What is a Migraine

1
What is a Migraine?

• J. Ned Pruitt II, MD
• Associate Professor
• Department of Neurology
• Medical College of Georgia

2
Case Study 1
Patient Description
41 year old female school teacher
Chief Complaint
Recurrent sinus headaches that last 2 days
Character of Pain
Patient described pain as pressure sensation
involving the maxillary sinus region
no
radiation of pain. Pain was moderate to severe
ranging from 6-8 on a 1-10 scale.
Headaches would begin and end gradually.
Frequency
1-2 times per month
Symptoms
Patient complained about nasal congestion and
runny nose. Patient denied any
visual disturbances, fever, or joint pain. Upon
probing, patient stated that she often
feels sick to her stomach during her headaches
and her headaches intensify when
she bends over.
Headache Triggers
Barometric pressure changes, cold, sleep
disturbance
Medical History
Headaches began in late teens without known
precipitant and have
recurred monthly
since onset.
Family History
Mother is also a long-standing sinus headache
sufferer
Physical Exam
Normal
Normal sinus CT scan
Test Results
Past Treatments
Sinus surgery with no change in her headaches.
Also multiple courses of
antibiotics. Decongestants seem to relieve pain
slightly.
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Case Study 2
Patient Description
43 year old local news producer
Chief Complaint
Tension Headaches that start about 10-11 am in
the morning and last until he goes to
bed at night
Character of Pain
Moderate pain that begins with stiffness in the
back of the neck and travels to right
temporal area.
Frequency
4-6 times a month
Symptoms
Neck tightness, malaise. Patient reports he
feels better when he can leave the lights
and noise of the newsroom.
Headache Triggers
Stress, missed meals
Medical History
Gastric Ulcer
Family History
Mom had similar headaches from stress
Physical Exam
Normal
Past Treatments
Unsatisfied with previous treatments
4
Case Study Questions

• What is the headache diagnosis?
• Can a patients self assessment of their headache
  influence diagnosis?
• How much does the location of the pain influence
  your diagnosis?
• How do you explain the location of pain?

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Diagnostic ChallengesSinus Headache, Tension
Headache or Migraine?
6
Migraine Prevalence(American Migraine Study II)

• There are currently 28 million migraine sufferers
  age 12 in the United States
• 21 million females
• 7 million males
• Migraine prevalence peaks in the 25-55 age range
• One in 4 households has at least 1 migraine
  sufferer

Lipton et al. Headache. 200141638-657.
7
International Headache Society Criteria for
Migraine
Migraine is an Episodic Headache lasting 4-72 hrs
with

• Any 2 of the pain qualities
• unilateral pain
• throbbing pain
• pain worsened by movement
• moderate pain
• severe pain

• Any 1 of the associated symptoms
• nausea
• vomiting
• photophobia and phonophobia

IMPORTANTLY, IHS criteria do not exclude
symptoms like sinus pain and pressure,
congestion, rhinnorhea, and watery eyes to make a
diagnosis of migraine.
Headache Classification Committee of the IHS.
Cephalalgia 1998, 8 (suppl 7).
8
Migraine is More Common than Asthma Diabetes
Combined
Disease Prevalence in the US Population
Data from the Centers for Disease Control and
Prevention, US Census Bureau, and the Arthritis
Foundation.
9
The Prevalence and Diagnosis of Migraine in a
Primary Care Setting The Landmark Study

• Background
• To determine the prevalence and diagnosis of
  migraine in patients presenting to primary care
  physicians (PCPs) with a complaint of headache
• Study Design
• Prospective, multi-center, international study
• PCPs from 128 centers in 14 countries recruited
  1203 patients
• Recruited patients consulting PCP with complaint
  of headache
• PCP diagnosed patients via customary practice
• Expert panel made final headache diagnoses for
  patients with a new migraine diagnosis or a
  non-migraine diagnosis (n377)

Newman et al. Poster presented at The Diamond
Headache Clinical Research and Educational
Foundation Meeting July 16-20, 2002 Lake Buena
Vista, Fl.
10
Patients Presenting with Headache Most Likely
Have Migraine

