11 12 ICM McClintock Headache and Migraine 03-19-12

7/30/2019 11 12 ICM McClintock Headache and Migraine 03-19-12

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11_12ICMDr.McClintock19March2012

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HeadacheandMigraineSlide1B:Weregoingtoswitchgearsherealittlebit,andtoillustratethat,letmegetashowofhandsforwhoheregetsheadachesonanykindofaregularbasis?Well,Imincludedinthat.Thatsquiteafewofyou.IwouldntgetthatsameanswerifIaskedwhohastuberoussclerosis.Sowearegoingfromrelativelyraredisorderstooneofthemostcommondisorders,thatallphysiciansmusthavesomeideahowtomanage,andhavesomeideaabout.Weregoingtotalkaboutheadachedisorders.Slide1C:Theobjectivesare,tounderstandthescopeofthisproblem.IthinkthatisonejobIhave.Theotheristoidentifythemajorprimaryheadachedisorders,andhowtodifferentiatethosefromsecondaryheadachedisorders,andthenknowwhoyouneedtorefer.Mostheadacheswillbehandledbytheprimaryphysicianorwhatevertypeofphysicianfirstseesthepatient.Andthen,inordertodothat,youhavetobecomfortablewithatleasttheinitialmanagementofcommonheadachedisorders,soweregoingtotalkaboutthat.Slide1D:Thisisoneofthemostcommoncomplaintsthatprimaryphysicianssee,barnone,anditsamajorcauseofmorbiditylossofschooldays,workdays,painandsuffering,allrelatedtoheadaches.Whichissomethingwethinkofasarelativelysimpledisorder,butitbecomesalittlebitdifficulttomanagesometimes.Slide1E:Youthinkofaheadacheassortoflikeafeveryouhavetofigureoutwhatthecauseis,beforeyoucanmanageit.Theincidenceofheadachesinchildrenandadultsismuchmorecommonthanpeoplerealize.WhenIwastrainedfirstofall,everybodyhashadaheadachesometimeintheirlife,itsalmost

universal.Butregular,recurrentheadachesiswhatweretalkingabout.Childrenby10yearsofagehaveafairlyhighincidenceofheadaches.Teenagersandadultsfirstofall,weseeitevenin6yearoldkids,about5%ofthetime;about10%in10yearoldkids,andthenonceyoubecomeanadultorateenager,girlsreallygoupinfrequency,muchmorethanboys.Girls,theincidenceofheadaches,dependingonthestudy,itsusuallybetween20and40%,anditsallkinds,notjustmigraines.Slide1F:Sowhatarethedefinitions?Theprimaryheadachedisordersareagroupofheadachedisordersthathaveageneticpredispositionandthereareusually,ifyouarepredisposed,thenoftenthereareenvironmentaltriggersforyourheadaches.Thatincludes,mostcommonly,migraine,tensionheadaches,thenaconditionwelltalkaboutcalledchronicdailyheadache,whichisnowcalledchronicmigraine.Thentherearethesecondaryheadaches,whichiswhatweareworriedaboutwithachildwhocomestomyoffice,an8yearoldwhoishavingregularheadaches,reallywhatthemomisworriedaboutisabrain

tumor.Sothatsoneofthethingsthatcancauseheadachesthatarenotprimaryheadaches.Slide2A:Theprinciplesofevaluationwhenyoufirstseesomebodywithheadachesistoseparatetheprimaryfromthesecondaryheadaches,andIwillsaynow,ifIdontsayitagaininthistalk,thatthegreatmajorityofpeople,ifnotover95%,thatyouseewithheadacheswillhaveprimaryheadachedisorders.Thatstrueeveninmyreferredpopulation.Secondaryheadachesincludeallkindsofthingslupus,abraintumor,diabetes,somethingwrongwithyourTMJ,sinusdisease,thoseallcancausesecondaryheadaches.AndwedidastudyofkidswhocomeintotheERthemostcommoncauseofheadachecomingtotheERisjustaURIsomesortofinfectiousprocess.

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Slide2B:Whendoyouworryaboutsomebodywhohasmaybeasecondaryheadacheversusaprimaryheadache?Sometimesitshardtotell,soIuseasystemofredflagsforwhenIwilllookcarefullytomakesureitsnotasecondaryheadachei.e.,doascan.Themostimportantthingisaworseningheadache.IfItalktosomebodyandtheysay,Oh,Ivehadaheadachefor3months,itsgettingworseandworseastimegoeson,thatisaredflag.Severeacuteheadacheisaspecialkindofheadache,sortoftheworstheadache

ofmylifekindofdeal,whichwelltalkaboutalittlebitthatalwaysneedsanevaluation.Headachesthatyouwakeupwith,orthatwakeyouupinthemiddleofthenight,Iworryaboutthose.Migrainedoesthatalot,butImgoingtomakesureitsnotsomethingelse.WithincreasedICP,ittendstogetworsewhenyoulaydown,sothatsthereasonforit.Ifyouhaveataxia,dizziness,orvertigowithyourheadache,weregoingtomakesureitsnotsomethingelse.Migrainedoesthatalot.Alterationofconsciousness,soifyoubecomelethargicorconfusedduringyourheadaches.Focalneurologicsigns,eitheronexamorbycomplaint,wouldalwaysdemandascan.Forinstance,someonehashemiplegicmigraine,whichisoneofthemigrainetypeswewilldiscuss,andyouknowthat,Istillwouldscanthatpatient,tomakesure,inotherwords,thatbecomesadiagnosisofexclusion.Associatedstiffneckwithyourheadache,doublevisionwithyourheadache,persistentheadacheafteraheadinjurywhatwereworriedaboutis,letssaythatsomebodyhasamildconcussion,buttheirheadachesgoonandon,thathappensallthetime,butyouareworriedaboutsubduralsandthingslikethat.Headachesinveryyoungchildrenusuallymycutoffis,eventhoughIknowitsmigraine,butiftheyre6orunder,iftheycometomewithregularheadaches,Iscanthosekids.AllthesethingswouldbeendorsedbytheAmericanAcademyofNeurology,theAmericanAcademyofPediatrics.Slide2C:Whataretheprimaryheadachedisorders?Imnotgoingtotalkalotaboutsecondaryheadaches,Ithinktheyallcanexplainthemselves,buttheprimaryheadachedisordersarewhatyoullseemost.These,again,areageneticallydeterminedgroupofdisorderswithenvironmentalinfluences.Andthatsimportanttorealize,fortreatment.Slide2D:Secondaryheadaches,again,aresuspectedbyhistoryandphysicalexam.Itoldyouabouttheredflags.Youmay

needtodolaboratoryteststoconfirm.Andthecourseoftheheadache,Ivealreadymentionedonce,isveryimportanttome.ProgressivelyworseningheadacheisactuallythemostcommonreasonthatIwouldscansomebodythatcomestomefor

headaches.Slide(on

Blackboard):(atright)Acuteheadachecanbeprimaryorsecondary.IfyoureintheERandsomeonehasanacutefirst


