory nervous system and is characterized by abnormal sensations such as burning or stabbing pain. It is estimated to affect 7-8% of adults. Common causes include diabetes, shingles, HIV, cancer treatments and injuries. Diagnosis involves medical history, exams and tests to rule out other conditions. Treatment involves pharmacologic options like antidepressants, anticonvulsants and opioids as well as non-pharmacologic therapies. However, neuropathic pain is difficult to treat and a multidisciplinary approach combining several therapies is often needed to provide effective relief.
1. The document discusses treating migraine headaches with compounded medications. It provides an overview of migraines including symptoms, phases, and common drug treatments.
2. A variety of compounded formulas are presented for treating migraines through different routes of administration to improve compliance and effectiveness. Compounding allows customizing medications to address individual patient needs.
3. Precipitating factors that can trigger migraines are listed, including dietary, environmental, hormonal, lifestyle, medication-related, and psychological causes. Compounded treatments aim to manage migraines and improve patients' quality of life.
Neuropathic pain strategies to improve clinical outcomewebzforu
This document discusses strategies for improving outcomes for patients with neuropathic pain. It begins by describing common conditions associated with neuropathic pain such as diabetes and shingles. It then discusses diagnostic approaches and distinguishing characteristics of neuropathic pain. Key points covered include the pathogenesis of neuropathic pain and new treatment options that modulate underlying mechanisms. Major forms of neuropathic pain like post-herpetic neuralgia and diabetic neuropathy are examined in depth. The document concludes by outlining a stepwise approach to managing neuropathic pain.
The document lists the 10 leading causes of disability worldwide according to cost in disability-adjusted life years (DALYs). Unipolar major depression is the leading cause, accounting for 10.3% of total cost. The top 3 causes are unipolar major depression, tuberculosis, and road traffic accidents. Together the top 10 causes account for over 40% of the total cost of disability worldwide.
The document provides an overview of pain management for nurses. It discusses [1] the prevalence and impact of pain, common barriers to treatment, and types of pain experienced by patients. It also [2] outlines principles of effective pain management including thorough assessment, appropriate medication selection and dosing, and multidisciplinary treatment. [3] Barriers to treatment include patients' and clinicians' attitudes as well as institutional factors, and uncontrolled pain negatively impacts multiple aspects of patients' lives.
Delirium: The Next Proposed “Never Event.” Is This Realistic?hospira2010
This document discusses delirium, which has been proposed as a "never event" by CMS. It summarizes evidence that delirium is common in ICU patients, associated with worse outcomes, and risk factors include older age, medications like benzodiazepines and opioids. Multicomponent protocols including monitoring, mobility, and reducing modifiable risk factors can help prevent delirium. Daily interruption of sedation with spontaneous breathing trials may help reduce duration of mechanical ventilation and ICU stay. Alternative sedatives like dexmedetomidine that are less likely to cause delirium should be considered over benzodiazepines when possible.
Recent advances in the mangement of extra pyramidal basal ganglia disorders webzforu
This document discusses recent advances in the management of extrapyramidal (basal ganglia) disorders. It defines movement disorders and lists various conditions such as Parkinsonism, dystonia, tremor, tics, chorea, tardive syndrome, and myoclonus. It provides details on classification, causes, treatment of these disorders and differential diagnosis of tics. Guidelines for treating tardive syndromes are also mentioned.
This document discusses neuropathic pain, its causes, symptoms, and treatment options. It begins by defining neuropathic pain as pain resulting from damage or disease affecting the somatosensory nervous system, such as diabetic neuropathy or postherpetic neuralgia. Symptoms include abnormal sensations like tingling, burning, and pain from stimuli that are normally non-painful. Treatment options discussed include tricyclic antidepressants, gabapentin, pregabalin, serotonin-norepinephrine reuptake inhibitors, topical lidocaine, opioids, and emerging treatments like botulinum toxin, cannabinoids, spinal cord stimulation, and intrathecal drug delivery.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
The document provides an overview of depression, including:
1. Defining depression and outlining the diagnostic criteria according to the DSM-IV, including symptoms such as persistent sadness, loss of interest, changes in appetite and sleep.
2. Describing different types of depression such as major depression, bipolar disorder, seasonal affective disorder, and discussing their symptoms.
3. Explaining various factors that can contribute to the development of depression including genetics, life stressors, medical conditions, and changes in the brain.
4. Outlining treatment approaches including antidepressant medications, psychotherapy, electroconvulsive therapy, and the nursing care role in monitoring safety, providing support, and promoting wellness
This document discusses the use of antidepressants to treat neuropathic pain. It begins with background on depression and types of pain, focusing on neuropathic pain. Neuropathic pain results from nerve damage and is described as burning or shocking. The document then discusses the link between depression and pain, and the use of tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) to treat pain. TCAs like amitriptyline are effective for some neuropathic pain cases by inhibiting norepinephrine reuptake. SNRIs like duloxetine and venlafaxine may also help by increasing norepinephrine and serotonin levels in the descending pain pathway. The pharmacology, dos
Efta Triastuti's document discusses competence targets and considerations for schizophrenia and bipolar disorder. It covers epidemiology, etiology, pathophysiology, clinical presentation, treatment algorithms, pharmacology, side effects, drug interactions, and monitoring protocols for both conditions. The document provides a comprehensive overview of schizophrenia and bipolar disorder for pharmacy students.
People with ME/CFS and FM often suffer from cognitive impairment that can lead to brain fog, trouble word finding and more debilitating symptoms. In this class, you will understand the types of cognitive issues that commonly occur, possible causes, and how to implement strategies for improving cognitive function.
Compassionate patient care is at the heart of what we do.
We set the standard for excellence in patient care through early diagnosis and evidence-based precision medicine. We reject the current healthcare system’s model of 10 minute visits. That doesn’t work for our patients. Our patient care is methodical, in-depth and allows us to really understand an individual and their illness.
We are a 501 c(3) dedicated to improving the lives of those that suffer from these devastating diseases.
Visit Batemanhornecenter.org to learn more.
This clinical review provides an overview of pain management for hospice and palliative care patients. It describes the prevalence of pain, barriers to treatment, and impact of uncontrolled pain. Guidelines for assessment, non-opioid and opioid medication use, and adjuvant therapies are presented. Effective communication and an interdisciplinary approach are emphasized for comprehensive pain management.
A 32-year-old pregnant woman at 29 weeks gestation presents to the ER with sudden onset of severe right flank pain radiating to her back and groin, associated with nausea and increased urination.
On examination, her vital signs are stable. The fetal heart sound is normal and there is no vaginal bleeding. Preliminary tests have been ordered.
The document discusses evaluating and treating pain using analgesics like paracetamol, NSAIDs, opioids, and adjuvants depending on the intensity of pain. Regional anesthesia techniques are also described.
For this pregnant patient, the document recommends treating her pain with paracetamol, NSAIDs initially given her gestational age and pain description. Close monitoring
This document provides an overview of pharmacology related to analgesic, antipyretic, and anti-inflammatory drugs. It discusses the nervous system and pain pathways, different types of pain including nociceptive and neuropathic pain, common pain-relieving medications like NSAIDs, acetaminophen, opioids, and neuropathic agents. It covers administration, patient education, and monitoring of pain treatment. Key points include the mechanisms and side effects of different drug classes, considerations for special populations, and the importance of the nurse's role in advocating for adequate pain relief.
12.09.09: Evaluating Diffuse Aches and PainsOpen.Michigan
Slideshow is from the University of Michigan Medical School's M2 Musculoskeletal sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Muscu
This document provides an overview of pain management including definitions of pain, categories and assessment of pain, pharmacology of common analgesics like opioids and NSAIDs, nerve blocks, acute pain management, chronic pain conditions like low back pain and cancer pain, and the WHO analgesic ladder for treating cancer pain. Key information covered includes definitions of pain, properties of different nerve fiber types, categories of acute, chronic and neuropathic pain, common pain scales, mechanisms and effects of opioids and NSAIDs, nerve block techniques, treatment of postoperative, labor, low back and cancer pain, and the three-step WHO approach to cancer pain relief.
Psychological disorder in people with Autism Spectrum DisordersDilemma consultancy
An overview of the mental health problems of people with Asperger syndrome: a workshop originally given to senior staff of the National Autistic Society
This document provides an overview of dementia, including:
- Dementia is a general term for cognitive decline caused by various underlying diseases and disorders. Alzheimer's disease is the most common cause.
- Worldwide prevalence is around 50 million people currently living with dementia. This number is projected to reach 152 million by 2050 due to increased life expectancy.
- Risk factors for dementia include age, family history, head trauma, depression, and certain genetic disorders.
- Symptoms include memory loss, impaired thinking, orientation issues, personality changes, and difficulties with language.
- Dementia is classified based on its underlying cause such as Alzheimer's, vascular, or Lewy body dementia.
-
The document discusses various topics in psychiatry including mental illness, mental disorders like anorexia, anxiety, obsessive-compulsive disorder, schizophrenia, and their symptoms and treatments. Biological and psychotherapeutic treatments are covered, including psychotropic drugs, electroconvulsive therapy, psychotherapy techniques, and medications like anxiolytics and antidepressants.
This document provides information about end-of-life care, including:
1. It describes the concept of "convergence of symptoms" where the failure of one organ system affects others in the final stage of life, leading to common symptoms like pain, shortness of breath, secretions, etc. regardless of the underlying illness.
2. It identifies strategies for managing common end-of-life symptoms like pain, shortness of breath, secretions, changes in consciousness, and delirium through the appropriate use of medications and other interventions.
3. It emphasizes the importance of expert symptom management, clear communication with families, and support from hospice professionals to help ensure a smooth passage for patients and loved
ME/CFS and FM present as complicated illnesses and getting the right diagnosis can be challenging or seem like an impossibility. Learn how to distinguish between these two diseases and recognize other conditions that may play a role in illness presentation.
Compassionate patient care is at the heart of what we do
We set the standard for excellence in patient care through early diagnosis and evidence-based precision medicine. We reject the current healthcare system’s model of 10 minute visits. That doesn’t work for our patients. Our patient care is methodical, in-depth and allows us to really understand an individual and their illness.
We are a 501 c(3) dedicated to improving the lives of those that suffer from these devastating diseases.
Visit Batemanhornecenter.org to learn more.
Pain is a common and often undertreated problem. Effective pain management is important as pain can have serious psychological and physical effects. It is also a basic human right. There are challenges to effective pain management, including conflicting views between patients and healthcare providers about reported pain levels and needed treatment. Proper use of the WHO analgesic ladder and comprehensive pain management regimens tailored to individual patients can help ensure patients' pain is adequately treated.
