MIGRAINE HEADACHES
From The 19th Annual Practicing Physician’s Approach to the Difficult Headache Patient, sponsored by Chicago
Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| DIET AND MIGRAINE: TRIGGERS AND PREVENTION —Stephen Peroutka, MD, PhD, New Brunswick,
NJ
|
| Introduction: elimination diets rarely work; 67% of migraines occur after 5 hr of fasting; “missing a
meal” one of most common reasons cited as cause of migraine (≈50% of patients)
|
| Yom Kippur headache: study in Israel during 25-hr religious fast; among hospital workers, headache occurred
in 66% of headache sufferers, in 29% of nonheadache sufferers, and in only 7% of nonfasters during
same period
|
| Timing of migraine: frequently 15 hr after last meal; most commonly between 6 and 10 AM
|
| Biology of eating: 3 sources of energy—carbohydrates (for energy); protein (for growth and tissue repair;
“emergency” supply of glucose; cannot be stored); fat (for energy storage and cell membranes); energy
stores in 155-lb human—carbohydrate, 400 g (1600 calories), <1-day supply; protein (muscle), 12 days;
fat, 55 days
|
| Brain nutrition: carbohydrates as “drugs”—most powerful drugs affecting brain function, yet rarely
dosed properly; key facts—brain 2.5% of body weight, but uses ≥25% of daily energy needs; brain 100%
dependent on glucose for energy (4-5 g/hr); dietary carbohydrate main source of glucose and stored as
glycogen in liver; brain requires 100 to 120 g glucose per day; glucose supply to brain—serum glucose
(20 g; ≈2 hr); liver (100 g; ≈12 hr); gluconeogenesis (glucose production from fat and protein) requires
activation of sympathetic nervous system (SNS), ie, stress response
|
| Eating and stress: act of eating required for energy but disruptive in homeostatic sense; stress response—
during fasting, serum glucose dropping, liver becoming depleted of glycogen, brain senses need for more
glucose; SNS activated, causing release of norepinephrine and thermogenesis, ie, physiologic stress response;
also can occur after fasting, from eating too much too fast or eating certain foods that rapidly
raise serum glucose; SNS activation—physiologic stress that can trigger or worsen migraine attack
|
| Glycemic index (GI): measure of serum glucose increase after ingestion of carbohydrates; foods with high
GI cause rapid increase in serum glucose; ingestion of these foods results in “roller coaster” of rapid
surges and drops in serum glucose; insulin release and physiologic stress response accompany glucose
surges; disadvantages of insulin secretion—increases fat synthesis and storage; causes intracranial epinephrine
and prostaglandin release, leading to cerebral vasoconstriction; oversecretion or hypersensitivity
may cause reactive hypoglycemia
|
 | Avoiding GI roller coaster: eat low-GI foods (release glucose at even rate)
|
| High-GI foods: glucose; doughnuts; waffles; breakfast bars; corn flakes; pretzels; potatoes; rice
|
| Low-GI foods: fructose; oatmeal; yogurt; milk; many fruits; pasta; sponge cake; peanut M&Ms
|
| Underlying scientific evidence: insulin receptor gene associated with migraine; after injection of low
doses of insulin, serum glucose level lower in migraineurs than controls
|
| Carbohydrate dosing: explain concept to patients with frequent migraine; do not go >4 to 5 hr without
eating while awake; content of food has significant effect on SNS activity; avoid high-GI foods; eat
foods that give gradual rise in glucose, causing less stress on brain
|
| General guidelines: no need to calculate hourly dose of carbohydrates (brain needs 10-15 g/hr); do not
exceed 40 to 60 g of carbohydrate per meal or snack; eat foods with lowest GI possible
|
| Daily guidelines: eat breakfast with 4- to 5-hr dose of carbohydrates
|
| Identify and use snacks providing 2- to 4-hr dose (20-40 g) of carbohydrate as bridge between meals
|
| Always have small carbohydrate bedtime snack (eg, yogurt, 1 banana, 1 slice sourdough bread)
|
| Ideal snack food: high in fructose; pure fructose does not change insulin level; enters liver as glycogen
and released as needed; apple best example
|
| COMPLICATED MIGRAINE AND MIGRAINE VARIANTS —Curtis P. Schreiber, MD, Associate Director,
Headache Care Center, Springfield, MO
|
| Introduction: headache most common neurologic disorder seen by neurologists and internists; physicians
able to make difference in lives of patients
|
| Comfort zone: knowing when able to care for patient and when need to refer
