HEADACHE

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HEADACHE
Andrew Charles Professor UCLA Department of
Neurology
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ADVANCES IN HEADACHE

• IMAGING
• PET
• fMRI
• GENETICS
• Familial Hemiplegic Migraine
• Migraine associated genes
• DIAGNOSTICS
• Newer diagnostic criteria
• Common diagnostic errors
• Migraine and stroke
• THERAPEUTICS
• Triptan tips
• Newer prophylactic drugs

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Is Migraine Pain Caused by Vasodilation?
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RECENT IMAGING STUDIES IN MIGRAINE

• PET - Woods et al., 1994
• Bilateral spreading hypoperfusion
• MRI-BOLD Cao et al., 1999
• Spreading vasodilation/ increased tissue
  oxygenation
• MRI PERFUSION WEIGHTED IMAGING Sanchez el Rio
  et al., 2000
• Decreased CBF in occipital cortex
• Occurred only contralateral to aura symptoms and
  only in patients with aura

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PET STUDY DEMONSTRATES SPREADING OLIGEMIA IN
MIGRAINE
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Mechanisms of migraine aura revealed by
functional MRI in human visual cortex Nouchine
Hadjikhani , Margarita Sanchez del Rio ,
Ona Wu, Denis Schwartz, Dick Bakker, Bruce
Fischl,Kenneth K. Kwong, F. Michael Cutrer ,
Bruce R. Rosen, Roger B. H. Tootell, A. Gregory
Sorensen,and Michael A. Moskowitz Nuclear
Magnetic Resonance Center and Stroke and
Neurovascular Laboratory, Massachusetts General
Hospital, Harvard Medical School, Charlestown, MA
02129
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MIGRAINE A MULTISYMPTOM COMPLEX
TRIGGER MECHANISM
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Is Migraine Pain Caused by Vasodilation?
MAYBE NOT
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Is Migraine Uncommon?
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Migraine Prevalence and Impact

• 20 of outpatient visits to neurologists
• PREVALENCE
• 18-25 women
• 6-10 men
• 112 million bedridden days per year
• Cost to U.S. Employers -- 13 Billion per year

Lipton RB, Stewart WF. Neurology. 199343(suppl
3)S6-S10. Stewart WF, et al. JAMA.
199226764-69. Hu XH, et al. Arch Intern Med.
1999159813-818.
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Diagnosed Migraine TIP OF THE ICEBERG

• Diagnosed
• Undiagnosed

29 41 71 59 Males Females
Lipton et al. Arch Intern Med 19921521273-1278
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Is Migraine Uncommon?
NO!
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Does a headache have to be severe to be a
migraine?
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MIGRAINE PAIN SEVERITY

• Varies widely in a given individual
• Varies widely from individual to individual
• May be absent altogether
• Often milder in patients with pronounced
  dizziness or sustained aura

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IHS CRITERIA FOR MIGRAINE WITHOUT AURA

• At least 5 attacks fulfulling the following
• Headaches lasting 4 to 72 hours
• During headache, at least one of the following
• Nausea and/or vomiting
• Photophobia and phonophobia
• At least 2 of the following criteria
• Unilateral location
• Pulsating quality
• Moderate or severe intensity
• Aggravated by physical activity

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Simplified Diagnostic CriteriaID Migraine

• Light sensitivity with headache
• Nausea with headache
• Decreased ability to function with headache
• Any 2 out of 3 Migraine

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Migraine Other Features

• Perimenstrual timing
• Stereotypical prodromal symptoms
• Characteristic triggers
• Abatement with sleep
• Childhood precursors (motion sickness,
  somnambulism, episodic vomiting, episodic
  vertigo)
• Osmophobia
• Diarrhea during attack

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KEY FEATURES IN DIAGNOSIS OF CLUSTER HEADACHE

• PREDOMINANTLY IN MEN
• OFTEN PRESENTS AS EYE PAIN
• CLUSTERS OF EPISODES WITH LONG PERIODS OF
  REMISSION
• UNILATERAL TEARING/NASAL DISCHARGE (AUTONOMIC
  PHENOMENA)
• TYPICALLY HAS A CIRCADIAN PATTERN OFTEN AT SAME
  TIME EACH NIGHT

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KEY FEATURES IN THE DIAGNOSIS OF TENSION HEADACHE

• OFTEN OCCURS DAILY
• MAY BE CONTINUOUS - NOT IN DISCRETE EPISODES
• NOT DISABLING IN SEVERITY
• TYPICALLY WORSENS AS DAY PROCEEDS
• USUALLY BILATERAL, CONSTANT
• DOESNT RESPOND TO TRIPTANS