This document provides an overview of primary and secondary headaches, including their classification, diagnostic criteria, symptoms, management and treatment options. It discusses differences between primary and secondary headaches, and covers criteria and management of common headache types such as tension-type headache, migraine, cluster headache, cough headache and others. Red flags are identified that could indicate an underlying secondary cause. The aim is to increase awareness of headache types and their appropriate management.
This document provides information on pain management for internal medicine housestaff. It begins with definitions of pain from the International Association for the Study of Pain. It then covers the basic approach to pain management, including assessing the etiology, classifying pain types, clinically assessing pain, and treating pain. It discusses treating cancer pain specifically and provides guidelines on the WHO analgesic ladder for treating mild, moderate, and severe pain. It also covers adjuvant analgesics, opioid selection, routes of administration, and equianalgesic dosing of common opioids like morphine, oxycodone, fentanyl, hydromorphone, and methadone.
The document discusses migraine, including:
1) Migraine affects 10% of the population and is more prevalent than diabetes or asthma. It places a large burden on individuals and healthcare systems.
2) Migraine involves complex neurological changes including cortical spreading depression, activation of the trigeminovascular system, and abnormal brainstem activity.
3) Treatment involves lifestyle modifications to avoid triggers, pharmacological interventions like triptans, and behavioral/psychological therapies. Managing migraine requires an integrated approach.
Este documento trata sobre el concepto de información. Define la información como un grupo de datos organizados y supervisados que sirven para construir un mensaje. Explica que la información debe ser de calidad, es decir, exacta, oportuna y relevante para poder tomar buenas decisiones. Además, señala que la información se puede encontrar en diferentes lugares gracias a la tecnología y a profesionales de la información.
This document discusses neuropathic pain, its causes, symptoms, and treatment options. It begins by defining neuropathic pain as pain resulting from damage or disease affecting the somatosensory nervous system, such as diabetic neuropathy or postherpetic neuralgia. Symptoms include abnormal sensations like tingling, burning, and pain from stimuli that are normally non-painful. Treatment options discussed include tricyclic antidepressants, gabapentin, pregabalin, serotonin-norepinephrine reuptake inhibitors, topical lidocaine, opioids, and emerging treatments like botulinum toxin, cannabinoids, spinal cord stimulation, and intrathecal drug delivery.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
The document provides an overview of depression, including:
1. Defining depression and outlining the diagnostic criteria according to the DSM-IV, including symptoms such as persistent sadness, loss of interest, changes in appetite and sleep.
2. Describing different types of depression such as major depression, bipolar disorder, seasonal affective disorder, and discussing their symptoms.
3. Explaining various factors that can contribute to the development of depression including genetics, life stressors, medical conditions, and changes in the brain.
4. Outlining treatment approaches including antidepressant medications, psychotherapy, electroconvulsive therapy, and the nursing care role in monitoring safety, providing support, and promoting wellness
This document discusses the use of antidepressants to treat neuropathic pain. It begins with background on depression and types of pain, focusing on neuropathic pain. Neuropathic pain results from nerve damage and is described as burning or shocking. The document then discusses the link between depression and pain, and the use of tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) to treat pain. TCAs like amitriptyline are effective for some neuropathic pain cases by inhibiting norepinephrine reuptake. SNRIs like duloxetine and venlafaxine may also help by increasing norepinephrine and serotonin levels in the descending pain pathway. The pharmacology, dos
Efta Triastuti's document discusses competence targets and considerations for schizophrenia and bipolar disorder. It covers epidemiology, etiology, pathophysiology, clinical presentation, treatment algorithms, pharmacology, side effects, drug interactions, and monitoring protocols for both conditions. The document provides a comprehensive overview of schizophrenia and bipolar disorder for pharmacy students.
People with ME/CFS and FM often suffer from cognitive impairment that can lead to brain fog, trouble word finding and more debilitating symptoms. In this class, you will understand the types of cognitive issues that commonly occur, possible causes, and how to implement strategies for improving cognitive function.
Compassionate patient care is at the heart of what we do.
We set the standard for excellence in patient care through early diagnosis and evidence-based precision medicine. We reject the current healthcare system’s model of 10 minute visits. That doesn’t work for our patients. Our patient care is methodical, in-depth and allows us to really understand an individual and their illness.
We are a 501 c(3) dedicated to improving the lives of those that suffer from these devastating diseases.
Visit Batemanhornecenter.org to learn more.
This clinical review provides an overview of pain management for hospice and palliative care patients. It describes the prevalence of pain, barriers to treatment, and impact of uncontrolled pain. Guidelines for assessment, non-opioid and opioid medication use, and adjuvant therapies are presented. Effective communication and an interdisciplinary approach are emphasized for comprehensive pain management.
A 32-year-old pregnant woman at 29 weeks gestation presents to the ER with sudden onset of severe right flank pain radiating to her back and groin, associated with nausea and increased urination.
On examination, her vital signs are stable. The fetal heart sound is normal and there is no vaginal bleeding. Preliminary tests have been ordered.
The document discusses evaluating and treating pain using analgesics like paracetamol, NSAIDs, opioids, and adjuvants depending on the intensity of pain. Regional anesthesia techniques are also described.
For this pregnant patient, the document recommends treating her pain with paracetamol, NSAIDs initially given her gestational age and pain description. Close monitoring
This document provides an overview of pharmacology related to analgesic, antipyretic, and anti-inflammatory drugs. It discusses the nervous system and pain pathways, different types of pain including nociceptive and neuropathic pain, common pain-relieving medications like NSAIDs, acetaminophen, opioids, and neuropathic agents. It covers administration, patient education, and monitoring of pain treatment. Key points include the mechanisms and side effects of different drug classes, considerations for special populations, and the importance of the nurse's role in advocating for adequate pain relief.
12.09.09: Evaluating Diffuse Aches and PainsOpen.Michigan
Slideshow is from the University of Michigan Medical School's M2 Musculoskeletal sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Muscu
This document provides an overview of pain management including definitions of pain, categories and assessment of pain, pharmacology of common analgesics like opioids and NSAIDs, nerve blocks, acute pain management, chronic pain conditions like low back pain and cancer pain, and the WHO analgesic ladder for treating cancer pain. Key information covered includes definitions of pain, properties of different nerve fiber types, categories of acute, chronic and neuropathic pain, common pain scales, mechanisms and effects of opioids and NSAIDs, nerve block techniques, treatment of postoperative, labor, low back and cancer pain, and the three-step WHO approach to cancer pain relief.
Psychological disorder in people with Autism Spectrum DisordersDilemma consultancy
An overview of the mental health problems of people with Asperger syndrome: a workshop originally given to senior staff of the National Autistic Society
This document provides an overview of dementia, including:
- Dementia is a general term for cognitive decline caused by various underlying diseases and disorders. Alzheimer's disease is the most common cause.
- Worldwide prevalence is around 50 million people currently living with dementia. This number is projected to reach 152 million by 2050 due to increased life expectancy.
- Risk factors for dementia include age, family history, head trauma, depression, and certain genetic disorders.
- Symptoms include memory loss, impaired thinking, orientation issues, personality changes, and difficulties with language.
- Dementia is classified based on its underlying cause such as Alzheimer's, vascular, or Lewy body dementia.
-
The document discusses various topics in psychiatry including mental illness, mental disorders like anorexia, anxiety, obsessive-compulsive disorder, schizophrenia, and their symptoms and treatments. Biological and psychotherapeutic treatments are covered, including psychotropic drugs, electroconvulsive therapy, psychotherapy techniques, and medications like anxiolytics and antidepressants.
This document provides information about end-of-life care, including:
1. It describes the concept of "convergence of symptoms" where the failure of one organ system affects others in the final stage of life, leading to common symptoms like pain, shortness of breath, secretions, etc. regardless of the underlying illness.
2. It identifies strategies for managing common end-of-life symptoms like pain, shortness of breath, secretions, changes in consciousness, and delirium through the appropriate use of medications and other interventions.
3. It emphasizes the importance of expert symptom management, clear communication with families, and support from hospice professionals to help ensure a smooth passage for patients and loved
ME/CFS and FM present as complicated illnesses and getting the right diagnosis can be challenging or seem like an impossibility. Learn how to distinguish between these two diseases and recognize other conditions that may play a role in illness presentation.
Compassionate patient care is at the heart of what we do
We set the standard for excellence in patient care through early diagnosis and evidence-based precision medicine. We reject the current healthcare system’s model of 10 minute visits. That doesn’t work for our patients. Our patient care is methodical, in-depth and allows us to really understand an individual and their illness.
We are a 501 c(3) dedicated to improving the lives of those that suffer from these devastating diseases.
Visit Batemanhornecenter.org to learn more.
Pain is a common and often undertreated problem. Effective pain management is important as pain can have serious psychological and physical effects. It is also a basic human right. There are challenges to effective pain management, including conflicting views between patients and healthcare providers about reported pain levels and needed treatment. Proper use of the WHO analgesic ladder and comprehensive pain management regimens tailored to individual patients can help ensure patients' pain is adequately treated.
This document provides an overview of primary and secondary headaches, including their classification, diagnostic criteria, symptoms, management and treatment options. It discusses differences between primary and secondary headaches, and covers criteria and management of common headache types such as tension-type headache, migraine, cluster headache, cough headache and others. Red flags are identified that could indicate an underlying secondary cause. The aim is to increase awareness of headache types and their appropriate management.
This document provides information on pain management for internal medicine housestaff. It begins with definitions of pain from the International Association for the Study of Pain. It then covers the basic approach to pain management, including assessing the etiology, classifying pain types, clinically assessing pain, and treating pain. It discusses treating cancer pain specifically and provides guidelines on the WHO analgesic ladder for treating mild, moderate, and severe pain. It also covers adjuvant analgesics, opioid selection, routes of administration, and equianalgesic dosing of common opioids like morphine, oxycodone, fentanyl, hydromorphone, and methadone.
The document discusses migraine, including:
1) Migraine affects 10% of the population and is more prevalent than diabetes or asthma. It places a large burden on individuals and healthcare systems.
2) Migraine involves complex neurological changes including cortical spreading depression, activation of the trigeminovascular system, and abnormal brainstem activity.
3) Treatment involves lifestyle modifications to avoid triggers, pharmacological interventions like triptans, and behavioral/psychological therapies. Managing migraine requires an integrated approach.
Este documento trata sobre el concepto de información. Define la información como un grupo de datos organizados y supervisados que sirven para construir un mensaje. Explica que la información debe ser de calidad, es decir, exacta, oportuna y relevante para poder tomar buenas decisiones. Además, señala que la información se puede encontrar en diferentes lugares gracias a la tecnología y a profesionales de la información.