|
| Taking history: enable patient to make observations helpful in establishing diagnosis
|
| Strategizing treatment: identify most effective tools
|
| What makes migraine complicated: accompanied by neurologic symptoms; retinal migraine; ophthalmoplegic
migraine; hemiplegic migraine; basilar-type migraine
|
| International Headache Society definition: changed; chronic migraine; status migrainosus; persistent aura;
migrainous infarction (migraine stroke); migraine-triggered seizure
|
| Retinal migraine: do not rely on diagnosis offered by patient, optometrist, or ophthalmologist
|
| Diagnosis: ≥2 episodes limited to 1 eye and fully reversible; aura (retinal migraine probably part of
aura); aura either positive (eg, zigzags, sparkles, shimmers) or negative (blind spot); blurry vision not
aura; aura occurs before attack; eye examination normal; uncommon
|
| Differential diagnosis: includes embolic disease, inflammatory disorders, other vascular problems
|
| Ophthalmoplegic migraine: rare; eye muscle stops working; patients have “goofy pointing eyes”; requires
referral to neurologist; more common in men and children; probably not migraine, but inflammatory
disorder of cranial nerves
|
| Diagnostic criteria: migraine-like headache accompanied or followed within 4 days of onset by paresis
of 1 cranial nerve (usually third, but may be fourth or fifth); pupils typically involved
|
| Differential diagnosis: requires neurologic work-up; refer patient
|
| Treatment: uncertain; possibly steroids, antivirals, or calcium-channel blockers; triptans contraindicated
|
| Hemiplegic migraine: rare; familial or sporadic
|
| Diagnostic criteria: ≥2 attacks; aura consisting of fully reversible motor symptoms (eg, weakness) and ≥1
visual or sensory symptom lasting ≤24 hr; not attributable to other disorder
|
| Clinical characteristics: usually starts in childhood, improving in adulthood; ≈50% of headaches on contralateral
side; hemiplegia may or may not follow usual time course of aura; weakness “marches,” ie,
gradual in onset (unlike stroke); ≈50% of patients experience numbness of one side; altered consciousness
possible
|
| Work-up: refer to neurologist; absence of family history requires more extensive investigation
|
| Basilar-type migraine: previously termed basilar or basilar artery migraine; symptoms affect both sides
of body at once (characteristic of brainstem lesions)
|
| Description: migraine with aura symptoms clearly originating from brainstem
|
| Diagnostic criteria: ≥2 episodes with ≥2 symptoms (dysarthria; vertigo; tinnitus; hyperacusis; diplopia;
visual symptoms on both sides simultaneously; ataxia); symptoms last 1 hr
|
| Speaker’s recommendation: note that tinnitus and vertigo common in migraine; avoid diagnosis if uncertain
(precludes use of triptans); reserve for patients “profoundly impaired with migraine symptoms”
|
| Clinical characteristics: neurologic deficits bilateral; can lead to temporary blindness (consider possible
embolism)
|
| About aura: altered metabolic activity evident in midbrain (involved in visual processing); not vascular in
origin; wave of depression spreading across cerebral cortex
|
| Aura symptoms: visual (in occipital lobe; most common); sensory (in parietal lobe; tingling; numbness);
motor (in frontal lobe; weakness)
|
| Complicated migraine: related to brain and aura symptoms
|
| Treatment considerations: determine need for referral
|
| Contraindication to triptans: drugs designed to be vasoconstrictors at time vascular theory of migraine current;
clinical trials excluded patients with basilar, hemiplegic, or ophthalmoplegic migraine, leading to
triptan contraindication; subsequently, good results reported using triptans for basilar migraine in case
series
|
| Be careful making diagnoses: since treating patients with triptans contraindicated
|
| International Headache Society definitions
|
| Chronic migraine: headaches occur >15 days/mo
|
| Status migrainosus: headache persists >72 hr
|
| Persistent aura without infarction: refer for work-up
|
| Migrainous infarction (migraine stroke): avoid vasoconstrictors for patients with blockage of arteries
|
| Migraine-triggered seizure: consider antiseizure medication
|
Educational Objectives
| The goal of this program is to educate the listener about migraine headaches. After hearing and assimilating
this program, the clinician will be better able to:
|
| 1. Identify dietary triggers for headache in frequent migraineurs.
