Update on Diagnosis and Optimizing Treatment of Migraine Daniel Kassicieh, D.O. Fellow, American Academy of Neurology Fellow, American Osteopathic Board of Neuropyschiatry

Headache An Ancient Health Problem Headaches have troubled humankind from the dawn of civilization Evidence of trepanation, an early form of neurosurgery, was found on skulls from 7000 BC Migraine symptoms, including headache, aura, prodrome, nausea, vomiting, and familial tendency have been described for over 1,000 years

Migraine Prevalence There are currently 36 million migraine sufferers age 12+ in the United States 27 million females 9 million males One in 4 households has at least 1 migraine sufferer Migraine prevalence peaks in the 25-55 age range Lipton et al. Headache. 2001;41:638-657.

Incidence of Pediatric Migraine About 5% of children suffer from migraine (3.2% to 10.6%) The gender ratio for migraine in children is about 1:1, with a slight preponderance of boys under 12 years of age After 12 years of age, the incidence of migraine increases in females Approximately 50% of all migraines begin before the age of 20 years

Migraine is More Common than Asthma & Diabetes Combined Disease Prevalence in the US Population Data from the Centers for Disease Control and Prevention, US Census Bureau, and the Arthritis Foundation.

Why Do More Than 14 Million Migraine Sufferers Remain Undiagnosed? Don’t ask --- Don’t Treat Patient apathy Physician attitude toward headache Does not have the medical liability associated with non-treatment as compared to CAD, DM, HTN Incorrect or incomplete diagnosis

Migraine Affects Patient’s Ability to Perform Daily Activities Work/School Productivity Reduced 51% by 50%+ Unable to Do Chores/Household 75% Work Household Work Productivity Reduced 66% by 50%+ Missed Family/Social 58% Leisure Activity Percent of Migraine Sufferers Lipton et al. Headache. 2001;41:646-57.

Neuropsychiatric Comorbidities There is a 2-3x higher incidence of psychiatric disease in the migraine population Depression Anxiety Bipolar Disorder Suicide Migraine has a high morbidity rate and yet remains under diagnosed and under treated

Economic Burden $5 Billion - Annual Cost for Medication Decrease Productivity / Missed Work Days $5.6 - 17.2 Billion Dollars Increase Health Care Costs ER Visit Average: $700 - without imaging $1400 - with Imaging Specialist Consultation / Tx. (1 year) $1200

Pathogenesis Trigeminovascular System Low Brain Levels of Serotonin Brainstem Migraine Generator

Migraine Headaches One sided-may shift sides Pulsating Pain Associated Symptoms *Nausea and Vomiting *Light/Sound Sensitivity Pain Increased With Movement Prefer Quiet, Dark Room--Sleep Moderate to Severe Intensity

Migraine Aura Occurs in 20% Migraine Sufferers Usually Visual Symptoms *Bright/Dark Spots or Wavey Lines *”Heat Waves” *Colored Zig-Zag Lines *Visual Loss Non-Visual Auras *Sensory or Motor Impairment *Slurred Speech

Undiagnosed Migraine Sufferers Often Receive Other Medical Diagnoses These data are derived from sufferers who meet the IHS symptom criteria for migraine but have not yet been diagnosed as a migraineur by their physician. These headache sufferers may be diagnosed incorrectly or they may also suffer from tension or sinus headaches. In either case, they are unlikely to receive migraine specific therapy. % of undiagnosed patients with another diagnosis Lipton et al. Headache. 2001;41:638-645.

Sinus Features at Onset of Headache Hide the Presence of Migraine Headache Symptoms at Screen 0% 33% 67% 100% 97% Moderate-Severe Pain Stuffiness 73% Common symptoms associated with sinus Photophobia 66% Drainage 67% Worsened by Activity 63% Unilateral 63% Nausea 63% Weather Associated 57% Pulsating 53% Phonophobia 40% Vomiting 20% n=30 (subjects may report more than one symptom) Cady et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.

Bilateral Trigeminal Pathways May Lead To Bilateral Location of Headache Pain

Trigeminal Nucleus Extends to Dorsal Horn for C2, C3, and C4, Resulting in Neck and Posterior Head Pain

Cranial Parasympathetic Nervous System Extends into Sinus Cavities and Tear Ducts

One Nerve Pathway, Multiple Symptoms, Multiple Manifestations of Migraine

Cluster Headaches “If I Had A Gun, I’d Shoot Myself” Male Predominance - Ratio: 10:1 Occurs on Same Side With Each Attack Extreme Pain - Pacing Floor, Incapacitated Associated Symptoms -Lid Drooping -Eye Redness -Facial Swelling -Sweating -Nasal Congestion -Nasal Drainage -Pupillary Constriction -Eye Tearing “If I Had A Gun, I’d Shoot Myself”

Cluster Headaches (cont’d) Duration: Less Than 2 Hours, Pacing May Have Multiple Attacks Daily Total Incapacitation, Extreme Pain Requires Aggressive Preventive and Abortive Therapy

Cluster Migraines Migraines That Occur in Clusters NOT same as Cluster Headaches Characteristics of Migraine Headaches Migraine Symptoms Duration: 4-24 Hours Treatment Same as ‘Regular’ Migraines

Tension Headaches More Appropriately: Non-Vascular Headaches Generalized Pain *Squeezing, Band-like Pain *Pressure Sensation *Pain May Migrate Around Scalp No Associated Autonomic Symptoms Usually Not Incapacitating Mild to Moderate Intensity

Headaches and Neuroimaging American Academy of Neurology position: “The routine use of neuroimaging in patients with headaches of more that 6 months with normal neurological exam and no history of seizures is not indicated.”