Este documento presenta las habilidades de Pablo Moreno en gráficos, animación, multimedia y presentaciones. Incluye una lista de sus capacidades técnicas en estas áreas y un diagrama que muestra cómo cuatro ideas principales se relacionan entre sí.
The document discusses innovation and teampreneurship. It states that innovation is a scalable and meaningful experience that results in new connections and disrupts the status quo. It also discusses various concepts related to innovation including business growth, validation, channels, and how new ideas can be embraced and change people's behavior. The document advocates for learning by doing through action and reflection both individually and as a team. It presents models and principles for dialogue, teamwork, and teampreneurship.
Este documento trata sobre el concepto de información. Define la información como un grupo de datos organizados y supervisados que sirven para construir un mensaje. Explica que la información debe ser de calidad, es decir, exacta, oportuna y relevante para poder tomar buenas decisiones. Además, señala que la información se puede encontrar en diferentes lugares gracias a la tecnología y a profesionales de la información.
This chapter discusses network interfaces, hubs, switches, bridges, routers, and firewalls. Hubs connect individual devices on an Ethernet network so they can communicate. A hub gathers signals from devices, amplifies them, and sends them to all other connected devices, allowing dozens of devices to connect but performance may degrade with high traffic. Dividing networks into multiple collision domains with switches, bridges or routers can improve performance.
This document details multivariate estimation and simulation studies conducted on an epithermal gold deposit in Peru, including ordinary kriging of gold grades, indicator kriging using 25 gold cut-offs, and cokriging of gold and gold cyanide values. Variography was performed on declustered data and using logarithmic and Gaussian transformations. Conditional simulation was also used to model gold grades and residuals from gold-gold cyanide regression models.
برونوين كويه التقييم البناء في الفصول الدراسية الابتدائية العلومIEFE
This document discusses formative assessment in primary science classrooms. It begins by defining formative assessment as a process used by teachers and students to notice, recognize, and respond to learning with the goal of enhancing that learning. The document then provides examples of formative assessment practices from New Zealand primary science classrooms, including using multiple sources of evidence of learning, planning formative assessments, creating a safe classroom, and engaging families. It concludes by sharing teacher insights on ensuring assessment supports valued learning outcomes and the importance of planning and collaboration for changing practices.
The document discusses various approaches to product development including design thinking, lean startup, agile, and stage gate. It compares the approaches across dimensions like discovery, build, measure and learn phases. It emphasizes the importance of customer focus, experimentation and iterative learning in lean startup and agile methodologies over traditional stage gate processes.
Dokumen tersebut merangkum proses perumusan Pancasila oleh BPUPKI dan PPKI. Terdapat usulan dasar negara dari Mohammad Yamin, Supomo, dan Sukarno di BPUPKI. Kemudian dibentuk Panitia Sembilan yang merumuskan Piagam Jakarta. Akhirnya, PPKI mengesahkan UUD 1945 sebagai dasar negara Indonesia.
Sabemos de tus retos profesionales al trabajar con equipos y personas diversos y plural es cada vez más exigentes. Por esa razón creamos Open Cards Methodology.
Certifícate con nosotros y podrás generar espacios participativos con un nivel de colaboración imparable para diseñar sesiones de estrategia, responder preguntas claves del negocio, evaluar el avance de proyectos, el estado del equipo, el ambiente laboral de manera objetiva es un reto.
Te esperamos en Medellín el 17, 28 y 29 de Octubre de 2016 para que transformes tu ejercicio de liderazgo de manera innovadora.
Más información en contacto@openmindex.com o en nuestro sitio web www.openmindex.com
Brian Chiang is a designer, planner, manager, and marketer with over 15 years of experience in web design, user interface design, strategy planning, project management, and digital marketing. He has worked at companies such as Sina.com, Yahoo!, and Intentarget, where he has led design, product development, and operations. His strengths include trend analysis, user experience design, multi-disciplinary skills, and helping companies achieve business goals through online opportunities.
Rencana Pelaksanaan Pembelajaran (RPP) ini membahas tentang pelaksanaan pembelajaran di SD Negeri Harapan Bangsa untuk tema 'Kehidupan Sehari-hari' pada kelas 5 semester 1. RPP ini menjelaskan standar kompetensi, kompetensi dasar, indikator, tujuan pembelajaran, materi pokok, dan karakteristik yang diharapkan dari pembelajaran tersebut."
This document discusses the different parts of speech used in language and how they are combined to form sentences. It outlines the 8 parts of speech - nouns, pronouns, verbs, adjectives, adverbs, conjunctions, prepositions, and interjections. Examples are provided for each part of speech. The document then explains how different parts of speech can be structured together such as noun-verb, pronoun-verb, adjective-noun, and verb-adverb to construct basic yet grammatically correct sentences. Knowledge of grammar ensures correct usage of language.
Headache can be classified into three main types - tension headache, migraine headache, and cluster headache. Tension headaches are the most common, accounting for 80-90% of headaches in community pharmacies. They involve mild to moderate bifrontal or bioccipital pain that worsens with stress or pressure. Migraine headaches can be with or without aura and involve moderate to severe unilateral throbbing pain along with nausea, vomiting, photophobia, and phonophobia. Cluster headaches predominantly affect men and involve intense orbital pain that lasts 10 minutes to 3 hours, often occurring at the same time daily or nightly. Common medications used to treat migraine include Migraleve, Midrid, and Buccastem M
Headache is classified into three main types - tension headache, migraine headache, and cluster headache. Tension headaches are the most common, accounting for 80-90% of headaches in community pharmacies. They involve mild to moderate bifrontal or bioccipital pain that worsens with stress or pressure. Migraines can be with or without aura and involve moderate to severe throbbing pain, nausea, photophobia, and phonophobia. Cluster headaches predominantly affect men and involve intense unilateral orbital pain with symptoms like conjunctivitis and nasal congestion. Common medications used to treat migraines include Migraleve, Midrid, and Buccastem M, but they can have side effects and
This document provides information on Dr. Ganta Rajasekhar's academic qualifications and areas of interest in neurology. It then discusses approaches to evaluating headache, classifications of primary and secondary headache disorders, migraine pathogenesis and management, tension-type headache, and trigeminal autonomic cephalalgias. Evaluation and treatment strategies for acute migraine, preventive migraine therapy, medication overuse headache, and special headache conditions are covered. Common questions in headache management are also addressed.
Migraine its presentation and managementdrmohitmathur
This document summarizes information about migraines including what they are, common symptoms, triggers, types (aura vs without aura), overuse of medications leading to chronic migraines, management through lifestyle changes and medications, and resources for more information. Migraines involve recurrent attacks of moderate to severe headaches that can last hours to days, often accompanied by nausea, sensitivity to light/sound, and visual disturbances prior to pain for those with aura. Management focuses on avoiding triggers through lifestyle modifications, medications as directed by a doctor, and self-care techniques like rest, heat/ice, and biofeedback.
This document provides an overview of approaches to evaluating and managing headaches. It begins with an introduction to headaches as a common medical complaint and cause of disability globally. It then outlines general principles for distinguishing between primary and secondary headaches. Key anatomy and physiology involved in headaches is described. Common causes of headaches are listed. Primary and secondary headache syndromes are defined. Diagnostic criteria and management strategies for common headache types like tension-type headache and migraine are summarized.
This document discusses migraine headaches including prevalence, definition, subtypes, mechanisms, clinical manifestations, treatment and conclusions. Some key points:
- Migraines are common, affecting 10-12% of the population, with higher rates in young women. They are often unrecognized or misdiagnosed.
- Migraines are defined by the International Headache Society criteria as recurrent headaches lasting 4-72 hours with characteristics like pulsating pain, nausea, sensitivity to light/sound.
- Common subtypes include menstrual, basilar, retinal and hemiplegic migraines. Migrainous vertigo is also described.
- The mechanism involves neurovascular and trigeminal pathways leading to vas
Practice pearls diagnosis and prophylaxis of migrainewebzforu
This document provides guidelines and recommendations for the diagnosis and prophylaxis of migraine. It begins with the International Headache Society criteria for diagnosing migraine which involves assessing head-related symptoms and associated non-headache symptoms. It emphasizes taking a detailed patient history including triggers and risk factors. The physical exam should include a neurological exam. It discusses differentiating migraine from other headache types like tension headaches and discusses migraine triggers. It provides recommendations for when prophylactic treatment should be considered and guidelines for successful prevention. It discusses common preventive medications and their mechanisms of action and side effects.
Dr.avs practice pearls in diagnosis and prophylaxis of migrainewebzforu
This document provides guidelines and recommendations for the diagnosis and prophylactic treatment of migraines. It begins with an overview of the International Headache Society criteria for diagnosing migraines based on the presence of head and non-headache symptoms. It then discusses taking a thorough patient history and performing a focused neurological examination to diagnose migraines and rule out secondary causes. Various migraine triggers and types are described. The document recommends candidates for migraine prevention based on monthly headache frequency and impairment. It reviews guidelines for successful prevention and duration of treatment. Potential mechanisms of preventive medications and common side effects of treatments like flunarizine, beta-blockers, and anti-epileptics are summarized. The progression of mig
This document provides information on evaluating and managing headaches in children and adolescents. It begins with epidemiology data showing headaches are very common in this age group. The document then reviews tools for taking a thorough headache history and differentiating primary from secondary headaches. It describes the major primary headache disorders - migraine, tension-type headache, and others. Treatment approaches are also discussed, including lifestyle modifications, acute pharmacologic options, and concerns around medication overuse headache. The goal is to identify headaches, formulate appropriate treatment plans, and prevent disease progression or medication overuse issues.
This patient likely has chronic tension-type headache. The key features are bilateral, pressing quality pain not worsened by activity and no associated nausea, visual changes or neurologic deficits. Stress is a common trigger. Naproxen provides relief indicating an inflammatory component. Preventive options include amitriptyline or tizanidine.
A 35-year-old female patient has been experiencing recurrent severe headaches over the last 4 months, with unilateral pulsating pain lasting over 6 hours accompanied by nausea and sometimes vomiting. She prefers sitting in a dark room during attacks and is unable to be active. Migraine should be suspected in patients presenting with recurrent headaches that are unilateral, pulsating, long-lasting and inhibit daily activities, especially in women aged 20-50. Migraine is characterized by moderate to severe throbbing headache on one side of the head and can present with aura, nausea, photophobia, phonophobia, or other neurological symptoms. Treatment involves managing acute attacks and considering prophylaxis for frequent episodes.
An acute medical condition.
Common in UK critical care patients.
Serious adverse outcomes.
Bedside diagnosis.
Maybe the first sign of a new infection.
Pathological, not psychological.
The document discusses the evaluation of headache in adults, including obtaining a thorough history focusing on potential danger signs, performing a physical exam to check for danger signs, and classifying the three main types of primary headaches as migraine, tension, or cluster headaches. It also provides guidance on when imaging studies are indicated based on the history and physical exam findings.
