Case-Based TeachingDidactic Component:

Headache & Migraine

Department of Neurology

University of Miami School of Medicine

Headache & MigraineLearning Objectives

• Describe the diagnostic criteria for migraine

• Describe when & how to perform a diagnostic evaluation in a pt w/ headache

• Describe the appropriate abortive & prophylactic therapies for migraine

Diagnosis & Management of Headaches Primary vs. Secondary Headaches

• primary headache– a condition in which headache is a primary

manifestation & no underlying disease is present, e.g., migraine and cluster

– due to chronic conditions w/recurrent acute attacks

• secondary headache– a condition in which headache is a secondary

manifestation of an underlying disease process– often due to diseases that require both urgent &

prolonged care

Diagnosis & Management of Headaches Goals of the Clinician

• diagnose the cause of headache

• provide emergency therapy

• provide a means for long-term care

Primary HeadachePractical Migraine Definition

• genetic condition in which a person has a predisposition to suffering recurrent episodes of any of the following:– headache– GI dysfunction– neurologic dysfunction

Primary HeadacheMigraine Pathophysiology

• autosomal dominant inheritance; multiple genes• origin is neurologic, not vascular:

– focal decrease in brain serotonergic activity– dysfunction of brainstem serotonergic &

noradrenergic pain pathways– vasoactive neuropeptide release by CN V– secondary arterial dilatation, constriction

Primary HeadacheMigraine Epidemiology

• by far, most common cause of headache• prevalence estimates:

– range of most estimates is 1-31%– more likely prevalence is 70%

• problems in determining prevalence include:– no objective pathology or diagnostic test– variable definitions based on clinical criteria– variable populations & methods of data collection

Primary HeadacheMigraine Triggers

• hormonal changes– stress, stress letdown, hyperthyroidism– menarche, menses, pregnancy, BCPs, menopause

• changes in sleep, eating habits, weather

• smoke, scents, fumes

• foods– esp. nitrates, MSG, tyramine, aspartame, citrus

• alcohol (esp. red wine)

• exercise, head trauma, motion

Primary HeadacheMigraine Phases

• prodrome• aura• headache• postdrome

• mood changes

• difficulty concentrating

• fatigue, malaise

• autonomic symptoms

• food cravings– esp. foods high in

serotonin, e.g., chocolate, bananas, peanut butter

Primary HeadacheMigraine Phases

• prodrome• aura• headache• postdrome

• visual– photopsia, scintillating scotomata

– silvery, clear

– fortification spectra, zig-zag lines

– wavy lines, heat-off-the-pavement

– spots, dots, bubbles

– vibrating, evolving, coalescing

• other (often migratory, stereotypical)– numbness, hemiparesis, aphasia

– ataxia, vertigo, tinnitus, diplopia

Primary HeadacheMigraine Phases

• prodrome• aura• headache• postdrome

• headache characteristics– unilateral, bilateral, variable location– throbbing, pulsating, pounding,

pressure, squeezing, dull, aching– severe, moderate, mild, absent– hours, days, weeks

• associated symptoms– photophobia, phonophobia– nausea, vomiting– cramping, flatulence, diarrhea– hypertension (dysautonomia)

Primary HeadacheMigraine Phases

• prodrome• aura• headache• postdrome

• fatigue, malaise• difficulty concentrating• mood changes• muscle aches• scalp tenderness

Primary HeadacheIHS Definition of Migraine w/o Aura

• frequency – > 5 episodes

• duration – 4-72 h untreated

• HA quality (> 2)– unilateral– pulsating– moderate or severe w/physical activity

• associated features (> 1)– nausea &/or vomiting– photo- & phonophobia

• no other cause of sxs

Useful for scientific studies, but impractical for daily use

Primary HeadacheTypes of Migraine

• migraine w/o aura– common

• migraine with aura – classic– hemiplegic– hemiparesthetic– aphasic– basilar– retinal, ocular– ophthalmoplegic

• migraine aura w/o HA – acephalgic– accompaniments– equivalents– abdominal– benign paroxysmal

vertigo

Primary HeadacheDifficulties in Diagnosing Migraine

• rationalization of symptoms– “regular, mild, tension, or sinus” headaches

– “GI virus, food poisoning, IBS/spastic colon”

