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Corbett JJ, Mehta MP. Cerebrospinal fluid pressure in normal obese subjects and patients with pseudotumor cerebri. Neurology 1983;33:1386-8
37
39
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Coronal T140
��RNFL thickness: Depth difference between inner border of NFL & internal limiting membraneRNFL thickness: Depth difference between inner border of NFL & internal limiting membrane43
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Migraine Aura
59
6
CGRP: calcitonin gene-related peptide
NK: neurokinin A
SP: substance P
CGRP
NK
SP
5-HT1F5-HT1D
5-HT1B
Blood vessel
Trigeminal
nerve
MOA of triptans
CONSTRICTION
INHIBITION
Adapted from Goadsby et al. Neurol Clin. 1997.
Triptans: Proposed Mechanism
of Action
74
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Cost* of Triptan Dose
Ranging from highest to lowest price
Amerge 2.5 mg $16.64
Zomig 5 mg $15.09
Axert 12.5 mg $14.75
Maxalt 5 mg or 10 mg $14.35
Imitrex 50 mg $14.29
Imitrex 100 mg $13.74
Zomig 2.5 mg $13.27
Relpax 40 mg $12.64
*Prices are WAC from First DataBank, May 200380
IHS CLASSIFICATION
Episodic
Chronic
�� Cluster Cluster headacheheadache
�� Episodic (90%)Episodic (90%)
�� Chronic (10%)Chronic (10%)
�� Cluster period lasts Cluster period lasts
for more than one for more than one
year without year without
remission or remission or
remission lasts less remission lasts less
than 14 daysthan 14 days
�� Related syndromesRelated syndromesCephalalgia. 1988.
129
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EPIDEMIOLOGYEPIDEMIOLOGY
Predominantly male Predominantly male
((3.5 3.5 –– 7:1 7:1 male:femalemale:female ratio)ratio)
Mean age of onset (27 Mean age of onset (27 ––
31 years)31 years)
Prevalence Prevalence
(0.1% (0.1% –– 0.4%)0.4%)
Ekbom C et al. Ekbom C et al. HeadacheHeadache. 1978.. 1978.Swanson JW et al. Swanson JW et al. NeurologyNeurology. 1994.. 1994.Manzoni GC. Manzoni GC. CephalalgiaCephalalgia. 1997.. 1997.
Rare before the age of Rare before the age of
10 years10 years
130
GENETICSGENETICS
11stst--degree relatives have a degree relatives have a
14X increased risk14X increased risk
Five identical twin pairs with Five identical twin pairs with
100% concordance100% concordance
Positive family history in Positive family history in
7% of sufferers7% of sufferers
Russel MB. Russel MB. CephalalgiaCephalalgia. 1997.. 1997.
AutosomalAutosomal dominant disorder?dominant disorder?
131
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CIRCANNUAL PERIODICITY
Waldenlind E. Cluster Headache and Related Conditions. 1999.Kudrow L. Cephalalgia. 1987.
132
CIRCADIAN PERIODICITY11--3 attacks daily (up to 8 attacks/day)3 attacks daily (up to 8 attacks/day)
Peak time periodsPeak time periods
PMPMPMPMAMAM
REM sleepREM sleep
Trucco M, Waldenlind E. Trucco M, Waldenlind E. CephalalgiaCephalalgia. 1993.. 1993.
133
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ATTACK PROFILEATTACK PROFILE
Unilateral orbital / temporal severe pain Unilateral orbital / temporal severe pain
intensityintensity
Rapid onset (5 Rapid onset (5 –– 15 min) / short duration 15 min) / short duration
(45 (45 –– 90 min)90 min)
“Agitated” patient (pacing / “Agitated” patient (pacing /
restless)restless)
‘‘MigrainousMigrainous’ symptoms (nausea, ’ symptoms (nausea,
photophobia, photophobia, phonophobiaphonophobia, aura), aura)
134
AUTONOMIC FEATURESAUTONOMIC FEATURESAUTONOMIC FEATURESAUTONOMIC FEATURES
Conjunctival injection lacrimationConjunctival injection lacrimation
Nasal congestion / rhinorrheaNasal congestion / rhinorrhea
Partial Horner’s syndromePartial Horner’s syndrome
Facial flushing / sweating Facial flushing / sweating
edemaedema
135
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ASSOCIATED ASSOCIATED FEATURESFEATURESASSOCIATED ASSOCIATED FEATURESFEATURES
High alcohol / tobacco usageHigh alcohol / tobacco usage
Leonine facies (heavy facial Leonine facies (heavy facial
features)?features)?
Peau d’orange skin?Peau d’orange skin?
HazelHazel--colored eyes?colored eyes?
Duodenal ulceration?Duodenal ulceration?
Type A personality?Type A personality?
136
HYPOTHALAMUS ABNORMAL –
FUNCTION AND STRUCTURE
May A et al. Lancet. 1998; Nat Med. 1999.
Function Structure
139
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PERIODICITY DYSFUNCTIONAL
HYPOTHALAMIC PACEMAKER
CircannualCircannual and and ciradianciradian
rhythmicityrhythmicity
Seasonal predilection of Seasonal predilection of
cluster periodscluster periods
Altered Altered secretorysecretory circadian circadian
rhythms of rhythms of hypophysealhypophyseal
hormone systems hormone systems (melatonin, (melatonin,
testosterone, betatestosterone, beta--endorphin, betaendorphin, beta--lipotropinlipotropin, ,
cortisolcortisol, , prolactinprolactin))
Leone M, Bussone G. Leone M, Bussone G. CephalalgiaCephalalgia. 1993.. 1993.140
SURGICAL PROCEDURES
FOR CLUSTER HEADACHES
Autonomic (parasympathetic) Autonomic (parasympathetic)
pathway procedurespathway procedures
Sensory trigeminal pathway Sensory trigeminal pathway
proceduresprocedures�� Radiofrequency or glycerol Radiofrequency or glycerol rhizotomyrhizotomy
�� Gamma knife Gamma knife radiosurgeryradiosurgery
�� Trigeminal root sectionTrigeminal root section
�� OtherOther
OnofrioOnofrio BM, Campbell JK. BM, Campbell JK. Mayo Mayo ClinClin ProcProc. 1986.. 1986.Mathew NT, Hurt W. Mathew NT, Hurt W. HeadacheHeadache. 1988.. 1988.TahaTaha JM, JM, TewTew JM. JM. HeadacheHeadache. 1995.. 1995.
148
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Frequency, Time of Onset, and Duration of HypnicHeadache (n=19)
32%
32%
37%
63%
37%
32%
68%
0% 20% 40% 60% 80%
<30
30-…
>120
1-3 …
3-6 …
1-3 …
>4 …
Feature:Feature:
FrequencyFrequency
Time of onsetTime of onset
Duration (min)Duration (min)
Dodick DW, Mosek AC, Campbell JK, Cephalgia, 1998, 18:152-6155
Laterality, Quality and Severity of Hypnic Headache in 19 Patients
21%
74%
5%
42%
58%
32%
68%
0% 50% 100%
Severe
Moderate
Mild
Throbbing, sharp, pulsating or stabbing
Pressure, dull or boring
Unilateral
Bilateral
Feature:Feature:
LateralityLaterality
QualityQuality
Severity (1Severity (1--10 scale)10 scale)
Dodick DW, Mosek AC, Campbell JK, Cephalgia, 1998, 18:152-6
157
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