Author: Dr Paul Masiowski

1. Migraine A neurologist’s overview Date: 20 September 2013 Author: Dr Paul Masiowski

2. Migraine A neurologist’s overview Outline and Objectives Migraine: a neurologist’s overview • Briefly review the diagnosis and pathophysiology of migraine • Review red flags for diagnosis of headache • Consider the spectrum of migraine-related symptoms • Outline strategies for acute and preventive treatment • When to refer

3. Migraine A neurologist’s overview Biography and disclosures Migraine: a neurologist’s overview • Queen’s Medicine, 2005 • USask Neurology residency, 2005-10 • FRCPC (Neurology) 2010 • Community practice at Lakeview Neurology Associates • Clinical Assistant Professor at USask • SMA Section Rep • Received honoraria from Allergan • Interests: Migraine, Neuropsychiatry, Movement Disorders

4. Migraine A neurologist’s overview Migraine is extremely common Epidemiology of migraine • Lifetime prevalence: 43% in women, 18% in men • Equal in boys and girls (4 - 5%) • After puberty, increasingly prevalent in females (role of estrogen) • New diagnosis possible at any age • Often hereditary (polygenic) • Rare monogenic forms • May be underdiagnosed

5. Migraine A neurologist’s overview Migraine is a brain disorder Pathophysiology of migraine • Cortical spreading depression (CSD) --> aura • Pain from dura, blood vessels, soft tissues • via trigeminal nerve (V3), upper cervical roots • Connections in brainstem • Projects up (pain signals to limbic areas, etc) • Projects peripherally (autonomic activation) • Produces a feedback loop • Hypersensitization (allodynia, etc)

6. Migraine A neurologist’s overview

7. Migraine A neurologist’s overview Diagnosis of migraine A spectrum of related conditions • Episodic migraine (with or without aura) • Chronic migraine • Acephalgic migraine (aura) • Other periodic disorders: • Hemiplegic migraine • Migraine associated vertigo • Cyclic vomiting syndrome • Retinal migraine

8. Migraine A neurologist’s overview Episodic migraine Diagnostic criteria

9. Migraine A neurologist’s overview Migraine aura A sensory experience • Aura can occur before or during the headache... . • ...or in the absence of a headache • About 20% of patients with migraines get auras (often unpredictable) • May also get prodrome or postdrome • Visual aura: enlarging scotoma with a shimmering edge (fortification), stars, dots, wavy lines, complex patterns, visual distortions • Sensory aura: paresthesia, usually unilateral, develop slowly and migrate, esp. in hand and face • Speech aura: dysphasia, often mild (hard to get words out, have to think about it) • Motor aura: a sense of slowness and difficulty in movement (subjective only)

10. Migraine A neurologist’s overview Migraine aura Diagnostic criteria

11. Migraine A neurologist’s overview Is this acute headache a migraine? Red flags • New after 50 years of age (temporal arteritis?)Sudden onset: (SAH? AVM? pituitary apoplexy?) • Worsening frequency and severity (mass lesion? subdural?)In patient with systemic disease: (mets? chronic meningitis? abscess?) • With fever +/- stiff neck, altered LOC: (meningitis? encephalitis?) • With focal signs or symptoms other than typical aura: (stroke?) • With papilledema: (mass lesion? pseudotumor cerebri?) • After trauma: (intracranial hemorrhage?) • SNOOP: Systemic, Neurologic, Onset (new), Other (associated), Progressive

12. Migraine A neurologist’s overview From episodic to chronic migraine Risk factors for progression

13. Migraine A neurologist’s overview Chronic migraine Diagnostic criteria • Headache fulfilling criteria C and D for migraine without aura • on ≥15 days/month for >3 monthsNot attributed to another disorder • Also includes ≥15 days of any headache, • including ≥8 days of migraineExpect previous history of episodic migraineMedication overuse is a confound

14. Migraine A neurologist’s overview Medication overuse headache Diagnostic criteria • Headache ≥15 days/month • meeting criteria C and D for migraine without auraRegular overuse for ≥3 months of one or more drugs that can be taken for acute treatment of headacheHeadache developed or markedly worsened during medication overuseHeadache resolves or improves within 2 months of discontinuation of overused medication