Post Concussion Headaches Not related to severity of concussion May aggravate pre-existing headaches Similar in nature to Mixed Headaches Treat with Migraine Blocking Medications Tricyclic Antidepressants SSRI’s Anticonvulsants Occipital Neuralgia Occipital Nerve Block

Treatment-Abortive Non-specific -Simple Analgesics -NSAID’s -Combination Analgesics Migraine Specific Ergotamines- Only Cafergot Triptans – Main Treatment Modality DHE-45

Triptans Imitrex - sumatriptan Zomig - zolmitriptan Maxalt - rizatriptan Amerge - naratriptan Axert - almotriptan Frova - frovatriptan Relpax - eletriptan Onzetra – sumatriptan powder

Onzetra Xsail Unique Device for Administration of Med Sumatriptan Nasal Powder 22 mg of Sumatriptan Delivered Bypasses GI System - gastroparesis Rapid Onset of Action Easy to Use, Portable

Onzetra Xsail Xsail Unit Onzetra Rx

Preventive Therapy Mainstay of Therapy Antidepressants Anticonvulsants Beta-blockers Calcium Channel Blockers WHEN TO USE: Use for >4 headache days per month

Antidepressants Tricyclics *Amitriptyline - Elavil *Imipramine - Tofranil *Nortriptyline - Pamelor Serotonin Reuptake Inhibitors *Prozac *Lexapro *Celexa Serotonin/Norepinephrine Reuptake Inhibitors Effexor XR Savella

Anticonvulsants Depakote Topamax Also used to treat psychiatric disorders Used as mood stabilizers

Beta-Blockers Naldolol - Corgard Propanolol - Inderal *Better tolerated in children *Contraindicated with asthma Average dosage: 80-120 mg daily

Calcium Channel Blockers Verapamil *Most effective CCB *May be helpful in migraine Primary Use: Cluster Headaches Dosing: 240-480 mg daily

Anti-inflammatory Agents Naproxen Sodium Aleve Gel Cap Ibuprofen – gel cap Diclofenic Acid Cambia – Fast acting – 5 minutes Zipzor – gel cap – 15 minute onset Use in combination with Triptans

BOTOX® Specific Criteria for Payment Need careful patient selection True migraines More than 15 headache days/mo Failed multiple preventative agents Not helpful in tension headache Average dosage: 155-200 units The toxin released by cultures of Clostridium botulinum are only mildly toxic until they are cleaved by endogenous proteases within the intestine or during fermentation. Consequently, the organisms are grown under fermentation conditions to ensure maximal toxin potency. In order to enhance the stability of the toxin, each molecule is bound to a nontoxic protein and hemagglutinin. This protects the toxin from enzymatic degradation.

Cluster Headache Therapy Lithium – Verapamil Combination Depakote - valproic acid Topamax - topiramate ABORTIVE THERAPY Oxygen inhalation Sumatriptan injectable Sumavel DosePro Narcotics NOT helpful

Rebound Headaches Associated with excessive use of analgesics *Narcotics *Ergotamines / Triptans *OTC Analgesics *Butalbital / Caffeine Compounds Constant, variable headache Unresponsive to any treatment Listless, poor concentration, depression, fatigued, insomnia

Non-pharmacologic Therapy Sleep Hygiene – same hours nightly Biofeedback Stress Management *Self Relaxation Avoid Headache Triggers Sleep – Too much, too little Dietary Factors Skipping meals Headache Diary

Treatment Summary Detailed History & Exam Aggressive Preventative Therapy >4 Headache Days/mo. Abortive Therapy: Triptans + NSAIDs Antiemetics – Reglan / Phenergan Patient Education Realistic Expectations Early Intervention Compliance with Headache Prevention Plan

Review Migraine can be frequently accompanied by sinus features The presence of congestion, rhinorrhea, and weather related triggers may lead patients to think that their migraines are “sinus headaches” The presence of sinus features should not preclude the diagnosis of migraine Triptan therapy is successful in treating migraine headaches with sinus-like features Preventive therapy is indicated in the majority of migraine and headache sufferers Look for other causes of headache Rebound Occipital Neuralgia

CONCLUSIONS Don’t under diagnose migraine “Sinus Headaches” ARE Migraines 99+% of the time Avoid over diagnoses of tension-type or sinus (Unicorn) headaches Treat migraine aggressively – NO NARCOTICS Early Intervention migraine treatment Treat until pain-free IMPROVE YOUR PATIENTS’ QUALITY OF LIFE

Comprehensive Headache Clinic DANIEL KASSICIEH, D.O., FAAN SARASOTA NEUROLOGY, P.A. 941-955-5858 SarasotaNeurology.com