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

2. 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

3. 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 age range
Lipton et al. Headache. 2001;41:

4. 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

5. 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.

6. 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

7. 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:

8. 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

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

10. Pathogenesis Trigeminovascular System Low Brain Levels of Serotonin
Brainstem Migraine Generator

12. 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

13. 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

14. 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:

15. 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.

16. Bilateral Trigeminal Pathways May Lead To Bilateral Location of Headache Pain

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

18. Cranial Parasympathetic Nervous System Extends into Sinus Cavities and Tear Ducts

19. One Nerve Pathway, Multiple Symptoms, Multiple Manifestations of Migraine

20. 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”

21. 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

22. 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

23. 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

24. 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.”

25. 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

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

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

28. 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

29. Onzetra Xsail
Xsail Unit
Onzetra Rx

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

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

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

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

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

35. 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

36. 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: 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.

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

38. 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

39. 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

40. 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

41. 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

42. 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

43. Comprehensive Headache Clinic
DANIEL KASSICIEH, D.O., FAAN
SARASOTA NEUROLOGY, P.A.
SarasotaNeurology.com