Migraines: Oh, my

aching head!

Saad Kanaan, M.D.

Neurologist

Via Christi Clinic, P.A.

848 N. St. Francis, Suite 3901

Wichita, KS 67214

Phone: 316-268-8500

My background Internship year in internal medicine: 2010-2011

General neurology residency: 2011-2014

Via Christi Clinic: 2014-current

Main interest in Neurology: Migraine and other

headache disorders

Main interests in life: soccer and traveling

Disclosures Hired by Via Christi Clinic

No affiliation with any pharmaceutical companies

Some parts of this talk represent my personal

experience

Objectives Discuss the epidemiology of migraine

Define migraine and chronic migraine

Identify common symptoms of migraine

List some migraine triggers

Explore treatment options

Epidemiology In the United States, more than 30 million people have

1 or more migraine headaches per year.

Approximately 75% of all persons who experience migraines are women.

The economic cost resulting from migraine-related loss of productive time in the US workforce is more than $13 billion per year, most of which is in the form of reduced work productivity.

The incidence of migraine peaks in girls between age 12-17

• Stewart WF et al. (1991) Age- and sex-specific incidence rates of migraine with and without visual aura. Am J

Epidemiol 134:1111-20.

• Kors EE et al. (1999) Genetics of primary headaches. Curr Opin Neurol 12:249-54.

• Lipton RB et al. (2002) Migraine in the United States: epidemiology and patterns of health care use. Neurology

58:885-94.

Migraine: DefinitionPersonal definition:

Migraine disorder is the tendency to develop recurrent

migraine attacks.

Migraine attack: an episode of “brain dysfunction”

causing a variety of nervous system symptoms, most

common of which is a moderate to severe headache.

Chronic migraine headache: More than 15 headache

days/month lasting more than 4 hours/day.

Migraine: Prodrome Migraine prodrome is the phase that preceded the

migraine attack and could last several hours.

Symptoms:

Heightened sensitivity to light, sound, and odors

Sleepiness, fatigue, or uncontrollable yawning

Food cravings

Mental and mood changes (e.g. depression, anger,

euphoria)

Excessive thirst

Constipation or diarrhea

Migraine: Aura Aura are complex neurological symptoms that precede

or accompany migraines or occur in isolation. Common

aura include:

Visual aura: spots, flashing lights, floater, zigzag lines.

These typically move around, change in size, and

persist with closing eyes.

Migraine Aura (cont.) Sensory aura: tingling, burning, pins and needles…etc.

that usually travel from one site to the other

Dizziness: spinning sensation or lightheadedness, in

real life, this is one of the most common symptoms of

migraine.

Motor: uncommon, weakness on one side of the body

mimicking stroke.

Migraine Triggers Each person has their own triggers

None of the triggers are universal to all patients

Learning your own triggers and avoiding them can be

an effective tool in fighting your migraines!

Common Triggers

Hormonal changes:

menstruation, pregnancy

Stress let down

Excessive or insufficient

sleep

Medications

Smoking

Bright or fluorescent lighting

Strong odors

Head trauma

Weather changes

Motion sickness

Lack of exercise

Fasting or skipping meals

Red wine

Certain foods:

Artificial sweeteners (eg,

aspartame, saccharin)

Monosodium glutamate (MSG)

Citrus fruits

Foods containing tyramine (eg,

aged cheese)

Meats with nitrites

Treatment 2 main treatment modalities:

1. Migraine prevention

2. Migraine abortion

The best treatment plan should cover both modalities

Most intractable headaches are easy to treat if you

follow the simple plan above.

Migraine abortion Home medications (oral, injections, nasal)

Infusions (ER, infusion center, clinic)

Devices:

Ceflay

Migraine prevention Oral medications:

Blood pressure medications

Antidepressants

Antiepileptics (seizure medications)

Miscellaneous

Injections:

Onabotulinum A (BOTOX)

Migraine prevention:

Indications and goalsIndications

Frequency of migraine attacks > 2/month

Duration of individual attacks > 24 hours

The headaches cause significant disability

Abortive therapy fails or is overused

Goals:

Reduce attack frequency, severity, and/or duration

Improve responsiveness to abortive medications

Reduce disability

Onabotulinum toxin A

for chronic migraine Only approved for Chronic migraine

Candidates must have failed 3 other oral preventative

agents

Treatment cycles every 12 weeks

Injection Paradigm

How do we know it works? PREEMPT trial (Phase III REsearch Evaluating

Migraine Prophylaxis Therapy)

Largest study of chronic migraine (1384 participants)

Responder defined as 50% reduction in headache days

or more

Results analyzed in this study and follow up study

ResultsResponders:

After 1st treatment: 49.3%

If no response after 1st treatment, 11.3% respond after

2nd treatment

If no response after 2nd treatment, 10.3% respond after

3rd treatment

Onabotulinum toxin A:

Pros. and Cons. Cons:

Side effects

Needle phobia

Cost

Pros:

Does not interact with other medications

All side effects are temporary

No effect on major organs (stomach, kidney, liver,

heart…etc.)

Assured compliance

Every 12 weeks rather than daily

Very effective

Kanaan’s way of treating

migraine Seek first to understand1

Then to be understood1

32 point checklist of items that cover all aspects of migraine symptoms, triggers, prior and current medication use, and red flags.

Full neurological examination

Individualized workup and treatment plan:

Abortive medications including infusions

Prophylactic medications including Botox

1. Stephen, RC. (2009) The 7 habits of highly effective people .

The End

Thank you!

Questions?