headache – practical scenario
TRANSCRIPT
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