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headache,thatmaybethefirstmigraineortheymayhavehadanintracranialbleed.Acuterecurrentheadachesarealwaysprimaryheadaches.Soifyouhaveaterribleheadache,youvehaditfor3years,andithappens4timesamonth,andtheycomeandtheygo,nothingelsedoesthatbutprimaryheadaches.Chronicprogressiveheadaches,wethinkofsecondaryheadaches,wedonotlikethatstory.Chronicnonprogressiveheadaches,sotheteenagerwhois16,comestomyoffice,hashadaheadachefor3years,hasbeenoutofschoolfor2years,probablydoesnthaveasecondaryheadache.Andthenthemixedheadache,

whereyouhaveachronicheadachewithbadheadachesontop,areusuallyprimaryheadaches.Slide2E:Theresawholelist,again,nottogooverittoomuch,aboutwhatsecondaryheadachesare,Ivementionedanumberofthese.Pseudotumorcerebrihasitsownspecialpresentationtobeawareof,withpositioningbeingimportant,dotheyhavepapilledemawhenyoulookinthebackoftheeyes,theycanpresentwith6thnervepalsies.Theotherthingtobeawareofinfolksthesedaysisproblemswithdrugs,onewayoranothereithertheonesyouprescribethemorillicitdrugs.Thosecanveryfrequentlycauseheadaches.Slide2F:Youwanttoknowabouttheonsetoftheheadaches,whendidtheystart.Youwanttoknowthefrequency,youwanttoknowtheseverity,andhowdoyouknowtheseverityofaheadache?Thatsaproblem,Ithink;itsveryhardtomeasure.IlikethescalewhereIsaytheheadache,theoneIusemostoftenis,1,2,or3?A3isdebilitating,thatshowsevereitis;a2isbad,butyoucancontinuetobeinschoolordoyourjob;a1isamildheadachethatssortoftherebutdoesntbotheryoutoomuch.Itrytogetafeelingforheadachesinthatway.Somepeopleuse110,or15.Ivehadpeoplesay,Myheadacheisa10/10rightnow,doc,Ireallyfeelhorrible,andtheyresittingtheretalkingandsmiling,andyouhavetosortofreadjustthescalealittlebitandgetthemtounderstandwhatthat10outof10means.Soscalesarenotthatgreat.Wedonothaveagoodwaytomeasuretheseverity.OnethingIllsayis,Ialwaysstartandusuallycontinuefromtheassumptionthatwhatthepatienttellsmeistrue.Idonttellkidstheyrefakingtheirheadaches.Idontknowhowyoudealwiththat.SoIjuststartwiththatassumptionandtrytohelptheminthatway.Now,theremaybeotherpsychological,orsecondarygain,orotherthingsgoingon,andyoudealwiththosethings,butdonttellthepatientyouthinkthattheyrefakingtheirheadache,itsnotreallythere.Donteventhinkthat,youlldobetter.Thatsabias.

Youwanttoknowthequality,thetimingoftheheadacheisitinthemorning,theafternoon?Ifitsalwaysinthemorning,itcouldbeincreasedintracranialpressure,ortheycouldhavesleepapnea,ormaybetheyrenotgettingenoughsleep,ormaybetheyredrinkingtoomuchcaffeineandtheyrewithdrawinginthemorning,andthatswhytheyregettingtheirheadache,ormaybetheyresleepingoverthegarageanditscarbonmonoxidefromthecarthatscausingit.Theresallkindsofthingsthatareinterestingthatyoucanpickup,justfromthetiming.TriggeringfactorsIaskthepatient,Whatcausesyourheadache?Usuallytheycantellyouwhattheirtriggersare:Itswhenitsrainingoutside,or,ItswhenIhavemyperiod,or,ItseverytimeIeataboxofchocolates,Stopeatingaboxofchocolates.Prodromealotofpeoplewithmigraineshaveaprodrome,theyfeellousyforadayevenbeforetheyhavetheirheadache,andtheyknowtheyregoingtogettheirheadache.Isitworsening?Morethanoneheadachesomepeoplehavemorethanoneheadachetype,andyoutrytoinvestigatethose:theymayhaveatensionlikeheadacheandamigrainelikeheadache.Andthen,theassociatedsymptoms,thatare

veryimportantbecausetheygoalongwiththediagnosticcriteriaformigrainethingslikenausea,vomiting,lightsensitivity,soundsensitivity,confusion,numbness,visualsymptoms,etc.ThenIalwaysask,Whatcausesyourheadache?Sometimesyougetananswer,andyoudonthavetodoanythingelse.Slide3A:Thephysicalexamination,youknow,signsofsystemicdisease,lookingforsecondaryheadaches.Headandneckexamisveryimportant,thewholethingthyroid,feeltoseeifthejawclicks,lookatthenoseandthroat,dotheyhaveanytenderness.Alwayscheckthebloodpressure,Ithinkpeoplehaveatendencytoheadachesiftheirbloodpressureishigh,theygetmoreheadaches.Headcircumferenceinchildren,kidswhohaveincreasedpressure,theirheadmaygrowtoofast.Growthanddevelopment,again,


