Migraine 2

8/14/2019 Migraine 2

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Common misdiagnosesCommon misdiagnoses

for migraine:for migraine:

– – Sinus HA Sinus HA

– – Stress HA Stress HA

Referral to ENT for sinusReferral to ENT for sinus

disease and facial pain.disease and facial pain.



Migraineurs more likely to haveMigraineurs more likely to have

motion sickness.motion sickness.

Half of Meniere’s patients claim toHalf of Meniere’s patients claim to

have migrainous symptoms.have migrainous symptoms.

BPPVBPPV



$13 billion/year in lost$13 billion/year in lost

productivityproductivity

1/3 participants in1/3 participants in American Migraine Study American Migraine Study

II missed work in prior 3II missed work in prior 3

monthsmonths



Migraine DefinitionMigraine Definition

IHS criteria: Migraine/aura (3 out of 4)IHS criteria: Migraine/aura (3 out of 4)

– – One or more fully reversible auraOne or more fully reversible aurasymptoms indicates focal cerebralsymptoms indicates focal cerebral

cortical or brainstem dysfunction.cortical or brainstem dysfunction. – – At least one aura symptom At least one aura symptom

develops gradually over moredevelops gradually over morethan 4 minutes.than 4 minutes.

– – No aura symptom lasts more thanNo aura symptom lasts more thanone hour.one hour.

– – HA follows aura w/free interval of HA follows aura w/free interval of less than one hour and may beginless than one hour and may beginbefore or w/aura.

IHS Diagnostic criteria: migraine w/oIHS Diagnostic criteria: migraine w/oauraaura

– – HA lasting for 4HA lasting for 4--72 hrs72 hrs

– – HA w/2+ of following:HA w/2+ of following: UnilateralUnilateral

PulsatingPulsating

Mod/severe intensity.Mod/severe intensity.

Aggravated by routine Aggravated by routine

physical activity.physical activity. – – During HA at least 1 of followingDuring HA at least 1 of following

N/VN/V

PhotophobiaPhotophobia

Phonophobia

before or w/aura.

Phonophobia

History, PE, Neuro exam show no other organic disease.History, PE, Neuro exam show no other organic disease.

At least five attacks occur At least five attacks occur



Migraine SubtypesMigraine Subtypes

Basilar type migraineBasilar type migraine – – Dysarthria, vertigo,Dysarthria, vertigo,

diplopia, tinnitus,diplopia, tinnitus,decreased hearing, ataxia,decreased hearing, ataxia,bilateral paresthesias,bilateral paresthesias,altered consciousness.altered consciousness.

– – Simultaneous bilateralSimultaneous bilateral

visual symptoms.visual symptoms. – – No muscular weakness.No muscular weakness.

Retinal or ocular migraineRetinal or ocular migraine – – Repeated monocularRepeated monocular

scotomata or blindness < 1scotomata or blindness < 1hrhr

– – Associated with or followed Associated with or followedby a HA by a HA



Migraine SubtypesMigraine Subtypes

Menstrual migraineMenstrual migraine

Hemiplegic migraineHemiplegic migraine – – Unilateral motor andUnilateral motor and

sensory symptomssensory symptoms

that may persist afterthat may persist afterthe headache.the headache.

– – Complete recoverComplete recover

Familial hemiplegicFamilial hemiplegicmigrainemigraine



Migrainous vertigoMigrainous vertigo

Vertigo Vertigo – – sole or prevailing symptom.sole or prevailing symptom.

Benign paroxysmal vertigo of childhood.Benign paroxysmal vertigo of childhood.

Prevalence 7Prevalence 7--9% of pts in referral dizzy9% of pts in referral dizzyand migraine clinics.and migraine clinics.

Not recognized by the IHSNot recognized by the IHS

Diagnosis (proposed criteria)Diagnosis (proposed criteria) – – Recurrent episodic vestibular symptoms of Recurrent episodic vestibular symptoms of

at least moderate severity.at least moderate severity.

– – One of the following:One of the following: Current of previous history of IHS migraine.Current of previous history of IHS migraine.

Migrainous symptoms during two or moreMigrainous symptoms during two or moreattacks of vertigo.attacks of vertigo.

MigraineMigraine--precipitants before vertigo in moreprecipitants before vertigo in more

than 50% of attacks.than 50% of attacks. – – Response to migraine medications in moreResponse to migraine medications in morethan 50% of attacksthan 50% of attacks



Migraine mechanismMigraine mechanism

Neurovascular theory.Neurovascular theory.

– – Abnormal brainstem Abnormal brainstemresponses.responses.

– – TrigeminoTrigemino--vascular system.vascular system. Calcitonin gene relatedCalcitonin gene related

peptidepeptide

Neurokinin A Neurokinin A

Substance PSubstance P

Extracranial arterial vasodilation.Extracranial arterial vasodilation.

– – TemporalTemporal

– – Pulsing pain.Pulsing pain.

Extracranial neurogenicExtracranial neurogenicinflammation.inflammation.

Decreased inhibition of centralDecreased inhibition of centralpain transmission.pain transmission.

– – Endogenous opioids.Endogenous opioids.



Important role inImportant role in

migrainemigraine

pathogenesis.pathogenesis. Mechanism of actionMechanism of action

in migraines not wellin migraines not well

established.established. Main target of Main target of

pharmacotherapy.pharmacotherapy.



