DOCTOR, MY HEAD HURTS!
| MIGRAINES —David Roby, MD, Assistant Professor, Department of Neurology, Temple University
School of Medicine, Philadelphia, PA
|
| Introduction: ≤10% of patients with migraine have one attack per week (some people have several attacks
per week); onset usually gradual; ≈50% of patients with migraine may have explosive onset in morning
that awakens them from sleep (“crash” or “early morning” migraine); migraine typically lasts 4 to 72 hr
in adults, few hours in children (may subside without treatment); ≈33% of patients (particularly children)
may have bilateral migraine; symptoms—throbbing; light and sound sensitivity; sensitivity to odor; nausea;
association with menstrual cycle; ≈50% of migraine patients diagnosed with migraine; 50% developed
migraine at age <20 yr; use of over-the-counter medications common (effective in 10%-20%);
severe migraine can be as disabling as quadriplegia and psychosis; positive family history common
|
| Vascular theory of migraine: 1941—developed by Wolff; aura associated with vasoconstriction; headache
due to dilatation and throbbing; 1980 to 2000—studies present notion that migraine is brain disease;
vascular changes present, but not initiating force; vascular changes secondary; neurogenic inflammation
demonstrated; phenomenon of abnormal central processing, with exaggerated sensitivity to stimuli
|
| Diagnosis: migraine most common cause of episodic disabling headache seen in primary care; may be
misconstrued as sinus disease (location often frontal near sinuses, and may subside with sinus medication;
headaches may be triggered by allergen or be seasonal); objective criteria for active sinus disease
not present; headaches often respond dramatically to migraine therapy
|
| Headache disorders: primary—1) tension; affects 90% of people; 2) migraine; affects 28 million people
(18% of women, 6% of men); 3) cluster; affects 1% of men; primary headache disorders chronic and recurring;
90% to 95% of all headaches; other primary headache disorders, eg, ice cream headache (“brain
freeze”); secondary—secondary to specific cause, eg, hydrocephalus or brain tumor
|
| Patient history: age of onset; frequency and duration; disability and severity; changes over time; location;
pattern; what makes headache better or worse; consider variants of migraine (eg, exertional migraine);
medication history; family history; comorbidities (eg, anxiety disorder, depression); SNOOP
mnemonic— systemic symptoms (eg, fever, weight loss, malaise) or serious illness (eg, advanced HIV,
metastatic cancer); neurologic symptoms or findings (eg, inability to concentrate, forgetfulness, vision
disturbances); onset (sudden onset of severe headache may indicate vascular event); older (headaches
beginning at age >50 yr may indicate secondary cause); prior headache history (compare current headaches
to past headaches)
|
| Migraine without aura: 80% to 85% of migraines; persist 4 to 72 hr; unilateral; often throb and aggravated
by movement (eg, shaking or leaning forward); most migraines of moderate or severe intensity; accompanied
by nausea, vomiting, light and sound sensitivity, and sensitivity to odor
|
| Migraine with aura: 15% of migraines; “classic migraine”; visual aura—fortification spectrum common
(reminiscent of walls of fort; patients often describe zigzag line); lasts for 15 to 20 min in most patients;
some patients develop aura only (retinal migraine; acephalgic migraine); sensory disturbances—often
travel, eg, numbness may begin in hand, subside after several minutes, and jump to face; may affect
speech for 10 min and develop into headache; often misconstrued in older individuals as vascular event;
aura phase linked to spreading depression of Leao (electrical event that travels over surface of brain);
aura may last ≤1 hr (if patient’s description of episode includes inability to speak for 2 hr, consider other
pathology)
|
| Nonpharmacologic treatment (behavioral): identify triggers—red wine; prolonged fasting; sleep disturbance;
exposure to high altitude; food containing monosodium glutamate (MSG); highly restrictive diet
not recommended; many patients have 2 or 3 triggers that should be avoided; recent study suggests migraine
can be preceded by behavioral changes (eg, elation/energy, repeated yawning, chocolate cravings)
|
| Triptans: 5-HT1B and 5-HT1D receptor agonists; pharmacologic properties similar, but patients tend to respond
better to one than to another; patients should try agent more than once (4 or 5 tries recommended);
different agents should be tried until optimal response reached; use of 2 triptans in one day not recommended;
faster-acting triptans—onset of almotriptan (Axert) ≈30 min; patients sensitive to quicker-acting
triptans may experience chest discomfort, tingling, dysphoria, and sleepiness, and may do well with