|
| 2. Advise patients about dietary guidelines for avoiding migraine attacks.
|
| 3. Describe the characteristics of complicated migraine and how it differs from standard migraine.
|
| 4. Diagnose complicated migraine variants, including retinal migraine, ophthalmoplegic migraine,
hemiplegic migraine, and basilar-type migraine.
|
| 5. Treat complicated migraine and identify patients needing referral to a neurologist.
|
Suggested Reading
Benatar M et al: Familial hemiplegic migraine: more than just headache. Neurology 64:592, 2005; De
Vries B et al: Genetic biomarkers for migraine. Headache 46:1059, 2006; Enoki H et al: Unilateral spatial
neglect in a child with hemiplegic migraine. Cephalalgia 26:1165, 2006; Flanagan JM et al: The identification
of a recurrent phosphoglycerate kinase mutation associated with chronic haemolytic anaemia and
neurological dysfunction in a family from USA. Br J Haematol 134:233, 2006; Epub 2006 Jun 1. Gardner
KL: Genetics of migraine: an update. Headache 46 Suppl 1:S19, 2006; Gladstein J: Headache. Med Clin
North Am 90:275, 2006; Grazzi L et al: Chronic headaches: pharmacological and non-pharmacological
treatment. Neurol Sci 27 Suppl 2:S174, 2006; rrington MG et al: Cerebrospinal fluid sodium increases in
migraine. Headache 46:1128, 2006; Jacob A et al: Imaging abnormalities in sporadic hemiplegic migraine
on conventional MRI, diffusion and perfusion MRI and MRS. Cephalalgia 26:1004, 2006; Kelman L: Pain
characteristics of the acute migraine attack. Headache 46:942, 2006; Kirchmann M et al: Basilar-type migraine:
clinical, epidemiologic, and genetic features. Neurology 66:880, 2006; Ramadan NM et al: Classification
of headache disorders. Semin Neurol 26:157, 2006; Rapoport AM et al: Which triptan for which
patient?. Neurol Sci 27 Suppl 2:S123, 2006; Schreiber CP et al: Prevalence of migraine in patients with a
history of self-reported or physician-diagnosed "sinus" headache. Arch Intern Med 164:1769, 2004; Specchio
N et al: The spectrum of benign infantile seizures. Epilepsy Res 70:156, 2006; Epub 2006 Jul 11. Striano
P et al: Linkage analysis and disease models in benign familial infantile seizures: a study of 16
families. Epilepsia 47:1029, 2006; von Brevern M et al: Migrainous vertigo: mutation analysis of the candidate
genes CACNA1A, ATP1A2, SCN1A, and CACNB4. Headache 46:1136, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Drs. Peroutka and Schreiber were recorded at the 19th Annual Practicing Physician’s Approach to the Difficult
Headache Patient, held in Rancho Mirage, CA, and sponsored by Chicago Medical School at Rosalind Franklin University
of Medicine and Science. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation
in the production of this program.
|
