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Curriculum Vitae• Nama : Muhammad Akbar

• Pendidikan :1. Dokter (dr) 1987, Unhas

. !"esia#is !ara$ (!".!) 199%, Unhas

&. Doktor (Ph.D) ''1, iroshima, e"an*.

+. Di"#oma in orensi- Medi-ine (DM) ''&, ronin*en, /e#anda.

%. 0onsu#tan erebro 2as-u#ar (!".!(0) '1&

Amanah :1. 0e"a#a Pusat 0a3ian Media dan !umber /e#a3ar, 4emba*a 0a3ian dan

Pen*emban*an Pendidikan UNA!, ''56'1'

. 0etua D i#aah !u#6!e# ''56''9

&. 0etua Perhim"unan Dokter !"esia#is !ara$ (P;D

Pusat, ''76'11 +. 0etua Perhim"unan Dokter mer*ensi ndonesia Pusat ''76'11

%. 0etua P

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HEADACHE AND MIGRAINEMANAGEMENT

Muhammad Akbar

NEUROLOGY DEPARTMENT

HASANUDDIN UNIVERSITY

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Introduction:

Headache is the most common problemneurologists encounter in their clinicalpractices

!i"etime pre#alence o" headache $allt%pes& is 96%

Although most o" these headaches are

benign $'()*&+ a small percentagere,uire urgent diagnostic studies and

treatment

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-#er .)) illnesses cause headache as as%mptom/

Temporal arteritis

0ubarachnoid1 subdural haemorrhage

Idiopathic intracranial h%pertension

Intracranial h%potension

Carotid1#ertebral arter% dissection

Cerebral #asculitis

Re#ersible cerebral #asospasm

Meningitis

Cerebral #ein thrombosis

Arnold chiari mal"ormation

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2hat to do 3rst4

Most important to 3nd out i" there is an%

red fag in this headache

Ta5e a good history: onset+ se#erit%+an% s%stemic "eatures6

Then+ tr% to identi"% i" %ou are dealing7ith primary or secondary headache

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Classi3cation o" Headache

Primary headaches (No underlying cause&MigraineTension-type TACs

-therSecondary headaches (Underlying cause)Medication o#eruseHead1nec5 in8ur%0pace9occup%ing lesion $ie brain tumour&Vascular cause $ie 0ubarachnoid hemorrhage+intracranial bleed&In"ectious cause $ie meningitis or upper respirator% tractin"ection& man% others

Headache Classi3cation Committee o" the International Headache Society+;(

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=rimar% HeadacheDisorders

More common Migraine+ 7ith or

7ithout aura Tension t%pe

Cluster

• Less commonLess common

• Paroxysmal hemicraniaParoxysmal hemicrania

• Idiopathic stabbingIdiopathic stabbing

• Cold-stimulusCold-stimulus

• Benign coughBenign cough• Benign exertionalBenign exertional

• Associated with sexual Associated with sexual

actiityactiity

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0econdar% HeadacheDisorders

• Associated with non- Associated with non-ascular intracranialascular intracranialdisorder disorder • Benign intracranialBenign intracranial

hypertensionhypertension• Intracranial in!ectionIntracranial in!ection

• Low CS" pressureLow CS" pressure

• Associated with Associated withnoncepalic in!ectionnoncepalic in!ection• #iral in!ection#iral in!ection

•Bacterial in!ectionBacterial in!ection

• Associated with ascular Associated with asculardisordersdisorders• SubarachnoidSubarachnoid

hemorrhagehemorrhage

• Acute ischemic Acute ischemiccerebroascular disorder cerebroascular disorder

• $nruptured ascular$nruptured ascularmal!ormationmal!ormation

• Arteritis Arteritis• Carotid or ertebral arteryCarotid or ertebral artery

painpain

• #enous thrombosis#enous thrombosis

• Arterial hypertension Arterial hypertension

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Associated 7ithhead trauma Acute post9

traumatic headache

Associated 7ithsubstance use or7ithdra7al

Acute use ore>posure Chronic use or

e>posure

Associated 7ithmetabolicdisorders

H%po>ia H%percapnia

Mi>ed h%po>ia ?h%percapnia

Dial%sis

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Associated 7ith head trauma Acute post9traumatic headache

Headache o" "acial pain associated 7ithdisorder o" cranium+ nec5+ e%es+ ears+nose+ sinuses+ teeth+ mouth or other

