A Practical Optometric Approach To Headaches

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A Practical Optometric Approach To A Practical Optometric Approach To

HeadachesHeadaches

Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCOLeonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO

Mayo Clinic Health System in Albert LeaMayo Clinic Health System in Albert Lea

Assistant Professor of OphthalmologyAssistant Professor of Ophthalmology

Mayo Clinic College of MedicineMayo Clinic College of Medicine

[email protected]@mayo.edu

A PRACTICAL OPTOMETRIC HEADACHE APPROACH


Ubiquitous symptom73% of adults experienced headache in past year10 million outpatient visits per yearOnly 15% actually sought medical help


ESTIMATED PREVALANCE OF MIGRAINE SUFFERERS IN THE UNITED STATES


IMPACT OF MIGRAINESOCIETAL COSTS


IMPACT OF MIGRAINEPERSONAL COSTS

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A PRACTICAL OPTOMETRIC HEADACHE APPROACH A PRACTICAL OPTOMETRIC HEADACHE APPROACH

IMPACT OF MIGRAINEHEALTH SURVEY SCORES FOR MIGRAINE AND OTHER CHRONIC

CONDITIONS


HEADACHE CLASSIFICATION

International Headache Society criteria1. Primary headache disorders

MigraineTension-typeCluster

2. Secondary headache disordersHeadache is symptomatic of an underlying condition such as temporal arteritis, brain tumor, stroke


BASIS OF DIFFERENTIAL HEADACHE DIAGNOSIS

THOROUGH PATIENT INTERVIEW

APPROPRIATE GENERAL EXAMINATION

ADEQUATE NEUROLOGIC EXAMINATION


HEADACHE DIAGNOSISP - Provokes, PalliatesQ - QualityR - RegionS - Severity, Associated signs/symptomsT - Timing

1. Onset2. Frequency3. Duration


Pathophysiology

Vascular

Neural

Unified or neurovascular

Serotonin (5-HT) neurotransmission

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POTENTIAL TRIGGERS OF MIGRAINE:

DRUGSHORMONESSENSORY STIMULICARBON MONOXIDEEMOTIONAL STRESSFOODS AND BEVERAGESENVIRONMENTAL CHANGESCHRONOBIOLOGIC CHALLENGES


MIGRAINE PREVALENCE BY AGE AND SEX


MIGRAINE CLASSIFICATION

Migraine without aura (common migraine)

Migraine with aura (classic migraine)

Complicated migraine1. Ophthalmoplegic migraine2. Basilar migraine3. Migraine equivalents


MIGRAINE WITHOUT AURA (COMMON MIGRAINE)


MIGRAINE WITH AURA (CLASSIC MIGRAINE)


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OPHTHALMOPLEGIC MIGRAINE

ONSET BEFORE AGE 10

3RD, 6TH, OR 4TH NERVEPARESIS

POSITIVE FAMILY HISTORY

PERMANENT WITH REPEATEPISODES


MIGRAINE EQUIVALENTS

ACEPHALGIC MIGRAINEEPISODIC, TRANSIENT DYSFUNCTION OF AN ORGAN OR SYSTEMNO ACCOMPANYING HEADACHE


MIGRAINE TREATMENT

Nonpharmacologic1. Eliminate trigger factors2. Stress management3. Biofeedback4. Acupuncture

Physical TechniquesPhysical Techniques

�� Massage, acupressureMassage, acupressure

�� Acupuncture + OTC painkillers: 44% < HAAcupuncture + OTC painkillers: 44% < HA

�� Trigger point injectionsTrigger point injections

�� Muscle stretching exercisesMuscle stretching exercises

�� Osteopathic manipulationOsteopathic manipulation

�� Chiropractic spinal manipulationChiropractic spinal manipulation

Peripheral Nerve StimulationPeripheral Nerve Stimulation

�� Eon Mini IPGEon Mini IPG

�� Stimulation of occipital nerves for intractable chronic Stimulation of occipital nerves for intractable chronic migraine: changes the pain signalmigraine: changes the pain signal

