1. Living with Headaches Bradford L Talcott, MD, PhD

2. Common Headache Types

3. What type of headache is this?  Acetaminophen does not help  Misses 1 day of work per month  Mother had migraine  Diagnosis??? n 26-year-old female with ten year history of headache n Frequency: two per month, each headache lasts 24 hours n Bilateral temporal pain n Throbbing, 9/10 n Associated with nausea, photophobia, phonophobia, osmophobia n No vomiting or aura n Often goes into a dark room and “sleeps it off”

4. Migraine without Aura

5. What is this Headache? n Four times a week she has an exacerbation of this continuous headache, rated 9/10 n Exacerbations are holocephalic, throbbing, last 24 hours, and are associated with nausea, phonophobia, osmophobia, and increased photophobia n Currently taking six Excedrin Migraine tablets per day n Diagnosis??? n A 36-year-old female presents with worsening headache n Her headaches started at age 26, initially occurred twice per month, associated with N/V/photophobia/phonophobia n Headache frequency has gradually increased over the last year, associated with an increased use of Excedrin Migraine (acetaminophen, aspirin, caffeine) n She has had a constant, background, holocephalic, non- throbbing headache associated with continuous photophobia for three months, rated 6/10

6. Chronic Daily HA (Transformed migraine) AND Medication overuse headache (Rebound Headache)

7. What is this Headache? n A 32-year-old male presents with worsening headache n He has had headaches since 23, they have always been under and around eyes n He has a history of sinus trouble n Headaches are associated with photophobia/osmophobia/occasional loss of appetite n Pain is a dull pulsing pain n Denies history of recent fevers, nasal discharge or bleeding n Diagnosis???

8. Migraine

9. Migraine vs. Sinus headache n Studies show that about 85% of people with self described sinus headaches actually have migraine headaches n Sinus problems, like many other things trigger migraine headaches n Bottom line– the majority of headaches severe enough to cause a person to seek medical attention are Migraines

10. More than you ever wanted to know about Migraines

11. Migraine Burden in U.S. n Migraineur in one in four households n 28 million migraineurs in the US n Estimated annual cost of labor lost to migraine greater than $ 13 billion per year n Peak prevalence ages 25-55 n Often ineffectively treated

12. Migraine Prevalence in U.S. Headache 2001;41:646-657 18.2 % Women 6.5% Men

13. Migraine Age-Specific Prevalence in U.S. n Headache 2001;41:646-657

14. Phases of Migraine Migraine are more than just pain

15. Migraine Triggers n Missing a meal or dehydration n Sleep (too little or too much) Caffeine Caffeine n Stress Weather/Barometric Pressure Changes Weather/Barometric Pressure Changes n Menses/ Hormonal changes n Fatigue n Exposure to environment (light, sound, smells) n Head trauma n Dietary triggers (Chocolate, nitrates, MSG, Aged cheeses, Alcohol, Nuts, Processed meats, Citrus)

16. Migraine Pathophysiology Goadsby PJ et al. N Engl J Med. 2002. Migraines are triggered by internal (dehydration, lack of sleep, stress) or external stimuli (smell, light, food) Deep nuclei in the brainstem begin to malfunction (trigeminal nucleus and Magnus raphe nucleus) Energy failure allows the nerves surrounding vascular structures in the brain (which are part of the trigeminal nerve) to propagate the problem and malfunction (throbbing pain) These malfunctioning nerves trigger thalamic dysfunction (nausea, severe pain)

17. Migraine Genes Migraines are a Genetic condition -3 genes discovered in past year -EAAT2 affects glutamate removal from synapse -TRSK is a potassium channel in nerves –Gene discoveries support the concept that migraine is caused by nerves that are hypersensitive

18. Treatment of Migraines: A brief history of natural and homoeopathic time-honored therapies

19. Treatment

20. Aretaeus A.D. 81? n For the treatment of headache, Aretaeus recommended inducing sneezing by placing testicle of beaver powder intranasally to “bring off phlegm”

21. 940-1010 AD “For the effective treatment of long-standing headache the patient may bind over his head a mole long dead and putrid”

22. Willis 1685 n “the use of Millepedes ought not here to be omitted, or set lightly by, in regard that their express’d Juice, distill’d Water, and also the Powder prepar’d of them, often contribute egregiously to the Cure of ancient and obstinate Head-achs.”