• Of 377 patients who returned diaries

3
Episodic Tension Headache
3
Other
Migrainous
18
Migraine
76
Newman et al. Poster presented at The Diamond
Headache Clinical Research and Educational
Foundation Meeting July 16-20, 2002 Lake Buena
Vista, Fl.
11
The Diagnosis of Migraine Has Increased Modestly
(Using IHS Criteria)
Diagnosed Migraine Undiagnosed Migraine
48
38
52
62
1999
1989
14.6 million migraine sufferers remain undiagnosed
Lipton et al. Headache. 200141638-645.
12
Why Do More Than 14 Million Migraine Patients
Remain Undiagnosed?
13
Undiagnosed Patients Often ReportReceiving a
Diagnosis of Sinus Headache
Diagnosed with Sinus Headache
Other/No diagnosis
Adapted from Lipton et al. Headache.
200141638-645.
14
Undiagnosed Migraine Sufferers Often Report
Receiving a Diagnosis of Tension Headache
Diagnosed with Tension Headache
Other/No diagnosis
Adapted from Lipton et al. Headache.
200141638-645.
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Is it Really Sinus Headache? Take a Closer Look

• Factors Confounding Diagnosis

• Weather Triggers
• Presence of Nasal and Ocular Symptoms
• Presence of Pain or Pressure in or around the
  Sinuses

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IHS Criteria for Sinus Headache

• According to IHS criteria, a diagnosis of acute
  sinus headache (11.5.1)
• Is considered a secondary diagnosis resulting
  from acute sinusitis
• Requires the presence of
• purulent nasal discharge
• pathologic sinus findings in tests including
  X-ray, CT or MRI
• Chronic sinusitis is not validated as a cause of
  headache or facial pain unless relapsing into an
  acute stage.

Headache Classification Committee of the
International Headache Society. Classification
and Diagnostic Criteria for Headache
Disorders, Cranial Neuralgias and Facial Pain.
Cephalalgia 19888(suppl 7)63-64.
17
Headache A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS

• Major factors
• Purulence in nasal cavity on exam
• Facial pain/pressure/congestion
• Nasal obstruction/blockage/ discharge
• Fever (in acute only)
• Hyposmia/anosmia

• Minor factors
• Headache
• Fever (chronic)
• Halitosis
• Fatigue
• Dental pain
• Cough
• Ear pain/pressure/fullness

Facial pain/pressure alone does not constitute
a suggestive history for rhinosinusitis in the
absence of another major nasal symptom or sign.
American Academy of Otolaryngology-Head and
Neck Surgery Lanza et al. Otolaryngol Head
Neck Surg 1997.117(pt 2) S1-S7.
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Migraine Can Be Triggered by Weather
(n 69)
of Migraine Patients with Triggers
Scharff et al., Headache 1995 35397-403
19
Presence of Autonomic Symptoms in Migraine
Attacks

• Study Objective
• To assess the percentage of migraineurs with
  autonomic symptoms and their clinical
  characteristics
• Study Design
• Patient interview (n177) of those seen
  consecutively at headache clinic
• Inclusion criteria Diagnosis of migraine with
  or without aura

Lacrimation, eye redness, eyelid edema, nasal
congestion, rhinorrhea.
Barbanti et al. Cephalalgia. 200222256-259.
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Nasal and Ocular Symptoms Can Accompany Migraine
Attacks
46 of patients had at least 1 autonomic symptom
during migraine attacks

• Of these . . .
• 46 had both nasal ocular symptoms
• 14 had only nasal symptoms
• 41 had only ocular symptoms

Barbanti et al. Cephalalgia. 200222256-259.
21
Is Physician-Diagnosed or Patient-Described
Sinus Headache Actually Migraine?

• Study Objective
• To determine the proportion of patients with
  either self-described or physician-diagnosed
  sinus headaches that meet IHS criteria for
  migraine
• Study Design
• Prospective, multi-center, open-label,
  observational, multi-attack, North American Study
  of sumatriptan 50mg
• Population (N2,524)
• Only diagnosis results presented here

Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA.
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Inclusion / Exclusion Criteria

• Inclusion Criteria
• 1865 years old
• at least 6 self described or physician diagnosed
  sinus headaches in the 6 mo prior to screen

• Exclusion Criteria
• Prior diagnosis of migraine
• Evidence of sinus infection
• Fever
• Purulent discharge
• Radiographic evidence of sinus infection

Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA.
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Study Design/Methods

• Subjects described symptoms of their typical
  sinus headache
• Physicians used IHS criteria to diagnose headache
  
• Subjects completed HIT-6TM to evaluate
  headache-related disability
• Subjects identified current therapy and rated
  their satisfaction with the treatment