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inkids,veryimportantendocrinedisorders,otherbrainproblemscauseproblemswithgrowthanddevelopment.Thenthefundoscopicexam,andIwouldpleadwithyouinyourphysicaldiagnosisthatyouactuallylearnhowtodothattherightway,becauseIdontnecessarilyseethathappening.Iwilljustsaytwothingsaboutthefundoscopicexam,becauseImnotgoingtoteachthattoday:thefirstistogetcloseenoughwhenyoulookatthefundus,youshouldbelookingfromrighthere(upatthepatientsface).Thesecondthingis,theresagreenlightonyourfundoscope,thatscalledtheredfreelight,anditcutsdown

contrast,thatswhatitsfor;youcanactuallyseesomethingswiththatyoucantseewithjustthewhitelight.Sousebothlights.Thenpracticeyoucanseealotmorethanyouthink,youjusthavegottopractice,oneverybodyyousee.Andthentheneurologicexamination.Mostofthetime,theneurologicexaminationiscompletelyunhelpfulinheadacheevaluation,butifyoufindsomething,obviouslyitshelpful.Slide3B:(pictureofTidalBasinandcherryblossoms)Wereearlythisyear.Thisisfromafewyearsago.Slide3C:Thegenetics.Migrainerunsinfamilies,andmigrainewithaura,whichIlldefineforyou,hasthestrongestgeneticinfluenceinepidemiologicstudies.Followedbymigrainewithoutaura,followedbytensionheadaches,whichalsoaregeneticallydetermined.Bothmigraineandtensionheadacheshavegeneticinfluences,andwerestartingtofigureitoutalittlebit.Forinstance,thereareanumberofgenesthathavebeenfoundthatcausecertaintypesofheadaches,especiallythemigraineswithauras.Thefirstonewasfamilialhemiplegicmigraine,thatwasfoundonchromosome19,anditturnsouttobeacalciumchannel,itsactuallyincreasedconductanceofthatcalciumchannel.SowhenItalkaboutthemechanismsofthis,itbecomesimportant.Slide3D:Howdowedefinemigraine?Iwasgivingatalktoagroupofpediatricians,whodontusuallybelieveinmigraines,bytheway,andthequestionwas,Well,howdoyouknowitsmigraine?AndIsaid,well,itsaclinicaldiagnosis.Butwhatsthetest?Howcanyouproveit?Andthetruthis,itsaclinicaldiagnosisyoucannotproveit.Ifitfitstheclinicalcriteriaformigraine,anditsnotsomethingelsebecausethatspartofthediagnosisthenthatsmigraine,andthatshowweusethatterm.Itsreallybestthoughofasaconstructofhowtoclassifythesepatientssoyoucanstartthinkingabouthowtotreatthem,

andimprovewhatsgoingon.Also,soyoullunderstand,becausethisissuchacommonproblemandsowellknown,youdonthavetodoa$5billiontesttomakesureitsnotsomethingelse.Theclinicalcriteriaare:youhavetohaveeithernauseaorvomiting,orsensitivitytolightorsound.Youhavetohaveoneofthosetwo.Thenyouresupposedtohaveacoupleofthefollowing:throbbinginnature,hemicranial,increasedwithmovementoractivity,thetimingis172hours,bydefinition.Thatdefinitionisnotusedinchildren,theyoftenhaveashorterheadache.Andatleastmoderatelysevere.Thatshowwedefinemigraine.Slide3E:Alwayswiththesedefinitions,becauseagroupofexpertssataroundandmadethem,theysay,andnotcausedbysomethingelse.Ihaveseenpeoplewholookverymuchlikemigraineturnouttohavesomethingelse,likeabraintumor.ThatswhyIusetheredflags,evenifitlookslikemigraine. Migrainewithoutaura,meansyouhavenoaura.Thatsprettysimple.Migrainewithaura,means

youdohaveanaura.Anauracanprecedetheheadacheorcomeonduringtheheadache,anditcanlastanywherefromafewminutesusuallynotsecondsupto1hour,bydefinition.Havingsaidthat,youwillfind,manyofyourpatientsdonotreadtextbooks,andIveseenmanypeoplewhohavelongeraurasthan1hour.Butbydefinition,its1hour.Thisgetsbacktothisclinicaldefinition,ifsomeoneisoutsideoftheclinicaldefinition,thenyoumaylookatthemalittleclosertomakesuretheydonthavesomethingelsegoingon.Sodontgettoowrappedupinthis,remember,thesearejustwhatusuallyhappens.Mostcommonly,theauraisvisualsymptoms.Andanyneurologicsymptomispossiblevertigo,doublevision,hemiparesis,confusionandconfusionaspartofmigraineisnottoounusual.Andthennootherexplanationfortheheadaches.


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Slide3F:Okay.Migrainewithorwithoutaura,geneticallydetermined.Therearesomespecialkindsofmigraine.Oneiscalledbasilarmigraine,thathassymptomsthatarereferabletothebasilararteryvertigo,bilateralvisionloss,doublevision,lossofconsciousness,rightattheonsetofyourheadache.Thenthefamilialhemiplegicmigraine,Ivementioned,theygethemiplegic,theyreweakononeside.

Slide(onBlackboard):Unilateralorbilateral.

Slide(onBlackboard):Moderateorsevere.

Slide(onBlackboard):Pounding,throbbingheadaches,andIlloftenask,doesitfeellikeyourheartisbeatinginyourheadwhenithappens?Isitgoingboomboomboom?Youhavetoask,whenyousay,Tellmewhatitslike,mostpeoplesay,Ithurts,soyouhavetosay,Isitsteady,ormoreboomboomboom?Sometimesyouhavetogivethemwords.Yourenotsupposedtodothat,butthatswhatyouhavetodo.

Slide(onBlackboard):Decreasedactivitymostpeoplewithmigrainewanttolaydownandgotobed,layinthedark.


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Slide(onBlackboard):Theygetnauseated.

Slide(onBlackboard):Theyvomit.

Slide(onBlackboard):Theyhavelightsensitivity.

Slide(onBlackboard):Orsoundsensitivity.

