New Developments in New Developments in MigraineMigraine

-or- -or-((Why do humans get so many Why do humans get so many

headaches?)headaches?)Stasha Gominak, M.D.Stasha Gominak, M.D. East Texas Medical Center Neurologic East Texas Medical Center Neurologic

InstituteInstitute700 Olympic Plaza, Suite 912700 Olympic Plaza, Suite 912

Tyler, TexasTyler, Texas

Despite what we Despite what we were all taught, were all taught, migraine is migraine is notnot a a vascular disordervascular disorder

I believe that I believe that migraine is a disorder migraine is a disorder

of electrical hyper of electrical hyper excitability of the excitability of the head pain system head pain system

coming from a coming from a brainstem “migraine brainstem “migraine

generator”generator”

I believe that all I believe that all humans with normal humans with normal

head anatomy who have head anatomy who have spontaneous head pain spontaneous head pain

have “migraine”. It have “migraine”. It comes in different sizes comes in different sizes

but all with the same but all with the same mechanism.mechanism.

Trigeminal Nucleus CaudalisTrigeminal Nucleus Caudalis perceives pain for perceives pain for the face and the front 2/3 of the head.the face and the front 2/3 of the head.

Dorsal Horn C2-C4Dorsal Horn C2-C4 perceives pain for the back perceives pain for the back 1/3 of the head and the neck.1/3 of the head and the neck.

The Head Pain SystemThe Head Pain System

The pain system of the head The pain system of the head was put there to tell us not to was put there to tell us not to

bang our heads.bang our heads.

PET Scans in Migraine PET Scans in Migraine PatientsPatients

show that the posterior brain stem is hyper show that the posterior brain stem is hyper metabolicmetabolic

Weiller C, May A, Limmroth V, et al. Nature Med 1995;1:658-660Weiller C, May A, Limmroth V, et al. Nature Med 1995;1:658-660

The migraine sufferer has a The migraine sufferer has a normal wiring diagram but normal wiring diagram but

inherits a gene that allows the inherits a gene that allows the pain wires to turn “on” without pain wires to turn “on” without

a blow to the head.a blow to the head.

The Gene Mutations that The Gene Mutations that Cause MigraineCause Migraine

Genes that cause migraine Genes that cause migraine affect the electrical affect the electrical

excitability of brain cellsexcitability of brain cells There are now about 40 genes that There are now about 40 genes that

are linked to migraineare linked to migraine All of these genes are mutations in All of these genes are mutations in

the cellular apparatus that allows us the cellular apparatus that allows us to turn our cells on and off: Channel to turn our cells on and off: Channel Mutations.Mutations.

About half the genes are Ca++ About half the genes are Ca++ channel mutations the other half are channel mutations the other half are Na+ channel mutations.Na+ channel mutations.

Ca++ channel in a membraneCa++ channel in a membrane

Our cellular electricity is more like a car battery, Our cellular electricity is more like a car battery, charges floating in water our brain uses Ca++, K+, charges floating in water our brain uses Ca++, K+, Cl-, Na+.Cl-, Na+.

The channels move these ions in and out of our cells The channels move these ions in and out of our cells to turn them “on” or “off”. to turn them “on” or “off”.

Most channels move a specific ion.Most channels move a specific ion. There are now multiple Ca++ channels, K+ There are now multiple Ca++ channels, K+

channels, etc., each has a specific role, or several channels, etc., each has a specific role, or several specific roles, in our body.specific roles, in our body.

Voltage gated Ca ++ channels Voltage gated Ca ++ channels turn cells“on” turn cells“on” Ca++ pumpsCa++ pumps turn turn

them “off”them “off” As the voltage of the cell As the voltage of the cell

rises the “voltage gated” rises the “voltage gated” Ca++ channels all open.Ca++ channels all open.

Ca++ floods the cell, the Ca++ floods the cell, the cell is now very positive cell is now very positive inside; it is “on”.inside; it is “on”.

It sends it’s message off It sends it’s message off down the axon. down the axon.

