1. Understanding Headaches Grace Forde, M.D Assistant Professor of Neurology New York University Director of Neurological Services North Shore Pain Service

2. Migraine Epidemiology Go Back to Main Menu

3. Lipton RB, et al. Neurology. 2007; 68(5):343-349. National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009. Migraine Prevalence  Approximately 26 million patients with migraine in the United States (> age 18)  One in 4 households has at least 1 migraine sufferer

4. Migraine Prevalence: Age and Gender Lipton RB, et al. Neurology. 2007;68(5):343-349. Migraine prevalence peaks in the 25-55 age range

5. Migraine Economic Impact, Productivity, and Quality of Life Go Back to Main Menu

6. Economic Burden of Migraine in US  Lost productivity is the greatest contributor to migraine economic burden  Productivity losses cost US employers up to $13 billion annually  Direct costs of migraine per patient range from ~$500-$7000/year  Total medical costs in households with at least 1 member with migraine are 70% higher than families without a member with migraine Hu XH et al. Arch Int Med. 1999;159(8):813-818. Hawkins K et al. J Occup Environ Med. 2007;49(4):368-374. Edmeads J and Mackell JA. Headache. 2002;42(6):501-509. Stewart WF et al. JAMA. 2003;290(18):2443-2454. Osterhaus JT et al. Pharmacoeconomics. 1992;2(1):67-76. Etemad LR, et al. JMCP. 2005;11(2):137–44. Pesa J and Lage MJ. Headache. 2004;44(6):562–70. Lafata JE, et al. J Gen Intern Med. 2004;19(10):1005–12. Hawkins K, et al. Value Health. 2006;9:A85. Stang PE, et al. Am J Manag Care. 2004;10(5):313–20.

7. * N=200 Full-Time Employees Timing and Impact of Migraine Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA. 58% of Migraines Occurred During Typical Work Hours *

8. Impact of Migraine: Productivity Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA. * N=157 Full-time employees Productivity Levels 74% of Patients With Migraine* Reported Productivity Levels Below 80%

9. Migraine Diagnosis and Treatment Go Back to Main Menu

10. Migraine Is an Episodic Recurrent Headache Lasting 4-72 Hours with: International Headache Society Criteria for Migraine + unilateral pain throbbing pain pain worsened by movement moderate or severe pain nausea vomiting photophobia and phonophobia Any 2 of these pain qualities: Any 1 of these associated symptoms: Features such as osmophobia and posterior head and neck pain can also be present in a headache that meets IHS criteria for migraine. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

11. Many Migraine Sufferers Remain Undiagnosed Diagnosed Migraine 56% Undiagnosed Migraine 44% Diamond S et al. Headache. 2007;47(3):355-363.

12. Patients with Recurrent Headache May Meet Criteria for Migraine 87% of patients presenting to PCP with recurrent headache met IHS criteria for migraine Migraine (n=237) Other (n=3) 1% Probable Migraine (n=31) Episodic Tension-type Headache (n=1) 0.4% Tepper SJ et al. Headache. 2004;44(9):856-864. 11% 87%

13. Focusing on Migraine Diagnosis  Opportunities for accurate diagnosis of migraine patients still exist: –80% of “sinus headache” patients met IHS criteria for migraine –85% of “tension/stress” headache patients met IHS criteria for migraine Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772. Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

14. Adapted from Cady RK. Headache. 2008;48(9):1415-1416. Headache Classification Subcommittee of the International Headache Society. Cephalalgia. 2004;24(suppl 1):117-118. Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone. 1999;1(6):21-32. Premonitory/ Prodrome Aura Mild Moderate to Severe Postdrome Time Migraine Intensity Phases of a Migraine Attack Migraine symptoms occurring hours/days prior to headache Migraine when headache is mild Migraine when headache is moderate to severe Migraine symptoms occurring hours/days after headache resolution Focal neurological symptoms preceding headache (<1 hour) Symptoms : Food cravings Mood changes Yawning Fatigue Symptoms: Tiredness Confusion Lowered appetite Stiff or sore muscles Symptoms: Same as mild but more intense Symptoms: Flashing lights or wavy lines Numbness Tingling in face Disturbed senses Symptoms: Sensitivity to light Sensitivity to sound Nausea Pain in the back of the head and neck National Institutes of Health. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/headache/detail_headache.htm. Accessed December 7, 2009. Pre-HAPost-HAHeadache Treatment Phase

15. Possible Triggers of a Migraine Attack  Food and food additives  Bright lights/glare  Smells/odors  Dieting/hunger  Loud noises/sounds  Changes in altitude/ air travel  Stress  Weather changes  Caffeine  Alcoholic beverages  Changes in sleep habits  Hormonal fluctuations/ menstrual cycle Wober C et al. J Headache Pain. 2006;7(4):188-195. Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.

16. Medication Options Available for Migraine Preventative Medications  May prevent or reduce the number of migraine attacks  Typically taken on a daily basis –Antiepileptics –Antidepressants –Beta blockers –Calcium channel blockers Acute Medications  May work quickly to relieve migraine pain and other symptoms  Usually taken during a migraine attack –Triptans –NSAIDs –Opioids –Analgesics (Rx and OTC) –Ergotamine/DHE –Antiemetics –Neuroleptics –Corticosteroids Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427. Silberstein SD. Neurol Clin. 2009;27(2):429-443.

