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Understanding Migraines: Prevalence and Treatment

This document discusses migraine, including its prevalence, definition, subtypes, mechanisms, clinical manifestations, and treatment approaches. Some key points: - Migraine is common but often underdiagnosed, affecting 17-18% of adult females and 6-6.5% of adult males. - It is characterized by moderate to severe pulsating headaches lasting 4-72 hours. Associated symptoms may include nausea, sensitivity to light/sound, and visual disturbances. - Treatment involves acute abortive therapies like analgesics, triptans, and ergots as well as preventive medications to reduce frequency like beta blockers and amitriptyine. - Migraine has a complex neurovascular

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335 views23 pages

Understanding Migraines: Prevalence and Treatment

This document discusses migraine, including its prevalence, definition, subtypes, mechanisms, clinical manifestations, and treatment approaches. Some key points: - Migraine is common but often underdiagnosed, affecting 17-18% of adult females and 6-6.5% of adult males. - It is characterized by moderate to severe pulsating headaches lasting 4-72 hours. Associated symptoms may include nausea, sensitivity to light/sound, and visual disturbances. - Treatment involves acute abortive therapies like analgesics, triptans, and ergots as well as preventive medications to reduce frequency like beta blockers and amitriptyine. - Migraine has a complex neurovascular

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danish sultan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

Migraine

„ UTMB Department of
Otolaryngology
„ 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
„ 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 criteria: Migraine/aura (3 out of 4) „ IHS Diagnostic criteria: migraine w/o
– One or more fully reversible aura aura
symptoms indicates focal cerebral – HA lasting for 4-72 hrs
cortical or brainstem dysfunction. – HA w/2+ of following:
– At least one aura symptom ƒ Unilateral
develops gradually over more ƒ Pulsating
than 4 minutes.
– No aura symptom lasts more than ƒ Mod/severe intensity.
one hour. ƒ Aggravated by routine
– HA follows aura w/free interval of physical activity.
less than one hour and may begin – During HA at least 1 of following
before or w/aura. 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
– 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
Migraine Subtypes
„ 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:
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

„ 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
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.
„ 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
„ 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
– Tylenol, opioids…
„ Antiphlogistics
– NSAIDs
„ Vasoconstrictors
– Caffeine
– Sympathomimetics
– Serotoninergics
ƒ Selective - triptans
ƒ Nonselective – ergots
„ Metoclopramide
Abortive care strategies
„ Stepped
– Start with lower level drugs, then switch to more specific drugs
if symptoms persist or worsen.
ƒ Analgesics – Tylenol, NSAIDs…
ƒ Vasoconstrictors – sympathomimetics…
ƒ Opioids (try to avoid) - Butorphanol
ƒ Triptans – sumatriptan (oral, SQ, nasal), naratriptan, rizatripatan,
zomatriptan.
– Limited by patient compliance.
„ Stratified
– Adjusts treatment according to symptom intensity.
ƒ Mild – analgesics, NSAIDs
ƒ Moderate – analgesic plus caffeine/sympathomimetic
ƒ 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.
References
1. Landy, S. Migraine throughout the Life Cycle: Treatment through the Ages. Neurology. 2004; 62
(5) Supplement 2: S2-S8.
2. Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.
3. Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of Migraine in
Adults. Up To Date online. 2005.
4. 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.
5. Cady, RK, Schreiber, CP. Sinus headache or migraine?: Considerations in making a differential
diagnosis. Neurology. 2002; 58 (9) Supplement 6: S10-S14.
6. Perry, BF, Login, IS, Kountakis, SE. Nonrhinologic headache in a tertiary rhinology practice.
Otolaryngology – Head and Neck Surg 2004; 130: 449-452.
7. Daudia, AT, Jones, NS. Facial migraine in a rhinological setting. Clinical Otolaryngology and
Allied Sciences. 2002; 27(6): 521-525.
8. Spierings, EL. Migraine mechanism and management. Otolarynogol Clin N Am 36 (2003): 1063 –
1078.
9. 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.
10. 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-facial-
pain-2001-0131/HA-facial-pain-2001.doc
11. 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.

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