It’s job is finished, now it It’s job is finished, now it is time to turn “off”. To is time to turn “off”. To turn off it has to pump turn off it has to pump out the positive charges. out the positive charges.

Voltage gated Ca++ channel

Lots of +’s cell Lots of +’s cell is ONis ON++++

++++

++++

++++++

++++

++++

++++

Migraine is a Channel Migraine is a Channel DisorderDisorder

There are now multiple reported There are now multiple reported Ca++ channel and Na+ channel Ca++ channel and Na+ channel mutations that are linked to mutations that are linked to migraine. migraine.

Also mutations of the Ca++ Also mutations of the Ca++ pumps and most recently Na-K pumps and most recently Na-K ATPase.ATPase.

Refs 1-6Refs 1-6

This may be why the brain stem nuclei This may be why the brain stem nuclei are inappropriately “on” in migraine are inappropriately “on” in migraine

patientspatients

Any migraine sufferer will Any migraine sufferer will tell you, (if you ask), that tell you, (if you ask), that

they go to bed not just they go to bed not just because their head hurts but because their head hurts but

because they also “can’t because they also “can’t think right”think right”Migraine is not just a disorder of Migraine is not just a disorder of

head pain. head pain. Any theory about Any theory about migraine has to explain this migraine has to explain this

global change in brain global change in brain functioningfunctioning..

1960’s Magnetic Field Studies1960’s Magnetic Field StudiesStarting with the visual aura they observedStarting with the visual aura they observed electrical electrical suppression, starting in the back during visual aura, suppression, starting in the back during visual aura, moving slowly forward taking 15 minutes to go from moving slowly forward taking 15 minutes to go from

back to frontback to front

Magnetic Field StudiesMagnetic Field Studieselectrical suppression, starting in the back during electrical suppression, starting in the back during

visual aura, moving slowly forward, 15 minutes to go visual aura, moving slowly forward, 15 minutes to go from back to frontfrom back to front

Magnetic Field StudiesMagnetic Field Studieselectrical suppression, starting in the back during electrical suppression, starting in the back during

visual aura, moving slowly forward, 15 minutes to go visual aura, moving slowly forward, 15 minutes to go from back to frontfrom back to front

Spreading Depression of Spreading Depression of Dr. LeaoDr. Leao

Observed in animal brain slices: Stimulating the brain Observed in animal brain slices: Stimulating the brain electrically causes a slowly spreading electrical wave.electrically causes a slowly spreading electrical wave.

Travels 3mm/min, contiguously, taking about 15 Travels 3mm/min, contiguously, taking about 15 minutes to cross the brainminutes to cross the brain

What conveys this slowly moving wave? Is it directly What conveys this slowly moving wave? Is it directly related to migraine in humans? Why is it so slow?related to migraine in humans? Why is it so slow?

Newest Brain Discoveries Newest Brain Discoveries that Explain Spreading that Explain Spreading

DepressionDepression Confocal Confocal

microscopes show microscopes show us brain cells in 3 us brain cells in 3 dimensions.dimensions.

Neuron

Astrocyte

Astrocytes are more Astrocytes are more influential than previously influential than previously

imaginedimagined Astrocytes are Astrocytes are

electrically active cells electrically active cells that can talk to one that can talk to one another and other brain another and other brain cells. cells.

Their dendrites wrap Their dendrites wrap around 20-30 neurons around 20-30 neurons with multiple endings on with multiple endings on the surface of the the surface of the neurons giving excitatory neurons giving excitatory or inhibitory input to the or inhibitory input to the neurons.neurons.

Each astrocyte is Each astrocyte is assigned several neurons assigned several neurons and a blood vessel. and a blood vessel.

Spreading Depression of Spreading Depression of Leao is an inter cellular Leao is an inter cellular

calcium wavecalcium wave Astrocytes have gap Astrocytes have gap

junctions that open between junctions that open between adjoining cells allowing adjoining cells allowing them to directly share their them to directly share their ionic environments.ionic environments.