Slide4A:Sowhatcausesmigraine?Anditssocommon,butitsstillnotcompletelyunderstood.Mostpeopledontdie,wedontcutthebrainsopen,sowedontknow.Buttherearesomebasictheories.Itsfeltnow,basedonalotofwork,alotofneurophysiologicwork,responsetomedicines,differentthings,thatthisisreallyadefectofneuronalhyperexcitability.Theresamechanismwithinthebrainwherethereareneuropathwaysthatgetactivateduringaheadache.Itsthoughttostartinthecortex,andagaintheneuronalchannels,asIhavementioned,areoften,ifwefindsomethingwrongwiththegenes,whatwefind.Whatsactivatedisthiscircuitcalledthecorticaltrigeminalvascularnetwork.


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Slide4B(plusslideonBlackboard): Itsprettycomplex,andweveworkedoutalotofthedifference.Theneurotransmittersthatareinvolved,serotoninbecomesinvolved,calcium,CCRP,andotherneurotransmitters,andwecaninterveneatdifferentlevelsofthis.Andmanyofourpreventativemedicines,forexample,ouranticonvulsants,whichactuallystabilizemembranes,thatshowtheywork.Thistrigeminalvascularsystem,thebloodvesselsdobecomeinvolved,theydodilate,theydothrob.Peoplehavewonderedinthepastifthebloodvesselsaretheinitialeventtheymaybe.Theremaybeafeedbackmechanismfromthe

bloodvesseluptobeginthispathway.Theresalotoffeedbackmechanisms,andalotnotunderstoodstill.Ithinkthestoryisstillopen.Slide(onBlackboard):This(atright)calciumgenerelatedpeptidereceptorantagonisthasrecentlybeenstudied,Illjustbringthatupbecauseyoullseealotaboutit.Wedontusethoseclinicallyyet,buttheyrebeingstudiednow,anditsalsowithinthisloop.Slide4C:Okay,letstalkaboutsomespecific

typesofmigraineorheadache.Theressomeunusualmigrainesyndromes.OnethatyoullhearaboutiscalledtheAliceinWonderlandsyndrome.Theseareusuallyinchildren,theypresentwithwhatwecallmacropsiaormicropsiawhereeverythinglooksbiggeroreverythinglookssmaller.Soyoullhaveakidcomeinyourroomandtrytoduckunderthedoorsotheycangetin.Theyseemtobereallymostlynotbotheredverymuchbythis.Actually,Igetmigraines,andIhadthiswhenIwasakid,andIdidntknowaboutthisuntilIbecameaneurologistandstartedreading,anditactually


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scaredthehelloutofmewhenIwasakid,becausethingsaregettingbiggerandbiggerandbigger,andImlike,ohmygosh,whatsgoingon?Whatswrongwithme?Thenacuteconfusionalmigraine,thisisafairlyimportantonetounderstand,becausethesekidsmaypresentintheER,theymaybeconfusedorcombative;theywonttellyoutheyhaveaheadachebecausetheyreconfused,andtheylookliketheyareonPCPorsomethinglikethat.SowithinyourdifferentialdiagnosisofpeoplecomingtotheERwithcomaorconfusion,shouldbemigraine.Thentheresthisconditionthatsveryrarecalledophthalmoplegic

migraine,whereitsnotjustthatyouhavedoublevision,butyouhavelikea3 rdnervepalsy,andthatusuallygoesonfordays.Slide4D:Theressomeveryatypicalmigraines.Oneiscalledacephalgicmigraine,whereyouhavetheaura,likevisualchanges,andthenyouhavenoheadache.Thatsalittlebithardertofigureoutwhatsgoingonsometimes.Butitssotypical,thescintillatingscotomaofthemigraineaura,thatusuallyyouknowwhatitis.Abdominalmigraines,whereyouhaveabdominalpainandmayormaynothaveheadaches.AndIseealotofkidswhohavebeenworkedupbytheGIdoctorsprettyextensively,andthenmigrainebecomesapossibility.Ithinkthisisasomewhatrarecondition.Onethatisnotrareistheconditioncalledcyclicvomiting.Youseethisinyoungkids.Likeevery3weeks,theyvomit,andtheymayvomittothepointthattheyaredehydrated,theyhavetogototheERandgetfluids,anditlasts6,12,24hours,andthentheyrefine.Theylookmiserable,buttheydonttellyoutheyhaveaheadache,andtheyindeedmaynothaveaheadache,butmostofthosekidsgoontohavemigraines.Wedoworryaboutotherthings,withcyclicvomitingyouhavetomakesureitreallyisntsomeGIproblemlikeanintermittentintussusceptionorintermittentvolvulusorsomethinglikethat,butmostofthetime,iftheyareperfectlynormalinbetween,Idontthinktheyneedabigworkupotherthanthat.Slide4E:Otherthingsthatmaylooklikemigraine,thatyouhavetohaveinyourmind.Someoftheepilepsiesinkids,particularlybenigncorticalepilepsiesofchildhood,theyalwayshavemigrainelikeheadaches,andtheseizuresmaybeprettymild,soyouneedtokeepthatinmind,youneedtotakeaverycarefulhistory.TheresthisconditioncalledMELASsyndrome,andtheypresentwithmigrainelikeheadaches;itsamitochondrialdisorderwithstrokelikesymptoms.Atleastinitiallyyoumightthinkaboutmigraines,buttheyusuallyarenotnormal,itleavesprettyquickly.Andthensecondaryheadaches,many

ofthemmayinitiallylooklikemigraines,andIvehadthatbadthinghappentomewhereIdiagnosesomebodywithmigraine,andthen6monthslaterIfindoutIwaswrong,thathappenedtomeonceinmylife.Slide4F:Tensionheadachesaredefinedbyepisodicheadacheslikemigraine,buttheydonthavealltheothersymptomsIjusttoldyouaboutmigraine,likenausea,vomiting,throbbingtheyreusuallysqueezing,bandliketheyusuallylastfromhourstoupto5days.Theymaybeonacontinuumwithmigraine.Alotofpeoplethinkthatsactuallyanartificialseparation.Slide5A:Theresthisconditionthatissomethingwedealwithandyouwillprobablydealwithtoo,calledchronicdailyheadacheorchronicmigraine.Bydefinition,ifyouhaveaheadachethatlastsbetween72hoursand2months,anditsmigraine,wecallthatstatusmigrainosis.Butifyouhaveaheadachethats

ongoingforlongerthan3months,andbydefinitionifitsover15daysinamonth,wecallthatchronicdailyheadache.Youseepeoplewhohaveheadachesforyears.Themostcommonreasonforthatbyfaristransformedmigraineinotherwords,peoplewhohadmigraineheadaches,andtheneventuallytheyjuststartedhavingmoreandmore,anditgetstransformedintochronicmigraineorchronicdailyheadache. Onethingyouhavetobeparticularlycarefulaboutisaconditioncalledanalgesicreboundheadache.Thatspeoplewhostarttakingmoreandmoreibuprofen,Tylenol,naproxen,whateveryouwanttotakeforyourpain,andifyoudothatformorethan34months,morethan45daysamonth,andyoureamigrainer,youcanturnyourheadachesintodailyheadaches.Oneofourfirsttreatmentsistosimplystopthat,andtheheadachewillgoaway.Therearereportsofsomebodywhohashadheadachesfor15