Neuropsychiatric consequences of traumatic brain injuryDikshya upreti
This document discusses the neuropsychiatric consequences of traumatic brain injury (TBI). It covers the epidemiology, pathology, clinical features, cognitive disorders, personality changes, and depressive disorders that can result from TBI. It describes how TBI causes both primary and secondary brain damage through mechanical forces. Common neuropsychiatric outcomes include delirium, neurocognitive disorders, depression, bipolar disorder, anxiety, and psychosis. Cognitive deficits often involve memory, attention, and executive function. Personality changes like irritability and disinhibition are also frequent.
This document outlines a presentation on headache classification, clinical features, and management. It begins with an introduction and outline separating headaches into primary and secondary types. Common primary headaches like migraine, tension-type headache, and trigeminal autonomic cephalgias are discussed in detail, covering classification, clinical features, pathophysiology, and treatment approaches. Case scenarios are also provided to demonstrate clinical applications of headache diagnosis and management.
This document provides information on common primary headaches including migraine, tension-type headache, and cluster headache. It discusses prevalence, diagnostic criteria, pathophysiology, comorbidities, and treatment approaches for each headache type. For migraine specifically, it notes higher prevalence in women ages 25-55 and common comorbidities like depression and anxiety. Treatment involves both acute and preventive options.
Placée en soins intensifs le soir même, elle sera alors prise en charge par le docteur Norbert Manzo et son équipe. Résultats des examens à l'appui, on lui annonce un méningiome, c'est-à-dire, une tumeur au cerveau. L'opération est programmée pour le 22 août. « J'ai pris la nouvelle avec beaucoup de philosophie. J'ai appelé mon fils, j'ai envoyé un texto à certains de mes amis leur disant que je venais de prendre un billet aller-retour et que mon retour se fera avec la bénédiction du seigneur. Je leur disais aussi que je n'avais que de l'amour à transmettre » . L'opération qui a débuté à 9 h s'est terminée à 19 h » . L'équipe soignante fut très étonnée de sa grande capacité de récupération suite à une si longue et délicate intervention.
Et si elle tient tant à témoigner aujourd'hui, c'est parce que Jocelyne considère qu'elle sort de loin et qu'elle a eu la chance de tomber sur un médecin et une équipe exceptionnelle de l'hôpital de la Meynard
The clinical study evaluated peripheral nerve stimulation of the occipital nerves for chronic migraine. 157 patients were randomly assigned to an active or control group in a 2:1 ratio. The primary endpoint of a 10% difference in responders between groups was not met. However, secondary analyses found that the active group experienced significantly greater reductions in headache days, migraine disability, and improvements in quality of life and satisfaction compared to the control group.
The clinical study evaluated peripheral nerve stimulation of the occipital nerves for chronic migraine. 157 patients were randomly assigned to an active or control group in a 2:1 ratio. The primary endpoint of a 10% difference in responders between groups was not met. However, significant differences were found at the 30% pain reduction level. Secondary analyses showed the active group experienced greater reductions in headache days, disability, and improvements in quality of life and satisfaction compared to the control group.
The clinical study evaluated peripheral nerve stimulation of the occipital nerves for chronic migraine. 157 patients were randomly assigned to an active or control group in a 2:1 ratio. The primary endpoint of a 10% difference in responders between groups was not met. However, secondary analyses found that the active group experienced significantly greater reductions in headache days, migraine disability, and improvements in quality of life and satisfaction compared to the control group.
UiPath Test Automation using UiPath Test Suite series, part 5DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 5. In this session, we will cover CI/CD with devops.
Topics covered:
CI/CD with in UiPath
End-to-end overview of CI/CD pipeline with Azure devops
Speaker:
Lyndsey Byblow, Test Suite Sales Engineer @ UiPath, Inc.
AI 101: An Introduction to the Basics and Impact of Artificial IntelligenceIndexBug
Imagine a world where machines not only perform tasks but also learn, adapt, and make decisions. This is the promise of Artificial Intelligence (AI), a technology that's not just enhancing our lives but revolutionizing entire industries.
Pushing the limits of ePRTC: 100ns holdover for 100 daysAdtran
At WSTS 2024, Alon Stern explored the topic of parametric holdover and explained how recent research findings can be implemented in real-world PNT networks to achieve 100 nanoseconds of accuracy for up to 100 days.
“An Outlook of the Ongoing and Future Relationship between Blockchain Technologies and Process-aware Information Systems.” Invited talk at the joint workshop on Blockchain for Information Systems (BC4IS) and Blockchain for Trusted Data Sharing (B4TDS), co-located with with the 36th International Conference on Advanced Information Systems Engineering (CAiSE), 3 June 2024, Limassol, Cyprus.
Threats to mobile devices are more prevalent and increasing in scope and complexity. Users of mobile devices desire to take full advantage of the features
available on those devices, but many of the features provide convenience and capability but sacrifice security. This best practices guide outlines steps the users can take to better protect personal devices and information.
HCL Notes and Domino License Cost Reduction in the World of DLAUpanagenda
Webinar Recording: https://www.panagenda.com/webinars/hcl-notes-and-domino-license-cost-reduction-in-the-world-of-dlau/
The introduction of DLAU and the CCB & CCX licensing model caused quite a stir in the HCL community. As a Notes and Domino customer, you may have faced challenges with unexpected user counts and license costs. You probably have questions on how this new licensing approach works and how to benefit from it. Most importantly, you likely have budget constraints and want to save money where possible. Don’t worry, we can help with all of this!
We’ll show you how to fix common misconfigurations that cause higher-than-expected user counts, and how to identify accounts which you can deactivate to save money. There are also frequent patterns that can cause unnecessary cost, like using a person document instead of a mail-in for shared mailboxes. We’ll provide examples and solutions for those as well. And naturally we’ll explain the new licensing model.
Join HCL Ambassador Marc Thomas in this webinar with a special guest appearance from Franz Walder. It will give you the tools and know-how to stay on top of what is going on with Domino licensing. You will be able lower your cost through an optimized configuration and keep it low going forward.
These topics will be covered
- Reducing license cost by finding and fixing misconfigurations and superfluous accounts
- How do CCB and CCX licenses really work?
- Understanding the DLAU tool and how to best utilize it
- Tips for common problem areas, like team mailboxes, functional/test users, etc
- Practical examples and best practices to implement right away
GraphRAG for Life Science to increase LLM accuracyTomaz Bratanic
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HCL Notes und Domino Lizenzkostenreduzierung in der Welt von DLAUpanagenda
Webinar Recording: https://www.panagenda.com/webinars/hcl-notes-und-domino-lizenzkostenreduzierung-in-der-welt-von-dlau/
DLAU und die Lizenzen nach dem CCB- und CCX-Modell sind für viele in der HCL-Community seit letztem Jahr ein heißes Thema. Als Notes- oder Domino-Kunde haben Sie vielleicht mit unerwartet hohen Benutzerzahlen und Lizenzgebühren zu kämpfen. Sie fragen sich vielleicht, wie diese neue Art der Lizenzierung funktioniert und welchen Nutzen sie Ihnen bringt. Vor allem wollen Sie sicherlich Ihr Budget einhalten und Kosten sparen, wo immer möglich. Das verstehen wir und wir möchten Ihnen dabei helfen!
Wir erklären Ihnen, wie Sie häufige Konfigurationsprobleme lösen können, die dazu führen können, dass mehr Benutzer gezählt werden als nötig, und wie Sie überflüssige oder ungenutzte Konten identifizieren und entfernen können, um Geld zu sparen. Es gibt auch einige Ansätze, die zu unnötigen Ausgaben führen können, z. B. wenn ein Personendokument anstelle eines Mail-Ins für geteilte Mailboxen verwendet wird. Wir zeigen Ihnen solche Fälle und deren Lösungen. Und natürlich erklären wir Ihnen das neue Lizenzmodell.
Nehmen Sie an diesem Webinar teil, bei dem HCL-Ambassador Marc Thomas und Gastredner Franz Walder Ihnen diese neue Welt näherbringen. Es vermittelt Ihnen die Tools und das Know-how, um den Überblick zu bewahren. Sie werden in der Lage sein, Ihre Kosten durch eine optimierte Domino-Konfiguration zu reduzieren und auch in Zukunft gering zu halten.
Diese Themen werden behandelt
- Reduzierung der Lizenzkosten durch Auffinden und Beheben von Fehlkonfigurationen und überflüssigen Konten
- Wie funktionieren CCB- und CCX-Lizenzen wirklich?
- Verstehen des DLAU-Tools und wie man es am besten nutzt
- Tipps für häufige Problembereiche, wie z. B. Team-Postfächer, Funktions-/Testbenutzer usw.
- Praxisbeispiele und Best Practices zum sofortigen Umsetzen
Communications Mining Series - Zero to Hero - Session 1DianaGray10
This session provides introduction to UiPath Communication Mining, importance and platform overview. You will acquire a good understand of the phases in Communication Mining as we go over the platform with you. Topics covered:
• Communication Mining Overview
• Why is it important?
• How can it help today’s business and the benefits
• Phases in Communication Mining
• Demo on Platform overview
• Q/A
Climate Impact of Software Testing at Nordic Testing DaysKari Kakkonen
My slides at Nordic Testing Days 6.6.2024
Climate impact / sustainability of software testing discussed on the talk. ICT and testing must carry their part of global responsibility to help with the climat warming. We can minimize the carbon footprint but we can also have a carbon handprint, a positive impact on the climate. Quality characteristics can be added with sustainability, and then measured continuously. Test environments can be used less, and in smaller scale and on demand. Test techniques can be used in optimizing or minimizing number of tests. Test automation can be used to speed up testing.
Full-RAG: A modern architecture for hyper-personalizationZilliz
Mike Del Balso, CEO & Co-Founder at Tecton, presents "Full RAG," a novel approach to AI recommendation systems, aiming to push beyond the limitations of traditional models through a deep integration of contextual insights and real-time data, leveraging the Retrieval-Augmented Generation architecture. This talk will outline Full RAG's potential to significantly enhance personalization, address engineering challenges such as data management and model training, and introduce data enrichment with reranking as a key solution. Attendees will gain crucial insights into the importance of hyperpersonalization in AI, the capabilities of Full RAG for advanced personalization, and strategies for managing complex data integrations for deploying cutting-edge AI solutions.
For the full video of this presentation, please visit: https://www.edge-ai-vision.com/2024/06/building-and-scaling-ai-applications-with-the-nx-ai-manager-a-presentation-from-network-optix/
Robin van Emden, Senior Director of Data Science at Network Optix, presents the “Building and Scaling AI Applications with the Nx AI Manager,” tutorial at the May 2024 Embedded Vision Summit.
