1. Chronic Daily Headache
The World Health Organization states that Headache disorders are ubiquitous, prevalent and
disabling. Yet they are under-recognized, underdiagnosedand under-treated worldwide: The Same is true in Sioux Falls,
Today I would like to discuss a particulary difficult diagnosis the CDH….
Carol B. Miles, MD
Jeffrey P. Krall, OD
The Headache Center

2. What is Chronic Daily Headache?
15 or more days per month
4-5% of the general population
Issues for General Practice
Hard to diagnose
Hard to Treat
Leads to Unhappy Patient Population

3. What are the consequences of Constant Daily Pain for the Patient?

4. Of the many types of headaches, none are more dibilitating to your patient than CDH….

5. As a neurologist focused on headache, I think the human element can never be underestimated…..CDH sufferers come to you with a profound sense of guilt, they most likely will reserve some of the consequences of CDH when you are taking your history.

6. CDH Subtypes Chronic migraine Chronic tension type headache Cluster
EyeGraine
Medication overuse

7. Chronic Migraine Episodic  daily
Unilateral, pulsating, moderate to severe pain, nausea/vomiting, photo/phonophobia, aggravated by physical activity,
Full blown migraines superimposed on background of less severe headaches

8. Chronic Tension-Type HA
Bilateral pressure
Mild to moderate intensity
Does not worsen with exertion

9. Cluster Headaches Severe, unilateral sharp pain
Occasional nausea and photophobia
Associated with unilateral lacrimation and rhinorrhea
More common in males and smokers
Pace and become suicidal

10. EyeGraine
Unilateral or bilateral headaches that tend to start later in the day
Headaches and lethargy with reading and working on the computer
Light sensitive, especially with headlights
Sensation of eye dryness
Neck pain and stiffness
We will come back to this diagnosis later in the talk

11. Medication Overuse HA When tx >2-3 days /week
Nondescript diffuse, dull, “annoying” headache that is “just there”
Less responsive to prophylactic meds

12. Traditional Treatment

13. Break the cycle Ketoralac IM/IV Steroids po/IV DHE SQ/IV
Valproic acid IV
What is the objective of CDH intervention …to stop the pain……..and we have done this historically using medical therapies exclusively with some succuess………..5 seconds per drug slide………

14. DHE SQ 1 mg BID x 5-7 days 1 mg q one hour x 3 prn.
Must wait 1 hour between doses
No more than 3mg per day

15. DHE IV Metochlopramide 10mg/ prochlorperazine 10mg Wait 10 min
DHE test dose of 0.5mg
Wait 30 min and repeat 0.5mg if no chest pain or significant nausea
Repeat mg q 8 hours prn x 5

16. Valproic acid
500mg in 100cc NS at 20 mg/min
May repeat q 8 hours prn

17. Add preventive med Antidepressants-nortriptyline, venlafaxine
Antihypertensives- propranolol, verapamil, candesartan, Lisinopril
Antiepileptics – divalproex sodium, topiramate, gabapentin
Botulinum toxin

18. Add Symptomatic Med
NSAIDs
Triptan
DHE NS/SQ

19. Complications from Current Therapies
GI distress
Chest pain or tightness
Teratogenicity
Lightheadedness
Cognitive issues
Weight gain
Tremor
List most common complications

22. eyeGraine A new root cause diagnosis A new no risk treatment,
A New Positive outcome
Up until now, we really didn’t have a plan to combat the root causes of headache, now we are encouraged that we may have identified a major contributor to headache pain……..What is an eyegraine, lets take a look

23. Proposed Pathophysiologic Root Cause
Symptomatic Profile (exacerbated by reading or working on the computer):
Syndrome of:
Chronic daily headaches (frontal and occipital)
Dry eyes
Photophobia
Stiffness in shoulders or neck
Lethargy
Working Hypothesis:
An imbalance between the patients peripheral vision (controlled by saccadic eye movements) and central vision (controlled by slow pursuits). Proprioceptive fibers of the extraocular muscles are activated which causes an overstimulation of the Trigeminal nerve. This in turn over activates the Trigeminal nucleus caudalis which causes the chronic daily head pain and neck pain.
This stimulation also triggers the exacerbation of migraine type headaches. Dry eyes and the perception of dryness mediated through the Trigeminal nerve is thought to be a symptom of the eyeGraine syndrome. We also have considered if the overstimulation of the occipital cortex causes cortical spreading depression, initiating the onset of the headache component of the eyeGraine syndrome.

24. Animated video

25. SightSync Testing
SightSync is a Neuro Adaption tool–Tracks the dynamic movements of the patients eye and creates a template for correction.
SightSync is NOT an eye exam – No chart, no testing of Visual Acuity at distance or near
Measures the Brain positioning of a target in space isolating one’s central vision from a peripheral image
Does this in 3D

26. eyeGraine Solution Full Neurological Work Up
eyeGrain Specialist examination
SightSync –Measure the 3D misalignment between central and peripheral vision
Custom neurolens dispensed… from sightSync 3D modeling (fingerprint)
Scheduled neuroLens fine tunes that are needed over the next 12 month period…
Manage changes in medical therapy over a 12 month period

27. Pilot Study Subjective Responses
(refractory, end-of-line patients)

28. Pilot Study Subjective Responses
Patient Willingness to Recommend (WTR)
PILOT STUDY DATA
Patient Willingness to Recommend
Headaches have decreased substantially or are basically gone
Study (n=153)
87%
62%
COMMERCIAL DATA
Day 30 (n=56)
93%
70%
Day 90 (n=21)
100%
86%

29. Medication Reduction (90 Days)
Average medication reduction = 51%
Reporting medication reduction = 72%
n = 21
NOTE: Patients have not been prompted by their physician to reduce their medication usage. All results were self-directed by the patient as a result of positive eyeGraine treatment results.

30. What patients are saying…
Although my headaches are not completely gone, they have decreased so much that I am able to do what I have always loved. Before my headaches hindered me from running long distances, but now I am training for a half marathon, running long distances every other day. I am now able to focus more when studying and I have to time to spend with friends. Before I would just sleep because I had such bad headaches. I’m not 100% but I am so much closer!
I really thought this was a joke at first, but after wearing wearing the lenses, I am impressed. I am really impressed. Thank you so much.
After adjustments, the glasses are working very well and decreased my migraines substantially. I can live again!
The NeuroLenses have taken away my headaches and given me back a normal life.
Since wearing NeuroLenses my headaches are basically gone and I am feeling better than I have in a long time. I would recommend this to anyone having this type of headache.
Life changing!!! Headaches almost gone! It’s worth every penny! Thank you for changing my life!
It is absolutely wonderful and I would recommend it to everyone.
Have had a great response to the lenses and have hardly had a headache that has interrupted my daily schedule! Can not say thank you enough for your efforts to make the connections for helping with eyeGraines! I am not without them since I took them out of the box!
I would consider replacing this with a patient testimonial video that lasted 60 seconds or less

31. Key Learnings after 2 Years of eyeGraine Treatments
Patients are attracted to the safety of the eyeGraine Treatment Plan
The proprioceptive feedback from of eyes to the brain requires Neurolens changes when headaches return
eyeGraine Treatment now plays a prominent role in headache management at Neurology Associates

32. The Headache Center 605-334-2662 IMA Building Suite 103
6709 S. Minnesota Ave
Sioux Falls, SD 57108