23. Other Interesting Headache Treatments n Drilling a whole in the skull n Bloodletting n Placing a hot iron on the head n Spinning a patient in a centrifuge

24. Historical Figures with Migraines n Thomas Jefferson n Joan of Arc n Vincent Van Gogh n Julius Caesar n Ulysses S Grant n Sigmund Freud

25. Headache Treatment: A More Modern Approach

26. Five Principles of Migraine Management n Treat occipital neuralgia and trigeminal nerve dysfunction n Avoid Rebound headache n Abortive therapy n Preventative therapy n Lifestyle Issues

27. Treat Occipital Neuralgia

28. Trigeminal Nerve

29. Avoid Rebound Headache (medication overuse headache) n In general if acute meds are used more the 3 days per week they will cause rebound headache. n This HA is usually a dull constant HA n Treatment: Tough love- stop taking meds completely n Things might get worse for 2 weeks but then will improve n The worst offenders: Narcotics, Excedrin, Fioricet, butalbital containing meds n This may also keep headache preventive medications from working well.

30. Acute (abortive) migraine treatment principles n Treat early, while headache is building n Use correct dose and formulation n Limit to 3 days per week (with exceptions) n Try drug with at least 2 headaches to see if it works before moving on to another agent n Use drug combinations often work when a single agent won’t work

31. Acute treatment options n Nonspecific –NSAIDs –simple analgesics –combination analgesics –Anti-Nausea meds n Specific –Triptans, e.g., Imitrex, Maxalt, Zomig, Relpax, ect –Ergotamine/DHE; Migranol

32. Rational polytherapy n NSAID plus Triptan n Antiemetic (metoclopramide 10 mg) plus NSAID (Naproxen sodium 550 mg) n Antiemetic plus triptan n Antiemetic plus NSAID plus triptan

33. Preventive med principles n No set rule on when to use, but consider use when severe headache occurs once a week n In order for preventive meds to be most effective, limit acute meds to 3 days per week n Make sure to use an appropriate dose n At least a 2 month trial at a proper dose is required n Goal is to decrease headache freq by 50%

34. Preventive med principles n Prepare for side effects first, benefit later n Reliable birth control n Keep trying until you find one that works n Preventives are not always lifelong treatments-can be tapered off after several months when frequency of headache decreases

35. Natural Preventatives n ButterBurr Root (be careful of source) n Feverfew n Magnesium n Alpha-linolenic acid and Gamma-linolenic acid n Vitamin D, E, B12, B2 n alpha lipoic acid n L-Carnatine n Fish oil n Co Q10

36. The preventive alphabet n Antidepressants: nortriptyline, amitriptyline, Cymbalta n B-blockers: propranolol, atenolol, nadolol n Calcium channel blockers: verapamil n Depakote (valproic acid) n Epilepsy meds (other than Depakote): gabapentin, topiramate, Lyrica n Misc: tizanidine, Namenda

37. Botox Treatment n Botox Injections- Approved by FDA in Oct 2010! n Approved for chronic migraine (migraine headaches happening more than 15 days/ month) n 32 injection sites in forehead, temples, shoulders and neck n Many insurance companies are still fighting not to cover this

38. Lifestyle Management n Sleep 8 hours consistent schedule n Eat 3 regular meals (or more) per day n Drink lots of fluids n Get Aerobic exercise regularly n Limit caffeine (or better yet avoid completely) n Identify your triggers n Keep a headache diary n Manage stress n Use correct posture and pause during repetitive activities

39. Nonpharmacologic Treatments n Biofeedback n Relaxation therapy n Cognitive Behavioral Therapy n Acupressure n Acupuncture n Physical Therapy n Chiropractic treatment

40. Additional Treatment Measures n Occipital Nerve Stimulators n TENS units n Transcranial Magnetic Stimulator n Special Diets

41. Transcranial Magnetic Stimulator (TMS)

42. Graham’s rules n There is no magic medicine that “cures” migraine n The patient is not to “blame” for having inherited the migraine trait n The pain of the migraine attack is very real and not “imaginary” n Getting Headaches under control sometimes requires a considerable period of time n There is definite hope for improvement through conscientious effort by both patient and physician, but that complete freedom from migraine is rarely achieved by any therapeutic program Graham, Treatment of Migraine, 1955

43. Questions?