Aura Mechanism Aura Mechanism

Cortical spreading depressionCortical spreading depression

– – Self propagating wave of neuronal and glial depolarization acrosSelf propagating wave of neuronal and glial depolarization across thes thecortexcortex

Activates trigeminal afferents Activates trigeminal afferents – – Causes inflammation of pain sensitive meninges that generatesCauses inflammation of pain sensitive meninges that generates

HA through central/peripheral reflexes.HA through central/peripheral reflexes.

Alters blood Alters blood--brain barrier.brain barrier.

– – Associated with a low flow state in the dural sinuses. Associated with a low flow state in the dural sinuses.



Auras Auras

– – Vision Vision – – most commonmost common

neurologic symptomneurologic symptom

– – ParesthesiaParesthesia of lips, lowerof lips, lower

face and fingers… 2face and fingers… 2ndnd

mostmostcommoncommon

– – Typical auraTypical aura

Flickering uncoloredFlickering uncolored

zigzag line in center andzigzag line in center andthen peripherythen periphery

MotorMotor – – hand and arm onhand and arm on

one sideone side

Auras (visual, sensory, Auras (visual, sensory,aphasia)aphasia) – – 1 hr1 hr

ProdromeProdrome

– – Lasts hours to days…Lasts hours to days…



Clinical manifestationsClinical manifestations

Clinical manifestationsClinical manifestations

– – Lateralized in severe attacksLateralized in severe attacks – –6060--70%70%

– – Bifrontal/global HA Bifrontal/global HA – – 30%30%

– – Gradual onset with crescendoGradual onset with crescendopattern.pattern.

– – Limits activity due to itsLimits activity due to itsintensity.intensity.

– – Worsened by rapid headWorsened by rapid headmotion, sneezing, straining,motion, sneezing, straining,constant motion or exertion.constant motion or exertion.

– – Focal facial pain, cutaneousFocal facial pain, cutaneousallodynia, GI dysfunction,allodynia, GI dysfunction,facial flushing, lacrimation,facial flushing, lacrimation,rhinorrhea, nasal congestionrhinorrhea, nasal congestionand vertigo…and vertigo…



Precipitating factorsPrecipitating factors

stressstress

head and neck infectionhead and neck infection

head trauma/surgeryhead trauma/surgery

aged cheeseaged cheese

dairydairy

red winered wine

nutsnutsshellfishshellfish

caffeine withdrawalcaffeine withdrawal

vasodilatorsvasodilators

perfumes/strong odorsperfumes/strong odorsirregular diet/sleepirregular diet/sleep

lightlight



TreatmentTreatment

Abortive Abortive

– – SteppedStepped – – StratifiedStratified

– – StagedStaged PreventivePreventive



Abortive Therapy Abortive Therapy

Reduces headache recurrence.Reduces headache recurrence.

Alleviation of symptoms. Alleviation of symptoms.

Analgesics Analgesics – – Tylenol, opioids…Tylenol, opioids…

Antiphlogistics Antiphlogistics

– –

NSAIDsNSAIDs

Vasoconstrictors Vasoconstrictors – – CaffeineCaffeine

– – SympathomimeticsSympathomimetics

– – SerotoninergicsSerotoninergics SelectiveSelective -- triptanstriptans

NonselectiveNonselective – – ergotsergots

MetoclopramideMetoclopramide



Abortive care strategies Abortive care strategies SteppedStepped

– – Start with lower level drugs, then switch to more specific drugsStart with lower level drugs, then switch to more specific drugsif symptoms persist or worsen.if symptoms persist or worsen. Analgesics Analgesics – – Tylenol, NSAIDs…Tylenol, NSAIDs…

Vasoconstrictors Vasoconstrictors – – sympathomimetics…sympathomimetics…

Opioids (try to avoid)Opioids (try to avoid) -- ButorphanolButorphanol

TriptansTriptans – – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,zomatriptan.zomatriptan.

– – Limited by patient compliance.Limited by patient compliance.

StratifiedStratified – – Adjusts treatment according to symptom intensity. Adjusts treatment according to symptom intensity. MildMild – – analgesics, NSAIDsanalgesics, NSAIDs

ModerateModerate – – analgesic plus caffeine/sympathomimeticanalgesic plus caffeine/sympathomimetic

SevereSevere – – opioids, triptans, ergots…opioids, triptans, ergots…

– – Severe sx treatment limited due to concomitant GI sx’s.Severe sx treatment limited due to concomitant GI sx’s. StagedStaged

– – Bases treatment on intensity and time of attacks.Bases treatment on intensity and time of attacks.

– – HA diary reviewed with patient.HA diary reviewed with patient.

– – Medication plan and backup plans.Medication plan and backup plans.



Preventive therapyPreventive therapy

Consider if pt has more than 3Consider if pt has more than 3--44episodes/month.episodes/month.

Reduces frequency by 40Reduces frequency by 40 – – 60%.60%.

Breakthrough headaches easier to abort.Breakthrough headaches easier to abort.

Beta blockersBeta blockers Amitriptyline Amitriptyline

Calcium channel blockersCalcium channel blockers

Lifestyle modification.Lifestyle modification.

Biofeedback.Biofeedback.



BotoxBotox

51% migraineurs treated51% migraineurs treated

had complete prophylaxishad complete prophylaxis

for 4.1 months.for 4.1 months.

38% had prophylaxis for 2.738% had prophylaxis for 2.7

months.months.

Randomized trial showedRandomized trial showed

significant improvementsignificant improvement

in headache frequencyin headache frequency

with multiple treatments.with multiple treatments.



ConclusionsConclusions

Migraine is common but unrecognized.Migraine is common but unrecognized.

Keep migraine and its variants in theKeep migraine and its variants in thedifferential diagnosis.differential diagnosis.





http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc

http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc

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Migraine 2