"acial or cranial structures

Cranial neuralgias+ ner#e trun5 pain and

dea@erentation pain

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Clues to Secondaryeadache

"e#er+ seiure+ beha#ioral change+ etc

age 'BB

posterior location

neurological de3cit

abrupt onset1se#ere intensit%:thunderclap

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Meningococcal rash

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attleFs sign

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Temporal arteritis

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Headache Histor%

Is this %our 3rst or 7orst headache4Ho7 bad is %our pain on a scale o" ;9;)4 Do%ou ha#e headaches on a regular basis4 Isthis headache li5e the ones %ou usuall%

ha#e4

2hat s%mptoms do %ou ha#e be"ore o"during the headache4 2hat s%mptoms

do %ou ha#e no74

2hen did this headache begin4 Ho7did it start $graduall%+ suddenl%&4

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Headache Histor%

• %here is your pain&%here is your pain&'oes the pain spread to any other area& %here&'oes the pain spread to any other area& %here&

• %hat (ind o! pain do you hae%hat (ind o! pain do you hae )throbbing*)throbbing*stabbing* dull* others+stabbing* dull* others+&&

• 'o you hae other medical problems&'o you hae other medical problems&• 'o you ta(e medicines&'o you ta(e medicines&

• Hae you recently hurt your head or had aHae you recently hurt your head or had a

medical or dental procedure&medical or dental procedure&

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Essential Questions

Headache duration+ location+ ,ualit%+se#erit%+ e>acerbating1relie#ing "actors+associated s%mptoms+ speci3c timing inthe da%6

!hy did the patient come to the ER4 2as the onset sudden or gradual4 Does the patient ha#e an% underl%ing

medical conditions+ eg+ are the%immunosuppressed4 An% recent head trauma4 An% medications4

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lue lag Headaches

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Red lag Headaches

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-ther Red lag Headaches

Associated 7ith rash Ma% indicate !%me disease or meningococcemia

Non9migraine headache in pregnanac% or post9

partum Ma% indicate cerebral thrombosis

Associated 7ith changes in posture Ma% indicate lo7 C0 pressure due to spontaneous C0

lea5

Associated 7ith pressing #isual disturbances Ma% be due to glaucoma or optic neuritis

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Headache Red lags: 09N9-9-9=90

S%stemic s%mptoms: "e#er+ 7eight loss Neurological s%mptoms or abnormal signs:

con"usion+ impaired alertness or consciousness

"nset: suddent+ abrupt or split9second "lder: ne7 onset or progressi#e headache+

speciall% in patients ' B) %o Pre#ious headache histor%: 3rst o ne7 or

di@erent headache Secondar% ris5 "actors: s%stemic cancers+

HIV

David Dodick, MD

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Tests for secondary causes

CT scan $mass lesion+ 0AH&

M#$M#&M#' $mass lesion+ dissection+AVM+ aneur%sm+ AVM+ #enous thrombosis&

umar puncture $meningitis+ 0AH+intracranial h%pertension&

&ngiography $aneur%sm+ AVM+ #asculitis+

#enous thrombosis+ dissection& as: E0R+ CC+ T0H+ drug screens+

electrol%tes

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International Classi!ication o! Headache),.+

Primary Headaches

Migraine 7ithout aura Migraine 7ith aura

Tension t%pe headache

Trigeminal Autonomic Cephalgias $TACs& Cluster headache =aro>%smal hemicrania

0NCT

-ther primar% headaches

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tension9t%pe headache

0imple analgesics paracetamol+ N0AIDs+ aspirin

=re#ention tric%clics+ gabapentin+ topama>+ epilim

Management o" stress and tension

E>ercise

2atch "or M-H

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cluster headache and other

trigeminal autonomic cephalgias

Cluster headache $episodic or chronic& Intermittent+ e>cruciating+ sharp1stabbing

Ipsilateral autonomic sign $con8uncti#al in8+ lacrimation+ nasalcongestion+ rhinorrhea+ e%elid oedema+ "orehead and "acials7eating+ miosis or ptosis&

;B9;

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other primary headaches

=rimar% stabbing headache

=rimar% cough headache

=rimar% e>ertional headache

=rimar% headache associated 7ith se>ual acti#it% H%pnic headache

Hemicrania continua

Ne7 dail%9persistent headache

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=rimar% stabbing headache

=aro>%smal + #er% short $o"ten less than ; sec& pain attac5s7hich occur as single or as repetiti#e pain stabs

