1. Migraine and Headaches Anish Bahra Headache Service NHNN

2. Migraine vs Headache

3. Classification of Head and Facial Pain Disorders Part I The Primary Head and Facial Pain Disorders Part II The Secondary Head and Facial Pain Disorders

4. Classification of Head and Facial Pain Disorders Part I The Primary Head and Facial Pain Disorders Part II Primary Care 0.1% A&E ~ 8%`

5. Primary Headaches Tension-Type headache Migraine Cluster headache & related disorders Other Primary headaches Prevalence 20-87%12%≤0.2%Uncommon

7. Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

8. Cause of Headache

11. Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

12. New onset Migraine coinciding with new area of inflammation MS : Haas, Headache 1993

13. Hypothalamic Neurostimulation in Cluster Headache : Leone,

16. Bahra et al. Lancet 2001 Brainstem Activation in Migraine Headache Afridi et al. Brain 2005 Weiller et al. Nat. Med.1995

17. Cluster HeadacheMRAMigraine Craniovascular Activation in Primary Headaches

19. Primary Headaches Tension-Type headache Migraine Cluster headache & related disorders Other Primary headaches FH 3 fold50%14 foldAnecdotal

20. Familial Hemiplegic Migraine

21. Pathogenic mutations in three genes → CACNA1A, ATP1A2 & SCNA1 genes 1. FHM 1 – CACNA1A gene → P/Q-type voltage-gated neuronal Ca 2 + channels 2. FHM2 –ATP1A2 gene → Na+ -K+ pump ATPases 3. FHM3 – SCNA1 gene → Voltage-gated Na+ channels Genetically predisposed dysfunction of ion-channels within the nervous system Familial Hemiplegic Migraine

22. Functional Consequences of Gene Mutations FHM-1 CACNA1A Gene Ca Channel FHM-3 SCN1A Gene Na Channel FHM-2 ATP1A2 Gene Na/K ATPase Pump Gain of functionLoss of functionGain of function Cortical Hyperexcitability

23. Hadjikhani, Proc Natl Acad Sci U S A, 2001 Cortical Spreading Depression in Aura

24. Genetic Neurological Disorder

25. Focus on Migraine

26. Lipton RB, Stewart WF. Neurology. 1993. Migraine Prevalence (5)

27. Headache Headache Normal Prodrom e Aura ResolutionNormalAppetite Awake/sleep Smell Fluid balance Light tolerance Noise Craving Tired Yawning Heightened perception Fluid retention Sleepy Yawning Anorexia Nausea Photophobia Phonophobia Osmophobia Limited food tolerance Tired Diuresis Feeling High / Low Appetite Awake/sleep Light tolerance Noise Smell Fluid balance Blau, Lancet 1992 Deep Sleep Vomiting

29. Eye Frontal Temporal Vertex Occipital Neck Diffuse 67 % 56 58 24 40 18 Kelman, Headache 2005 Migraine : Location of Pain

31. Aura in Migraine Visual 99 % Visual only39 Sensory 54 Aphasia32 Visual & sensory28 Visual & aphasic25 All 36 Eriksen ( Cephalalgia 2004) N=362

32. Migraine and ‘Headaches’

33. 90% with disabling headache have a Migraine disorder Disabling tension-type headache is rare % Lipton, Headache 2000

34. Spectrum Study: Sumatriptan Response % Response

35. Management of Migraine

36. Susceptibility to ‘Triggers’ Exogenous Factors Missed Meal Too much sleep / too little sleep Stress / Immediate post-stressful period Alcohol Sensory stimuli → Visual and Olfactory Dietary → Over-estimated Caffeine and ARM → Under-estimated Endogenous Factors Hormonal

37. TTH Scher et al. Headache 1998 Castillo Headache 1999 Wang et al. Neurology 2000 % Population CHINA CHRONIC DAILY HEADACHE Headache > 15 days / month > 3 months USA SPAIN 1 2 3 4 5 Migraine Other

38. TTH Scher et al. Headache 1998 Castillo Headache 1999 Wang et al. Neurology 2000 % Population CHINA USA SPAIN 1 2 3 4 5 Migraine Other Medication-Overuse : 1-2%

39. 0 10 No. subjects with headache 1 12 6 Week Caffeine Decaffeinated Switch from one to the other Van Dusseldorp, BMJ. 1990

40. 0 10 No. subjects with headache 1 12 6 Week Caffeine Decaffeinated Switch from one to the other Van Dusseldorp, BMJ. 1990

43. Migraine Prevalence (5) Lyngburg, 2005 – Longitiudinal Observation 1989-2001 Prognosis 42% Remission 38% < Frequent 20% CDH

44. Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse

45. Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse Opioids

46. Migraine Prevalence (5) Wang, 2000; Lu, 2001 Predictors for Chronic daily headache Older Age ‘Daily’ headache Medication overuse Opioids

47. Management : Acute Attack Treatment Level of effectiveness Side – effects Consistency

48. Management : Acute Attack Treatment Level of effectiveness → 2 hrs mild / no pain Side – effects → Outweigh benefit Consistency → Adequate dose 3 trials

49. Management : Acute Attack Treatment Basic Principle: Adequate single abortive dose of the most effective drug Can repeat for recurrence within 24 hours Will not work for initial non-response Maximum use < 6-8 days / month

50. Ibuprofen 600mg Severity TIme

51. Ibuprofen 600mg

52. Sumatriptan 50mg

54. Simple AnalgesiaAbortive dose Aspirin900mg po Ibuprofen400-800mg po Naproxen500mg po Paracetamol 1g ANTIEMETIC Domperidone10-20mg po / 30-60mg PR Metoclopramide10mg po/IM/IV

55. Efficacy Almotriptan Eletriptan Rizatriptan Side-Effect Profile Almotriptan Frovatriptan Naratriptan Formulation : Preference Vomiting Rizatriptan Wafer Sumatriptan sc / IN Zolmitriptan Wafer / IN Recurrence Almotriptan Eletriptan Naratriptan

56. Management Keep a headache diary Optimise acute treatment Frequency < 4 headache days/month → Acute Rx Frequency > 4 disabling HA days / month → Prevention Ensure ARM use restricted to < 6-8 HA days / month Early introduction of prevention for  frequency

57. PREVENTATIVESTART DOSEINCREMENTSMAX DOSES Propranolol* Start Low Increase Slow Aim for the Maximum Tolerated (or lower if effective) 320 mg Amitriptyline*200 mg Nortriptyline150 mg Pizotifen4.5 mg Sodium valproate* 2g Gabapentin3.6g Topiramate*200mg (can use higher doses)

58. Severity of Migraine Disorder Time Propranolol 20mg bd Propranolol 80mg bd + 100mg bd Propranolol 80mg bd + Topiramate 50mg bd Propranolol 80mg bd Propranolol 40mg bd

59. Genetic Neurological Disorder QUESTIONS