17. Differences in Patients with Migraine  Migraine patient’s brain is in a state of hyperexcitability –Reduced threshold for stimuli –Everyday things can trigger a migraine attack  Migraine patient’s gut is slowed –Gastric stasis is common and can delay tablet absorption –Conventional tablets rely on surface erosion and gastric motility for dissolution in the stomach, which must occur before being absorbed Hargreaves RJ and Shepheard SL. Can J Neurol Sci. 1999;26(suppl 3):S12-S19. Aurora S et al. Headache. 2006;46(1):57-63.

18. The Triptans  Sumatriptan  Zolmatriptan  Naratriptan  Rizatriptan  Almotriptan  Frovatriptan  Eletriptan  Sumatriptan and Naproxen sodium

19. Triptan Prescribing Information: Contraindications and Precautions for ALL Triptans  Ischemic cardiac disease  Cerebrovascular disease  Uncontrolled hypertension  Hypersensitivity  Use within 24 hours of other 5-HTs/ergots  Hemiplegic/basilar migraine  History of risk factors for CAD  SSRI precaution

20. Case Scenario 2  29-year-old single woman, sales clerk; history of 8-9 migraines / month lasting for 12-14 hours, frequent recurrence  HA associated with nausea and sensitivity to light and sound  Currently taking an oral triptan tablet  Says that current treatment takes too long to act and does not fully relieve headache pain  Looking for a way to prevent attacks

21. Preventive Medication Groups Preventive Medication Groups  Anticonvulsants –valproate* –topiramate*  Antidepressants –TCAs –SSRIs  β-adrenergic blockers –propranolol* –timolol*  Calcium channel antagonists  Serotonin antagonists  Others –Botulinum toxin A* –coenzyme Q10 –NSAIDs –Petasites –Riboflavin –Magnesium Silberstein SD. Lancet. 2004;363:381-391. SSRI = selective serotonin reuptake inhibitor TCA = tricyclic antidepressant *Approved by FDA for this use.

22. Nonpharmacologic Therapies Tested in Clinical Trials Behavioral Treatments Relaxation training* Hypnotherapy Thermal biofeedback training* Electromyographic biofeedback therapy* Cognitive / behavioral management therapy* Physical Treatments Acupuncture Transcutaneous electrical nerve stimulation (TENS) Occlusal adjustment Cervical manipulation *Proven effective in clinical trials Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

23. Case Scenario #3

24. Sinus headache is the most common misdiagnosis Migraine Is Often Overlooked  Sinus pain caused by inflammation induced allergens or by infection occurs when exudate in inflamed, blocked sinuses exerts pressure that stimulates local trigeminal nerve fibers  Chronic sinusitis is not validated as a cause of headache unless it relapses into an acute stage

25.   Major factors – –Purulence in nasal cavity on exam – –Facial pain/pressure/congestion** – –Nasal obstruction/blockage/ discharge – –Fever (in acute only) – –Hyposmia/anosmia ** Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign. * American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7. Headache: A Minor Criteria in AAO-HNS Sinusitis   Minor factors –Headache –Fever (chronic) –Halitosis –Fatigue –Dental pain –Cough –Ear pain/pressure/fullness Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*

26. Sinus Features May Hide the Presence of Migraine Headache Symptoms at Screen Among IHS Diagnosed Migraineurs % of Subjects IHS Migraine Symptom Criteria Sinus Like Features 96% 84% 87% 84% 82% 70% 65% 57% 42% 38% 28% 27% 23% n=2257 Schreiber et al. Poster Presented at: American Headache Society Meeting; June 21-23, 2002: Seattle, WA. Data on file, GlaxoSmithKline.

27. Why do so many Americans think they have Sinus Headache? In his 1988 review, “Sinus Headache: A Neurologist’s Viewpoint,” Couch writes: In my experience and in that of others, “sinus headache,” as reported by patients, is a popular conception that is often erroneous. Patients reason that, since the sinuses are close to the eyes (as depicted in advertisements in popular magazines), headaches located in the frontal, supraorbital, or infraorbital region are sinus headaches… [These] headaches frequently are associated with some gastrointestinal symptomatology, photophobia, and phonophobia, and may have some visual or neurologic symptoms. In short, these “sinus headaches” are usually migraine headaches, most often of the common migraine type. Couch, J. Seminars in Neurology. 1988;8(4):298-302.

28. Cady et al. Headache Free. 1993;36-38. Migraine Is Often Overlooked (cont’d)  Tension headache is another common misdiagnosis  Symptoms include –Dull steady ache –Physical activity does not worsen pain –Nausea, photo/phonophobia are not usually present –Vomiting never present –Patients have likely tried OTCs and failed

29. Migraine Pain Can Be Felt in Peripheral Locations Such as the Neck  In Kaniecki’s study of 144 patients with migraine Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY. 75% reported neck pain with their migraine –75% reported neck pain with their migraine – 43% described neck pain as bilateral and 57% as unilateral – 69% described the neck pain as “tightness” and 17% as stiffness”

30. Activation of the TNC May Result in Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Network

31. Case Scenario 5  26-year-old man, computer programmer, married with 2 children  Has severe, stabbing pain behind his right eye  Headaches are accompanied by lacrimation and nasal congestion  Pain lasts 30 to 45 minutes; attacks occur daily for several weeks, then stop for months at a time

35. Treatment of Hypnic Headach  Lithium Carbonate (200- 600mg)  Indomethacin  Verapamil (160my QHS)  Methysergide  Caffeine (60mg)  Lamotrigene

36. TRIGEMINAL NEURALGIA