A@ect a circumscribed area+ usuall% in VI 0tabbing+ mild to mod intensit%

; a %ear to ;)) a da% More common in patients 7ith other headache disorders 0pontaneous or triggered eg Cold ice or drin5s+ ice9pic5 li5e

pain No cranial autonomic s%mptoms

=athoph%siolog% un5no7n suall% no treatment Indomethacin i" #er% "re,uent JB to B) mg bd Tr% melatonin+ ni"edipine+ gabapentin

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=rimar% cough headache

0udden onset and lasts one second to .) minutes

Triggered b% coughing or #alsal#a

;; to B) * o" cases cough ha is s%mptomatic+ most commonis Arnold9Chiari t%pe ;+ other causes incl post "ossa mass+

craniocer#ical abnormalities+ non9ruptured aneur%sms Mean age o" onset BB to LB and men .9B > more common

than 7omen

-"ten spontaneous remission+ usuall% J months to J %ears

suall% no treatment+ a#oid coughing

Indomethacin B)mg bd range JB to J))mg+ mean duration

o" treatment L mths to K %ears Alternati#e isacetaolamide+ or topama>+ !=

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=rimar% e>ertional headache

Triggered b% di@erent t%pes o" ph%sical e>ercise eg 7eightli"ting+ s7imming and running

=ulsating headache lasting B mins to K< hours JJ to K.* o" cases are secondar% 0AH+ cer#ical arter%

dissection+ Arnold9Chiari mal"ormation+ post "ossa lesions+intracranial #enous anomalies or stenoses

suall% in earl% adult %ears Co9morbidit% 7ith primar% ha associated 7ith se>ual

acti#it% in about K)* and KL* ha#e migraine

0pontaneous remission is common A#oid e>ercise or slo7 increase esp in heat or high altitude Indomethacin or propranolol or short term proph%la>is 7ith

indomethacin JB to B) mg ; hour be"ore e>ercise

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=rimar% headache associated 7ith se>ualacti#it%

• Not assoc 7ith other sorts o" ph%sical acti#it% but pts can also ha#ee>ertional or cough headache Independent to the 5ind o" se>ualpractice

• -rgasmic$.9K > more common& or pre9orgasmic

• =ain is bilateral+ di@use or occipital

• suall% about .) mins and up to JK hours

• E>clude secondar% headache $;;* o" 0AH occur during se>ual acti#it%&

• Mechanism o" disorder is un5no7n

• su spontaneousl% remit but can last da%s to %rs and recur

• Men . to K > more "re,uent

• 0pontaneousl% remit

• Treatment is to stop as soon as headache starts

• =anadol+ #oltaren+ aspirin or nuro"en ine@ecti#e+ triptans can settle ha+B)9Bmg indomethacin is recommended proph%lacticall% $

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H%pnic headache

Almost e#er% night $at least e#er% 7ee5& a occursheadache during sleep t%picall% at the same time eachnight

=ulsating or dull+ moderate+ .) mins to . hours+ bilateral"rontotemporal or di@use

No assoc autonomic s%mptoms

suall% starts o#er the age o" B)

Main problem is disturbed sleep

-nl% treat i" impaired ,ualit% o" li"e

0trong co@ee or oral ca@eine at bedtime+ or lithium+indomethacin

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=rimar% thunderclap headache

0udden headache o" ma>imal intensit% similar to that o" aruptured aneur%sm 7ith normal imaging and C0

In the acute headache phase+ di@use+ segmental or multi"ocal#asospasms in all #essel territories 7ithout e#idence o"aneur%sm or bleeding

Vasospasm is completel% re#ersible

Re#ersible cerebral #asoconstriction s%ndrome

suall% once in a li"etime

Can be triggered b% heat

-ther disorders can cause sudden se#ere headache and needto be considered

No data on pre#alence+ 7omen'men+ mean age KB $JB9L&

Treat acutel% 7ith paracetamol and opioids

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Hemicrania Continua

irst described in ;(

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Ne7 dail% persistent headache

irst described in J))K

DiOcult to distinguish "rom chronic tension9t%pe ha

Acute or subacute onset 7ithin . da%s and then continuous

Resembles chronic t9t ha but can ha#e migrainous "eatures

su bilateral+ mostl% not pulsating+ dull and mild to modintensit%

No preceding episodic ha 7ith increasing "re,uenc%

Consider medication o#eruse

=ost in"ectious occurrence considered

MP+ onset ;) to .) or B) to L) %rs

No e#idence based treatment recommendation but e>pert

consensus agrees treatment is #er% diOcult Treatment choicedepends on primar% "eatures

