By Dr. David Greene, CEO Nevada Pain Network NevadaPainNetwork.com THE BASICS OF MIGRAINES.

By Dr. David Greene, CEO

Nevada Pain Network

NevadaPainNetwork.com

THE BASICS OF MIGRAINES

• Chronic headaches that affect people from a few hours up to 72 hours straight.

• Complicated, recurrent headache disorder.

• Most common in women and those between 15 and 55.

• Most become less severe and less frequent with age.

WHAT IS A MIGRAINE?

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• Affects 18% of women, 8% of men.

• 30 million in US have at least one migraine per year.

• Every 10 seconds, someone in the United States goes to the emergency room with a headache or migraine.

• 70% have a 1st degree relative who suffers.

• If one parent suffers from migraine, there is a 40% chance a child will suffer. If both parents suffer, the chance rises to 90%.

• More than 90% of sufferers are unable to work or function normally during their migraine.

HOW COMMON ARE MIGRAINES?



• There’s a LOT we don’t know.

• Genetics and Environment

• Imbalances in brain chemicals – serotonin levels drop during migraines.

• Low serotonin, a pain management chemical, levels can trigger a migraine by letting too much blood flow through vessels that should be constricted—inducing a throbbing sensation.

WHAT CAUSES MIGRAINES?



• Foods – aged cheese, red wine (tyramine), beer, whisky, food additives (nitrates), cold foods, citrus fruits, MSG, caffeine.

• Elevated Stress

• Weather changes – barometric

• Strong scents – perfume, paint

• Hair accessories – ponytail

• Exercise – e.g. sex

• Poor Posture

• Skipping Meals

• Smoking

WHAT ARE TYPICAL MIGRAINE TRIGGERS?



CHOCOLATE

Small silver lining – NO evidence to clearly substantiate that chocolate is a trigger of

migraine headaches. It’s a myth!



• Often unilateral head pain that is throbbing and aggravated by activity.

• Aura – visual or sensory symptoms prior to the onset of the headache (photophobia, visual scintillations).

• 80% of migraines have no aura.

SYMPTOMS OF MIGRAINES



• No objective testing available.

• CT or MRI can rule out badness causing similar symptoms.

• Diagnosed on patient history and pattern of symptoms.

• Migraine diary can be very helpful.

DIAGNOSING MIGRAINES



• International Headache Society requires pt to have at least 5 attacks fulfilling 3 criteria:

1. 4-72 hour duration

2. At least 2 of these:

1. Unilateral

2. Pulsating

3. Moderate to severe pain intensity

4. Aggravation by or causing avoidance of routine physical activity

3. At least one of these:

1. Nausea +/- Vomiting

2. Photophobia and phonophobia

MAKING THE DIAGNOSIS OF MIGRAINE



• Triptans – target Serotonin

• Almotriptan (Axert)

• Eletriptan (Relpax)

• Frovatriptan (Frova)

• Naratriptan (Amerge, Naramig)

• Rizatriptan (Maxalt)

• Sumatriptan (Alsuma, Dosepro, Imitrex, Sumavel, Treximet, Zecuity)

• Zolmitriptan (Zomig)

ABORTIVE TREATMENT OPTIONS



• Acetaminophen-isometheptene-dichloralphenazone (Midrin)

• Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)

• Ergotamine tartrate (Cafergot)

• Over- the-counter medications such as Advil Migraine (containing ibuprofen), Excedrin Migraine (containing aspirin, acetaminophen, caffeine), and Motrin Migraine Pain (containing ibuprofen)




• Narcotics

• Barbiturates

• Nausea

• Metoclopramide (Reglan)

• Prochlorperazine (Compazine)

• Promethazine (Phenergan)




• Goal is to lessen the frequency and severity of migraines.

• High blood pressure medications

• Beta blockers

• Calcium Channel Blockers

• Antidepressants

• Amitriptyline (Elavil)

• Nortriptyline (Pamelor)

• Antiseizure medications

• Gabapentin

• Topamax

• Depakote

• Pizotifen (Sanomigran)

• Serotonin antagonist

PREVENTIVE TREATMENT OPTIONS



INTERVENTIONAL TREATMENTS

• FDA has approved Botox injections for chronic migraines.

• 3 month intervals

• Injected into 32 sites in a 10 minute procedure.

• Covered if certain medications have been tried and failed.

• For chronic migraines = “distinct and severe neurological disorder characterized by patients who have a history of migraine and suffer from headaches on 15 or more days per month with headaches lasting four hours a day or longer.”

• Patients treated with BOTOX® (onabotulinumtoxinA) averaged 8 to 9 fewer headache days per month compared to baseline (vs 6 to 7 days with placebo) as demonstrated in the Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) study.1



• Occipital Nerve Blocks

• Cervical Facet Injections

• Cervical Epidural Injection

• Sphenopalatine Ganglion Blocks

• Supratrochlear Nerve Blocks

• Supra/ Infraorbital Nerve Blocks

• Pulsed radiofrequency energy of Occipital Nerves

INTERVENTIONAL TREATMENTS



NERVE BLOCKS• Study of 100 pts.receiving GON blocks (Migrainetrust.org) - 53% achieved pain

relief averaging 3 weeks.

• Retrospective study on the efficacy of GON block in refractory migraine patients. [5] A mixture of lidocaine and methylprednisolone was used for nerve blockade. Fifty-four percent of migraine patients reported on being "significantly better" after the blocks, and the duration of response lasted up to 6 months. (Gawel and Rothbart 1992, Cephalalgia)

• Caputi and Firetto examined the benefit of PNBs in the treatment of migraine. [6] They assessed 27 migraine patients before and after GON and supraorbital nerve (SON) blocks. Maximum of 10 injections with 85% effectiveness rate for 6 months.



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By Dr. David Greene, CEO Nevada Pain Network NevadaPainNetwork.com THE BASICS OF MIGRAINES.

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Transcript of By Dr. David Greene, CEO Nevada Pain Network NevadaPainNetwork.com THE BASICS OF MIGRAINES.