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years,theytakeaspirineverydaybecausetheyhaveaheadache,andsomebodyfinallytellsthemtostoptakingaspirin,andtheirheadachegoesaway.Sobeawareofthat. Thisisnotrareinadolescents.Theoverallincidenceinadultsisprobablyabout2%ofthepopulation;inadolescentsits12%,thatsalotofpeople.Especiallyinadolescentslookfordrugandalcoholuse,andruleoutpsychologicalfactors.Psychologicalfactorsusuallydonotcausethis.WhenIwastrainedinneurology,Iwastoldthatanybodythathadadailyheadachehadapsychiatricdisorder,period.

Thatspatentlynottrue.Butthereisahighincidenceofpsychologicalproblemsinanybodywithchronicpain,sodepression,anxiety,theyremissingschool,theyrenotwiththeirfriends,soyouhavetodealwithallthatinonewayoranother.Slide5B:Theressomehiddenreasonsforchronicdailyheadachethatyouneedtothinkabout.Oneofthemispseudotumorcerebri,whereyouhaveincreasedpressure,idiopathic,withoutpapilledema.Howoftenthatoccurswedontknow,butmaybe2%ofthetime,ifyouhaveincreasedintracranialpressure.Andthensleepdisorders,IspendmoretimetalkingaboutsleepinmyheadacheclinicthanIdotalkingaboutheadaches,Ithink.Notenoughsleep,toomuchsleep,othersleepdisorderslikesleepapneayouneedtomakesurethatsnotwhattheproblemis,becausethatcanleadtochronicheadache.Slide5C:Weregoingtotalkaboutsomeotherspecificprimaryheadachedisorders.Oneisclusterheadache,whichisdifferentinaremarkablewayfrommigraineheadachesandalmostalloftheotherheadachesthatwearetalkingabout,inthatitisalmostentirelyinmales,itsabout90%inmales.Itsanautonomicsotheresagroupofdisorderscalledautonomiccephalgias,andthisisoneoftheautonomiccephalgias.Andthatmeansyouhaveautonomicsymptoms,liketearing,Hornerssyndrome,increasedlacrimation,onthesidewhereyouhaveaheadache.Andthistendstooccurinclusters.Themosttypicalpictureofclusterheadacheisthatyouhavenoheadachesforayear,letssay,thenyouhave6monthsofdailyheadaches,thenitgoesawayforanotheryearortwo.Thatswhatwemeanbyclusters.Andtheheadachestendtooccuratthesametimeeveryday,youwakeupat2inthemorning,youhavethisterribleheadache,itlasts20minutes,actually15180minutes,andthengoesaway.Adifferenceintheseheadaches,ifyouseesomebodywithmigraine,theywanttolaydowninthedark.Butwithclusterheadache,theyalwayswanttogetupandmove.Itsaboring,stabbing,severeheadache,usuallyonone

side,thesamesidethatyouhavetheautonomicsymptoms.Thisistheheadachethatrespondstooxygen.Slide5D:Theresanotherautonomiccephalgiacalledparoxysmalhemicrania.Thishasafemalepredominance.Theheadachesareshorter,theylast245minutes,andyoullnoticetheresoverlapinthesesyndromes,buttheyhavemanymoreattacksupto40attacksaday!Theyhaveautonomicsymptoms,andtheywanttoliestillwhentheyrehavingthese,inthedark.Thisheadacherespondsalmostbydefinitiontoindomethacin,whichisanNSAID.Soifwesuspectthis,wewilltryindomethacin.Slide5E:TheresamuchrarerconditioncalledSUNCTsyndrome,whichissuddenunilateralheadachewithautonomicsymptoms.Itsveryrare,italsohasamalepredominance,butonlyabout60%.Itlastsveryshort,5250seconds.Theymayhave510episodesanhour,andwithautonomicsymptoms.Iactuallyhaveneverseenthisanddiagnosedit,anditsbecauseoftheagegroupIseethishappensto

adults,youngadultsandmiddleagedadults.Slide5F:Thenhemicraniacontinua,arepeoplewhohaveparoxysmalhemicraniathatbecomesalmostcontinuous.Withautonomicsymptoms,again.Unilateral,severe,boringpain.Slide6A:Thentheresagroupofdisordersthatarenotassociatedwithautonomicfeatures,andthemostcommon,andtheonethatyoullsee,isaconditioncalledtrigeminalneuralgia.TrigeminalneuralgiaisusuallyV1orV2,ismostcommon,anditsastabbing,lancinatingheadache,thatoftenhasatictoit,itsbeencalledticdoulerauxifyoutouchtheface,youmaybringiton.Thisisaheadachethatcanrespond,