– interview significant other

• unknown family history– symptoms most prominent in early adulthood:

• pt was too young to realize parent had headaches• pt no longer lives with parents or siblings

– interview relatives directly

Primary HeadacheConditions Due to (or Related to) Migraine

• episodic tension headache• sinus headache• “regular” or “ordinary” headache• premenstrual syndrome• irritable bowel syndrome/spastic colon• recurrent vertigo (?Meniere’s disease)• motion sickness• postconcussion/posttraumatic headache• transient global amnesia• atypical chest pain

Primary HeadacheImportance of Diagnosing Migraine

• common

• disabling

• avoiding iatrogenic disease– hysterectomy/oophorectomy– abdominal surgery– sinus and ear surgeries– anxiolytics, antidepressants

Primary HeadacheMigraine Abortive Therapy

• selective 5-HT1D/1B agonists– sumatriptan (Imitrex)– naratriptan (Amerge)– rizatriptan (Maxalt)– zolmitriptan (Zomig)

• nonselective 5-HT1D agonists– Cafergot, Wygraine– DHE 45

• nonspecific combinations– Midrin, Excedrin Migraine

– Fiorinal, Fioricet, Esgic

– BC & Goody Powders

• nonspecific single agents– aspirin, Tylenol, NSAIDs

– Vistaril, narcotics

• phenothiazine-related– Thorazine, Compazine,

Phenergan

Primary HeadacheMigraine Prophylactic Therapy

• beta-blockers– propranolol (Inderal)– nadolol (Corgard)– atenolol (Tenormin)– timolol (Blocadren)

• verapamil (Calan, Isoptin, Verelan)

• valproic acid (Depakote)• topiramate (Topamax)• lamotrigine (Lamictal)• naproxen (Naprosyn)• nortriptyline (Pamelor)• amitriptyline (Elavil)• Mg gluconate or oxide• +/- feverfew

Secondary HeadacheSuggestive Headache Features

• first, worst, persistent, or different

• onset after:– Valsalva’s maneuver– head trauma– age 50

• exacerbation with head position

Secondary HeadacheSuggestive Associated Features

• focal neurologic signs or symptoms

• change in consciousness• fever• seizure• nuchal rigidity• papilledema• (pre)retinal hemorrhages

• history of:– bleeding diathesis– hypercoagulable

state– cancer– HIV or AIDS risk

factors• daily or near-daily

use of analgesics

Secondary HeadacheGiant-Cell (Temporal) Arteritis

• HA onset after age 50• Incidence s w/ age• Associated sxs & signs:

– temporal tenderness– jaw claudication– polymyalgia rheumatica

(neck/shoulder/hip pain)– fever, night sweats– weight loss– monocular visual loss

(arteritic AION)– MI or stroke (esp. PCA

territory)– anemia, ESR & CRP

• Management:– draw ESR & CRP– if no visual sxs, start:

• prednisone 80 mg qd

– if visual sxs, start:• IV methylprednisolone 1

g qd x 5 d, then prednisone 80 mg qd

– arrange temporal artery biopsy (ophthalmologist or neurosurgeon) within 2 weeks of starting steroids

– attempt to taper prednisone to off only after sxs resolve

Secondary HeadacheAnalgesic Rebound

• most common cause of daily chronic HA• relationship to migraine:

– more common in migraineurs– renders migraine therapies ineffective

• caused by:– excessive analgesic use (> 2 d/wk)– any analgesic (over-the-counter to narcotic)

• treatment:– withdraw analgesic, begin migraine prophylactic– sedate (e.g., w/ Vistaril) for 3-5 d (d pain 3d-4wk)

Secondary HeadacheDiagnostic Testing

• brain CT scan (w/ & w/o contrast)

• brain MRI (w/ & w/o contrast) and MRV

• lumbar puncture

• cerebral angiogram

• sed rate (ESR), C-reactive protein (CRP)

• other labs (CBC, chemistries, etc.)

Secondary HeadacheEmergency Management

First ConsiderationSurgical Therapy

• subdural hematoma• brain tumor• brain abscess• ICH• SAH• AVM• hydrocephalus

First ConsiderationMedical Therapy

• meningitis• cerebral vein

thrombosis• giant-cell arteritis• systemic illness

The End

Department of Neurology

University of Miami School of Medicine