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headache management

Good 7or5ing relationship 7ith the patient

Trial and error rarel% a simple 3>/

Manage e>pectations Diar% o" headache and medication use

Regular consultations

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Headache diar% 777migraineclinicorgu5

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Chronic 'aily Headache

=rimar% headache occurring on at least ;B da%s o" themonth

. to B* o" the population

suall% a mi>ture o" tension9t%pe headache and migraine About ;)* o" this group ha#e ne7 dail% persistent

headache

-"ten complicated b% head in8ur% and medication o#eruse

-"ten accompanied b% mood disorder Increased ris5 o" chroni3cation o" migraine also occurs

7ith obesit%+ ca@eine inta5e and stress Q

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Medication o#eruse headache

• An% analgesic can cause M-H/

• A neurobeha#ioural disorder / =h%sical receptor alterations / eha#ioural e>cessi#e1obsessi#e drug9ta5ing+

anticipator% an>iet%+ "ear o" pain

Man% use drugs to cope 7ith li"e and stress+ e#en7hen not #aluable "or pain

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Treatment o" M-H

Multidimensional approach

Discontinuation o" dail% medication

=re#enti#e therap% to limit headache occurenceand1or se#erit%

Diar% $the !ondon Migraine Clinic Headache

Diar%& Ma% need i# dih%droergotamine protocol as

inpatient

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0%mptomatic Therap%

As aborti#e therap% Goal: to abort+ reduce or stop a

headache+ head pain or s%mptoms

accompan%ing a headache

=urpose:

"or acute attac5s that are in"re,uent "or brea5through attac5s 7hile onpre#enti#e therap%

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0%mptomatic Therap%

Notes: etter used at onset o" headache

re,uentl% combined 7ith pre#enti#e therap% Can cause rebound headaches

0hould not e>ceed . da%s17ee5

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=re#enti#e Therap%

As proph%la>is or pre#ention o" recurrence Goal: reduce "re,uenc%+ se#erit% and

duration o" attac5s

=urpose: or "re,uent attac5s o" headache or moderate to se#ere headaches or those on e>cessi#e use o" s%mptomatic

medication 7ithout relie"

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=re#enti#e Therap%

Notes: Gi#en dail% "or at least .9L months

egin at lo7er dose 7ith up7ard titration Reassess e#er% L months 0ome medications need tapering be"ore

discontinuation

Encourage e@ecti#e birth control in "ertile7omen 7hile on pre#enti#e therap%

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The pre#enti#ealphabet Antidepressants: nortript%line+

amitript%line+ C%mbalta

9bloc5ers: propranolol+ atenolol+nadolol

Calcium channel bloc5ers: #erapamil

Depa5ote $#alproic acid&

Epileps% meds $other than

Depa5ote&: gabapentin+ topiramate+!%rica

Misc: tianidine+ Namenda

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oto> Treatment

oto> In8ections9 Appro#ed b% DA in -ctJ);)/

Appro#ed "or chronic migraine $migraine

headaches happening more than ;Bda%s1 month&

.J in8ection sites in "orehead+ temples+shoulders and nec5

Man% insurance companies are still3ghting not to co#er this

!i"est%le

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!i"est%leManagement 0leep < hours consistent schedule

Eat . regular meals $or more& per da% Drin5 lots o" uids Get Aerobic e>ercise regularl% !imit ca@eine $or better %et a#oid

completel%& Identi"% your triggers Seep a headache diar% Manage stress se correct posture and pause during

repetiti#e acti#ities

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Nonpharmacologic

Treatments io"eedbac5io"eedbac5 Rela>ation therap%Rela>ation therap%

Cogniti#e eha#ioral Therap%Cogniti#e eha#ioral Therap% AcupressureAcupressure

AcupunctureAcupuncture

=h%sical Therap%=h%sical Therap% Chiropractic treatmentChiropractic treatment

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Additional Treatment

Measures -ccipital Ner#e 0timulators TEN0 units

Transcranial Magnetic 0timulator

0pecial Diets

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2hat Is Migraine4

A chronic disorder 7ith episodicattac5s

Comple> changes in the brain

• During attac5s / Headache

/ 0e#eral associated

s%mptoms / unctional disabilit%

• In9bet7een attac5s Enduring predisposition to

"uture attac5s

Anticipator% an>iet%

TG0 P trigeminal s%stem TNC P trigeminal nucleus candalis

igal ME et al Neurology J))

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Migraine:A Continuum o" 0%mptoms