Spreading depression is a Spreading depression is a spreading inter cellular spreading inter cellular calcium wave traveling calcium wave traveling through the astrocyte through the astrocyte population through these population through these gap junctionsgap junctions

The wave travels slowly, The wave travels slowly, 3mm/min, and contiguously, 3mm/min, and contiguously, because it is because it is transmitted transmitted by the astrocytes, not the by the astrocytes, not the neuronsneurons

Astrocytes link blood Astrocytes link blood signals to neuronal signalssignals to neuronal signals

A single astrocyte and it’s A single astrocyte and it’s neurons are called neurons are called ““astrocyte astrocyte neurovascular unitneurovascular unit””

A chemical blood signal is A chemical blood signal is received by the astrocyte, received by the astrocyte, then sent to the neurons then sent to the neurons amplifying the messageamplifying the message

Thus spreading Thus spreading depression has a similar depression has a similar arterial vasoconstrictive arterial vasoconstrictive wave that accompanies it.wave that accompanies it.

But I believe the change But I believe the change in mental status is the in mental status is the neuronal effect not the neuronal effect not the vascular effect.vascular effect.

Most headaches are Most headaches are “migraine”“migraine”

I believe that all the headaches that most of us have I believe that all the headaches that most of us have are “migraine” meaning a are “migraine” meaning a genetically inherited genetically inherited tendency to turn on the head pain system tendency to turn on the head pain system without a blow to the head.without a blow to the head.

This This excludesexcludes people who have headache because of people who have headache because of brain infection, a blow to the head, a brain tumor, or brain infection, a blow to the head, a brain tumor, or a stroke. All of those people have head pain because a stroke. All of those people have head pain because of irritated nerve endings.of irritated nerve endings.

Always have a scan. The headache of a brain Always have a scan. The headache of a brain tumor is no different than daily headache from tumor is no different than daily headache from migrainemigraine..

Why do humans think headaches are “normal”? It is Why do humans think headaches are “normal”? It is the only pain syndrome we think is “normal”.the only pain syndrome we think is “normal”.

What is unique about the head What is unique about the head pain system that makes it turn on pain system that makes it turn on

spontaneously?spontaneously?The other, analogous pain areas of the rest of the The other, analogous pain areas of the rest of the

spinal cord don’t just switch on when ever they feel spinal cord don’t just switch on when ever they feel like it.like it.

What about the other migraine What about the other migraine symptoms? They’re not in the symptoms? They’re not in the

trigeminal caudal nucleustrigeminal caudal nucleus

Nausea from the Nausea from the Chemotrigger Zone Chemotrigger Zone

Facial congestion Facial congestion from the Salivatory from the Salivatory Nucleus which Nucleus which innervates the innervates the mucosa of the mucosa of the sinus cavitiessinus cavities . .

Several brainstem Several brainstem nuclei are being nuclei are being excited together.excited together.

What causes this excitation? What causes this excitation? Remember our friend the Remember our friend the

astrocyte?astrocyte?

Astrocytes act more as a Astrocytes act more as a syncytium joining all of the syncytium joining all of the

neurons of the brainneurons of the brain

Migraine as an astrocyte Migraine as an astrocyte disorderdisorder

The channel abnormalities linked to The channel abnormalities linked to migraine are probably manifested in the migraine are probably manifested in the astrocytesastrocytes,, not in the neurons, thus the not in the neurons, thus the syndrome is not a single brainstem syndrome is not a single brainstem nucleus, but a nucleus, but a regionregion of the brain that of the brain that is hyper excitable.is hyper excitable.

Snuggled right up against the migraine Snuggled right up against the migraine brainstem generator is the brainstem generator is the sleep sleep switchswitch, which is , which is designed to go on designed to go on and off spontaneously.and off spontaneously.

Why would humans have so Why would humans have so many genes to give them many genes to give them

headaches?headaches?

Those 40 genes for migraine are Those 40 genes for migraine are probably not there to cause probably not there to cause headaches, they’re there to make headaches, they’re there to make the sleep switch work better.the sleep switch work better.

Sleep is the most important thing we Sleep is the most important thing we do every day. If you sleep better you do every day. If you sleep better you survive longer and have more survive longer and have more children.children.