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usuallyweuseanticonvulsantslikecarbamazapineorneurontin,forthoseheadaches,butitsbeenfoundthatsometimestheresavessel,usuallytheposteriorinferiorcerebellarartery,thathasloopedupandistouchingthetrigeminalnerve,anditmayrespondtoasurgicalproceduretorelievethat.Thentheresthisconditionwecallepisodicstabbingheadache,andyougoalongandyoujusthavethis10secondsofstabbing,sharppainthatslocalizedinthehead,Ihearthatprettyfrequently.Thatisamigrainevariant.Thentheresthebenignexertionalheadache,thesearethepeoplewhoexerciseanddevelopasevere

generalizedheadache,likewhentheyreliftingweightsortheyrerunning.Itlastsafairlyshortperiodoftime,therearenoautonomicsymptoms,andthatsalways,ofcourse,adiagnosisofexclusion,butthatsawellknownworkoutheadachesyndrome,usuallyinyoungmales.Andtherearevariantsofthat,therescoitalheadache,samething.Slide6B:Theresthisonesyndromethateveryonehastolearnaboutinmedicalschoolandknowabout,calledtheworstheadacheofmylife.Weworryaboutsubarachnoidhemorrhageduetoleakageofananeurysm.Thesecrettothisheadacheisthatitcomesonsuddenly,andIdontmeanoveracoupleminutes,Imeanyourheadacheisthere(clap),likethat,thundercloud.Quickly.Veryrapidonsetshouldmakeyouworryaboutthis.Itcanhappenwithexertion,itcanbeoneofthesebenignexertionalheadaches,itcanbeyourfirstmigraine,butwealways,whentheycometoERandsay,Itstheworstheadacheofmylife,anditssevere,particularlyifitsassociatedwithstiffneck,confusion,anyotherneurologicfindings,weregoingtoruleoutsubarachnoidhemorrhage.Slide6C:ThemanagementistodoaCTofthebrainasthefirststep,andthereasonwedoaCTisthatyoucanseeasubarachnoidhemorrhage90%ofthetimeonaregularCT.Thattellsyouwhatitis,thenthenextstepistofindtheaneurysmandwhatever.IfyoudontseethebloodontheCT,thenextstepistolookattheLP,andyouneedtodoanLP.Yourelookingforsubarachnoidblood.Doesanybodyknowwhatwelookforbesidesblood?Somebodyshadableedintheirspinalfluid?Openingpressurewouldbeimportant,thatmaybeincreased.TheresacouplethingsthatwedowhenwedotheLP.Wealwayslookforopeningpressure,Imgladyousaidthat.WeneverdoanLPwithoutdoingthat.Thenwhatwouldyoulookforbesidesblood?Ifyouseebloodinyourspinalfluid,onethingwedoisweseehowmanyredcellsareintube1versustube4,becausewewanttoseeifitclears,becausewethinkthatmightjustbeabloody

tap.Buttherealwaytoruleoutasubarachnoidhemorrhageistospinitdownandlookforxanthochromia.Ifyouhavexanthochromia,nothingdoesthatexceptbloodthatsbeeninyourspinalfluidforalittlewhile,foratleastseveralhours.Evenifbloodsitsaroundinthetubeforseveralhoursandbreaksdown,itwontmakexanthochromia.Sothatsaveryimportanttesttodo,lookforxanthochromia.Andtheothersecrettothatisthatxanthochromiasticksaroundforaweekto10daysafterthebleed.Letssaysomeonehadtheworstheadacheoftheirlife45daysago,andyoudontseeanythingontheCT,youcanstilldoanLPandlookforxanthochromia.Okay?Slide6D:Okay.Whoareyougoingtorefertotheneurologist?BecauseIlltellyouhowtotreatandmanage,atleastinitially,kidsandadultswithmigraine,earlyon.Peoplewhoyoufeelyouhaventreallyfiguredoutwhatsgoingon,theyreadiagnosticpuzzleforyou,whateverthatisforyou.Forsomepeople,thatsanybodywhowalksintheroomwithaheadache;for

otherpeople,theyreprettygoodatit,anditsjusttheinterestingonesthattheysendus.Ifyoutrytomanagesomebodyanditsnotreallyworking,thenyeah,thatswhatweretherefor.Inthisarea,everybodyhastoseetheneurologist.Therearefamiliesthatareanxious,orsay,Weneedtheexpert,sosendthemover.Slide(onBlackboard):Treatment,howdoyoutreatheadaches?Itsmultimodal.Wethinkabouttreatmentsthat


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aremeanttohelpmanagetheheadache,bothbehaviorallyandanxiety,lifestyle,etc.Therearestrategiestoaborttheheadacheswhentheyfirstcomeon,andthenifyourheadachesaretoofrequentortoodebilitating,thenwethinkabouttreatmentsthataremeanttoactuallypreventheadaches.Slide6F:Theinitialmanagementisalwaystoeducate.SpendalotoftimejusttalkingabouttheverythingsImtalkingtoyouabout,youknow,thisiscommon,itrunsinyourfamily,look,Marthahasit,you

haveit,everybodyhasit,whyshouldntlittleJohnnyhaveit?Talkaboutthelifestyleandinfluences,Ispendmoretimedoingthatthananythingelse,whenItalktopeoplewithheadaches.Theymayneedstressmanagement,thatisacommontrigger,andiftheyrehavingfrequentheadaches,thatmaybeinandofitselfverystressful.TheyneedreassuranceIdontscaneven50%ofpeopleIseewithheadaches,Itrytoreassurethem,sometimesyoucantandyouhavetoscanthemjustforthatreason.Slide7A:Stressmanagementcanbemanythings.Itcanbemusclerelaxation,itcanbebiofeedback,itcanbeallkindsofdifferentthings.Icemask,thatsfelttobehelpfulforsomepeoplewhohaveacuteheadaches,putanicemaskoricebagontheirface.Youwanttotreatanycomorbidanxietyordepression,ifthoseexist,andtheydoexist.Thencopingmechanisms,onhowtodealwithyourheadachesonceyougetthem.Itmaybesimpleyoumayneedtolaydownforalittlewhile,maybetakeyourmedicinerightattheonset,youmayneedtodrinksomemorewater,andhowdoyoucopewithyourheadache,stressoftheheadache,anxietyoftheheadache.Sometimestheheadachesaresobadthatpeoplegetstressedoutwhentheystarttogetamigraine.Soyouneedtoidentifysomeofthesestressors,andforinstanceifsomebodyisatworkoratschool,andtheymisshalfaday,halfayearofschool,andyouretryingtogetthembackontrack,whathappensistheygobacktoschoolandtheschoolwantsthemtodoallofthemakeupworkthisweek.Soyoumayhavetodealwiththeschoolorworkforareasonablewaytogetthembackin.Thenidentifydrugandalcoholuse,Ivesaidthatafewtimes,youhavetoaskthemdirectly,andthatsalwaysthebestway.Whenyoureseeingteenagers,youalwaysneedtotalktothemforatleastafewminuteswithouttheirparentsintheroom.Slide7B:Triggeringfactors.Someofthetriggeringfactorsforheadachesarecompletelyoutofyourandmycontrol,likeweatherchangeisacommontriggerfactor,wehaventfiguredouthowtochangethat.A

