1. Migraines Mark Green, MD Clinical Professor Department of Neurology Columbia University New York, NY

2. Mark Green, MD

3. Patient History Patient is a 36-year old woman with a 10- year history of recurring headaches Average 2 headaches per month Headaches are left-sided, hemicranial, and associated with nausea and vomiting Attacks last 2 days, afterwards she is well

4. Mark Green, MD

8. Patient History Patient is a 38-year old woman with a long history of unilateral throbbing headaches associated with nausea and vomiting Headaches last 2 days and are particularly likely to occur while menstruating Over past 6 months, headaches have increased; still unilateral but continuous Taking 50 Excedrin Migraine tablets each week for headache and getting only temporary relief

9. Mark Green, MD

10. Drug Overuse in Headache Patients Regular use of Analgesics Vasoconstrictors Decongestants Caffeine Triptans, NSAIDs (rare)

11. Mark Green, MD Why is a migraine disabling? Pain Nausea, vomiting Photophobia and phonophobia Encephalopathy

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13. Common Comorbidities of Migraine Cardiovascular –Hypertension or hypotension –Raynaud’s disease –Mitral valve prolapse –Angina / myocardial infarction –Stroke Respiratory –Asthma –Allergies

14. Mark Green, MD Common Comorbidities of Migraine Gastrointestinal –Irritable bowel disease Neurologic –Epilepsy Psychiatric –Depression –Bipolar disorder –Panic disorder –Anxiety disorder

15. Mark Green, MD

16. Problems with Narcotic Analgesics Sedating Increases nausea and vomiting Vasodilator Rebound headaches Drug-seeking behavior

17. Mark Green, MD Dopamine Antagonists Chlorpromazine Metoclopramide Prochlorperazine Droperidol

18. Mark Green, MD Problems with Dopamine Antagonists Sedating Orthostatic hypotension Extrapyramidal effects

19. Mark Green, MD NSAIDs Ketorolac (parenteral) Indomethacin (suppositories)

20. Mark Green, MD Injectable sumatriptan most likely to work in a prolonged migraine Comorbidities Medications taken before ER Triptans in the ER

21. Mark Green, MD Intravenous or intramuscular Pretreat with an antiemetic Cannot mix with triptans/other ergots Dihydroergotamine

22. Mark Green, MD Reduce rate of headache recurrence Little immediate relief Corticosteroids

23. Mark Green, MD Depacon 1 gram IV in 50 cc NS by rapid infusion over 5 minutes Compatible with use of triptans/ergots same day No sedation Improvement in associated migraine symptoms Can begin prophylaxis immediately if desired

24. Mark Green, MD

26. Patient History Patient is a 37-year old woman who had abrupt onset of a severe occipital headache with mild nausea Had transient diplopia, which resolved before she arrived at the hospital Headache remained constant without any photophobia but with moderate nausea Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

27. Mark Green, MD Patient History A 45-year old male presented to the emergency room in the evening. He had a long history of migraine without aura, which was treated with rizatriptan. This treatment has been generally successful in the past, but he did not respond on this occasion. He had taken it at 3am when he was awakened with a unilateral throbbing headache accompanied by nausea and vomiting. The rest of the evening and throughout the morning he continued to vomit frequently and did not appear to improve taking ibuprofen every 4 hours.

28. Mark Green, MD When would you do a CT scan on this man? A.If his neurological examination is normal. B.If he does not respond to another dose of rizatriptan. C.If he does not have a pre-existing history of migraines.

29. Mark Green, MD What would be your next treatment? A.Another dose of rizatriptan, in the MLT formation. B.Injectable sumatriptan. C.Intravenous prochlorperazine. D.Intravenous divalproex.

30. Mark Green, MD Patient History Patient is a 37-year old woman who had abrupt onset of a severe occipital headache with mild nausea Had transient diplopia, which resolved before she arrived at the hospital Headache remained constant without any photophobia but with moderate nausea Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

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33. The response to medication is not diagnostic of the problem.

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