In this presentation, van Emden covers the basics of scaling edge AI solutions using the Nx tool kit. He emphasizes the process of developing AI models and deploying them globally. He also showcases the conversion of AI models and the creation of effective edge AI pipelines, with a focus on pre-processing, model conversion, selecting the appropriate inference engine for the target hardware and post-processing.
van Emden shows how Nx can simplify the developer’s life and facilitate a rapid transition from concept to production-ready applications.He provides valuable insights into developing scalable and efficient edge AI solutions, with a strong focus on practical implementation.
Unlock the Future of Search with MongoDB Atlas_ Vector Search Unleashed.pdfMalak Abu Hammad
Discover how MongoDB Atlas and vector search technology can revolutionize your application's search capabilities. This comprehensive presentation covers:
* What is Vector Search?
* Importance and benefits of vector search
* Practical use cases across various industries
* Step-by-step implementation guide
* Live demos with code snippets
* Enhancing LLM capabilities with vector search
* Best practices and optimization strategies
Perfect for developers, AI enthusiasts, and tech leaders. Learn how to leverage MongoDB Atlas to deliver highly relevant, context-aware search results, transforming your data retrieval process. Stay ahead in tech innovation and maximize the potential of your applications.
#MongoDB #VectorSearch #AI #SemanticSearch #TechInnovation #DataScience #LLM #MachineLearning #SearchTechnology
Essentials of Automations: The Art of Triggers and Actions in FMESafe Software
In this second installment of our Essentials of Automations webinar series, we’ll explore the landscape of triggers and actions, guiding you through the nuances of authoring and adapting workspaces for seamless automations. Gain an understanding of the full spectrum of triggers and actions available in FME, empowering you to enhance your workspaces for efficient automation.
We’ll kick things off by showcasing the most commonly used event-based triggers, introducing you to various automation workflows like manual triggers, schedules, directory watchers, and more. Plus, see how these elements play out in real scenarios.
Whether you’re tweaking your current setup or building from the ground up, this session will arm you with the tools and insights needed to transform your FME usage into a powerhouse of productivity. Join us to discover effective strategies that simplify complex processes, enhancing your productivity and transforming your data management practices with FME. Let’s turn complexity into clarity and make your workspaces work wonders!
Essentials of Automations: The Art of Triggers and Actions in FME
Chu Fort de France !!!
1. Manjit S Matharu
Headache Group, Institute of Neurology &
The National Hospital for Neurology and Neurosurgery
London
UK
St Jude Medical
Intractable Chronic Migraine Course
22nd February 2012
2. ICHD-‐II Diagnostic Criteria
Episodic attacks of headache lasting 4-‐72 hours with the following
features:
Headache has at least two of the following During headache at least one of the following:
characteristics:
Nausea and/or vomiting
Unilateral location
Photophobia and phonophobia
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
Further sub-‐classified on basis of frequency of headaches
Episodic migraine <15 days/month
Chronic migraine >15 days/month
3. Phases of Migraine
Time
Premonitory Aura Headache &
Resolution
Associated Features
4. Complex array of Aura symptoms occur with
symptoms reflecting focal headache:
cortical or brainstem – Always 18%
dysfunction – Sometimes 13%
– Never
Gradual evolution 69%
5-‐30minutes (<60minutes) Types of aura:
– Visual 99%
Usually before headache; – Sensory 31%
can be during or even – Language 18%
after headache – Motor 6%
5. Pain: • Unilateral or bilateral
• Throbbing, worsened by movement or
activity
• Cutaneous allodynia
• Neck stiffness/pain (80%)
Associated Sensory hyperexcitability
Symptoms: • Photophobia, phonophobia, osmophobia
• Motion sensitivity/vertigo
Gastrointestinal disturbance
• Nausea/Vomiting/Diarrhoea
MIGRAINE IS A FEATUREFUL HEADACHE
6. ICHD-‐IIR DIAGNOSTIC CRITERIA
Migraine headache occurring on
of medication overuse, not attributed to another disorder.
On During headache at least one
has at least two of the following characteristics: of the following:
Unilateral location Nausea and/or vomiting
Pulsating quality Photophobia and phonophobia
Moderate or severe pain intensity and/or treated and relieved by triptan(s) or
ergot before developing into a migraine
Aggravation by routine physical activity
1. ICHD 2006 Headache Classification Committee of the International Headache Society. Olesen J et al. Cephalalgia 2006;26:742
7. One-‐year prevalence of migraine is approximately 10%1
Migraine is more prevalent than common disorders such as
diabetes and asthma.2
In Europe and America, WHO estimates the prevalence of
migraine to be 6–8% in men and 15–18% in women.3
Chronic migraine affects 1.4-‐2.2% of people wordwide4
European Union
Migraine 50M Chronic Medically Refractory
Migraine Chronic Migraine
7.3M 1M?
1. Stovner LJ et al. Cephalalgia 2007;27:193–210. 2. World Health Organization. The Global Burden of Disease: 2004 update, Part 3, 28–37.
3. World Health Organization. Headache disorders, 2004. 4. Natoli JL, et al. Cephalagia 2010;30:599-‐609.
8. Migraine is one of the 20 most common causes of
years of life lived with disability1
WHO global burden of disease survey rates severe
migraine, along with quadriplegia, psychosis and
dementia, in a group as the most disabling chronic
disorders1
80% of migraine patients report severe or very severe
pain2
91% of migraine patients report disability2
1. Menken M,Munsat T, Toole J. Archives of Neurology 2000; 57:418-420.
2. Lipton RB et al. Headache. 2001.
9. 91% of migraine patients report disability
Work/School Productivity 51%
Reduced by 50%
Unable to Do Chores/ 76%
Household Work
Household Work Productivity 67%
Reduced by 50%
Missed Family/Social 59%
Leisure Activity
0% 20% 40% 60% 80% 100%
Lipton RB et al. Headache. 2001.
10. Affects 1.4-‐2.2% of people wordwide1
Significantly more burdensome than episodic
migraine:2
80
70 71.7 * 67.2
61.4 *
60 56.5 *
Mean MSQ score
48.3
50 44.4
40 Chronic migraine
30 Episodic migraine
20
* P<0.0001
10
0
Unable to perform normal Difficult to perform Emotional effects
activities normal activities
1. Natoli JL, et al. Cephalagia 2010;30:599-‐609.
2. Blumenthal AM et al Lancet 2010
11. Migraine is an important public health problem
that is associated with substantial costs1–3
Direct costs Indirect costs
Medication Absence from work (absenteeism)
Reduced productivity at work
Consultation
(presenteeism)
Hospital admission Lost career opportunities
Diagnostic investigations Unemployment
In Europe, 41 million patients with migraine cost
the economy €27 billion overall in 20044
1. Steiner TJ et al. Cephalalgia 2003;23:519–527. 2. Hawkins K et al. Headache 2008;48:553 563. 3. Stewart WF et al. JAMA 2003;290:2443 2454. 4. Andlin-‐Sobocki
P et al. Eur J Neurol 2005;12(Suppl 1):1
12. Aura: Pathophysiological Hypotheses
Wolff’s vascular hypothesis Cortical spreading depression of Leao
Migraine aura secondary to cerebral Wave of excitation followed by inhibition that
hypoxia traverses the cortex at 3-‐6 mm/min
Hyperperfusion
Normal
CBF
Hypo-‐
perfusion
Aura Headache
2 4 6 8 10 12
Hours after angiography
Leao. J. Neurophysiol. 1944; Leao and Morison. J. Neurophysiol. 1945
Wolff. Headache and other head pain. 1963 Silberstein SD et al. Headache in Clinical Practice. 2nd ed. 2002
13. Xenon-‐133 Studies
Relative timing of CBF, Aura and
Headache
Hyperperfusion
Normal
CBF
Hypo-‐
perfusion
Aura Headache
2 4 6 8 10 12
Hours after angiography
Olesen et al, Ann Neurol 1990; Olesen, Migraine and other headaches: the vascular mechanisms. 1991; Olesen, The headaches. 1993
14. BOLD fMRI
(i) Initial cortical gray hyperemia,
with
(ii) Characteristic duration, and
(iii) Characteristic velocity, which is
(iv) Followed by hypoperfusion, and
shows
(v) Attenuated response to visual
activation, and
(vi) Recovery to baseline mean level,
and
(vii) Concurrent recovery of the
stimulus driven activation
(viii) Spreading phenomenon did not
cross prominent sulci
Hadjikhani et al, PNAS 2001
Cortical spreading depression rather than vasoconstriction is the basis of aura
15. Specific dorsal rostral pontine activation in migraine
Spontaneous Spontaneous Chronic
Episodic Migraine Episodic Migraine Migraine
Weiller et al, Nature 1995 Afridi et al, Arch Neurol 2005 Matharu et al, Brain 2004
16. CSD-‐triggered Trigeminovascular Activation?
Visually-‐triggered Migraine
BOLD-‐fMRI Study
Meninges
Trigeminal
nerve
Sphenopalatin
e ganglion Trigeminal
ganglion
Pain
Cao et al, Arch Neurol 1999; Cao et al, Neurology 2002
Superior salivatory
nucleus
Trigeminal BOLD signal changes in brainstem
nucleus
before occipital cortex signal changes
Adapted from (consistent with CSD) or onset of visual
Iadecola C. Nat Med 2002; Bolay H et al. Nat Med. 2002.
symptoms
17.
Abnormal cortical Abnormal brain stem
activity function
Hyperexcitable brain Excitation of brain
( Ca++, Glu, Mg++) stem, PAG, etc.
Cortical Spreading Depression
Activation/Sensitization of TGVS Headache
Pain
Vasodilation Central Sensitization
Neurogenic
Inflammation
TGVS=trigemino-‐vascular system.
Adapted from Pietrobon D, Striessnig J. Nat Rev Neurosci. 2003;4:386-‐398.
