headache – practical scenario

Headache – Practical ScenarioDr. Thomas Mathew

MD,DNB,DM(Neurology)Associate Professor

Department of NeurologySt.John’s Medical College and Hospital

Bangalore-560034

Case 1

On history…• 24 year old lady

• Episodic vertigo lasting 30 minutes

• 1-2/ week for the past 2 years

• No history of tinnitus/deafness

• No history of loss of consciousness

On examination…

• No focal neurological deficits

• Fundus normal

What will you ask next ?

Options are…

A. Postural variationB. Head traumaC. Alcohol intakeD. History of headache

Diagnosis

Migraine related vertigo

How will you manage ?

Options are…A. CinnarizineB. ProchlorperazineC. BetahistineD. None of the above

What you should do ?

• Flunarizine

• Topiramate

• Betablockers

• Amitriptyline

• Valproate

Flunarizine – Practical Scenario

Prof. A.V. SRINIVASAN,MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.

Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University

Former HeadInstitute of Neurology, Madras Medical College

Adjunct Prof. IIT Madras

Prof. A.V. SRINIVASAN,MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.

Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University

Former HeadInstitute of Neurology, Madras Medical College

Adjunct Prof. IIT Madras

Flunarizine: Indications

• Prophylaxis of migraine• Symptomatic treatment of dizziness• (Peripheral vascular disease)• (Alternating hemiplegia)• (Epilepsy adjuvant)

Contra-indications

• Parkinson’s disease• History of EP syndromes• History of depression• Breast feeding• (Pregnancy)Caution• Elderly• Hepatic disease

Adverse effects

• Weight gain• Sedation• Depression• EP syndrome (de Melo-Souza syndrome)• Headache/insomnia/asthenia/GI

Interactions

• Alcohol• Hypnotics /tranquilizers• COC• Anticholinergics• Anticonvulsants

HC Deiner et alCephalalgia 2002;22:209-221

• 808 patients• Double blind 16 week treatment phase• Flunarizine 10mg(5days/week) v Flunarizine

5mg v Propranolol 160mg• Responders (50% reduction) 5mg:46%. 10mg:53%. Propranolol:48%• Drop out due to adverse effects5mg:16.7%. 10mg: 19.3%. Propranolol:16.7%

M. ThomasHeadache 31:613-615, 1991

• India• 29 patients (14 dropped out)• 6months double blind crossover• 10mg v placebo• No decrease in migraine frequency• Reduced duration and severity

Experience of use

• Reduce if excessive daytime drowsiness• Watch for mood change• Use 5-15mg• Very useful even for refractory patients/prolonged

aura/hemiplegic aura/severe migrainous vertigo

Headache – Practical ScenarioDr. Thomas Mathew

MD,DNB,DM(Neurology)Associate Professor

Department of NeurologySt.John’s Medical College and Hospital

Bangalore-560034

Case 2

On history…• 28 year old

• Episodic headaches

• 12 hours• 4-5/week

• Severe/throbbing/worsens with exertion

On History…

• Photo/phonophobia/vomiting

• Family history of headache present

• Feels like crying/sad/thought of even suicide

• Takes vasograine 4-5/week

On examination…

• Obese . BP 130/90 mm of Hg

• BMI >35

• No deficits

• Fundus normal

What is the drug of choice?

A. FlunarizineB. BetablockerC. AmitriptylineD. ValproateE. Topiramate

Patient was started on topiramate

• 25 mg per day

What else you will advise ?

Options are…

A. Stop vasograine abuse

B. Identify precipitating factors

C. Life style modification

D. All the above

Patient comes back after 1 week of Topiramate

• “ I can’t see clearly from today morning”

What will you do ?

Options are…

A. Fundus examination

B. Urgent ophthalmological consult

C. Check Intraocular pressure

D. IV mannitol

E. All the above

Diagnosis

Topiramate induced acute angle closure glaucoma

Thank you

Practice Patterns in Headache Management

E- Voting Module

When would you initiate prophylaxis for migraine?

A. Patients with 4 or 5 migraine days per month with normal functioning

B. 3 migraine days with some impairment C. 2 migraine days with severe impairmentD. Any one of the above

What can be the duration of therapeutic trial for a migraine prophylactic drug?

A. Less than 1 weekB. 2-4 weeksC. 2- 6 monthsD. 4-6 weeks

What are the ‘red flags’ in headache history?

A. New headache onset in an older patient B. Rapid onset of headacheC. Systemic Symptoms such as fever or weight

lossD. All of the above

Which channels are blocked by Flunarizine?

A. Calcium channelsB. Sodium channelsC. BothD. None of the above

What is the typical characteristic of migraine headache?

A. Pulsating, throbbingB. Pressing, tightening but not pulsatingC. Boring, searingD. None of the above

Thank you