MigraineMigraine

UTMB Department UTMB Department of Otolaryngologyof Otolaryngology

Grand Rounds March Grand Rounds March 20052005

Jeffrey Buyten, MDJeffrey Buyten, MD David C. Teller, MDDavid C. Teller, MD Francis B. Quinn, MDFrancis B. Quinn, MD

PrevalencePrevalence

FamilialFamilial Young, healthy women; F>M: 3:1Young, healthy women; F>M: 3:1

– 17 – 18.2% of adult females17 – 18.2% of adult females– 6 – 6.5% adult males6 – 6.5% adult males

2-32-3rdrd decade onset… can occur sooner decade onset… can occur sooner Peaks ages 22-55.Peaks ages 22-55. ½ migraine sufferers not diagnosed.½ migraine sufferers not diagnosed. 94% pt’s seen in primary care 94% pt’s seen in primary care

settings for HA have migrainessettings for HA have migraines

Common Common misdiagnoses for misdiagnoses for migraine:migraine:– Sinus HASinus HA– Stress HAStress HA

Referral to ENT for Referral to ENT for sinus disease and sinus disease and facial pain.facial pain.

Migraineurs more likely to Migraineurs more likely to have motion sickness.have motion sickness.

Half of Meniere’s patients Half of Meniere’s patients claim to have migrainous claim to have migrainous symptoms.symptoms.

BPPVBPPV

$13 billion/year in lost $13 billion/year in lost productivityproductivity

1/3 participants in 1/3 participants in American Migraine American Migraine Study II missed work Study II missed work in prior 3 monthsin prior 3 months

Migraine DefinitionMigraine Definition IHS Diagnostic criteria: migraine IHS Diagnostic criteria: migraine

w/o auraw/o aura– HA lasting for 4-72 hrsHA lasting for 4-72 hrs– HA w/2+ of following:HA w/2+ of following:

UnilateralUnilateral PulsatingPulsating Mod/severe intensity.Mod/severe intensity. Aggravated by routine Aggravated by routine

physical activity.physical activity.– During HA at least 1 of During HA at least 1 of

followingfollowing N/VN/V PhotophobiaPhotophobia PhonophobiaPhonophobia

IHS criteria: Migraine/aura (3 out IHS criteria: Migraine/aura (3 out of 4)of 4)– One or more fully reversible One or more fully reversible

aura symptoms indicates focal aura symptoms indicates focal cerebral cortical or brainstem cerebral cortical or brainstem dysfunction.dysfunction.

– At least one aura symptom At least one aura symptom develops gradually over more develops gradually over more than 4 minutes.than 4 minutes.

– No aura symptom lasts more No aura symptom lasts more than one hour.than one hour.

– HA follows aura w/free HA follows aura w/free interval of less than one hour interval of less than one hour and may begin before or and may begin before or w/aura.w/aura.

History, PE, Neuro exam show no other organic History, PE, Neuro exam show no other organic disease.disease.

At least five attacks occurAt least five attacks occur

Migraine SubtypesMigraine Subtypes Basilar type migraineBasilar type migraine

– Dysarthria, vertigo, Dysarthria, vertigo, diplopia, tinnitus, diplopia, tinnitus, decreased hearing, decreased hearing, ataxia, bilateral ataxia, bilateral paresthesias, altered paresthesias, altered consciousness.consciousness.

– Simultaneous bilateral Simultaneous bilateral visual symptoms.visual symptoms.

– No muscular weakness.No muscular weakness. Retinal or ocular Retinal or ocular

migrainemigraine– Repeated monocular Repeated monocular

scotomata or blindness scotomata or blindness < 1 hr< 1 hr

– Associated with or Associated with or followed by a HAfollowed by a HA

Migraine SubtypesMigraine Subtypes

Menstrual migraineMenstrual migraine Hemiplegic Hemiplegic

migrainemigraine– Unilateral motor and Unilateral motor and

sensory symptoms sensory symptoms that may persist that may persist after the headache.after the headache.

– Complete recoverComplete recover Familial hemiplegic Familial hemiplegic

migrainemigraine

Migrainous vertigoMigrainous vertigo Vertigo – sole or prevailing symptom.Vertigo – sole or prevailing symptom. Benign paroxysmal vertigo of Benign paroxysmal vertigo of

childhood.childhood. Prevalence 7-9% of pts in referral Prevalence 7-9% of pts in referral

dizzy and migraine clinics.dizzy and migraine clinics. Not recognized by the IHSNot recognized by the IHS Diagnosis (proposed criteria)Diagnosis (proposed criteria)

– Recurrent episodic vestibular Recurrent episodic vestibular symptoms of at least moderate symptoms of at least moderate severity.severity.

– One of the following:One of the following: Current of previous history of IHS Current of previous history of IHS

migraine.migraine. Migrainous symptoms during two or Migrainous symptoms during two or

more attacks of vertigo.more attacks of vertigo. Migraine-precipitants before vertigo in Migraine-precipitants before vertigo in

more than 50% of attacks.more than 50% of attacks.– Response to migraine medications in Response to migraine medications in

more than 50% of attacksmore than 50% of attacks

Migraine mechanismMigraine mechanism Neurovascular theory.Neurovascular theory.