Migraine and Sleep are Migraine and Sleep are intertwinedintertwined

I believe that the unique aspect of the I believe that the unique aspect of the trigeminal caudal nucleus is not the nucleus trigeminal caudal nucleus is not the nucleus itself but instead its proximity to the itself but instead its proximity to the periaquiductal grey.periaquiductal grey.

Most daily headache sufferers have a sleep Most daily headache sufferers have a sleep disorder underlying.disorder underlying.

But if you don’t have a migraine gene your But if you don’t have a migraine gene your sleep disorder won’t produce headache.sleep disorder won’t produce headache.

Patients with a migraine gene often have a Patients with a migraine gene often have a headache that lasts longer after mild head headache that lasts longer after mild head injury as well. They can’t turn “off” their injury as well. They can’t turn “off” their migraine generator.migraine generator.

What about chronic neck pain and What about chronic neck pain and “tension headaches”“tension headaches”

If mild head injury can become chronic daily headache because If mild head injury can become chronic daily headache because the pain center cannot turn off, thenthe pain center cannot turn off, then

Mild irritation of cervical roots might also lead to daily headache.Mild irritation of cervical roots might also lead to daily headache. To make the neck pain resolve To make the neck pain resolve we have to decrease the excitability we have to decrease the excitability

of the brain stem centerof the brain stem center that receives the input instead of focusing that receives the input instead of focusing on the neck. on the neck.

The neck looks normal because it is normal.The neck looks normal because it is normal.

Are daily headaches Are daily headaches migraine too?migraine too?

What some authors are calling “transformed What some authors are calling “transformed migraine” is just daily migraine, some days migraine” is just daily migraine, some days milder, some days more severe.milder, some days more severe.

Daily headache or daily “migraine” is Daily headache or daily “migraine” is probably one of the biggest causes of daily, probably one of the biggest causes of daily, non radiating neck pain.non radiating neck pain.

Sinus headaches without green or yellow Sinus headaches without green or yellow snot are just migraine in the face.snot are just migraine in the face.

In order to assume this the In order to assume this the anatomy must anatomy must be normal, so always scan first.be normal, so always scan first.

Key Points of Brainstem Hyper Key Points of Brainstem Hyper excitabilityexcitability

• Activation observed in the posterior brain stem Activation observed in the posterior brain stem on PET scans is probably that whole region of on PET scans is probably that whole region of the brainstem.the brainstem.

• Activation of the posterior brain stem can Activation of the posterior brain stem can result in pain anywhere along the trigeminal-result in pain anywhere along the trigeminal-cervical network; including the head, the neck, cervical network; including the head, the neck, and the face.and the face.

• Activation of the TNC can cause cross-over Activation of the TNC can cause cross-over activation of the Salivatory Nucleus leading to activation of the Salivatory Nucleus leading to sinus congestion symptoms, nausea through sinus congestion symptoms, nausea through the chemotrigger zone, hypersensitivity to light the chemotrigger zone, hypersensitivity to light sound and smell through connections to the sound and smell through connections to the thalamus.thalamus.

Sleep disorders cause Sleep disorders cause migrainemigraine

• Most patients with daily headache have a Most patients with daily headache have a primary sleep disorder, either sleep apnea, primary sleep disorder, either sleep apnea, restless leg syndrome or periodic limb restless leg syndrome or periodic limb movements of sleep.movements of sleep.

• Many just don’t get into the right phases of Many just don’t get into the right phases of sleep.sleep.

• Most of these patients have vitamin D Most of these patients have vitamin D deficiency with or without accompanying B12 deficiency with or without accompanying B12 deficiency.deficiency.

• Measure D 25OH, B12, iron and replace all Measure D 25OH, B12, iron and replace all that are low first. D 60-80 ng/ml. B12 > 500. that are low first. D 60-80 ng/ml. B12 > 500.

• The good sleep cures the headache, not the D The good sleep cures the headache, not the D or B12, so if sleep is still terrible help with that or B12, so if sleep is still terrible help with that also.also.