15. Migraine A neurologist’s overview Underrecognized migraine chronic or recurring head and neck pain • “sinus” headaches (dysautonomia) • menstrual headaches • occipitonuchal pain • post-traumatic headache • headaches related to psychiatric conditions • ...also, associations with: • stroke / TIA • epilepsy • MRI changes (white matter lesions)

16. Migraine A neurologist’s overview Other migraine-related conditions Recurring paroxysmal disorders of the nervous system • Cyclic vomiting syndrome • Migraine associated vertigo • Persistent positive visual phenomena • Olfactory hallucinations • Paresthesiae • “frequent TIAs” • “seizures”

17. Migraine A neurologist’s overview Is it a migraine? Three pillars to the diagnosis • RecurrenceStereotypic symptoms • Resolution The characteristics of a paroxysmal neurological disorder ...of which migraine is by far the most common

18. Migraine A neurologist’s overview Management of migraine Trigger threshold theory • Migraine has many characteristic triggers: • stress • change in sleep pattern • change in eating pattern • change in weather • hormonal influences • lights, noises, smells • exertion • food & alcohol • etc

19. Migraine A neurologist’s overview Management of migraine Trigger threshold theory • Migraine may be viewed as the interaction of environmental triggers and a susceptible host. • Mechanism of triggers unknown, may involve nitric oxide (NO) signalling

20. Migraine A neurologist’s overview Acute migraine therapy Medications for migraine attacks • Goal is to relieve pain and associated symptoms and reduce disability • Response unpredictable, even for same patient to same drug • Early treatment is best: • interrupt the migraine build-up • easier to prevent than reverse migraine physiology • Medication choice depends on severity and patient, do not need to step up • OTC analgesics --> NSAIDs --> triptans • SC (sumatriptan) or nasal spray (sumatriptan) or wafers (rizatriptan) if early vomiting • Fluids, caffeine, rest / sleep, ice packs, etc • Avoid medication overuse (max 15 days per month of OTC, 10 per month of others) • Avoid opioids if possible

21. Migraine A neurologist’s overview Management of chronic migraine Medications for migraine prevention • Response can be gradual (over months) • side effects worst first • titrate up slowly • Medication choice depends on severity, side effect profile • HTN: beta-blocker, ARB; • mood disorder: TCA, valproic acid • insomnia: amitriptyline • weight loss: topiramate • But side effects also limit choices: • asthma: avoid beta-blockers • kidney stones: avoid topiramate • elderly: avoid TCAs at higher doses (anticholinergic)

22. Migraine A neurologist’s overview Management of chronic migraine Strategies I use • Milder symptoms, less disability • nortriptyline (amitriptyline if insomniac) • propranolol, flunarazine • candesartan • More severe symptoms and disability • topiramate • valproic acid • TCA or beta blocker at higher dose • Patient prefers not to take medications • magnesium, riboflavin, coenzyme Q10, feverfew, butterbur • In all cases: • trigger management, education • avoid medication overuse (caffeine too)

23. Migraine A neurologist’s overview How about Botox? Botulinum toxin injections for chronic migraine • Clinical experience dates back >25 years • PREEMPT trials (placebo-controlled RCT) published 2009-19 • Health Canada approved for chronic migraine prevention, 2011 • Used second-line or third-line in most cases • Favorable side effect profile • Injections usually well tolerated • Cost is an issue • Applying for new billing code for injections • Many patients discontinue other preventive medications, and reduce use of acute medications

24. Migraine A neurologist’s overview Multidisciplinary approach is best The modern headache clinic • Neurology, Family medicine • Nursing • Occupational therapy, Physiotherapy • Social work, Psychology • Dietician • .... strategies for acute and preventive treatment

25. Thanks! Any questions? Feel free to email me with questions: pmasiowski@gmail.com

26. Migraine A neurologist’s overview Migraine is a primary headache disorder Classification of primary headaches by frequency