slower-acting agents (eg, frovatriptan [Frova] and naratriptan [Amerge]; onset 1-2 hr); triptans (both
faster- and slower-acting) contraindicated in patients with (or with risk factors for) coronary artery disease
|
| Failure to respond to triptans: check diagnosis (eg, work-up with imaging studies); check for Arnold-
Chiari malformation (in patients 20-40 yr of age; headache often posterior and immediately precipitated
by coughing or sneezing; perform magnetic resonance imaging [MRI]); consider formulations (eg, patient
who vomits with headache may need injectable therapy or nasal spray); consider refractory headache
(analgesic rebound headache or medication overuse syndrome) especially with use of agents that
contain butalbital and caffeine, eg, butalbital, acetaminophen, and caffeine (eg, Fioricet, Esgic), butalbital,
aspirin, and caffeine (eg, Fiorinal); similar effects seen with butalbital and acetaminophen (eg, Phrenilin);
butalbital-containing headache therapy removed from market in Germany (currently being
debated in United States)
|
| Prophylactic therapy: β-blockers (eg, propranolol [Inderal]); calcium channel blockers; older tricyclic
antidepressants; studies on selective serotonin reuptake inhibitors (SSRIs) unimpressive; high comorbidity
of uncontrolled migraine in depression (use antidepressant); serotonin syndrome with use of SSRI
and triptan rare; low dose of amitriptyline (Elavil) at night promotes sleep, with antiheadache and mild
antidepressant effects; topiramate (Topamax)—approved by Food and Drug Administration (FDA) in August
2006; patients who took 25 mg daily described tingling (acral paresthesia); low dose usually well
tolerated (titrate up to 50-100 mg); data show 50% decrease in migraine frequency in 50% of patients,
≥80% decrease in 20% of patients; consider in patients with 5 to 10 migraines per month; consider other
prophylactic approaches (eg, behavioral therapy, biofeedback, relaxation techniques)
|
| Summary: identify headache pattern; exclude serious organic disease; start reasonable program; advise
patients to keep headache diary to document progress
|
| Menstrual migraine: affects >60% of women with migraine; headache precedes menses by 1 to 2 days
and may last 3 to 5 days; frovatriptan—pulse prophylaxis not approved by FDA (3 controlled studies
show benefit); once daily for 3 to 5 days; expensive ($15–$25 per pill; consider patient’s prescription
plan)
|
| ADDITIONAL THOUGHTS ON HEADACHES —Neil H. Raskin, MD, Professor of Neurology, University
of California, San Francisco, School of Medicine
|
| Syndromes that require imaging studies: brain tumors—headaches usually nondescript and not particularly
severe; if no evidence of benignity, proceed to imaging studies; headache occurs abruptly with
coughing, bending, or lifting and lasts few seconds to 1 to 2 min; sinusitis or meningitis—patients often
keep head rigid; slight movement causes headache; requires imaging study and lumbar puncture (LP)
|
| Evidence of benignity: change in severity and frequency; determine onset of all headaches; location of
headache (ask patient to point to where headache most severe); ask, “is it ever on the other side?” (determine
whether headache multifocal); ask whether pain feels pulsating or pounding; unilateral headache
with nausea not highly specific for benignity; “icepick” headaches (sharp, momentary jabs of pain; usually
multifocal); headaches ever linked with menses; headaches provoked by hunger, change in weather,
or sustained exertion (eg, headache during third mile of 5-mile run; “effort migraine”); hereditary headache
|
| Tension headache: pain in entire head; pressing pain; muscles not particularly contracted; studies show
patients as responsive to triptans as patients with migraine; no support for presumption that patient under
psychologic stress or has tight muscles (speaker has never recognized tension headache as bonafide diagnosis)
|
| Migraine: mechanism recognized by activators (eg, alcohol, food) and deactivators (eg, sleep, triptans);
emotional change generates biochemical change and may activate or deactivate headache; headache that
has never awakened patient from sleep likely benign; in patients with somatic disease (eg, carcinoma
metastatic to bone), pain appears without rhythm or pattern; migraine characteristically starts 1 to 2 hr
after awakening, peaks midafternoon, and resolves by bedtime; ask whether pain mild, moderate, or severe;
pain severity has no diagnostic sensitivity (assess effect of severe pain on patient’s function); do
not rule out other conditions (eg, brain tumor, giant cell arteritis) in patients who respond to triptans
|
| Abdominal pain in childhood: associated with migrane in adulthood; nausea and diarrhea with headache