Hormones and MigraineHormones and Migraine

Any migraine theory has to Any migraine theory has to explain:explain:

Why do migraines start at puberty?Why do migraines start at puberty? Why do they start in boys and girls Why do they start in boys and girls

around the same age but get much around the same age but get much better in boys?better in boys?

Why are they worse around the menses?Why are they worse around the menses? Why are they much worse Why are they much worse

perimenopausally?perimenopausally? Why do they go away after menopause?Why do they go away after menopause?

HypothalamusGnRH

Anterior PituitaryLH/FSH

Ovariesinhibin, estradiol, progesterone

Adapted from MacGregor EA. Neurologic Clinics 1997;15(1):125-141.

Menstruation and Releasing Menstruation and Releasing HormonesHormones

Gonadotropin Releasing Gonadotropin Releasing HormonesHormones

The releasing hormones (GnRH) boss the ovaries and the The releasing hormones (GnRH) boss the ovaries and the testicles. GnRH starts to spike in boys and girls at puberty. testicles. GnRH starts to spike in boys and girls at puberty.

GnRH is also a GnRH is also a neurotransmitteneurotransmitter. There are GnRH r. There are GnRH receptors in the brainstem. GnRH levels affect sleep snd receptors in the brainstem. GnRH levels affect sleep snd brainstem excitability.brainstem excitability.

After age 18 the boys have a constant daily testosterone After age 18 the boys have a constant daily testosterone level, (their GnRH levels stay steady), but their sisters level, (their GnRH levels stay steady), but their sisters have monthly GnRH spikes at ovulation and menstruation.have monthly GnRH spikes at ovulation and menstruation.

At menopause ovaries are out of eggs, estrogen goes down At menopause ovaries are out of eggs, estrogen goes down and so GnRH levels go up. Low doses of estrogen and so GnRH levels go up. Low doses of estrogen replacement may not be enough to inhibit GnRH replacement may not be enough to inhibit GnRH completely. Women in menopause can’t stay asleep when completely. Women in menopause can’t stay asleep when their vitamin D is low and GnRH is high.their vitamin D is low and GnRH is high.

Fix the D/B12 system first to get the sleep as good as Fix the D/B12 system first to get the sleep as good as possible and the headaches might go away. possible and the headaches might go away. Estrogen/progesterone replacement also makes sleep Estrogen/progesterone replacement also makes sleep better.better.

Children Have Children Have Headaches TooHeadaches Too

There is absolutely no difference between adults There is absolutely no difference between adults with headache and children with headache.with headache and children with headache.

All of the children I see with headache have All of the children I see with headache have poor sleep and vitamin D deficiency.poor sleep and vitamin D deficiency.

Some have leg pain from kicking in sleep (which Some have leg pain from kicking in sleep (which is basically what the kids with rickets is basically what the kids with rickets complained of).complained of).

Children who get significant headaches before Children who get significant headaches before puberty all have sleep disorders and D puberty all have sleep disorders and D deficiency. Fix that first. deficiency. Fix that first. Always have a CT Always have a CT scan.scan.

Episodic Treatment: TriptansEpisodic Treatment: Triptanssumatriptan, naratriptan, eletriptan, sumatriptan, naratriptan, eletriptan,

etc.etc. They work on Serotonin 1B and 1D receptors that They work on Serotonin 1B and 1D receptors that

are are feedback inhibitors of Serotonin releasefeedback inhibitors of Serotonin release. . They are not pain relievers or anti-inflammatories.They are not pain relievers or anti-inflammatories. We told our patients to “save them for your We told our patients to “save them for your

migraines”, but our patients were smarter.migraines”, but our patients were smarter. ““if I can get my medicine soon enough it works”if I can get my medicine soon enough it works” It turned out that the triptans worked better when It turned out that the triptans worked better when

used earlier, on the little headaches, teaching us used earlier, on the little headaches, teaching us that all the headaches are migraine in mechanism.that all the headaches are migraine in mechanism.

I believe they act on the Serotonergic Raphe NucleiI believe they act on the Serotonergic Raphe Nuclei

Where are the Serotonin Where are the Serotonin receptors ?receptors ?