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MIGRAINES ARE OFTEN MISDIAGNOSED

• SINUS HEADACHES
• SIMILAR DISTRIBUTION OF PAIN
• MIGRAINES CAN BE SEASONAL
• DECONGESTANTS CAN TAKE THE EDGE OFF OF MIGRAINE
  
• WITHDRAWAL FROM DECONGESTANTS CAN PRECIPITATE
  MIGRAINES

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SINUS HEADACHE
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OTHER COMMON MIGRAINE MISDIAGNOSES

• TMJ
• MIGRAINES MAY CAUSE PAIN IN JAW
• TENSION HEADACHE/CERVICOGENIC HEADACHE
• MIGRAINE COMMONLY ASSOCIATED WITH NECK PAIN
• NECK PAIN MAY OCCUR BEFORE, DURING, OR AFTER
  HEADACHE

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Does a headache have to be severe to be a
migraine?
NO
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Do most migraine patients need an imaging study
of the brain?
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Ill want to get a few tests on you, just to
cover my ass
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Reasons to Consider Neuroimaging in Headache
Patients

• Abnormal unexplained neurological exam
• Onset of headache over age of 55
• Associated fever
• Headache with extremely abrupt onset
• Headache refractory to aggressive treatment
• First or worst headache ever experienced
• Increasing frequency and/or severity of headaches
  
• Change in headache clinical features

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Do most migraine patients need an imaging study
of the brain?
NO
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Should migraine patients stop caffeine?
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COMMON HEADACHE TRIGGERS

• IRREGULAR MEALS
• IRREGULAR CAFFEINE, CHOCOLATE, NUTS, BANANAS,
  ETC.
• IRREGULAR SLEEP (PARTICULARLY EXCESSIVE SLEEP)
• STRESS OR LET-DOWN FROM STRESS
• ANY COMBINATION OF ABOVE

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CONCEPTS FOR PATIENTS

• MIGRAINE IS A GENETIC DISORDER WITH DISTINCT
  PATHOPHYSIOLOGY AND IS NOT DUE TO WEAKNESS OR
  STRESS
• MIGRAINE PATIENTS ARE HYPERSENSITIVE TO
  ENVIRONMENTAL FLUCTUATIONS THAT MAY LEAD TO
  CHANGES IN NEUROTRANSMITTER LEVELS
• THE HEADACHE LIFESTYLE SHOULD BE GEARED TOWARD
  MINIMIZING FLUCTUATIONS

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Should migraine patients stop caffeine?
Not Necessarily
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KEYS TO EFFECTIVE ABORTIVE THERAPY

• INITIATE THERAPY AS EARLY AS POSSIBLE
• USE ADEQUATE DOSES
• COMBINATION THERAPY MAY BE MORE EFFECTIVE THAN
  SINGLE MEDICATION THERAPY
• USE ADEQUATE SYMPTOMATIC THERAPY FOR PAIN, NAUSEA

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ABORTIVE THERAPIES

• TRIPTANS Selective 5HT 1b 1d agonists
• SUMATRIPTAN (IMITREX TABLETS, NASAL SPRAY,
  INJECTION)
• RIZATRIPTAN (MAXALT MELTABS, TABLETS)
• NARATRIPTAN (AMERGE TABLETS)
• ZOLMITRIPTAN (ZOMIG)
• ALMOTRIPTAN (AXERT)
• FROVATRIPTAN (FROVA)
• DHE NASAL SPRAY (MIGRANAL)
• NSAIDS
• METACLOPRAMIDE

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HOW HAVE TRIPTANS CHANGED OUR APPROACH TO
MIGRAINE?