HIT-6 is a trademark of Quality Metrics Inc.
Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA.
24
Most Sinus Headache Patients Met IHS Criteria
for Migraine
82
8
Migrainous IHS 1.7
n2,524
7
Tension-Type IHS 2.1
4
Other Type Headache
Only 4 patients were excluded for active sinus
infections.
0
100
33
67
Percentage of Subjects
Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA.
25
Sinus Features May Hide the Presence of Migraine
Headache Symptoms at Screen Among IHS Diagnosed
Migraineurs
96
87
84
84
82
70
65
n2257
57
42
38
IHS Migraine Symptom Criteria Sinus Like Features
28
27
23
of Subjects
Schreiber et al. Poster Presented at American
Headache Society Meeting June 21-23, 2002
Seattle, WA. Data on file, GlaxoSmithKline.
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Is it Really Tension Headache? Take a Closer Look

• Factors Potentially Confounding Diagnosis
• Triggers
• Location and Quality of Head Pain
• Presence of Neck Pain

Migraine Physician Segmentation Study, July 2001,
Data on File
27
Migraine Pain Can Be Bilateral and Non-Pulsating

• 41 of migraine patients had bilateral pain.1
• 50 of the time, pain was non-pulsating2

1. Lipton et al. Headache. 200141646-657. 2.
Pryse-Phillips et al. Can Med Assoc J.
1997156(9)1273-1287.
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Neck Pain Can Occur with Migraine

• Study Objective
• To document the clinical features of neck pain as
  a component of migraine
• Study Design
• Retrospective chart analysis (n378)
• Patients who met inclusion criteria and agreed to
  be interviewed (n144)
• Inclusion criteria
• Diagnosis of IHS migraine 1.1 or 1.2
• Age 18 - 75 years old
• 1 - 8 migraines per month
• Absence of
• significant trauma history
• second IHS diagnosis
• interval neck pain

Kaniecki et al. Poster presented at 10th IHC
June 29-July 2, 2001 New York, NY.
29
Migraine Pain Can Be Felt in Peripheral Locations
Such as the Neck

• In Kanieckis study of 144 patients with migraine

• 75 reported neck pain with their migraine
• 43 described neck pain as bilateral and 57 as
  unilateral
• 69 described the neck pain as tightness and
  17 as stiffness

75 reported neck pain with their migraine
Kaniecki et al. Poster presented at 10th IHC
June 29-July 2, 2001 New York, NY.
30
Neck Pain Can Occur in all Phases of Migraine
100
92
75
61
Percentage of Patients with Neck Pain
50
41
25
0
Prodrome
Headache
Postdrome
Phases of Migraine
n108
Kaniecki et al. Poster presented at 10th IHC
June 29-July 2, 2001 New York, NY.
31
In the Presence of Neck Pain Tension Headache is
Frequently Diagnosed
100
82
80
60
of Patients
40
18
20
0
No
Yes
n108
Previous Diagnosis of Tension Headache
Kaniecki et al. Poster presented at 10th IHC
June 29-July 2, 2001 New York, NY.
32
Confused?
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Spectrum of Migraine
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New Insights into the Pathophysiology of
Migraine
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The Migraine Process Activation of the
Trigeminal Nucleus Caudalis (TNC)
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Activation of the TNC May Result in Referred Pain
that Could be Perceived Anywhere along the
Trigeminocervical Network
37
In a Sinus-Like Presentation of Migraine Pain
Can Be Perceived in the Maxillary and Ophthalmic
Regions of Trigeminocervical Network
In the sinus-like presentation of migraine, pain
and pressure can be felt in or near eyes and
sinuses.
38
Activation of the TNC May Result in Reflex
Activation of Cranial Parasympathetic Nerves
Extending into Sinus Cavities and Tear Ducts
39
Cranial Parasympathetic Activation May
ExplainSinus-Like Symptoms in Migraine
40
Referred Pain Could Explain the Presence of
Bilateral Head Pain During a Migraine Attack
Migraine pain can be bilateral
41
Migraine Pain Can Be Perceived in the Posterior
Head and Neck Regions
Migraine pain can be felt in the posterior head
and neck.
42
Key Points of this Hypothesis of Migraine
Pathophysiology

• Migraine is neurovascular disorder involving
  activation of the trigeminal nucleus caudalis
  (TNC).
• Activation of the TNC can result in referred pain
  anywhere along the trigeminocervical network
  including the sinus areas and neck.
• Activation of the TNC can cause reflex activation
  of the cranial parasympathetic nerves leading to
  sinus-like symptoms and bilateral headache.

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