Most of the serotonin Most of the serotonin measured throughout the measured throughout the brain originates from the brain originates from the Raphe nuclei in the Raphe nuclei in the brainstem.brainstem.

So the triptans are So the triptans are probably not acting probably not acting primarily on blood primarily on blood vessels in the brain they vessels in the brain they are working at the are working at the “migraine brainstem “migraine brainstem generator”. To turn it generator”. To turn it “off”.“off”.

Serotonergic cells in Raphe Serotonergic cells in Raphe Nuclei of the Periaquiductal Nuclei of the Periaquiductal

GreyGrey Brain serotonin levels are Brain serotonin levels are

directly related to the level directly related to the level of vigilance or alertness.of vigilance or alertness.

The brainstem The brainstem chemoreceptor trigger zone chemoreceptor trigger zone is in the same area, is in the same area, controlling nausea, (the controlling nausea, (the newer anti nausea agents newer anti nausea agents act on serotonergic act on serotonergic receptors in the brainstem).receptors in the brainstem).

Animal studies show that Animal studies show that the Serotonergic Raphe the Serotonergic Raphe Nuclei directly control the Nuclei directly control the level of excitability of the level of excitability of the TNC.TNC.Ref 9Ref 9

Trigeminal Nucleus Caudalis

Treatment: PreventionTreatment: Prevention• Use the triptans early! Use the triptans early! • Treat the sleep first if possible, before a daily Treat the sleep first if possible, before a daily

preventative.preventative.• Very severe headaches not responding to Very severe headaches not responding to

triptans may need a daily preventative. triptans may need a daily preventative. • Once the daily headache patient gets on the Once the daily headache patient gets on the

right preventative medication, (correcting right preventative medication, (correcting their genetic hyper excitability), their their genetic hyper excitability), their headaches become episodic and are no headaches become episodic and are no different than any other migraine.different than any other migraine.

• After the preventative medication decreases After the preventative medication decreases the severity and incidence of the headaches, the severity and incidence of the headaches, try the triptans again. try the triptans again.

Daily Preventatives are Daily Preventatives are all Channel Stabilizersall Channel Stabilizers

Verapamil SR 180 to 360 (careful in renal failure)Verapamil SR 180 to 360 (careful in renal failure) Atenolol 100 mg qd (Ca++ channel active in Atenolol 100 mg qd (Ca++ channel active in

migraine)migraine) Topiramate75-100mg hsTopiramate75-100mg hs Zonisamide 100mg -200mg BID, 300-400 qhsZonisamide 100mg -200mg BID, 300-400 qhs Divalproex sodium 500- 1000 qd (ER) or BIDDivalproex sodium 500- 1000 qd (ER) or BID GabapentinGabapentin CyproheptidineCyproheptidine Other, newer seizure medications, Levetiracetam, Other, newer seizure medications, Levetiracetam,

Lamotragine, Oxcarbazepine, Tiagabine, Lamotragine, Oxcarbazepine, Tiagabine, PregabalinPregabalin

Are there other things like Are there other things like Migraine?Migraine?

Episodic vertigo is a channel disorder as well. Episodic vertigo is a channel disorder as well. Ca++ or Na+. (Ca++ or Na+. (Assumes normal anatomy Assumes normal anatomy so always have a scanso always have a scan.).)

Ringing in the ears is a “turning on” of the Ringing in the ears is a “turning on” of the central brainstem hearing system and central brainstem hearing system and frequently acts like migraine: i.e., comes on frequently acts like migraine: i.e., comes on spontaneously for hours to days, can be daily, spontaneously for hours to days, can be daily, gets worse when the sleep is bad. gets worse when the sleep is bad.

When it’s both sides, When it’s both sides, no hearing loss,no hearing loss, with with or without “dizzy”, treat it the same way you or without “dizzy”, treat it the same way you would migraine; check the vitamin levels, get would migraine; check the vitamin levels, get the sleep better.the sleep better.

Mouse models of MigraineMouse models of Migraine One of the Ca++ One of the Ca++

channel mutations that channel mutations that causes migraine is causes migraine is found in mice.found in mice.