18. Pharmacological
Treatments
Lifestyle
modification Psychological
and trigger and behavioural
management treatments
Education and Headache Surgical
Support Management treatments
19. • A high percentage of migraine patients report triggers
• 76% to 95% of patients report triggers1
• The mean number of triggers per patient is 6.71
90
80
70
Percentage of patients
60
50
40
30
20
10
0
Stress Hormones Missed Weather Sleep Perfume Neck Lights Alcohol Smoke Sleeping Heat Food
meals disturbance /odours pain late
Triggers
1. Kelman L. Cephalalgia 2007;27:394–402.
20. Pharmacological
Treatments
Lifestyle
modification Psychological
and trigger and behavioural
management treatments
Education and Headache Surgical
Support Management treatments
21. Non-‐specific Treatments Specific Treatments
• Paracetamol 1g • Triptans:
• NSAIDs (high-‐dose & soluble): Sumatriptan
Aspirin 600-‐900mgs Rizatriptan
Ibuprofen 600-‐800mgs Zolmitriptan
Naproxen 500-‐1000mgs Almotriptan
Tolfenamic acid 200mgs Eletriptan
Diclofenac 50-‐75mgs Naratriptan
• Opioids Frovatriptan
• Use concurrently with Prokinetics: • Ergot derivatives:
Domperidone 10-‐20mgs Ergotamine 1-‐2mg tablet or
Metoclopramide 10mgs suppository
Acute medications are used to provide relief of pain and associated symptoms1
Overuse of acute medication is common in individuals with chronic migraine1–3
20-‐30% in population; 50%–80% in headache clinics
Avoid opioids and ergots if possible in patients with frequent attacks4,6
Limit the use of acute medication to <3 days/week4,5
1. Silberstein SD et al. eds. Headache in Clinical Practice. 2nd ed. London: Martin Dunitz; 2002:69–146. 2. Lipton RB et al. Neurology 2003;61;154–155. 3. Wang SJ et
al. Pain 2001;89:285–292. 4. Diener HC et al. Lancet Neurol 2004;3:475–483. 5. Silberstein SD et al. eds. Headache in Clinical Practice. 2nd ed. London: Martin
Dunitz; 2002:69–111. 6. Bigal ME et al. Headache 2008;48:1157–1168
22. Develops through chronic overuse of acute medication taken to treat
headache or other pain1
Defined in the 2006 ICHD-‐IIR guideline as:2
– Headache on
– Regular overuse for >3 months of acute symptomatic treatment drugs,
during which time headaches have developed or worsened markedly
Overuse of all headache medication taken on an ad hoc basis to relieve pain
may result in medication overuse headache3
Most commonly associated with regular use of:
– Simple analgesics or NSAIDs on
– Opioids, ergots, combination analgesics or triptans on 3
Preventives less effective with concurrent medication (analgesic) overuse
1. Manack A et al. Headache 2009;49:1206
2. ICHD 2006 Headache Classification Committee of the International Headache Society. Olesen J et al. Cephalalgia 2006;26:742
3. World Health Organization (WHO) in collaboration with the European Headache Federation (EHF). J Headache Pain 2007;8:S1 .
23. Very common
Worldwide prevalence estimated to be 2%
60–85% patients seen in tertiary referral centres with
chronic daily headache have medication overuse
headache
Greater impact on daily functioning than episodic
migraine
In one study significant impairment or reduction in
function in 71% of days
24. Medication overuse1,2*
Preventative therapy Detoxification
FAIL
* 15 days/month: simple analgesics, combinations of drugs; or 10 days/month: combination analgesics, ergotamines, triptans, opioids, barbiturates.
1. Diener HC, Limmroth V. Lancet Neurol 2004;3:475–483.
2. Katsarava Z et al. Curr Neurol Neurosci Rep 2009;9:115–119.
26. Pharmacological
Treatments
Lifestyle
modification Psychological
and trigger and behavioural
management treatments
Education and Headache Surgical
Support Management treatments
27. Chronic Migraine is a relatively common primary headache
disorder
Migraine is a neurovascular disorder
Chronic Migraine is a very painful and highly disabling disorder
While there are numerous medical treatment options, a subset
of these patients is intractable to conventional medical
treatments.
There is a clear need for novel approaches for the management
of this highly disabled patient group
28.
29. DEFINITION
• Headache on > 15 days/month for at least 3 months
• Affects 3-‐4% of the population
• Descriptive term
• Not diagnosis
• Encompasses heterogeneous group of primary and
secondary headache syndromes
30. CAUSES
After secondary
causes are ruled out
Primary headache
disorders
Chronic daily headache Episodic headache
Frequency Frequency <15 days/month
Short-‐duration chronic Long-‐duration chronic
daily headache daily headache With or without
Duration <4 hours or multiple Daily or near-‐daily headache medication overuse
discrete episodes lasting
Chronic tension-‐ New daily Hemicrania
Chronic migraine
type headache persistent headache continua
1. Silberstein SD et al. Neurology 1996;47:871
31. Migraine is typically most prevalent during the most productive
years of adulthood – between the ages of 20 and 50 years1
One study suggests that 75–90% of the total economic cost of
migraine is associated with absenteeism or reduced/lost
workplace productivity2
People with chronic migraine are less likely to be actively
working full-‐time, with an employment rate that is 81% of that
for patients with low-‐frequency headache3
For those patients with chronic migraine who can work, their
disorder results in a >50% reduction in productivity at work or
school4
1. Stovner LJ et al. Eur J Neurol 2006;13:333–345.
2. Brown JS et al. Headache 2005;45:1012
3. Stewart WF et al. Poster presented at the 14th International Headache Congress, September 10–13 2009, Philadelphia, PA, USA.
4. Munakata J et al. Headache 2009;49:498–508.
32. Primary diagnosis ICHD-‐II migraine or chronic migraine
Refractory Headaches cause signi quality of
life despite modi factors, and adequate
trials of acute and preventive medicines with established ef
1. Failed adequate trials of preventive medicines, alone or in
combination, from at least 2 of 4 drug classes:
a. Beta-‐blockers
b. Anticonvulsants
c. Tricyclics
d. Calcium channel blockers
2. Failed adequate trials of abortive medicines from the following
classes, unless contraindicated:
a. Both a triptan and DHE intranasal or injectable formulation
b. Either NSAID or combination analgesics
Disabling With signi disability
Schulman et al, Headache 2008;48:778-78
33. Manjit S Matharu
Headache Group, Institute of Neurology &
The National Hospital for Neurology and Neurosurgery
London
UK
St Jude Medical
Intractable Chronic Migraine Course
22nd February 2012
34.
Weiner 1995
Started performing ONS in patients who responded to repeated greater occipital
nerve blocks
Weiner & Reed, 1999
Peripheral neurostimulation for control of intractable occipital neuralgia
Most of these patients were reported to had chronic migraine in subsequent
functional imaging study
Subsequently, numerous groups reported positive experiences in several primary and
secondary headache syndromes
Weiner R, Reed KL. Neuromodulation. 1999;2(3):217-21.
36.
• Open Label series
• ONSTIM Study
• PRISM Study
• St Jude Medical Study
37. OPEN LABEL CASE SERIES
Author Number Mean duration Number Follow up
of disorder improved (>50%) (yrs)
(yrs)
Popeney 25 10 22 1.5
Oh 10 12 10 0.5
Matharu 8 5.8 8 1.5
Schwedt 8 Not stated 3 1.5
TOTAL 51 43 (84%)
Medication overuse probably negatively affects outcome
Popeney& Alo Headache 2003; Oh et al. Neuromodulation 2004;
Schwedt et al Cephalalgia 2007; Matharu et al Brain 2004
38. Occipital Nerve Stimulation for the Treatment of Intractable
Chronic Migraine Headache
Multicentre, prospective, single blind, controlled feasibility
study
66 medically intractable chronic migraine
Failed at least 2 classes of preventives
Bilateral ONS
Randomised 2:1:1 to
– Adjustable stimulation (AS)
– Preset stimulation (PS)
– Medical Management (MM)
• Responder defined as:
– 50% reduction in headaches days/month
– 3-‐point drop (VRS 0-‐10) in pain intensity
Saper JR, et al Cephalalgia. 2011;31(3):271-285.
39. This prospective, randomized, double-blind, controlled study examined the efficacy and
safety of occipital nerve stimulation in adult chronic migraine patients.
Adjustable Stimulation (AS)
Patients
(Active, N=29 completed)
enrolled
who
responded to
an occipital
nerve block Preset Stimulation (PS)
2:1:1 ratio (Control, N=16 completed)
Medical Management (MM)
(Comparator, N=17 completed)
12 Weeks
40. Mean percent reduction (SD) Mean (SD) reductions in actual
in headache days per month headache days per month
Baseline 22.4+6.3 23.4+5.1 23.7+4.3
30% 8
27.0% 7
25%
(44.8) 6.7
6 (10.0)
20%
5
15% 4
3
10%
8.8% 2
(28.6)
5%
1 1.5
4.4% (4.6) 1
(19.1)
(4.2)
0% 0
Adjustable Preset Medical Adjustable Preset Medical
Stimulation (AS) Stimulation (PS) Management Stimulation (AS) Stimulation (PS) Management
(MM) (MM)
42. Fifty-six device-related adverse events occurred in 36 out of 51 patients.
Adverse Events % Adverse Events %
Lead migration/dislodgement 24% Implant site (IPG) hematoma 2%
Therapeutic product ineffective 16% Implant site (IPG) irritation 2%
Implant site (lead/extension tract) Implant site (lead/extension tract)
14% 2%
infection inflammation
Incision site complications 8% Lead fracture 2%
Implant site (IPG) infection 4% Migraine 2%
Implant site (IPG) pain 4% Post-procedural nausea 2%
Neck pain 4% Post-procedural pain 2%
Burning sensation 2% Rash 2%
Discomfort 2% Sensation of pressure 2%
Extension migration/dislodgement 2% Stitch abscess 2%
High impedance 2% Suture-related complications 2%
Hypotension 2% Tenderness 2%
43. Lipton RB, et al. PRISM study: Occipital nerve stimulation for treatment-refractory migraine. Presented at: 14th
Congress of the International Headache Society; September 10-13, 2009; Philadelphia, PA.
Multicentre, prospective, double blind, controlled study
132 migraine patients ( 6 days/month, 4 hrs each)
Failed at least 2 acute and 2 preventive treatments
Bilateral ONS
Trial stimulation for 5-‐10 days
Randomised in 1:1 ratio for 12 weeks
– Active stimulation (<12.7mA, 60 Hz, 250 sec)
– Sham stimulation (>1mA, 2Hz, 10 sec for 1sec/90 mins)
• All subjects has active stimulation from 12 weeks onwards
• Primary end-‐point: change in headache days/month at 12
weeks
44. This prospective, randomized, double-blind, controlled study examined the safety and
efficacy of occipital nerve stimulation for the preventive treatment of refractory migraine in
132 patients in 13 centres.
Patients
enrolled Active Stimulation
1:1 ratio
Trial stimulation to Two-year follow-up
assess its predictive conducted to assess
value safety.
