The Mystery of Migraines

Andrew Massey, M.D. UKSM-W

May 14, 2013

Classification of Headaches (circa 1977)

1. Vascular headachea. Classic migraineb. Common migraine

2. Muscle tension headache3. Traction and inflammatory headache

Classification of HeadachesInternational Headache Society 1988

• 14 major categories• 195 separate, individually defined headaches • 19 migraine types

Classification of HeadacheInternational Headache Society 2005

• Part I: The Primary Headaches

• 1. Migraine • 2. Tension-type headache • 3. Cluster headache and other trigeminal autonomic cephalalgias • 4. Other primary headaches

• Part II: The Secondary Headaches

• 5. Headache attributed to head and/or neck trauma • 6. Headache attributed to cranial or cervical vascular disorder • 7. Headache attributed to non-vascular intracranial disorder • 8. Headache attributed to a substance or its withdrawal • 9. Headache attributed to infection • 10. Headache attributed to disorder of homoeostasis • 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or • other facial or cranial structures • 12. Headache attributed to psychiatric disorder

• Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches

• 13. Cranial neuralgias and central causes of facial pain • 14. Other headache, cranial neuralgia, central or primary facial pain

Migraine: Subtypes

1.1 Migraine without aura1.2 Migraine with aura

1.2.1 Typical aura with migraine headache1.2.2 Typical aura with nonmigraine headache1.2.3 Typical aura without headache1.2.4 Familial hemiplegic migraine1.2.5 Sporadic hemiplegic migraine1.2.6 Basilar-type migraine

1.3 Childhood periodic syndromes 1.3.1 cyclic vomiting 1.3.2 abdominal migraine 1.3.3 benign paroxysmal vertigo of childhood

Migraine: Subtypes (continued)

1.4 Retinal migraine1.5 Complications of migraine

1.5.1 Chronic migraine 1.5.2 Status migrainosus 1.5.3 Persistent aura without stroke 1.5.4 Migrainous stroke 1.5.5 Migraine-triggered seizure1.6 Probable migraine

1.6.1 Probable migraine without aura 1.6.2 Probable migraine with aura 1.6.3 Probable chronic migraine

8. HA attributed to a substance or its withdrawal 8.1 HA induced by acute substance exposure 8.1.4 Alcohol induced headache

8.1.4.1 Immediately induced 8.1.4.2 Delayed induced headache

Migraine

• 90% of all headache due to one of 3 disorders:– Tension-type headache– Migraine headache– Cluster headache

• 15% of people in U.S. experience migraine– 17% of women, 6% of men

Migraine: Symptoms

• Pain– Dull, deep, steady when mild to moderate– Throbbing or pulsatile when severe– Worsened by light, noise, motion, sneezing,

straining– 70% with pain only on one side of the head

• Other symptoms– Nausea, vomiting, photophobia, phonophobia– 20% with auras

Migraine: Symptoms

• Migraine Aura– Preceeds or accompanies the headache– May be sensory, visual, motor, or speech– Last 5 to 20 minutes (uncommonly 60 minutes)

• Headache may last a few hours to several days– Usually resolve in sleep

• Postdrome phase– Patient feels “drained” or exhausted

Migraine: Triggers

• Emotional stress, worry• Medications & chemicals– Nitroglycerin, hydralazine, estrogens– Strong perfumes, smoke, organic solvents

• Certain foods or additives– Nitrites, monosodium glutamate, aspartate, alcohol

• Other triggers– Fasting, sleep deprivation, physical exertion, weather,

lights, caffeine withdrawal, menstruation

Migraine: Diagnostic Criteria

A. At least 5 attacks fulfilling B-DB. HA lasting 4-72 hoursC. HA has at least two of the following

1. Unilateral location2. Pulsating quality3. Moderate or severe intensity4. Aggravation by walking stairs or similar routine

physical activityD. Headache not explained by another disorder

Diagnosis of headache 1. Take a careful history 2. Do a careful examination

History: 30 y.o. British soldier with two year history of

headache and trouble fitting his helmet

Exam:

See next slide

Migraine: Treatment

1. Recognize & avoid triggers2. Preventive treatment to reduce frequency &

intensity of headaches3. Acute treatment of migraine

Preventive Treatment 1/4

• Medications for control of hypertension– Beta blockers: • propranolol, metoprolol, timolol, nadolol, atenolol

– Calcium channel blockers: • verapamil, nifedipine, nimodipine

– ACE inhibitors or ARBs: • lisinopril, candesartan

Preventive Treatment 2/4

• Antidepressants– Tricyclics: • amitriptyline, nortriptyline, protriptyline, doxepin

– Serotonin/norepinephrine reuptake inhibitors: • venlafaxine

Preventive Treatment 3/4• Anti-Epileptic medications:– Valproate, – topiramate, – gabapentin

• Other agents:– Botulinum toxin– Coenzyme Q10– Nonsteroidal antiinflammatory drugs:

• Naproxen, indomethacin– Narcotics – Riboflavin (vitamin B2)

Preventive Treatment 4/4

• Nonpharmacologic therapy– Relaxation training– Behavioral therapy– Hypnosis– Occipital nerve electrical stimulation– Acupuncture– Surgery (eg., removal of glabellar muscle)– Closure of patent foramen ovale (PFO)– Exercise

Acute Treatment of Migraine

• Mild analgesics– Nonsteroidals: ibuprofen, diclofenac, naproxen– Acetaminophen– Aspirin

• Triptans– Sumatriptan, zolmitriptan, naratriptan, rizatriptan,

almotriptan, eletriptan, frovatriptan• Ergots– Ergotamine, dihydroergotamine (DHE)

Acute Treatment of Migraine

• Anti-nausea medications– Metoclopramide, chlorpromazine,

prochlorperazine• Others– Benzodiazepines, narcotics, barbiturates– Steroids (eg., dexamethasone)

• Investigational drugs– CGRP receptor antagonists– lasmiditan

Acute Treatment of Migraine

• General principles for preventive medications1. Take early in the attack2. Non-oral med if prominent nausea &vomiting3. Consider anti-nausea medication 4. Consider caffeinated beverage5. Guard against medication overuse headache

a. Expecially with barbiturates or narcoticsb. Increase risk with >2-3 acute treatments per week