Unfortunately the miceUnfortunately the mice can not tell us if they can not tell us if they have a headachehave a headache

They do have They do have staggering episodes staggering episodes and occasionally, and occasionally, epilepsy.epilepsy.

There are also There are also inherited epilepsy inherited epilepsy syndromes and syndromes and vertigo syndromesvertigo syndromes that are caused by Ca+that are caused by Ca++ channel mutations.+ channel mutations.

Boy do I have

a Headac

he!

Epilepsy and ChannelsEpilepsy and Channels

If you can make a mouse epileptic If you can make a mouse epileptic with a channel mutation it should with a channel mutation it should not be surprising thatnot be surprising that

Most of the inherited epilepsies are Most of the inherited epilepsies are now known to be channel disorders now known to be channel disorders as well, usually Na+ or Cl- channels.as well, usually Na+ or Cl- channels.

So this is what

they meant

by “knocko

ut mouse”

Most epilepsy medications are “channel Most epilepsy medications are “channel stabilizers”. They act on malfunctioning stabilizers”. They act on malfunctioning

channels to make them act more normally. channels to make them act more normally. Which is probably why some of them are Which is probably why some of them are

also migraine preventatives and treat also migraine preventatives and treat vertigo.vertigo.

LyricaLyrica NeurontinNeurontin DepakoteDepakote TopamaxTopamax TrileptalTrileptal TegretolTegretol

KeppraKeppra GabatrilGabatril DiamoxDiamox ZonegranZonegran LamictalLamictal DilantinDilantin

Can Epilepsy be like Can Epilepsy be like Migraine?Migraine?

If there is no abnormality of the brain If there is no abnormality of the brain anatomy it is a spontaneous “turning on” anatomy it is a spontaneous “turning on” of neurons in the brain.of neurons in the brain.

It gets worse when the sleep is worse.It gets worse when the sleep is worse. We use the same medicines.We use the same medicines. Can be genetically linked to vertigo Can be genetically linked to vertigo

attacks and migraine.attacks and migraine. Any of the hyperexcitability disorders that Any of the hyperexcitability disorders that

we use seizure medicines for can be we use seizure medicines for can be thought of as inappropriate “turning on” thought of as inappropriate “turning on” of a part of the nervous system.of a part of the nervous system.

Do animals have migraines? Do animals have migraines?

(Bella can’t tell us if she has a (Bella can’t tell us if she has a headache.)headache.)

I always get a headache when I

have to ride in the car.

ReferencesReferences1.1. Joutel A, Bousser MG, Biousse V, et Joutel A, Bousser MG, Biousse V, et aal. l. A gene for fA gene for faamilimiliaal hemiplegic l hemiplegic

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5.5. Ophoff ROphoff RAA, v, vaan Eijk R, Sn Eijk R, Saandkuijl Lndkuijl LAA, et , et aal. l. Genetic heterogeneity of Genetic heterogeneity of ffaamilimiliaal hemiplegic migrl hemiplegic migraaine. Genomics 1994;22:21-26.ine. Genomics 1994;22:21-26.

6.6. Ducros Ducros AA, Joutel , Joutel AA, V, Vaahedi K, et hedi K, et aal. Ml. Maapping of pping of aa second locus for second locus for ffaamilimiliaal hemiplegic migrl hemiplegic migraaine to 1q21-q23 ine to 1q21-q23 aand evidence of further nd evidence of further heterogeneity. heterogeneity. AAnn Neurol 1997;42:885-890.nn Neurol 1997;42:885-890.

7.7. HHaans M, Luvisetto S, Willins M, Luvisetto S, Williaams ME, et ms ME, et aal. Functionl. Functionaal consequences of l consequences of mutmutaations in the humtions in the humaan n aalphlphaa11AA c caalcium chlcium chaannel subunit linked to nnel subunit linked to ffaamilimiliaal hemiplegic migrl hemiplegic migraaine. J Neurosci 1999;19:1610-1619 ine. J Neurosci 1999;19:1610-1619

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