Migraine headache presentation resident

1. Zori Stoilova, MD
Virginia Mason Neurology

2. The Primary Headaches
 Migraine Headache
 Tension-type Headache
 Cluster Headache and Other Trigeminal Autonomic
Cephalgias
 Other Primary Headaches

3. One year Prevalence of Common Headaches
0
5
10
15
20
25
30
35
40
45
Migraine Episodic Tension
Headache
Frequent
Headache
(>15/month)
18
41
56
40
3
Female
Male

4. Migraine Headache Definition
 Any two:
 Unilateral pain
 Throbbing pain
 Pain worsened by movement
 Moderate or severe pain
+
 Any one of associated symptoms:
 Nausea
 Vomiting
 Photo or phonophobia
International Headache Society 2003

5. Migraines
Who has migraines in the US:
 25% of women and 8% men lifelong
 18% of women and 6% of men over past year
 30 million have migraine
 Up to 10 million have Chronic Daily Headache

6. Migraine Prevalence
Ages 25-55 show highest prevalence
Silberstein SD, Lipton RB. Neurologic Clinics. 1996

7. Pathophysiology
 Dysfunction in brainstem pathway modulation of
sensory input (neuronal spreading depression)
 Vascular factors
 1/3 experience migraine
aura

8.  Migraine patients have enhanced sensory and
neurophysiologic responses during as well as between
attacks
 Visual (photosensitivity)
 Auditory (phonophobia, tinnitus)
 Balance (dizziness, motion sickness)
 Allodynia

9. Common Migraine Comorbidities
 Depression
 Anxiety
 Social Phobias
 Bipolar Disease
 Irritable Bowel Syndrome
 Sleep Disorders
 This means medications can be chosen to treat 2 issues
with one drug

10. Migraine Comorbidities
 Anxiety (tend to precede onset of migraine in about
80% of patients)
 Depression (tended to follow onset of migraine in 75%
of cases)
Merikangas, 1990

11. Migraine Treatment - Abortive
 Triptans
 DHE
Avoid in patients:
 <18, >65
 CAD
 Uncontrolled HTN

12. Migraine Preventive/Prophylactic Treatment
 If migraine headache more than 4-6/month
 If significant work lost
 If quality of life impaired or
 If patient prefers this mode

13. Options
 Beta Blockers, ?CCB
 Anticonvulsants (Topiramate, Depakote)
 Antidepressants
 TCA (Amitriptyline)
 SNRI (Venlafaxine)
 Others (Butterbur, Feverfew, Magnesium, Riboflavin)
 Botox
 CGRP Antibody treatments (Aimovig, Ajovy, Emgality)

14. Multimodal Approach
 Education, education, education
 Decrease OTC anelgesics to <2/week
 Encourage Exercise
 Biofeedback and behavioral therapies
 Good sleep hygiene/OSA evaluation
 Set up realistic expectations of therapy

15. Tension Headache
 Prevalence: Episodic ~40%, Chronic ~2-5%
 Peak 30-40 year olds
 8% patients miss work days
 However 43% have decreased work efficacy
Schwarts BS et al. JAMA 2009

16. Tension Headache
Definition
 Episodic headache lasting minutes to days
 Typically bilateral, pressing or tightening in quality
 Mild to moderate intensity
 Does not worsen with routine physical activity
 No nausea
 Phonophobia and photophobia may be present
International Headache Society 2003

17. Tension Headache vs. Migraine
Many Tension Headaches may actually be migraine
 75% of migraine patients report neck
tightness/pain/stiffness
 Stress, anxiety, sleep deprivation can trigger migraine
 Migraines can present with bilateral pain
***Pharmacologically tension headache is equivalent to
migraine headache

18. Cluster Headache
 Attacks of severe, strictly unilateral pain
 Orbital, supraorbital, temporal
or in any combination of these sites
 Lasts 15-180 minutes
 Occurring every other day to 8 times per day
 Often circadian pattern
International Headache Society 2003

19. Cluster Headache
 One or more of ipsilateral:
-conjunctival injection,
-lacrimation,
-nasal congestion,
-rhinorrhea,
-facial sweating,
-miosis,
-ptosis,
-eyelid edema.
International Headache Society 2003

20. Therapy - Abortive
 Smatriptan: injectable or nasal
 100% O2 at 7-15L/min x 15mins
 DHE: IM, SQ or IV
 Ergotamine: Oral, suppository
 Greater Occipital nerve block

21. Therapy - Preventive
 Verapamil 120mg -240mg ER BID
 Lithium 300mg-900mg daily
 Divalproex Sodium 500-3000mg
 Topiramate

22. Therapy -Transitional
 Prednisone 10-12 day taper
 Naratriptan: 2.5mg BID x7days
 Ergotamine 2mg qhs – BID for seven days
 DHE
 Occipital nerve blockade

23. Evaluation
 No study can establish headache subtype
 Diagnostic testing should be considered to rule out
organic pathology.
 If new onset HA in middle aged or elderly patient
 Abrupt change in headache character, frequency
 Precipitation by valsalva
 Focal neurologic symptoms
 Systemic symptoms

24. Evaluation
 CT/MRI brain
 Cervical imaging
 Dental evaluation
 Lumbar Puncture
 Sleep Study

25. Bibliography
 Bigal ME, Rapoport AM, Sheftell FD, et al. Transformed migraine and medication overuse in a tertiary headache
center –clinical charachteristics and treatment outcomes. Cephalalgia 2004;24:483-490.
 Continuum: Headache. American Academy of Neurology. Volume 12, Number 6; December 2006.
 International Headache Society 2003 Guidelines (ICHD-II). Part one -The Primary Headaches.
 Silberstein SD, RB. Headache Epidemiology Emphasis on Migraine. Neurologic Clinics Vol 14, Issue 2 (May 1996).
 Merikangas, Kathleen R. PhD; Jules Angst, MD; Hansruedi Isler, MD Migraine and Psychopathology Results of the
Zurich Cohort Study of Young Adults. Arch Gen Psychiatry. 1990;47(9):849-853.
 Schwartz BS, et al. Epidemiology of Tension-Type Headache. JAMA, February 4, 1998 – Vol 279, No.5. 381-384.
 Zwart JA, Gyb G, Hagen K, et al. Analgesic overuse among subjects with headache, neck and low-back pain.
Neurology 2004:62:1540-1544.

26. A simple case
 56 y/o woman with new onset visual scatoma

27.  Visual symptoms come on in L temporal field and
spread to the right temporal field. No loss in vision.
Describes as “broken vision” with lights and flashes.
 Headache lasts 4-5 hours, coming on slowly after the
initial visual symptoms. +Nausea.

28.  PMH
 Migraine/cluster headache
 Neck pain s/p C4-5 fusion 10/09
 s/p 9mm basilar artery tip aneurysm coiling 8/09
 Depression
 Anxiety
 Severe insomnia