– Abnormal brainstem Abnormal brainstem responses.responses.

– Trigemino-vascular Trigemino-vascular system.system. Calcitonin gene related Calcitonin gene related

peptidepeptide Neurokinin ANeurokinin A Substance PSubstance P

Extracranial arterial Extracranial arterial vasodilation.vasodilation.– TemporalTemporal– Pulsing pain.Pulsing pain.

Extracranial neurogenic Extracranial neurogenic inflammation.inflammation.

Decreased inhibition of Decreased inhibition of central pain transmission.central pain transmission.– Endogenous opioids.Endogenous opioids.

Important role in Important role in migraine migraine pathogenesis.pathogenesis.

Mechanism of Mechanism of action in migraines action in migraines not well not well established.established.

Main target of Main target of pharmacotherapy.pharmacotherapy.

Aura MechanismAura Mechanism Cortical spreading depressionCortical spreading depression

– Self propagating wave of neuronal and glial depolarization Self propagating wave of neuronal and glial depolarization across the cortexacross the cortex Activates trigeminal afferentsActivates trigeminal afferents

– Causes inflammation of pain sensitive meninges that Causes inflammation of pain sensitive meninges that generates HA through central/peripheral reflexes.generates HA through central/peripheral reflexes.

Alters blood-brain barrier.Alters blood-brain barrier.– Associated with a low flow state in the dural sinuses.Associated with a low flow state in the dural sinuses.

AurasAuras– Vision – most common Vision – most common

neurologic symptomneurologic symptom– Paresthesia of lips, Paresthesia of lips,

lower face and fingers… lower face and fingers… 22ndnd most common most common

– Typical auraTypical aura Flickering uncolored Flickering uncolored

zigzag line in center zigzag line in center and then peripheryand then periphery

Motor – hand and arm Motor – hand and arm on one sideon one side

Auras (visual, sensory, Auras (visual, sensory, aphasia) – 1 hraphasia) – 1 hr

ProdromeProdrome– Lasts hours to days…Lasts hours to days…

Clinical manifestationsClinical manifestations

Clinical manifestationsClinical manifestations– Lateralized in severe Lateralized in severe

attacks – 60-70%attacks – 60-70%– Bifrontal/global HA – 30%Bifrontal/global HA – 30%– Gradual onset with Gradual onset with

crescendo pattern.crescendo pattern.– Limits activity due to its Limits activity due to its

intensity.intensity.– Worsened by rapid head Worsened by rapid head

motion, sneezing, straining, motion, sneezing, straining, constant motion or constant motion or exertion.exertion.

– Focal facial pain, cutaneous Focal facial pain, cutaneous allodynia, GI dysfunction, allodynia, GI dysfunction, facial flushing, lacrimation, facial flushing, lacrimation, rhinorrhea, nasal rhinorrhea, nasal congestion and vertigo…congestion and vertigo…

Precipitating factorsPrecipitating factorsstressstresshead and neck head and neck infectioninfectionhead trauma/surgeryhead trauma/surgeryaged cheeseaged cheesedairydairyred winered winenutsnutsshellfishshellfishcaffeine withdrawalcaffeine withdrawalvasodilatorsvasodilatorsperfumes/strong odorsperfumes/strong odorsirregular diet/sleepirregular diet/sleeplightlight

TreatmentTreatment

AbortiveAbortive– SteppedStepped– StratifieStratifie

dd– StagedStaged

PreventivPreventivee

Abortive TherapyAbortive Therapy Reduces headache Reduces headache

recurrence.recurrence. Alleviation of symptoms.Alleviation of symptoms. AnalgesicsAnalgesics

– Tylenol, opioids…Tylenol, opioids… AntiphlogisticsAntiphlogistics

– NSAIDsNSAIDs VasoconstrictorsVasoconstrictors

– CaffeineCaffeine– SympathomimeticsSympathomimetics– SerotoninergicsSerotoninergics

Selective - triptansSelective - triptans Nonselective – ergotsNonselective – ergots

MetoclopramideMetoclopramide

Abortive care strategiesAbortive care strategies SteppedStepped

– Start with lower level drugs, then switch to more specific Start with lower level drugs, then switch to more specific drugs if symptoms persist or worsen.drugs if symptoms persist or worsen.

Analgesics – Tylenol, NSAIDs…Analgesics – Tylenol, NSAIDs… Vasoconstrictors – sympathomimetics…Vasoconstrictors – sympathomimetics… Opioids (try to avoid) - ButorphanolOpioids (try to avoid) - Butorphanol Triptans – sumatriptan (oral, SQ, nasal), naratriptan, Triptans – sumatriptan (oral, SQ, nasal), naratriptan,

rizatripatan, zomatriptan.rizatripatan, zomatriptan.– Limited by patient compliance.Limited by patient compliance.

