Migraine

Prevalence

► Familial

► Young, healthy women; F>M: 3:1

 17 – 18.2% of adult females

 6 – 6.5% adult males

► 2-3rd decade onset… can occur sooner

► Peaks ages 22-55.

► ½ migraine sufferers not diagnosed.

► 94% pt’s seen in primary care settings for HA have migraines

► Common misdiagnoses for migraine:

 Sinus HA

 Stress HA

► Referral to ENT for sinus disease and facial pain.

► Migraineurs more likely to have motion sickness.

► Half of Meniere’s patients claim to have migrainous symptoms.

► BPPV

► $13 billion/year in lost productivity

► 1/3 participants in American Migraine Study II missed work in prior 3 months

Migraine Definition

► IHS Diagnostic criteria: migraine w/o aura

 HA lasting for 4-72 hrs

 HA w/2+ of following:

► Unilateral

► Pulsating

► Mod/severe intensity.

► Aggravated by routine physical activity.

 During HA at least 1 of following

► N/V

► Photophobia

► Phonophobia

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

 One or more fully reversible aura symptoms indicates focal cerebral cortical or brainstem dysfunction.

 At least one aura symptom develops gradually over more than 4 minutes.

 No aura symptom lasts more than one hour.

 HA follows aura w/free interval of less than one hour and may begin before or w/aura.

Migraine Subtypes

► Basilar type migraine

 Dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, bilateral paresthesias, altered consciousness.

 Simultaneous bilateral visual symptoms.

 No muscular weakness.

► Retinal or ocular migraine

 Repeated monocular scotomata or blindness < 1 hr

 Associated with or followed by a HA

► Menstrual migraine

► Hemiplegic migraine

 Unilateral motor and sensory symptoms that may persist after the headache.

 Complete recover

► Familial hemiplegic migraine

Migrainous vertigo

► Vertigo – sole or prevailing symptom.

► Benign paroxysmal vertigo of childhood.

► Prevalence 7-9% of pts in referral dizzy and migraine clinics.

► Not recognized by the IHS

► Diagnosis (proposed criteria)

 Recurrent episodic vestibular symptoms of at least moderate severity.

 One of the following:

► Current of previous history of IHS migraine.

► Migrainous symptoms during two or more attacks of vertigo.

► Migraine-precipitants before vertigo in more than 50% of attacks.

 Response to migraine medications in more than 50% of attacks 

Migraine mechanism

► Neurovascular theory.

 Abnormal brainstem responses.

 Trigemino-vascular system.

► Calcitonin gene related peptide

► Neurokinin A

► Substance P

► Extracranial arterial vasodilation.

 Temporal

 Pulsing pain.

► Extracranial neurogenic inflammation.

► Decreased inhibition of central pain transmission.

 Endogenous opioids.

► Important role in migraine pathogenesis.

► Mechanism of action in migraines not well established.

► Main target of pharmacotherapy.

Aura Mechanism

► Cortical spreading depression

 Self propagating wave of neuronal and glial depolarization across the cortex

► Activates trigeminal afferents

 Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.

► Alters blood-brain barrier.

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

► Auras

 Vision – most common neurologic symptom

 Paresthesia of lips, lower face and fingers… 2nd most common

 Typical aura

► Flickering uncolored zigzag line in center and then periphery

► Motor – hand and arm on one side

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

► Prodrome

 Lasts hours to days…

Clinical manifestations

► Clinical manifestations

 Lateralized in severe attacks – 60-70%

 Bifrontal/global HA – 30%

 Gradual onset with crescendo pattern.

 Limits activity due to its intensity.

 Worsened by rapid head motion, sneezing, straining, constant motion or exertion.

 Focal facial pain, cutaneous allodynia, GI dysfunction, facial flushing, lacrimation, rhinorrhea, nasal congestion and vertigo…

Precipitating factors

Treatment

► Abortive

 Stepped

 Stratified

 Staged

► Preventive

Abortive Therapy

► Reduces headache recurrence.

► Alleviation of symptoms.

► Analgesics

 Tylenol, opioids…

► Antiphlogistics

 NSAIDs

► Vasoconstrictors

 Caffeine

 Sympathomimetics

 Serotoninergics

► Selective - triptans

► Nonselective – ergots

► Metoclopramide

Abortive care strategies

► Stepped

 Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.

► Analgesics – Tylenol, NSAIDs…

► Vasoconstrictors – sympathomimetics…

► Opioids (try to avoid) - Butorphanol

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

 Limited by patient compliance.

► Stratified

 Adjusts treatment according to symptom intensity.

► Mild – analgesics, NSAIDs

► Moderate – analgesic plus caffeine/sympathomimetic

► Severe – opioids, triptans, ergots…

 Severe sx treatment limited due to concomitant GI sx’s.

► Staged

 Bases treatment on intensity and time of attacks.

 HA diary reviewed with patient.

 Medication plan and backup plans.

Preventive therapy

► Consider if pt has more than 3-4 episodes/month.

► Reduces frequency by 40 – 60%.

► Breakthrough headaches easier to abort.

► Beta blockers

► Amitriptyline

► Calcium channel blockers

► Lifestyle modification.

► Biofeedback.

Botox

51% migraineurs treated had complete prophylaxis for 4.1 months.

38% had prophylaxis for 2.7 months.

Randomized trial showed significant improvement in headache frequency with multiple treatments.

Conclusions

► Migraine is common but unrecognized.

► Keep migraine and its variants in the differential diagnosis.