Cad% R et al Headache. J))JKJ:J)KJ;L!inde M Acta Neurol Scand J))L;;K:;

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Migraine:Headache Not Al7a%s Gradual

Cad% R et al Headache. J))JKJ:J)KJ;L!inde M Acta Neurol Scand J))L;;K:;

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migraine

Migraine 7ithout aura K to J hrs duration

nilateral+ pulsing ,ualit%+ mod to se#ere pain+aggra#ated b% usual ph%sical acti#it%

At least one o" :nausea and1or #omiting+ photophobia and phonophobia

Migraine 7ith aura

ull% re#ersible #isual and1or sensor% and1or speech s>sbut no motor 7ea5ness

Headache begins during the aura or "ollo7s aura 7ithinL) mins

T i 0 t Th t Mi i

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Triggers 0uggest That MigraineIs a Disorder o" the brain $CN0&

The case orthe sensiti*emigraine rain

Normal lie

e*ents trigger orare associated.ith attac/s inthosepredisposed

CN0 P central ner#ous s%stemCoppola G et al Cephalalgia J))J:;KJ(;K.( Selman ! Cephalalgia J)) J:.(KK)J =ietrobon D et al

Nat )e Neurosci J)).K:.

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Causes o" Migraine

Increased excitability of CNS

Meningeal blood vessel dilation

Activation of perivascular sensory trigeminal nerves

Pain impulses Vasoactive neuropeptides contain:

substance P

calcitonin gene-related peptide C!"P#

neuro$inin A

combination of increased pain sensitivity% tissue and

vessel s&elling% and inflammation

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K 0tages o" Migraine

'( Prodrome

)( Aura

*( +eadac,e

( Postdrome

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=rodrome -ccurs hours to da%s be"ore

migraine 7ithout headache Aura

Neurological phenomenasuch as disturbance o"#ision 8ust be"ore headache

=ain phase Headache on one side o"

head 7ith nausea+photophobia and other

classic migraine s%mptoms =ostdrome

E>haustion+ irritabilit%+depression

The K phases o" a migraine

=hases o" Migraine

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=hases o" MigraineMigraine are more than 8ust pain

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Prodrome

0tage o" Migraine that is characteriedb% diOcult% concentrating+ %a7ning+"atigue and1or sensiti#it% to light and

noise Duration: A "e7 hours to a "e7 da%s

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Aura

0tage o" migraine that is characteriedb% #isual illusions o" spar5s and lights+o"ten "ollo7ed b% blind or dar5 spots in

the same place as the brighthallucinations

Duration: J)9L) minutes

http:11777health8oc5e%com1J))1;;1J)1brain9di@erences9detected9in9migraine9su

@erers1

http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/

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d h

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Headache

0tage characteried b%e>cruciating or throbbingpain along 7ith sensiti#it%to light and sound

Ma% be accompanied b%nausea and #omiting

0ometimes onl% hal" o" the

head or part o" the head isin pain

Duration: K J hours

P d

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Postdrome

Characteried b%: sensiti#it% to light and

mo#ement

!etharg%

atigue DiOcult% "ocusing

Also called a ombie phase

Duration: A "e7 hours to a

"e7 da%s

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Menstrual Migraine

Da% 9J to .

Migraine 7ithout aura

Estrogen patches poor result

Mini9proph%la>is 7ith N0AIDs and1or sumatriptan

Tric%cle coc pill or reduced pill9"ree inter#al orsupplemental estrogen

0top o#ulation 7ith ceraette or depo pro#era

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2 t T t Mi i

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2a%s to Treat Migraines

A#oiding Trigger actors

0imple Non9Drug Treatment

=ain Medications

=roph%lactic Medications Aborti#e Medications

$acute+ speci3c medications&

Magnesium

A idi T i t

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A#oiding Trigger actors

or reasons un5no7n+ migraines can beset o" b% man% "actors li5e alcohol+per"ume+ deh%dration+ e>cessi#e

e>ercise+ menstruation+ stress+ 7eatherchanges+ seasonal changes+ allergies+lac5 o" sleep+ altitude+ ic5ering lightsand hunger

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Acute Therap% "or Migraine

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Clinical Pracic! Guid!lin! "#r h! Dia$n#%i% and Mana$!m!n #" Mi$rain!& IEHP& N#'!mb!r ()*)

Acute Therap% "or Migraine$=harmacolog%&

&orti*e(symptomatic)

Pre*enti*e(prophylactic)

=ain9"ree response at J hours$IH0+J);)&

Nonspecific Specific

Aborti#e Medications

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Aborti#e Medications

Triptans Current Triptans in use:

Sumatriptan Naratriptan olmitriptan

Riatriptan Almotriptan ro#atriptan Eletriptan

Ergots Current ergots in use

0, Ergotamine Tartrate Ca"ergot Isomethaheptane

WHY THE NEED FOR PROPHYLAXIS ?

