HEADACHE
CHAIRMAN : DR. P.G.MANTUR
MODERATOR : DR. AVINASH
PRESENTER : DR. SNEHA
RED FLAGS
1. Sudden onset of headache
2. First severe headache
3. “Worst” headache
4. Vomiting that precedes headache
5. Worsening over days or weeks
6. Pain induced on bending , coughing , lifting
7. Onset after 55 years
8. Associated with fever
9. Pain associated with local tenderness like in the region of temporal
artery
Presymptomatic hyperexcitability increases brain stem response to triggers
Release of neurotransmitters
5-HT, NE ,DA ,GABA ,NO, CGRP, Substance P
Neurotransmitter activates the trigeminal nucleus
Dilation of
meningeal Activation of
vessels Activation Activation of cervical
{THROBBING} Activation of of cortex hypothalamus trigeminal
area postrema and {HYPERSENSITIVTY} system
thalamus {MUSCLE PAIN}
PHENOTHIAZINE
Promethazine
• Available PO IM PR
• Dose 25-50mg 6hrly
• Blocks dopamine and histamine receptors
Prochlorperazine
• Available PO IM IV PR
• Dose 5-10mg 6hrly
• Blocks dopamine receptors
MIGRANE SPECIFIC MEDICATIONS
FAST ONSET/ SHORT DURATION SLOW ONSET/LONG
DURATION
• Sumatriptans
• Naratriptan
• Rizatriptans • frovatripton
• Zomitriptan
• Almotriptan
• Eletriptan
• treximet
PRECAUTIONS
• Ischemic heart disease
• Stroke
• High risk for CAD
• Pregnancy
• Hemiplegic or basilar migraine
• Ergots
• Use with SSRI?
POINTS TO BE REMEMBERED :
• Reasonable first choice for patients with moderate to severe disability from migraines
• Limit use to 2-3 days/week
• Patients who fail on triptan often respond to another
• Do not use one triptan within hours of another
MECHANISM OF ACTION
• 5HT-1B/1D agonist
• Inhibit release of CGRP and substance p
• Inhibit activation of the trigeminal nerve
• Inhibit vasodilation in the meninges
SIDE EFFECTS : Flushing , Chest pressure or heaviness , Throat
tightness , Paresthesia , Dizziness fatigue, drowsiness
ACUTE TREATMENT : ERGOTS
• Constrict peripheral and cranial blood vessels
• Binds to 5HT , NE , DA , alpha and beta receptors
CONTRAINDICATION :
• CAD or CVD , uncontrolled HTN
• Hemiplegic or basilar migraine
• Pregnancy and breast feeding
BETA BLOCKERS
FDA approved for migraine prevention
• Propranolol 60-240mg PO OD or divided BID / TID
• Timolol 10-30mg PO daily or in two divided doses
Limited evidence for migraine prevention
• Nadalol 20-240mg po OD
• Atenolol 50-150mg po daily divided BD
• Metrolol 100-200mg daily or BD
ADVANTAGES DISADVANTAGES
• Thoroughly studies and widely • Side effects – fatigue dizziness
used depression exercise intolerance
• Avoid in patients with severe
• Timolol and propranolol are asthma , depression ,
FDA approved bradycardia
• Good choice for patient with
HTN , CAD , tremor or anxiety
CALCIUM CHANNEL BLOCKERS
• Although the mechanism by which calcium antagonist affect migraine
is not known
• Vasoconstriction prevention of platelet aggregation and alteration in
release and reuptake of serotonin
• Verapamil in doses of 80-160 mg 3 times a day reduces the incidence
of migraine with aura
TRICYCLIC ANTIDEPRESSANTS
• Amitriptyline 10-200mg nightly
• Nortriptyline 10-150mg nightly
• Desipramine 25-200mg nightly
• Imipramine 10-200mg nightly
• Doxepin 10-200mg nightly
ADVANTAGES DISADVANTAGES
• Inexpensive • None are FDA approved
• Once daily dosing • Side effect sedation , weight gain
• Good choice for patients with , dry mouth , urinary retention
insomnia neuropathy mood • Avoid in seizures disorders,
disorders cardiac conduction abnormalities
• Fibromyalgia , BPH
NSAIDS
• Diclofenac 75mg PO BID
• Naproxen 500mg PO BID
• Meloxicam 7.5-15mg PO BID
• Celecoxib 200mg PO DAILY
• ASPIRIN 81-325 MG PO DAILY
ANTIEPILEPTIC DRUGS
FDA approved for migraine prevention
• Divalporex sodium
• Topiramate
Limited evidence for migraine prevention
• Gabapentine
• Lamotrigine
• Levetiracetam
• zonisamide
DIVALPOREX SODIUM
• Increases GABA and stabilizes nerve membrane activates thresholds
• Dose 500-1500mg BID or TID
• s/e – tremor , drowsiness , nausea vomiting , weight gain
TOPIRAMATE
• Blocks NMDA receptors
• Blocks voltage dependent sodium channels
• Enhances GABA
• Weakly inhibits carbonic anhydrase
• Dose 25 mg OD , Titrate by 25mg every week
• No additional benefit seen in doses >100mg
• S/E – paresthesia, cognitive problem , fatigue , dizziness , nausea
GABAPENTINE
• Enhances GABA activity
• Binds to alpha -2-delta subunit of voltage gated calcium channel
• Inhibits high voltage activated calcium current
• Results is decreased synaptic transmission
BOTULINUM TOXIN
• Recently FDA approved for chronic migraine
• Dose 155-195 units injected into muscles of face and neck
• blocks release of substance P and CGRP inhibits peripheral signals to
CNS and and Blocks central sensitization
REFERENCES
• HARRISON TEXTBOOK
• ADAM AND VICTOR’S PRINCIPLES OF NEUROLOGY
• INTERNATIONAL CLASSIFFICATION OF HEADACHE
DISORDER SOCIETY GUIDELINES
THANK YOU