StratifiedStratified– Adjusts treatment according to symptom intensity.Adjusts treatment according to symptom intensity.

Mild – analgesics, NSAIDsMild – analgesics, NSAIDs Moderate – analgesic plus caffeine/sympathomimeticModerate – analgesic plus caffeine/sympathomimetic Severe – opioids, triptans, ergots…Severe – opioids, triptans, ergots…

– Severe sx treatment limited due to concomitant GI sx’s.Severe sx treatment limited due to concomitant GI sx’s. StagedStaged

– Bases treatment on intensity and time of attacks.Bases treatment on intensity and time of attacks.– HA diary reviewed with patient.HA diary reviewed with patient.– Medication plan and backup plans.Medication plan and backup plans.

Preventive therapyPreventive therapy

Consider if pt has more than 3-4 Consider if pt has more than 3-4 episodes/month.episodes/month.

Reduces frequency by 40 – 60%.Reduces frequency by 40 – 60%. Breakthrough headaches easier to abort.Breakthrough headaches easier to abort. Beta blockersBeta blockers AmitriptylineAmitriptyline Calcium channel blockersCalcium channel blockers Lifestyle modification.Lifestyle modification. Biofeedback.Biofeedback.

BotoxBotox

51% migraineurs treated 51% migraineurs treated had complete had complete prophylaxis for 4.1 prophylaxis for 4.1 months.months.

38% had prophylaxis for 38% had prophylaxis for 2.7 months.2.7 months.

Randomized trial Randomized trial showed significant showed significant improvement in improvement in headache frequency headache frequency with multiple with multiple treatments.treatments.

ConclusionsConclusions

Migraine is common but Migraine is common but unrecognized.unrecognized.

Keep migraine and its variants in the Keep migraine and its variants in the differential diagnosis.differential diagnosis.

ReferencesReferences1.1. Landy, S. Migraine throughout the Life Cycle: Treatment through the Ages. Neurology. Landy, S. Migraine throughout the Life Cycle: Treatment through the Ages. Neurology.

2004; 62 (5) Supplement 2: S2-S8.2004; 62 (5) Supplement 2: S2-S8.2.2. Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.Bailey, BJ. Head and Neck Surgery – Otolaryngology 3rd Edition. 2001. Pgs. 221-235.3.3. Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of Bajwa, ZH, Sabahat, A. Pathophysiology, Clinical Manifestations, and Diagnosis of

Migraine in Adults. Up To Date online. 2005.Migraine in Adults. Up To Date online. 2005.4.4. Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the Lipton, RB, Stewart, WF, Liberman, JN. Self-awareness of migraine: Interpreting the

labels that headache sufferers apply to their headaches. Neurology. 2002; 58(9) labels that headache sufferers apply to their headaches. Neurology. 2002; 58(9) Supplement 6: S21-S26.Supplement 6: S21-S26.

5.5. Cady, RK, Schreiber, CP. Sinus headache or migraine?: Considerations in making a Cady, RK, Schreiber, CP. Sinus headache or migraine?: Considerations in making a differential diagnosis. Neurology. 2002; 58 (9) Supplement 6: S10-S14.differential diagnosis. Neurology. 2002; 58 (9) Supplement 6: S10-S14.

6.6. Perry, BF, Login, IS, Kountakis, SE. Nonrhinologic headache in a tertiary rhinology Perry, BF, Login, IS, Kountakis, SE. Nonrhinologic headache in a tertiary rhinology practice. Otolaryngology – Head and Neck Surg 2004; 130: 449-452.practice. Otolaryngology – Head and Neck Surg 2004; 130: 449-452.

7.7. Daudia, AT, Jones, NS. Facial migraine in a rhinological setting. Clinical Otolaryngology Daudia, AT, Jones, NS. Facial migraine in a rhinological setting. Clinical Otolaryngology and Allied Sciences. 2002; 27(6): 521-525.and Allied Sciences. 2002; 27(6): 521-525.

8.8. Spierings, EL. Migraine mechanism and management. Otolarynogol Clin N Am 36 Spierings, EL. Migraine mechanism and management. Otolarynogol Clin N Am 36 (2003): 1063 – 1078.(2003): 1063 – 1078.

9.9. Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of Avnon, y, Nitzan, M, Sprecher, E, Rogowski, Z, and Yarnitsky, D. Different patterns of parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-parasympathetic activation in uni- and bilateral migraineurs. Brain. 2003; 126: 1660-1670.1670.

10.10. Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Stroud, RH, Bailey, BJ, Quinn, FB. Headache and Facial Pain. Dr. Quinn’s Online Textbook of Otolaryngology Grand Rounds Archive. 2001. Textbook of Otolaryngology Grand Rounds Archive. 2001. http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.dochttp://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc

11.11. Ondo, WG, Vuong KD, Derman, HS. Botulinum toxin A for chronic daily headache: a Ondo, WG, Vuong KD, Derman, HS. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel design study. Cephalalgia 2004 (24): 60-65.randomized, placebo-controlled, parallel design study. Cephalalgia 2004 (24): 60-65.