Sham Stimulation
(Control)
5–10 days 12 Weeks
45. Primary efficacy measure: reduction in migraine days per month
Mean reduction (SD) in Mean percent reduction in
migraine days per month migraine days per month
6 100%
90%
5.5
5
(8.7) 80%
70%
4
3.9 60%
3 (8.2) 50%
40%
2
30%
20% 27%
1 20%
10%
0 0%
Active Stimulation Sham Stimulation Active Stimulation Sham Stimulation
46. A two-year follow-up was conducted to assess safety. Complications included the following:
Adverse Events Number of Cases
Non-‐targeted area sensory symptoms 18.0%
Implant site pain/discomfort 17.3%
Infection 15.0%
Incision site pain/discomfort 7.9%
Lead migration 6.8%
47. In this study, occipital nerve stimulation did not produce a
statistically significant benefit in the active vs. control group.
However, subgroup analysis identified several predictors of a
favourable response to stimulation, including the following:
Not overusing headache medications
Not using opiates
A positive response to a trial stimulation
48. Silberstein et al. The Safety and Efficacy of Occipital Nerve Stimulation for the Management of Chronic
Migraine. Presented at: 15th Congress of the International Headache Society; June 23-‐26, 2011; Berlin.
Multicentre, prospective, double blind, controlled study
157 chronic migraine patients, with VAS score > 6/10
Headache pain is posterior head pain or pain originating in
the cervical region
Failed at least 2 acute and 2 preventive treatments
Bilateral ONS
Randomised in 2:1 ratio for 12 weeks
• All subjects has active stimulation from 12 weeks onwards
• Primary end-‐point: 50% VAS with no increase in average
headache frequency or duration.
• Secondary end-‐points: MIDAS-‐disability days, Headache
Index, Zung Pain and Distress Scale, Patient Satisfaction,
Safety
49. Patient
Enrolled
Group A: Active
PNS
Implanted
2:1 Ratio
Randomize and
Device Activation Group B: Control (Blind)
80-‐ to 90-‐day roll in 4-‐week visit 12-‐week visit 24-‐week visit 52-‐week visit
Control pts were blinded using pt programmers that did not communicate with the IPG,
plus pts were also told that a range of settings were being tested.
Neither the patient nor the study investigator knew whether the patient was active or
control (“double-blind”) during the first 12 weeks.
50.
Primary Outcome
50% VAS reduction with no increase in average headache frequency or duration
18
16
P=0.21
14
12
10
8
6
4
2
0
Active Sham
51. Continuous Proportion Responder Analysis Based on Mean Daily Average Pain Intensity
VAS Measurements With No Increase in Average Headache Frequency or Duration
met
Control Group Active Group
% reduction protocol
% responders % responders p-‐value1
Patients Achieving Various Levels of Pain Relief from baseline objective
(n=52) (n=105)
(>10% dif.)2
100% 0,0% 38,5% 69,5% <0,001 Yes
Percentage of Patients
10,0% 30,8% 58,1% 0,001 Yes
80%
20,0% 19,2% 41,9% 0,005 Yes
60%
30,0% 17,3% 37,1% 0,011 Yes
40% 40,0% 15,4% 25,7% 0,143 No
50,0% 13,5% 17,1% 0,553 No
20%
60,0% 9,6% 11,4% 0,731 No
0% 70,0% 1,9% 4,8% 0,664 No
0% 20% 40% 60% 80% 100%
80,0% 1,9% 3,8% 1 No
Percentage of Pain Reduction
90,0% 0,0% 1,0% 1 No
Control (n=52) Active (n=105) 100,0%
1 Two-sided test of no difference
2 One-sided lower 95% confidence bound
Significance demonstrated at 30% reduction in pain (p-value=0.011)
52. Patient diaries recorded whether or not patients had a headache each day, the
daily average headache intensity, and the daily headache duration, in hours.
Data was used to identify Headache Days, defined as a day with a headache
lasting four or more hours with at least moderate intensity.
Mean Baseline and Change From Baseline in Headache Days per month—Last Value Carried Forward
Visit Control Group (n=52) Active Group (n=105) P-Value
Baseline
Mean ( std) 17,1 ( 8.2) 20,5 ( 7,6) 0,011
Week 12
Mean Change1 -4,3 (25,1%) -7,3 (35,6%) 0,02
Difference (95% CI) -3,0 (-5,5, -0,5)
1 Adjusted for study center, prior use of alternative therapy, and baseline
Significant reduction -3.0 days in Headache Days (per month) between Active & Control
groups (p=0.02)
53. The patient-recorded average pain intensity in their electronic diary using a
VAS with a 100 mm line to indicate severity progression.
Patients were asked to record these measurements on each day that they
experienced headache.
Mean Baseline and Change From Baseline in Daily Average Pain Intensity VAS Measurements By Visit —Last Value Carried Forward
Visit Control Group (n=51) Active Group (n=99) P-Value
Baseline
Mean ( std) 56,0 ( 17,2) 59,5 ( 16,2) 0,221
Week 12
Mean Change1 -6,1 -13,6 0,006
Difference (95% CI) -7,5 (-12,8, -2,2)
1 Adjusted for study center, prior use of alternative therapy, and baseline
The active group had significant reduction in relief in average pain intensity on days
with pain vs. the control group (P=0.006).
54. The Migraine Disability Assessment (MIDAS) is a questionnaire which
measures headache-related disability during the previous 90 days based on
five disability questions.
Mean Baseline and Change From Baseline in the MIDAS Headache Questionnaire Sum of Items 1 – 5—Last Value Carried Forward
Visit Control Group (n=52) Active Group (n=105) P-Value
Baseline
Mean ( std) 152,7 ( 77,1) 158,4 ( 76,8) 0,664
Week 12
Mean Change1 -20,4 -64,6 <0,001
Difference (95% CI) -44,1 (-65,4, -22,9)
1 Adjusted for study center, prior use of alternative therapy, and baseline
The MIDAS questionnaire was completed at baseline and 12 weeks after the system was
implanted. The reduction in disability of 44.1 days between the groups is statistically
significant (p<0.001).
55. The differences reported between the Active and Control Groups for both measures were
statistically significant (p<0,001).
Percentage of Pain Relief Since Surgery Percentage of Patients Satisfied
With Headache Relief
100%
100%
80%
80%
60% 60%
51,4%
42,1%
40% 40%
17,2% 19,2%
20% 20%
0% 0%
Control Group (n=52) Active Group (n=105)
Control Group (n=52) Active Group (n=105)
Active group participants reported (on average) 42,1% pain relief and 51,4% of them
were satisfied with their level of pain relief.
56. A total of 76 patients experienced one or more anticipated adverse events during the first open label study phase (50 in the Active
group and 26 in the Control group).
A total of 114 adverse events occurred in these 78 patients. All events were reviewed and classified into the appropriate category.
According to this classification, 42 events were classified as hardware-related, 28 events were classified as biological-related, 28
events were classified as stimulation-related, and 16 events were classified as non-device/procedure-related.
Total Total
Adverse Event + (N=153) Adverse Event + (N=153)
n (%) n (%)
Lack of efficacy/return of symptoms 15 (9,8%) Nausea/vomiting 3 (2,0%)
Persistent pain and/or numbness at IPG/lead site 15 (9,8%) Expected post-‐op pain/numbness at IPG/lead
2 (1,3%)
site
Normal battery depletion 12 (7,8%) Skin erosion 2 (1,3%)
Unintended stimulation effects 10 (6,5%) Hematoma 1 (0,7%)
Lead migration 9 (5,9%) Seroma 1 (0,7%)
Battery failure 8 (5,2%) Wound site complications 1 (0,7%)
Lead breakage/fracture 5 (3,3%) Pain or swelling at IPG site–trauma-‐related 1 (0,7%)
Infection 4 (2,6%) Allergic reaction to surgical materials 1 (0,7%)
Battery passivation 3 (2,0%) Device malfunction–IPG 1 (0,7%)
Device malfunction–programmer 3 (2,0%) IPG migration 1 (0,7%)
58. MECHANISM OF ACTION
Functional Convergence of Trigeminal and Cervical input
Bartsch et al, Brain 2002
59. MECHANISM OF ACTION
1. Effect at Segmental level
Gate-Control Theory of Pain
Activation of somatosensory
afferent A- nerve fibres blocks
nociceptive transmission at a
segmental level
2. Involvement of Supraspinal
Structures
Gate control at supraspinal level
Activation of descending
antinociceptive pathways
3. Neuroplasticity
60. MECHANISM OF ACTION
Paraesthesia-related rCBF changes
Significant activation in the dorsal rostral pons, anterior
cingulate cortex and left pulvinar
Matharu et al, Brain 2004
61. Patients with chronic migraine are often left without effective treatment,
leading lives that are painful and compromised.1
Occipital nerve stimulation involves a minimally invasive surgical procedure.
While the body of evidence is still emerging, ONS appears to be promising in
managing the pain and disability of intractable chronic migraine.
Frequent causes of adverse events are related to lead migration.
Predictors of response and long-‐term outcome are largely unknown
Reserved for medically-‐intractable and highly disabled patients
Performed in experienced headache centres
1. Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ; ONSTIM Investigators. Occipital nerve stimulation for the treatment
of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011;31(3):271-285.
62.
63. A total of 76 patients experienced one or more anticipated adverse events during the first open label study phase (50 in the
Active group and 26 in the Control group).
A total of 114 adverse events occurred in these 78 patients. All events were reviewed and classified into the appropriate
category. According to this classification, 42 events were classified as hardware-related, 28 events were classified as biological-
related, 28 events were classified as stimulation-related, and 16 events were classified as non-device/procedure-related.
Total
Category Adverse Event + (N=153)
n (%)
Patients with one or more anticipated AE 76
Normal battery depletion 12 (7,8%)
Lead migration 9 (5,9%)
Battery failure 8 (5,2%)
Hardware-‐Related Lead breakage/fracture 5 (3,3%)
Battery passivation 3 (2,0%)
Device malfunction–programmer 3 (2,0%)
Device malfunction–IPG 1 (0,7%)
IPG migration 1 (0,7%)
Lack of efficacy/return of symptoms 15 (9,8%)
Stimulation-‐Related Unintended stimulation effects 10 (6,5%)
Nausea/vomiting 3 (2,0%)
64. A total of 76 patients experienced one or more anticipated adverse events during the first open label study phase (50 in the Active
group and 26 in the Control group).
A total of 114 adverse events occurred in these 78 patients. All events were reviewed and classified into the appropriate category.
According to this classification, 42 events were classified as hardware-related, 28 events were classified as biological-related, 28
events were classified as stimulation-related, and 16 events were classified as non-device/procedure-related.