�� 41% reduction in overall disability41% reduction in overall disability

�� 89% of patients would recommend to others89% of patients would recommend to others

�� 27% reduction in number of headache days27% reduction in number of headache days

�� 68% improved quality of life68% improved quality of life

HomeopathicHomeopathic

�� Feverfew Feverfew –– herb, 50herb, 50--100 mg daily, (100 mg daily, (parthenolideparthenolide))

Can cause oral ulcers, tongue irritation, lip swelling.Can cause oral ulcers, tongue irritation, lip swelling.

�� Riboflavin Riboflavin –– Vitamin BVitamin B22 –– 400 mg daily400 mg daily

Increases energy efficiency of mitochondria.Increases energy efficiency of mitochondria.

�� Vitamin B Complex Vitamin B Complex –– BB66 25 mg, B25 mg, B1212 400 mcg, 400 mcg,

folic acid 2 mg: 50% < HAfolic acid 2 mg: 50% < HA

�� Butterbur Butterbur –– herb, 75 mg BID x 4 months: 50% <HAherb, 75 mg BID x 4 months: 50% <HA

Use the brand Use the brand PetadolexPetadolex..

�� Magnesium 600 mg daily: 50% < HAMagnesium 600 mg daily: 50% < HA

Start with 200 mg daily, slowly increase to 600 mg.Start with 200 mg daily, slowly increase to 600 mg.

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Botulinum Toxin InjectionBotulinum Toxin Injection

�� Peripheral effect Peripheral effect –– muscle relaxantmuscle relaxant

�� Central effect Central effect –– inhibits release of trigeminal inhibits release of trigeminal

cellcell--mediated neurotransmittersmediated neurotransmitters


MIGRAINE TREATMENT

Symptomatic (Abortive)

1. Over-the-counter medicationa. Aspirinb. Acetaminophenc. Non-steroidal anti-inflammatory drugs

Motrin Migraine PainAdvil Migraine

d. Combination drugs: Excedrin Migraine


MIGRAINE TREATMENT

Symptomatic (Abortive)2. Prescription medication

a. Combination drugs with narcoticb. Ergotamine tartratec. Dihydroergotamine: Migranald. Narcotics: Stadol NSe. Midrin

Selective Serotonin Receptor AgonistsSelective Serotonin Receptor Agonists

�� ImitrexImitrex ((sumatriptansumatriptan))

�� ZomigZomig ((zolmitriptanzolmitriptan))

�� AmergeAmerge ((naratriptannaratriptan))

�� MaxaltMaxalt ((rizatriptanrizatriptan))

�� AxertAxert ((almotriptanalmotriptan))

�� FrovaFrova ((frovatriptanfrovatriptan))

�� RelpaxRelpax ((eletriptaneletriptan))

�� TreximetTreximet ((sumatriptansumatriptan/naproxen)/naproxen)

Selective Serotonin Receptor AgonistsSelective Serotonin Receptor Agonists

�� Efficacy: if first triptan does not work, try Efficacy: if first triptan does not work, try

another another –– may require trial and errormay require trial and error

�� Onset: injection Onset: injection –– 1010--15 minutes15 minutes

nasal spray nasal spray –– 15 minutes15 minutes

troche troche –– no faster than oral tabletsno faster than oral tablets

�� Route: nasal spray or injection for N/VRoute: nasal spray or injection for N/V

�� Duration: longest acting Duration: longest acting –– Frova and AmergeFrova and Amerge


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MIGRAINE TREATMENT

Prophylactic (Preventive)a. Beta blockersb. Tricyclic antidepressantsc. Nonsteroidal anti-inflammatory drugsd. Calcium channel blockerse. Monoamine oxidase inhibitors: Nardilf. Anticonvulsants: Depakote, Depakene, Topamax

Topamax 50% < HA by 6 weeks


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A Practical Optometric Approach To Headaches