highly likely migraine; children often describe pounding, sharp, or stabbing pain; attacks often provoked
by missing meals, bright lights, odors, or loud sounds; headaches often milder than abdominal pain (ask
about headache); children who need treatment (eg, cyproheptadine) to prevent episodes usually 7 to 14 yr
of age; some clinicians may attribute headache and abdominal pain to peer pressure or pressure from parents
to do well in school
|
| Changes in headache pattern: patients with long history of headache rarely awaken from pain; changes
(eg, left-sided aura switches to right side, or aura presents with no headache) often concern patients;
changes in headache pattern require further analysis
|
| Cluster headache: more common in men than women; starts at age 30 to 50 yr; eyeball pain that lasts 40
to 45 min; 1 to 3 attacks daily over 6 wk, resolves, and returns after 1 yr; patients who describe having
pain “all the time” may be experiencing low level of pain superimposed over explosive pain; treatment—
9 mg of melatonin every night (side effects include grogginess next day); verapamil (>240 mg daily;
480 mg, 540 mg, or 720 mg daily often used) remarkably effective; lithium specific to cluster headache
(ineffective for migraine); topiramate; gabapentin; propranolol and amitriptyline effective for migraine
but ineffective for cluster headache; preventive drugs have same efficacy (55%-60%) in cluster as in migraine;
choice of initial drug dependent on side effect profile; speaker rarely uses valproate due to weight
gain; propranolol and gabapentin also can cause weight gain; topiramate and zonisamide (Zonegran) do
not cause weight gain (appetite suppressants); calcium channel blockers (start with amlodipine [eg, Norvasc]
and follow with verapamil) do not affect appetite and do not interfere with cognition; failure of one
calcium channel blocker does not predict failure with another; response to drug by patient’s family member
does not predict patient’s response
|
| More about migraine with aura: if patient has aura, mother or father likely to have similar aura (ask
about aura symptoms); oral contraceptive pills or estrogen increase risk for stroke in these patients; important
to distinguish migraine with aura from migraine without aura; aura expression of migraine; headache
not necessary for migraine; vertigo and dizziness (usually nonrotary, rocking, or kinesigenic) can be
main symptoms; dizziness can be accompanied by seeing spots; ask about spots, especially if fainting or
dizziness dominant symptoms
|
Suggested Reading
Couch JR: Headache to worry about. Med Clin North Am 77:141, 1993; Ferrari MD et al: Oral triptans (serotonin
5-HT(1B/1D) agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 358:1668,
2001; Frishberg BM: The utility of neuroimaging in the evaluation of headache in patients with normal neurologic
examinations. Neurology 44:1191, 1994; Goadsby PJ et al: Migraine--current understanding and
treatment. N Engl J Med 346:257, 2002; Lipton RB et al: Prevalence and burden of migraine in the United
States: data from the American Migraine Study II. Headache 41:646, 2001; Pascual J et al: Cough, exertional,
and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 46:1520, 1996;
Schwartz BS et al: Epidemiology of tension-type headache. JAMA 279:381, 1998; Silberstein SD et al:
Butalbital in the treatment of headache: history, pharmacology, and efficacy. Headache 41:953, 2001;
Silberstein SD et al: Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology
47:871, 1996; Silberstein SD: Migraine: preventive treatment. Curr Med Res Opin 17 Suppl 1:s87,
2001.
Educational Objectives
| The goals of this program are to aid the diagnosis and improve the management of migraine and other
common headache disorders. After hearing and assimilating this program, the clinician will be better able
to:
|
 | 1. Identify migraine based on patient history and clinical findings.
|
| 2. Differentiate characteristics of migraine with aura from migraine without aura.
|
| 3. Prescribe an effective therapy regimen for migraine.
|
| 4. Recognize common signs of benign headache.
|
| 5. Choose effective therapy for cluster headache.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to
disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality
in health care and not a proprietary business or commercial interest. For this program, the faculty reported
nothing to disclose.
Acknowledgements
Dr. Roby spoke in Lancaster, PA, at the 30th Annual Fall Family Practice Review, presented September 25-
29, 2006, by Temple University School of Medicine, and Lancaster General Hospital. Dr. Raskin was recorded
in San Francisco, CA, on February 6, 2007, at the University of California, San Francisco, School
of Medicine’s Annual Review in Family Medicine. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
|