verycommononeissleepbothtoomuchsleepandtoolittlesleep,oraverydisorderedsleepcycle,wheretheygetupforschoolat6,andthengetuponweekendsat1youhavetochangethat,andthatsnoteasytochange.Regularmealsandhydration,forinstance,ifIseesomebodywithheadaches,Imayencouragethemtodrink24bottlesofwateraday.Certainodorsareverycommontriggerscigarettesmoke,dieselfuel,butalsothingsthatyouthinkofasgoododors,likeperfumes,airfresheners,scentedcandles,thingslikethattakethemoutoftheenvironmentasmuchaspossible.Thiskindoflightingisnotgoodforsomekids,thatsoneofthethingsthatshardtochangeinschools.Butsunlight,youknow,wearahat,wearsunglasses.ProlongedconcentrationIsortoffocusonthatsoifkidsaresittinginfrontofthecomputeroravideogame,orifyoureatworkandyouresittinginfrontofyoucomputerallday,havetimedbreaks.Iusuallyhavethematthecomputerfor20,30minutes,maybesetakitchentimerbecauseweallgetengrossed,thengetupfor23minutes,drinksomewater,walkaround,thatsveryhelpful.Thenlookatalltheirmedicines,andtalkaboutdrugsandalcohol.

Slide7C-D:Therearesomefoodtriggers,whichmayormaynotbeimportant.Themostimportantonesinmymindarechocolate;foodsthathavenitrateslikehotdogs,baloney,sausage,bacon,pepperoni,salami.Youcangetallthosethingswithoutnitrates.AndthingshighinMSG,likeChinesefood,cupofnoodles,ramennoodles,thatarehighlyprocessed.Alcoholforalittlebitolderpeople.Slide7E:Thentherearealternativemeasures,noneofthemhaveverygoodevidencethattheyworkthatwell.Botoxinjectionforchronicheadache,Iwillmention,thatsactuallybeenshowntobehelpfultheyinjecttheparaspinalmuscles,frontalis,temporalis.


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Slide7F:Useanabortivemedicinetostoptheheadacheattheonset.Forpeoplewhoarenothavingreallyfrequentheadaches,thatsthebeststrategy.Usuallyweusetheusualmedicinestostartwithibuprofen,acetaminophen,andnaproxen,andthedosesarethereforthepediatricpopulation.Youshouldknowtheadultdosagesalready.Ifyouregoingtotakeanabortivemedicine,doitrightattheonsetoftheonset,itworksbetter,dontwaittillitgetsrealbad.Everythingworksbetterifyoutakeitrightattheonset.And

takeadequatedosesalotofpeopleunderdosethemselves.Ifyouunderdoseyourselfanditworksfine,thatsallright,butthatsonereasonforquitting.Slide8A:Ineverprescribenarcoticsformigrainesthatsnottrue,Idoitrarely.Butitsusuallyforpeoplewhohaveveryinfrequentheadaches,becauseitcancausereboundprettyquickly.Andthesamethingforfiorinal,fioricet,andMidrinsnotevenonthemarketanymore.Slide8B:Thesecondarymanagementthatweuseoccurswhenthosethingsthatwejusttalkedaboutfailinotherwords,thepatientisstillhavinglotsofheadaches,andtheyvebeensortofreallypersistentandnotreallytracting.Webreakthatupintomoresophisticatedabortivemedicines,andthenpreventativemedicines,andthentheressomenontraditionaltypetreatments,too.Slide8C:Themedicinesthatweusethemostasabortivemedicinesformygraineisthetriptans,andtheyweredesignedspecificallyformigraines.Actually,thishasjustrecentlychangeditsaysnonehavebeenapprovedforunderage18,butactuallyAxert,whichisalmotriptan,isapprovedfor1218.Weusethembecausetheyreselective5HT1Dagonists,andmostofthemhavealso1Bproperties,whichisvascular,andthatleadstosomeoftheirsideeffects.Slide8D:Eachtriptan,theresabout10ofthem,hassortoftheirownproperties,butifyoulookatthemacrosstheboard,theyreallaboutequallyeffective.Youneedtogetcomfortablewith1or2ofthem,figureoutwhichonesyouregoingtouse.Now,onereasontouseoneoveranotherishowitsdeliveredsoifsomeonehasalotofnauseaandvomiting,theymaynotbeabletoswallowapill,youmaywanttouseanasalspray.

Slide8E:Heresalistofthetriptan.SumatriptanorImitrexwasthefirst;rhizotriptanorMaxalthasalittlemorebioavailability,sometimesitworkswhenImitrexdoesnt.Zolmotriptanisanasalspray,IusethatoverImitrexnasalspray,andthosearetheonlytwonasalsprays,becauseitdoesnttastesogood.Axertisapprovedinchildrennow.Frovahasaspecialuseformenstrualmigraine,becauseitsasloweronsetbuthasaverylongdurationofaction,soitsmeantforusethroughyourmenstrualcycle.Slide8F:Othermedicinestoabortheadachesincludedihydroergotamine,andthatsgivenasanasalsprayalso,Migrainol.DHEisIV,andweusethatalottostopmigrainesthathavegoingforalongtime.ToradolisusedIVintheER;Depacon,whichisvalproicacid,givenIV,isaveryeffectivewaytostopongoingheadaches,anditsactuallymyfirstchoiceforsomebodywhocomesinwithstatusmigrainosis.Thenphenothiazines,oxygen,allthesethingshavebeenusedforheadachetreatment.

