Migraine 2

Migraine

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UTMB Department of Otolaryngology

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Grand Rounds March 2005

Jeffrey Buyten, MD „ David C. Teller, MD „ Francis B. Quinn, MD „

Prevalence „ „

Familial Young, healthy women; F>M: 3:1 – 17 – 18.2% of adult females – 6 – 6.5% adult males

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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

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Common misdiagnoses for migraine: – Sinus HA – Stress HA

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Referral to ENT for sinus disease and facial pain.

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Migraineurs more likely to have motion sickness. Half of Meniere’s patients claim to have migrainous symptoms. BPPV

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$13 billion/year in lost productivity 1/3 participants in American Migraine Study II missed work in prior 3 months

Migraine Definition „

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.

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IHS Diagnostic criteria: migraine w/o aura – HA lasting for 4-72 hrs – HA w/2+ of following: ƒ Unilateral ƒ Pulsating ƒ Mod/severe intensity. ƒ Aggravated by routine physical activity. – During HA at least 1 of following ƒ N/V ƒ Photophobia ƒ Phonophobia

History, PE, Neuro exam show no other organic disease. At least five attacks occur

Migraine Subtypes „

Basilar type migraine

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Retinal or ocular migraine

– Dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, bilateral paresthesias, altered consciousness. – Simultaneous bilateral visual symptoms. – No muscular weakness.

– Repeated monocular scotomata or blindness < 1 hr – Associated with or followed by a HA

Migraine Subtypes „ „

Menstrual migraine Hemiplegic migraine – Unilateral motor and sensory symptoms that may persist after the headache. – Complete recover

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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:

ƒ Current of previous history of IHS migraine. ƒ Migrainous symptoms during two or more attacks of vertigo. ƒ 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. ƒ Calcitonin gene related peptide ƒ Neurokinin A ƒ Substance P

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Extracranial arterial vasodilation. – Temporal – Pulsing pain. Extracranial neurogenic inflammation. Decreased inhibition of central pain transmission. – Endogenous opioids.

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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 ƒ Activates trigeminal afferents – Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes. ƒ Alters blood-brain barrier. – Associated with a low flow state in the dural sinuses.

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Auras – Vision – most common neurologic symptom – Paresthesia of lips, lower face and fingers… 2nd most common – Typical aura ƒ Flickering uncolored zigzag line in center and then periphery ƒ Motor – hand and arm on one side ƒ Auras (visual, sensory, aphasia) – 1 hr

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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 ¾stress ¾head and neck infection ¾head trauma/surgery ¾aged cheese ¾dairy ¾red wine ¾nuts ¾shellfish ¾caffeine withdrawal ¾vasodilators ¾perfumes/strong odors ¾irregular diet/sleep ¾light

Treatment „ Abortive

– Stepped – Stratified – Staged „ Preventive

Abortive Therapy „

Reduces headache recurrence. Alleviation of symptoms. Analgesics

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Antiphlogistics

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Vasoconstrictors

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– Tylenol, opioids… – NSAIDs

– Caffeine – Sympathomimetics – Serotoninergics

ƒ Selective - triptans ƒ Nonselective – ergots

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Metoclopramide

Abortive care strategies „

Stepped

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

Analgesics – Tylenol, NSAIDs… Vasoconstrictors – sympathomimetics… Opioids (try to avoid) - Butorphanol Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan, zomatriptan.

– Limited by patient compliance.

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Stratified

– Adjusts treatment according to symptom intensity. ƒ ƒ ƒ

Mild – analgesics, NSAIDs Moderate – analgesic plus caffeine/sympathomimetic Severe – opioids, triptans, ergots…

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

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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.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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Landy, S. Migraine throughout the Life Cycle: Treatment through the Ages. Neurology. 2004; 62 (5) Supplement 2: S2-S8. Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235. Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of Migraine in Adults. Up To Date online. 2005. Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the labels that headache sufferers apply to their headaches. Neurology. 2002; 58(9) Supplement 6: S21-S26. Cady, RK, Schreiber, CP. Sinus headache or migraine?: Considerations in making a differential diagnosis. Neurology. 2002; 58 (9) Supplement 6: S10-S14. Perry, BF, Login, IS, Kountakis, SE. Nonrhinologic headache in a tertiary rhinology practice. Otolaryngology – Head and Neck Surg 2004; 130: 449-452. Daudia, AT, Jones, NS. Facial migraine in a rhinological setting. Clinical Otolaryngology and Allied Sciences. 2002; 27(6): 521-525. Spierings, EL. Migraine mechanism and management. Otolarynogol Clin N Am 36 (2003): 1063 – 1078. Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-1670. Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Textbook of Otolaryngology Grand Rounds Archive. 2001. http://www.utmb.edu/otoref/Grnds/HA-facialpain-2001-0131/HA-facial-pain-2001.doc Ondo, WG, Vuong KD, Derman, HS. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel design study. Cephalalgia 2004 (24): 60-65.