1. Migraine
 UTMB Department of
Otolaryngology
 Grand Rounds March 2005
 Jeffrey Buyten, MD
 David C. Teller, MD
 Francis B. Quinn, MD

2. Prevalence
 Familial
 Young, healthy women; F>M: 3:1
– 17 – 18.2% of adult females
– 6 – 6.5% adult males
 2-3rd decade onset… can occur sooner
 Peaks ages 22-55.
 ½ migraine sufferers not diagnosed.
 94% pt’s seen in primary care settings for
HA have migraines

3.  Common misdiagnoses
for migraine:
– Sinus HA
– Stress HA
 Referral to ENT for sinus
disease and facial pain.

4.  Migraineurs more likely to have
motion sickness.
 Half of Meniere’s patients claim to
have migrainous symptoms.
 BPPV

5.  $13 billion/year in lost
productivity
 1/3 participants in
American Migraine Study
II missed work in prior 3
months

6. Migraine Definition
 IHS criteria: Migraine/aura (3 out of 4)  IHS Diagnostic criteria: migraine w/o
– One or more fully reversible aura aura
symptoms indicates focal cerebral – HA lasting for 4-72 hrs
cortical or brainstem dysfunction. – HA w/2+ of following:
– At least one aura symptom  Unilateral
develops gradually over more than  Pulsating
4 minutes.
 Mod/severe intensity.
– No aura symptom lasts more than
one hour.  Aggravated by routine
– HA follows aura w/free interval of physical activity.
less than one hour and may begin – During HA at least 1 of following
before or w/aura.  N/V
 Photophobia
 Phonophobia
History, PE, Neuro exam show no other organic
disease.
At least five attacks occur

7. Migraine Subtypes
 Basilar type migraine
– Dysarthria, vertigo,
diplopia, tinnitus,
decreased hearing, ataxia,
bilateral paresthesias,
altered consciousness.
– Simultaneous bilateral
visual symptoms.
– No muscular weakness.
 Retinal or ocular migraine
– Repeated monocular
scotomata or blindness < 1
hr
– Associated with or followed
by a HA

8. Migraine Subtypes
 Menstrual migraine
 Hemiplegic migraine
– Unilateral motor and
sensory symptoms
that may persist after
the headache.
– Complete recover
 Familial hemiplegic
migraine

9. Migrainous vertigo
 Vertigo – sole or prevailing symptom.
 Benign paroxysmal vertigo of childhood.
 Prevalence 7-9% of pts in referral dizzy
and migraine clinics.
 Not recognized by the IHS
 Diagnosis (proposed criteria)
– Recurrent episodic vestibular symptoms of
at least moderate severity.
– One of the following:
 Current of previous history of IHS migraine.
 Migrainous symptoms during two or more
attacks of vertigo.
 Migraine-precipitants before vertigo in more
than 50% of attacks.
– Response to migraine medications in more
than 50% of attacks

10. Migraine mechanism
 Neurovascular theory.
– Abnormal brainstem
responses.
– Trigemino-vascular system.
 Calcitonin gene related
peptide
 Neurokinin A
 Substance P
 Extracranial arterial vasodilation.
– Temporal
– Pulsing pain.
 Extracranial neurogenic
inflammation.
 Decreased inhibition of central
pain transmission.
– Endogenous opioids.

11.  Important role in
migraine
pathogenesis.
 Mechanism of action
in migraines not well
established.
 Main target of
pharmacotherapy.

12. Aura Mechanism
 Cortical spreading depression
– Self propagating wave of neuronal and glial depolarization across the
cortex
 Activates trigeminal afferents
– Causes inflammation of pain sensitive meninges that generates
HA through central/peripheral reflexes.
 Alters blood-brain barrier.
– Associated with a low flow state in the dural sinuses.

13.  Auras
– Vision – most common
neurologic symptom
– Paresthesia of lips, lower
face and fingers… 2nd most
common
– Typical aura
 Flickering uncolored
zigzag line in center and
then periphery
 Motor – hand and arm on
one side
 Auras (visual, sensory,
aphasia) – 1 hr
 Prodrome
– Lasts hours to days…

14. Clinical manifestations
 Clinical manifestations
– Lateralized in severe attacks –
60-70%
– Bifrontal/global HA – 30%
– Gradual onset with crescendo
pattern.
– Limits activity due to its
intensity.
– Worsened by rapid head
motion, sneezing, straining,
constant motion or exertion.
– Focal facial pain, cutaneous
allodynia, GI dysfunction,
facial flushing, lacrimation,
rhinorrhea, nasal congestion
and vertigo…

15. Precipitating factors
stress
head and neck infection
head trauma/surgery
aged cheese
dairy
red wine
nuts
shellfish
caffeine withdrawal
vasodilators
perfumes/strong odors
irregular diet/sleep
light

16. Treatment
 Abortive
– Stepped
– Stratified
– Staged
 Preventive

17. Abortive Therapy
 Reduces headache recurrence.
 Alleviation of symptoms.
 Analgesics
– Tylenol, opioids…
 Antiphlogistics
– NSAIDs
 Vasoconstrictors
– Caffeine
– Sympathomimetics
– Serotoninergics
 Selective - triptans
 Nonselective – ergots
 Metoclopramide

18. Abortive care strategies
 Stepped
– Start with lower level drugs, then switch to more specific drugs if
symptoms persist or worsen.
 Analgesics – Tylenol, NSAIDs…
 Vasoconstrictors – sympathomimetics…
 Opioids (try to avoid) - Butorphanol
 Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,
zomatriptan.
– Limited by patient compliance.
 Stratified
– Adjusts treatment according to symptom intensity.
 Mild – analgesics, NSAIDs
 Moderate – analgesic plus caffeine/sympathomimetic
 Severe – opioids, triptans, ergots…
– Severe sx treatment limited due to concomitant GI sx’s.
 Staged
– Bases treatment on intensity and time of attacks.
– HA diary reviewed with patient.
– Medication plan and backup plans.

19. Preventive therapy
 Consider if pt has more than 3-4
episodes/month.
 Reduces frequency by 40 – 60%.
 Breakthrough headaches easier to abort.
 Beta blockers
 Amitriptyline
 Calcium channel blockers
 Lifestyle modification.
 Biofeedback.

20. Botox
51% migraineurs treated
had complete prophylaxis
for 4.1 months.
38% had prophylaxis for 2.7
months.
Randomized trial showed
significant improvement
in headache frequency
with multiple treatments.

21. Conclusions
 Migraine is common but unrecognized.
 Keep migraine and its variants in the
differential diagnosis.

23. References
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