Slide9A:Preventativemedicinesyouwillusetheseiftheheadachesaretoofrequent,thepersonhastoomuchmorbidity,andyouneedtodecreasethefrequencyofheadaches.Theydecreasethefrequencyandseverity,buttheydontcureanything.Useaheadachediarywhenyouusethem,tomakesureyouredoingsomegood.Youneedtostartlow,thenincreaseeverycoupleweeksuntilyougettothetargetdose,andthebiggestreasonforfailureisyoudontusethemlongenoughorattheproperdose.Youreallytrytousethedoseyoucangetto,dependingontoleranceanddependingonwhatthedoseis,foratleast2monthsbeforeyousayitsnotgoingtowork.Becausealotofthemhaveadelayedeffect.Theproblemwithpreventativemedicine,especiallyinchildrenbutinanybodyis,well,howlongdoyouusethem?Andit


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dependsonhowbadyourproblemis,Ithink.Andyouretryingtochangeotherthings,likeyoursleephabitsorotherthings,alongthewaytoo,somaybeyoucanstopthedrug.Slide9B:ThefirstoneImgoingtomentionisPeriactinorcyproheptadine.Weuseitinyoungerkids.Itsanantihistamine,butithasserotonergiceffects.Itsbiggestproblemisdrowsinessandbigtimeweightgain.Anditsmoderatelyeffective,butitsverysafeforkids,soIusuallyuseitinkidsunder8,Idontuseit

inolderpeoplebecauseoftheweightgainandthedrowsiness.Slide9C:Betablockershavebeenusedforalongtime,andpropanololistheonethatsbeenusedmostoften.Ilikeatenololornadolol,theyhavemuchfewersideeffectsthanpropanolol.Theyrenothighlyeffective,thoughsometimestheyworkquitewell,andingeneraltheyreprettysafe.Slide9D:Youcantusethemifyouhaveaheartblock,orasthma,ordepression,becauseitllmakeallofthosethingsworse.Yourenotsupposedtousethemindiabetes,andyourenotsupposedtousetheminRaynauds.Slide9E:Theycancausefatigue,dizziness,depression.Idontusealotofbetablockers.Slide9F:Tricyclicantidepressantshavebeenusedformanyyearsasapreventive.Thetwothatareusedisamitriptyllineandnortriptylline,andinstudiesamitriptyllineismoreeffective,butithasmoreanticholinergicsideeffects,soyoumightusenortriptyllinewhenyouhavetoomanyanticholinergicsideeffects.Iuseverylowdoses,Istartanybodyat10mg,theyuseitallatnight,andtheyreveryeffectiveiftheyretolerated.Andtheyreoneofthemedicinesweuseforchronicdailyheadaches.Slide10A:Thesideeffectsaredrowsiness,drymouth,weightgain,urinaryretention,alltheanticholinergicsideeffects.Slide10B:Thesearethecontraindications,usuallynotaproblem.Noneofthesemedicinescanbeusedinpregnancy,andthatbecomesabigproblem.

Slide10C:Calciumchannelblockershavebeenused,andverapamilisreallytheonlyonewehaveinthiscountry.Itsmildlyeffective.Itsverysafeifyoudonthaveanykindofcardiacconductiondefect,butIdontusethemverymucheitherbecausetheyreonlymildlyeffective,butithasaverygoodsafetyprofile,soIfallbacktoitsometimes.Slide10D:ThesideeffectsincludeAVblock,andedemaisnotuncommonwithcalciumchannelblockers,allofthem.Slide10E:Andyourenotsupposedtousetheminanykindofheartblockproblem.Slide10F:Whatweusemostoftenin2012areanticonvulsants.Depakotewasthefirstonethatwas

used,itsveryeffectiveinadultstudiesandinkids,anditcomesinanextendedreleaseform,thatsthekindweuse,anditsgoodforchronicdailyheadache.2501500mgadayissortofthedoserangethatwerein.Slide11A:Ithasanumberofsideeffectsthatinmypopulationwereallydontlike.Firstisweightgain,thisisabigone.Wemakeyoungladiesreallymadwhenwecausethemtogainweight.Liverfunctionabnormalities,thrombocytopenia,hairloss,tremor,andneurotoxicity,allthesethingscanbeseenassideeffectsofvalproicacid.Actually,itsnotrealdangerous,itsjustthesebothersomesideeffects.Soitsfinetotryit,butyouvegottawarnthemaboutthesideeffects,andtheniftheystartseeingit,thenyouchangethemtosomethingelse.ThisisonethatIwouldnotuseinpregnancyatall,valproidaciditcausesneural


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tubedefectsandcleftlipandcleftpalate.Anditdoesitataprettygoodclip,soitabsolutelyshouldnotbeusedinpregnancy.Thatsanotherreasonnottouseitinyoungwomen.Slide11B:Topamaxhasbecomethesortofgotopreventativemedicineformigraine,mostlyinwomen,butforanybody.Itsveryeffectiveinadultstudies,andweusebetween25and150mg.Iusuallystartwith2550atnight,thengoupinthedose,maybe50inthemorningand100atnight,butdontgoany

higher,eventhoughweusemuchhigherdosesforepilepsy,becausethestudiesshowitsnotanymoreeffective.Slide11C:Weightlossisthemajorsideeffect.Butthesideeffectthatgetsusintroubleistheneurotoxicitywordfindingdifficulties,notbeingabletothinkclearly,fogginess;peopleworryaboutacidosis,butnotatthedosesweuse.Reallyrareisacuteglaucoma,causingapainfulredeye,itsalwaysreversible,Idowarnpeopleaboutthat.TheotherthingIwarnpeopleaboutisjust,anditsnotdangerousatall,isalittlebitofparesthesiasofthefingersandtoes,thatworriessomepeople,thathappenstoabout5%ofpeople.Slide11D:Gabapentindoesnthavegreatstudies,butitsokay,andIusethatoccasionallywhenotherthingsfail.Slide11E:Thentherearesomestudieswithlevetiracetam.Imnotgoingtogooveragreatdealmoreaboutthemedications,becauseyoullgetawholetalkaboutthepharmacologyofthesemedicinesformigraine.SoImgoingtostopthereandansweranyquestions,wehavejustacoupleminutes.Anyquestions?Allthisisclear,allright.Okay,thankyou.

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11 12 ICM McClintock Headache and Migraine 03-19-12

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Transcript of 11 12 ICM McClintock Headache and Migraine 03-19-12