Migraine and Headaches Anish Bahra Headache Service NHNN

Migraine vs Headache

Classification of Head and Facial Pain Disorders Part I The Primary Head and Facial Pain Disorders Part II The Secondary Head and Facial Pain Disorders

Classification of Head and Facial Pain Disorders Part I The Primary Head and Facial Pain Disorders Part II Primary Care 0.1% A&E ~ 8%`

Primary Headaches Tension-Type headache Migraine Cluster headache & related disorders Other Primary headaches Prevalence 20-87%12%≤0.2%Uncommon

Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

Cause of Headache

Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

New onset Migraine coinciding with new area of inflammation MS : Haas, Headache 1993

Hypothalamic Neurostimulation in Cluster Headache : Leone,

Bahra et al. Lancet 2001 Brainstem Activation in Migraine Headache Afridi et al. Brain 2005 Weiller et al. Nat. Med.1995

Cluster HeadacheMRAMigraine Craniovascular Activation in Primary Headaches

Primary Headaches Tension-Type headache Migraine Cluster headache & related disorders Other Primary headaches FH 3 fold50%14 foldAnecdotal

Familial Hemiplegic Migraine

Pathogenic mutations in three genes → CACNA1A, ATP1A2 & SCNA1 genes 1. FHM 1 – CACNA1A gene → P/Q-type voltage-gated neuronal Ca 2 + channels 2. FHM2 –ATP1A2 gene → Na+ -K+ pump ATPases 3. FHM3 – SCNA1 gene → Voltage-gated Na+ channels Genetically predisposed dysfunction of ion-channels within the nervous system Familial Hemiplegic Migraine

Functional Consequences of Gene Mutations FHM-1 CACNA1A Gene Ca Channel FHM-3 SCN1A Gene Na Channel FHM-2 ATP1A2 Gene Na/K ATPase Pump Gain of functionLoss of functionGain of function Cortical Hyperexcitability

Hadjikhani, Proc Natl Acad Sci U S A, 2001 Cortical Spreading Depression in Aura

Genetic Neurological Disorder

Focus on Migraine

Lipton RB, Stewart WF. Neurology Migraine Prevalence (5)

Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

Eye Frontal Temporal Vertex Occipital Neck Diffuse 67 % Kelman, Headache 2005 Migraine : Location of Pain

Aura in Migraine Visual 99 % Visual only39 Sensory 54 Aphasia32 Visual & sensory28 Visual & aphasic25 All 36 Eriksen ( Cephalalgia 2004) N=362

Migraine and ‘Headaches’

90% with disabling headache have a Migraine disorder Disabling tension-type headache is rare % Lipton, Headache 2000

Spectrum Study: Sumatriptan Response % Response

Management of Migraine

Susceptibility to ‘Triggers’ Exogenous Factors Missed Meal Too much sleep / too little sleep Stress / Immediate post-stressful period Alcohol Sensory stimuli → Visual and Olfactory Dietary → Over-estimated Caffeine and ARM → Under-estimated Endogenous Factors Hormonal

TTH Scher et al. Headache 1998 Castillo Headache 1999 Wang et al. Neurology 2000 % Population CHINA CHRONIC DAILY HEADACHE Headache > 15 days / month > 3 months USA SPAIN Migraine Other

TTH Scher et al. Headache 1998 Castillo Headache 1999 Wang et al. Neurology 2000 % Population CHINA USA SPAIN Migraine Other Medication-Overuse : 1-2%

0 10 No. subjects with headache Week Caffeine Decaffeinated Switch from one to the other Van Dusseldorp, BMJ. 1990

0 10 No. subjects with headache Week Caffeine Decaffeinated Switch from one to the other Van Dusseldorp, BMJ. 1990

Migraine Prevalence (5) Lyngburg, 2005 – Longitiudinal Observation Prognosis 42% Remission 38% < Frequent 20% CDH

Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse

Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse Opioids

Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse Opioids

Management : Acute Attack Treatment Level of effectiveness Side – effects Consistency

Management : Acute Attack Treatment Level of effectiveness → 2 hrs mild / no pain Side – effects → Outweigh benefit Consistency → Adequate dose 3 trials

Management : Acute Attack Treatment Basic Principle: Adequate single abortive dose of the most effective drug Can repeat for recurrence within 24 hours Will not work for initial non-response Maximum use < 6-8 days / month

Ibuprofen 600mg Severity TIme

Ibuprofen 600mg

Sumatriptan 50mg

Simple AnalgesiaAbortive dose Aspirin900mg po Ibuprofen mg po Naproxen500mg po Paracetamol 1g ANTIEMETIC Domperidone10-20mg po / 30-60mg PR Metoclopramide10mg po/IM/IV

Efficacy Almotriptan Eletriptan Rizatriptan Side-Effect Profile Almotriptan Frovatriptan Naratriptan Formulation : Preference Vomiting Rizatriptan Wafer Sumatriptan sc / IN Zolmitriptan Wafer / IN Recurrence Almotriptan Eletriptan Naratriptan

Management Keep a headache diary Optimise acute treatment Frequency < 4 headache days/month → Acute Rx Frequency > 4 disabling HA days / month → Prevention Ensure ARM use restricted to < 6-8 HA days / month Early introduction of prevention for  frequency

PREVENTATIVESTART DOSEINCREMENTSMAX DOSES Propranolol* Start Low Increase Slow Aim for the Maximum Tolerated (or lower if effective) 320 mg Amitriptyline*200 mg Nortriptyline150 mg Pizotifen4.5 mg Sodium valproate* 2g Gabapentin3.6g Topiramate*200mg (can use higher doses)

Severity of Migraine Disorder Time Propranolol 20mg bd Propranolol 80mg bd + 100mg bd Propranolol 80mg bd + Topiramate 50mg bd Propranolol 80mg bd Propranolol 40mg bd

Genetic Neurological Disorder QUESTIONS