• DIAGNOSIS RESPONSE TO TRIPTANS CAN BE USED TO
  DISTINGUISH MIGRAINE COMPONENT
• THERAPY
• THE CLEAR CHOICE FOR FIRST-LINE THERAPY
• CAN START WITH ABORTIVE THERAPY, EVEN IN
  PATIENTS WITH FREQUENT ATTACKS

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OBSERVATIONS WITH NEW MIGRAINE THERAPIES

• PATIENTS MAY HAVE PREFERENTIAL RESPONSE TO
  SPECIFIC MEDS
• PATIENTS MAY HAVE DOSE-DEPENDENT RESPONSE
• THERE IS SIGNIFICANT ATTACK-TO-ATTACK
  VARIABILITY IN RESPONSE TO THERAPY - CANT JUDGE
  RESPONSE TO AGENT ON BASIS OF SINGLE EPISODE
• TRANSIENT NEUROLOGICAL SYMPTOMS ARE COMMON WITH
  MIGRAINE AND DO NOT REPRESENT A CONTRA-INDICATION
  TO THERAPY WITH TRIPTANS

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CONTRAINDICATIONS FOR TRIPTAN THERAPY

• BASILAR OR HEMIPLEGIC MIGRAINE
• Triptans have been used successfully in patients
  in whom neurological deficits have largely
  resolved (Klapper et al., 2000)
• OTHER COMPLICATED MIGRAINE
• Transient neurological symptoms are common with
  migraine and often do not represent a
  contra-indication to triptan use
• RISK FACTORS FOR CORONARY ARTERY DISEASE
• Most headache practitioners do not consider
  isolated vascular risk factors a contraindication
  to triptan use
• ESTABLISHED CORONARY ARTERY DISEASE

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BOTOX FOR HEADACHE?
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I realize that those lines are annoying, but I
cant recommend Botox injections for your scrotum
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TRADITIONAL THERAPEUTIC OPTIONS FOR MIGRAINE
PROPHYLAXIS

• BETA BLOCKERS
• TRICYCLICS
• CALCIUM CHANNEL BLOCKERS
• SEROTONIN UPTAKE INHIBITORS
• MAO INHIBITORS
• NONSTEROIDAL ANTI-INFLAMMATORIES
• METHYLSERGIDE

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NEW THERAPEUTIC OPTIONS FOR MIGRAINE PROPHYLAXIS

• RIBOFLAVIN (Vitamin B2)??
• BOTULINUM TOXIN??
• NEURONTIN??
• HIGH-DOSE Ca2, Mg2??
• VALPROIC ACID, DIVALPROEX SODIUM (DEPAKOTE)
• TOPIRAMATE (TOPAMAX)
• ZONISAMIDE (ZONEGRAN)
• LEVATIRACETAM (KEPPRA)

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CLUSTER HEADACHE THERAPY

• SHORT COURSE OF STEROIDS MAY ABORT CLUSTER
  EPISODE IF TAKEN EARLY IN CLUSTER
• VERAPAMIL IS DRUG OF CHOICE FOR CLUSTER HEADACHE
  PREVENTION START AT 180 mg. qd, increase prn
• TRIPTANS WORK FROVATRIPTAN MAY BE USED AS
  PREVENTIVE THERAPY

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CASES FROM THE FILES

• 38 year old female, general surgeon
• Menstrual headaches for 20 years
• Typically occur 2-3 days prior to menstrual
  period
• Uses non-steroidal anti-inflammatories with
  limited success
• Thinks neurologists are ineffectual dorks

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APPROACH

• DIAGNOSIS MIGRAINE with perimenstrual
  exacerbation
• TREATMENT
• Supplemental calcium/magnesium
• Triptan at earliest onset of her headaches
• OUTCOME
• Changes her opinion about neurologists

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CASES FROM THE FILES

• 42 year old businessman
• Initially had intermittent headaches
• For last 5 years has had headache 24 hours a
  day
• Constant moderate headache, with intermittent
  severe headache
• Takes 8-10 fiornal with codeine per day
• Tried imitrex twice helped once

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APPROACH

• DIAGNOSIS Transformed migraine or chronic daily
  migraine
• TREATMENT
• Start topiramate 25 mg. Qhs, increase as needed
  to 50 mg. Qhs.
• Taper fioricet on time-dependent basis
• Triptans for intermittent severe headache
• Avoid analgesics
• OUTCOME
• Off fioricet, headaches now respond reliably to
  triptans

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TAKE HOME MESSAGES

• MIGRAINE IS COMMON AND UNDERDIAGNOSED
• SINUS HEADACHE IS UNCOMMON AND OVERDIAGNOSED
• MENSTRUAL HEADACHES ARE MIGRAINES
• THE CENTRAL FEATURE OF THE HEADACHE LIFESTYLE IS
  CONSISTENCY
• TRIPTANS ARE WELL TOLERATED AND EFFECTIVE
• SOME NEWER PROPHYLACTIC DRUGS ARE WORKING WELL
• MOST HEADACHES PATIENTS CAN BE EFFECTIVELY AND
  SAFELY TREATED

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