1. The Basics of Migraines
By Dr. David Greene, CEO
Nevada Pain Network
NevadaPainNetwork.com

2. What is a migraine?
Chronic headaches that affect people from a few hours up to 72 hours straight.
Complicated, recurrent headache disorder.
Most common in women and those between 15 and 55.
Most become less severe and less frequent with age.
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3. How common are migraines?
Affects 18% of women, 8% of men.
30 million in US have at least one migraine per year.
Every 10 seconds, someone in the United States goes to the emergency room with a headache or migraine.
70% have a 1st degree relative who suffers.
If one parent suffers from migraine, there is a 40% chance a child will suffer. If both parents suffer, the chance rises to 90%.
More than 90% of sufferers are unable to work or function normally during their migraine.
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4. What causes migraines?
There’s a LOT we don’t know.
Genetics and Environment
Imbalances in brain chemicals – serotonin levels drop during migraines.
Low serotonin, a pain management chemical, levels can trigger a migraine by letting too much blood flow through vessels that should be constricted— inducing a throbbing sensation.
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5. What are typical migraine triggers?
Foods – aged cheese, red wine (tyramine), beer, whisky, food additives (nitrates), cold foods, citrus fruits, MSG, caffeine.
Elevated Stress
Weather changes – barometric
Strong scents – perfume, paint
Hair accessories – ponytail
Exercise – e.g. sex
Poor Posture
Skipping Meals
Smoking
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6. chocolate
Small silver lining – NO evidence to clearly substantiate that chocolate is a trigger of migraine headaches. It’s a myth!
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7. Symptoms of migraines
Often unilateral head pain that is throbbing and aggravated by activity.
Aura – visual or sensory symptoms prior to the onset of the headache (photophobia, visual scintillations).
80% of migraines have no aura.
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8. Diagnosing migraines No objective testing available.
CT or MRI can rule out badness causing similar symptoms.
Diagnosed on patient history and pattern of symptoms.
Migraine diary can be very helpful.
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9. Making the diagnosis of migraine
International Headache Society requires pt to have at least 5 attacks fulfilling 3 criteria:
4-72 hour duration
At least 2 of these:
Unilateral
Pulsating
Moderate to severe pain intensity
Aggravation by or causing avoidance of routine physical activity
At least one of these:
Nausea +/- Vomiting
Photophobia and phonophobia
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10. Abortive Treatment options
Triptans – target Serotonin
Almotriptan (Axert)
Eletriptan (Relpax)
Frovatriptan (Frova)
Naratriptan (Amerge, Naramig)
Rizatriptan (Maxalt)
Sumatriptan (Alsuma, Dosepro, Imitrex, Sumavel, Treximet, Zecuity)
Zolmitriptan (Zomig)
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11. Abortive Treatment options
Acetaminophen-isometheptene- dichloralphenazone (Midrin)
Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
Ergotamine tartrate (Cafergot)  
Over- the-counter medications such as Advil Migraine (containing ibuprofen), Excedrin Migraine (containing aspirin, acetaminophen, caffeine), and Motrin Migraine Pain (containing ibuprofen)
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12. Abortive Treatment options
Narcotics
Barbiturates
Nausea
Metoclopramide (Reglan)
Prochlorperazine (Compazine)
Promethazine (Phenergan)
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13. Preventive Treatment options
Goal is to lessen the frequency and severity of migraines.
High blood pressure medications
Beta blockers
Calcium Channel Blockers
Antidepressants
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Antiseizure medications
Gabapentin
Topamax
Depakote
Pizotifen (Sanomigran)
Serotonin antagonist
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14. Interventional treatments
FDA has approved Botox injections for chronic migraines.
3 month intervals
Injected into 32 sites in a 10 minute procedure.
Covered if certain medications have been tried and failed.
For chronic migraines = “distinct and severe neurological disorder characterized by patients who have a history of migraine and suffer from headaches on 15 or more days per month with headaches lasting four hours a day or longer.”
Patients treated with BOTOX® (onabotulinumtoxinA) averaged 8 to 9 fewer headache days per month compared to baseline (vs 6 to 7 days with placebo) as demonstrated in the Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) study.1
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15. Interventional treatments
Occipital Nerve Blocks
Cervical Facet Injections
Cervical Epidural Injection
Sphenopalatine Ganglion Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks
Pulsed radiofrequency energy of Occipital Nerves
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16. Nerve Blocks
Study of 100 pts.receiving GON blocks (Migrainetrust.org) - 53% achieved pain relief averaging 3 weeks.
Retrospective study on the efficacy of GON block in refractory migraine patients.[5] A mixture of lidocaine and methylprednisolone was used for nerve blockade. Fifty-four percent of migraine patients reported on being "significantly better" after the blocks, and the duration of response lasted up to 6 months. (Gawel and Rothbart 1992, Cephalalgia)
Caputi and Firetto examined the benefit of PNBs in the treatment of migraine.[6] They assessed 27 migraine patients before and after GON and supraorbital nerve (SON) blocks. Maximum of 10 injections with 85% effectiveness rate for 6 months.
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