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WHY THE NEED FOR PROPHYLAXIS ?

Ab#ri'! dru$% %h#uld n# b! u%!d m#r! han (+, im!% a

-!!k

L#n$+!rm .r#.h/la0i% im.r#'!% 1uali/ #" li"! b/ r!ducin$

"r!1u!nc/ and %!'!ri/ #" aack%

2)3 #" mi$rain!ur% ma/ r!1uir! .r#.h/la0i%

=roph%lactic Medications

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=roph%lactic Medications

or those patients 7ho e>perience se#ere andcomplicated migraines more than J times a month

Three categories

Anticon#ulsants

Topiramate $Topama>& Antidepressants

Verapamil or Nortript%line

Antih%pertensi#es

=ropranolol or Venla"a>ine I" one doesnFt 7or5 then it is gi#en in combination

7ith the others

acute treatment o" migraine

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acute treatment o" migraine

Triptan is the treatment o" choice "or migraine Contraindications include pregnanc%+ age+ cardiac

histor%+ pre#ious ad#erse e@ects o" triptans

A number o" patients 7ill respond to simple analgesicsearl% in the course o" the headache

I" no contraindications to use o" a triptan+ then 7hichmight be the most suitable triptan and 7hich route o"deli#er%4

Is nausea present4 -ral #s subcutaneous #s nasal spra%

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acute treatment o! migraine

ri1atiptan(ma2alt) ;)mg

sumatriptan B)9;)) mg

1olmitriptan(1omig) Bmg intranasal spra%

$recurrence+ triptan9speci3c side e@ects and cardio#ascularsa"et%&

9 0tudies con3rm earl% treatment produces greatereOcac% $0TART stud% J);)+ LJ* J hr pain9"ree #s .B*&

9 In non9responders to sumatriptan+ riatriptan 7as "oundto be e@ecti#e $J hr pain relie" B;*+ pain "reedom JJ*&

$J);)+Cephalalgia&

$ca"ergot or codeine phosphate or tramadol&

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acute treatment o! migraine

=aracetamol rapid ;g W9 N0AID

parama> J tabs W9 N0AID Napro>en sodium BB)mgtra+ co@ee+ co5e

anti9emetics ma>olon+ buccastem+ ondansetron Q

=re#enti#e treatment

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B)* reduction in B)* o" patients

=ropranolol use ;) or K)mg tabs and increase to B9;))mg1da%+ ma>imum J))mg1da%

Epilim use J))mg tabs and increase graduall% to L)) to

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Adances in the preentie treatment o! migraine

Topiramate is currentl% one o" the best studied pre#enti#edrugs

It can be e@ecti#e "or migrainous #ertigo e#en at a small

dose o" B)mg1da% Cannot stop the de#elopment o" chronic dail% ha but

reduces o#erall ha da%s

Its e@ecti#eness ma% be due to augmentation o" the

GAAa receptor+ modulation o" sodium channels+glutamate receptor antagonism+ carbonic anh%draseprotein 5inase inhibition+ possible serotonin acti#it% oralteration o" neuroinammator% "actors

Special areas in treatment o! migraine

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• Menopause i" go in 7ith episodic better than CDH• =regnanc%

/ TcaFs+ beta9bloc5ers / =aracetamol+ diclo"enac JB9B)mg $ not 3rst trimester

and not "or more than or . consecuti#e da%s&+ codeine

• Complementar% and alternati#e treatments / Riboa#in $#itamin J& K)) mg1da% / Magnesium

/ Coen%me X;) / Vitamin D / Iron supplements


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Diet Dair% "ree diet minimum o" . 7ee5s

Gluten "ree diet minimum o" . months

E>ercise #er% important////

Massage and acupuncture

Ice to Head

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!i"est%le Modi3cation "or

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!i"est%le Modi3cation "orMigraine Eat health"ull% and regularl% do not s5ip meals

Get enough sleep+ but do not o#ersleep

Seep a regular sleep schedule

Seep 7ell h%drated

E>ercise regularl%

Rest during a migraine+ and do not o#ere>ert

a"ter7ard

Reduce %our stress

Identi"% %our triggers and a#oid 7hen possible

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