Total
Category Adverse Event + (N=153)
n (%)
Patients with one or more anticipated AE 76
Persistent pain and/or numbness at IPG/lead site 15 (9,8%)
Infection 4 (2,6%)
Expected post-‐op pain/numbness at IPG/lead site 2 (1,3%)
Skin erosion 2 (1,3%)
Biological Hematoma 1 (0,7%)
Seroma 1 (0,7%)
Wound site complications 1 (0,7%)
Pain or swelling at IPG site–trauma-‐related 1 (0,7%)
Allergic reaction to surgical materials (sutures, antibiotic, anesthesia) 1 (0,7%)
Non-‐Device-‐Related Other 16 (10,5%)
67. Chronic Headache
Chronic Headache = HA
The reasons to define chronic vs. episodic HA
Individual burden
Burden of social environment
Co-morbidities
Costs
69. 69
After Secondary
Causes Are Ruled
Out Primary
Headache
Disorders
Chronic Headache Episodic Headache
Frequency Frequency <15
days/month days/month
Chronic Daily
Short-Duration Headache (Long
Chronic Daily With or Without
Headache Duration)
Medication
Duration <4 hours or Daily or near-‐daily Overuse
multiple discrete
episodes headache
lasting
Chronic
New Daily
Chronic Tension- Hemicrania
Persistent
Migraine Type Continua
Headache
Headache
Silberstein SD et al. Neurology. 1996;47:871-‐875.
Dodick D. N Engl J Med. 2006;354:158-‐165.
70. 70
CM = migraine on 15 days/month
CTTH = TTH on 15 days/month
73. 73
Migraine
With With
migraine migraine
Visual analogue scale
features features
Without
Without migraine
migraine fetures
features
Triptan
TTH?
Abortive Migraine? TTH
Abortive Migraine
time
74. 74
IHS 2004,
CM = migraine on 15 days/month
No medication overuse
Diary is needed
Rely on patients recall
Too restrictive
75. 75
IHS 2006,
CM =
Migraine
HA on
8 HA days is migraine
No medication overuse
76. 76
Allergan, PREEMPT,
CM =
Migraine
HA on
50% is migraine
77. 77
American way to do it, Silberstein-‐Lipton
CM =
Migraine
HA on
No diary is needed
82. 82
Low Medication
Definition Females Age BMI Education Overuse*
CM-‐I ( 70% 44 26.4 70% 27%
CM-‐II (
69% 45 26.5 73% 31%
migrainous, including overuse)
CM-‐III ( any migrainous) 71% 46 25.9 78% 11%
High-‐frequency EM (9-‐14 days/month) 70% 40 24.3 66% 13%
Low frequency EM (0-‐8 days/month) 66% 40 24.1 60% 16%
Katsarava et al. Migraine Trust
GHC = German Headache Consortium.
2008. Abstract.
83. 83
70 *
60 Chronic migraine
Episodic migraine
* *
50
41
40 * * * * *
%
31 30
30 * 26 *
* 19
20 15
10
0
Allergies or Sinusitis Asthma Bronchitis Depression Chronic Anxiety High Blood High Obesity Arthritis
Hay Fever Pain Pressure Cholesterol
• Chronic migraine was defined as reported ICHD-2 diagnosis of migraine and
days/month
*p<0.05.
Data from the American Migraine Prevalence and Prevention (AMPP) study. Buse D et al. J Neurol Neurosurg Psychiatry. 2010; In press.
84. 84
9944 responders (of 18.000 = 55%)
Prevalences:
HA : cHA = 255, eHA = 5361, noHA = 4040, missing = 288
MIG : cMIG = 108, eMIG = 1601, noHA = 4030, 4205
excluded
TTH : cTTH = 50, eTTH = 1203, noHA = 4030, 5283 excluded
Combination of MIG and TTH and unclassifiable excluded
Chronic back pain = 1290
88. Central sensitization
Blink reflex and pain evoked
potentials in MOH
Transient increase, normalizing
again after withdrawal
(Ayzenberg et al. 2006)
50
45
40
35
30
25
20
15
10
Tr
A n
Tr
A n
C
Ep rols
na M
na M
on
ip
ip
m
ta
lg OH
ta
lg OH
t
ig
es
es
ra
ic
ic
in
s
M
e
M
O
O
H
H
89. 1. Central disinhibition
2. Stimulation of 6. PAIN
meningeal sensory
nerve (trigeminal)
3. Release of Thalamus
pain-
Nerve enhancing TNC
Vessel
dilation neuropeptid
es, such as Spinothala 5. Activation of
Peptide
CGRPTrige mic cortical pain
release minal
Inflammation track centers via
TrigeminGangli
al Nerve on thalamus
4. Activation of trigeminal
nucleus caudalis can result
in central sensitization
1. Pietrobon D et al. Nat Rev Neurosci. 2003;4:386-
CGRP = calcitonin gene-related peptide; TNC = trigeminal nucleus 398.
candalis. 2. Pietrobon D. Neuroscientist. 2005;11:373-386.
91. 91
Low- High-
frequency frequency Chronic
No migraine
episodic episodic migraine
migraine migraine
Transformation is often gradual and can evolve over several months or
years1,2
Transformation is neither inexorable nor irreversible; spontaneous or
induced remissions are possible and common1,2
Transformation happens in some but not all episodic patients (~3% of
episodic migraine sufferers)2
1. Lipton RB. Neurology. 2009;72:S3-S7.
2. Bigal ME, Lipton RB. Curr Opin Neurology
2008;21:301-308.
95. Suggestion for IHS classification
17. Chronic migraine due to .....
17.1. divorce
17.2. hyperactive child
17.3. sick and bed fasted parent
17.4. ………….
96. Medication
Overuse1,2
Preventive
Therapy Detoxification
* 15 days/month: simple analgesics, combinations of drugs; or 10 days/month: 1. Diener HC, Limmroth V. Lancet Neurol. 2004;3:475-483.
combination analgesics, ergotamines, triptans, opioids, barbiturates. 2. Katsarava Z et al. Curr Neurol Neurosci Rep. 2009, 9:115-119.
98. Single analgesic Ergotamines
Triptans
Combination analgesics
3
Patients With Headache (%)
100
90
Headache Intensity
80
2 70
60
50
40
1
30
20
10
0 0
1 2 3 4 5 6 7 8 9 1011121314 1 2 3 4 5 6 7 8 9 1011121314
Days of Withdrawal Therapy Days of Withdrawal Therapy
Diener HC, Limmroth V. Lancet Neurol. 2004;3:475-483.
99. Controls
Abrupt withdrawal Controls
Abrupt withdrawal
Prophylaxis
only Prophylaxis
only
No. of Headache Days/Month
30
from the start from the start
60
Headache Days/Month
Patients Exhibiting a
P = 0.01
25
50% Reduction in
50
20 40
(%)
15 30
10 20
5 10
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 Month 3 Month 5 Month 12
Months Following Withdrawal Months Following Withdrawal
Hagen K et al. Cephalalgia. 2009;29:221-232.
100. 1. Everything that is true for conservative
treatment is also true for ONS
1. Education
2. Realistic goals
3. Take your time
4. Give time to patients
104. Peripheral Nerve Stimulation for
the Management of Intractable
Chronic Migraine
Implant Techniques
Laurence Watkins
Consultant Neurosurgeon
National Hospital for Neurology & Neurosurgery, London
Intractable Chronic Migraine Course, Leiden February 2012
105. Introducing a novel procedure
Theoretical background and peer support
Registered with NICE (on hold until CE mark awarded)
Likely to now “re-‐visit” guidance
Business case to Trust – novel procedures protocol
Support from Trust management, R&D, host PCT (Funding Body)
Cadaveric workshops
Developing a PCT “application pack” and a strict protocol for
Multidisciplinary assessment
Rigorous consent procedure so that patients are aware of relative novelty of the procedure
Documented audit of complications and outcome
106. First Meeting (with implanter)
Check have been fully assessed in Headache Neurology Clinic
(chronic, disabling, intractable)
General fitness & airway satisfactory; reflux?
MRI ? (because can’t have MRI once ONS is implanted)
Any major surgery planned ? (because restriction of monopolar
diathermy once ONS implanted)
Explaining procedure
107. Discussion with patient
Known risks:
may not help
infection requiring removal of implant
electrode migration
neck stiffness
breakage or failure of components
tethering to skin or muscle
skin erosion
Clearance from Funding Body/PCT
108. Hospital Stay
Typically 3-‐4 days, but could be reduced
if pre-‐op assessment, implant activation
and patient education all done in clinic
Postoperative programming of the
implant
Teaching patient to use the “handset
control” +/-‐ recharger
109. Follow up clinics
Typically 4 in first year
Joint assessment with Headache Neurologist
and Specialist Nurse, additional post-‐operative
appointments in Neurosurgery Clinic.
Sometimes all combined in day care unit
Gradually refine the settings to get best
response (headache diary), without patient
discomfort
110. Stages of the operation
Insertion of electrodes
LA + Sedation
Test stimulation of electrodes
Awake
Insertion of battery and tunnelling of leads
Asleep (GA with LMA)
Alternatively GA throughout
if difficult airway or reflux (or patient preference)
USA: 2 stage procedure
111. Occipital Nerve Anatomy
PNS electrode should overlay the course
of the occipital nerves
Epifascial plane
Direction of insertion
Medial to lateral
Lateral to medial
Fluoroscopic control
Anchoring
115. Occipital Nerve Anatomy
PNS electrode should overlay the course
of the occipital nerves
Epifascial plane
Direction of insertion
Medial to lateral
Lateral to medial
Fluoroscopic control
Anchoring
116.
117.
118.
119. Main technical challenges
Placing electrodes to get paraesthesiae
Anchoring/looping the electrodes
Minimising infection risk
Not “instant” result so can’t really do “trial electrodes”
126. Anchoring the Electrodes
Attach to the hard underlying fascia
Use non-‐absorbable sutures
Choice of anchor
long (tubular) anchor, butterfly
anchor
others commercially available
Anchor direction—no kinks
Loops at “every level” (cervical, chest and
behind IPG)
127. Lead Tunneling and IPG
Placement: Gluteal,
Infraclavicular, or Abdominal
CAUTION: It is important to place strain relief loops at the site of the lead-extension connection and at the
IPG connection.
129. “Out” Migration
Migration of occipital nerve stimulation electrode leads
Both left and right leads have migrated away from their original position
Try reprogramming prior to revision surgery
130. Extreme “Out” Migration
“Extreme” migration of occipital nerve stimulation electrode lead
The electrode lead has migrated all the way toward the generator pocket
131.
132.
133. “In” Migration
A. B.
“In” migration of the occipital nerve stimulation electrode lead.
A. Original electrode lead position, B. Electrode position 8 month after insertion
with “in” migration to the contralateral side of the neck
135. Skin Erosion
Erosion of occipital nerve stimulation electrode lead
PRECAUTION: Skin Erosion—Because PNS leads used to aid in the management of intractable chronic
migraine are placed under the skin, be careful to place the lead at the appropriate depth to avoid the risk
of skin erosion.