1. Comprehensive Migraine Care
Duren Michael Ready, MD FAHS ADAAPM
Director, Headache Clinic
Baylor Scott & White central division

2. Disclosures Family Physician Certified in Headache Medicine
Advanced Diplomate Am Academy Pain Management
Meyers Briggs ISTJ

3. Objectives Detail components of successful migraine management
Identify and utilize physician and patient resources available for migraine management
And to make it worth your time

4. Limbic Influences in Migraine
All Pain has meaning
The Sorrow that hath no vent in tears may make organs weep— Henry Maudsley
(When) the mind is hurt the body cries out Italian Proverb
The body remembers what the mind forgets– J.L. Moreno

5. Not All Pain is Nociceptive
San Francisco Spine study 1992
Five childhood traumas: Loss of parent, emotional neglect, substance abuse, physical abuse, sexual abuse
No risk factors = 95% chance surgical cure
1-2 risk factors = 73% chance surgical cure
3 or more risk factors = 15% chance of a surgical cure
Increased incidence of Chronic Migraine in victims of Sexual Abuse.

6. Case 1 27yo C♀ ICU nurse. Onset @ 5y +FH
Episodic to CDH over last 2 years
2 prior hospitalizations for headache no DHE
Sleep non-restorative, Schedule erratic
Awakens with HAs,
N/V, Photophobia,
Propoxyphene / ASA/APAP/Caffeine
Recently started on Topiramate

7. Evaluate & Treat as Appropriate
What does that mean?
The referring physician has given up!
Restore quality of Life
Prevent progression to disability

8. What a Headache… Patient Needs Provider Needs A Path to healing
Foundation
With that Foundation you build a plan
Believe that what they do will make a difference
Self Efficacy
Perfectly Honest, Perfectly Kind
Recognize the Pain
Validate the experience
Colleagues
Foundation

9. What a Headache Specialist does
Triage
Intake
Staging
Expectation
Education
Coach
CARE!

10. Triage Who do you need to see right away? Cluster (my personal)
Chronic Migraine / Acute rescue
School or Work absences
Red Flags?
New HA in pt over 50 Years of age
Serious risk morbidity/mortality

11. SNOOP 4: Ruling Out Secondary Causes of Headache in Migraine
Systemic symptoms and signs
Neurologic symptoms or signs
1 / Silberstein 2008 book, p316/Table 13.1
2 / Dodick NEJM 2006,p
3 / Bigal J Headache Pain 2007, p265/Table 1
Onset: peak at onset or <1 minute
Older: after age 50 years
Previous headache: pattern change
Postural, positional aggravation
[NOTE TO SPEAKER: This slide is a build.]
Ruling out secondary causes of headache in migraine in general (not specific to chronic migraine)1-3: Systemic symptoms and signs, such as fever, myalgias, and weight loss, could point to giant cell arteritis or an infection; systemic disease, such as malignancy or AIDS, suggests metastatic disease or an opportunistic CNS infection.
Neurologic symptoms or signs raise suspicion for structural, neoplastic, inflammatory, or infectious CNS disease.
Onset, as in sudden-onset conditions (eg, thunderclap headache), could indicate an underlying stroke, subarachnoid hemorrhage, cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, or arterial dissection.
Onset after age 50 suggests structural, neoplastic, inflammatory, or infectious central nervous system disease, or giant cell arteritis.
Pattern change (if there is a previous history) could point to progressive headache with loss of headache-free periods or be precipitated by valsalva, which suggests Chiari malformation, structural lesions that obstruct cerebrospinal fluid flow, or cerebrospinal fluid leak. In addition, pattern change could involve postural aggravation that is worsened by either standing or lying down, suggesting intracranial hypotension from cerebrospinal fluid leak or intracranial hypertension, or by certain neck movements and positioning, which might indicate cervicogenic headache. Lastly, papilledema, when present, raises suspicion for intracranial hypertension.
References:
1. Dodick D. Chronic daily headache. N Engl J Med. 2006;354:
2. Bigal ME, Lipton RB. The differential diagnosis of chronic daily headaches: an algorithm-based approach. J Headache Pain. 2007;8:
3. Merriman J. When should physicians test for dangerous headache? Neurol Rev. 2008;16(5); Available at: Accessed February 1, 2010.
Precipitated by valsalva, exertion, etc.
1 / Dodick NEJM 2006,p
2 / Bigal J Headache Pain 2007, p265/Table 1
3 / Merriman 2008, website, p1-2
Papilledema
Silberstein SD, Lipton RB. In: Silberstein SD et al, eds. Wolff’s Headache and Other Head Pain. 8th ed. New York: Oxford University Press; 2008: Dodick D. N Engl J Med. 2006;354:
Bigal ME et al. J Headache Pain. 2007;8:

12. Headache Pattern Recognition
Minutes Hours/Days Weeks/Months Months/Years
Vascular
Infectious
Inflammatory,
Neoplastic
Primary
headache
Secondary Headache Disorders

13. Intake Allows patient to tell their story Use Open Ended Questions
Use “Ask – Tell – Ask” format
Helps to determine the HA pattern
Helps identify pattern that leads to diagnosis
Helps to identify the perpetuating factors

14. Profiling Headache Pattern Recognition
Primary Headaches
Migraine
Tension-type
Cluster
Misc. headaches unassociated with structural lesions
Secondary Headaches
Post-traumatic
Vascular disorders – CVA, Aneurysm
Nonvascular intracranial disorder
Neoplasm, meningitis, low or high CSF pressures
Substances/withdrawal
Systemic infection or metabolic d/o
Cranial, extracerebral lesions
Review profile as the means of selecting a diagnostic pathway. This is done through history not non-discriminate use of imaging studies.
CSF, cerebral spinal fluid
Intl Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004;24(Suppl 1):31-32.

15. Cluster vs Migraine

16. Cluster vs. Migraine LOE = SIMU Periodic nature
Cluster almost always side-locked
Duration of attack
Cluster 30m – 120 minutes
Migraine 4 – 72 hours
Awaken from sleep: middle of night vs. early morning
Movement: avoidance vs. pacing
Thoughts of harm

17. Cluster Headache Treatment
Peter Goadsby AHS handout
Acute
High flow O Lpm /c NRB mask
Injectable DHE or Suma
May use Triptan NS
Prevention
Verapamil –Must be instant release!
Start 120mg BID ↑TID in 3 days. Reevaluate in 1 week
baseline & /c dose increases >360mg/day

18. Why Migraine Why Should I Care
TTH & Migraine 2nd & 3rd most prevalent medical disorder
Migraine accounts 30% of global burden of disability & 50% of all Neuro disability
4th leading cause of disability in women & 7th overall
Lancet 2012

19. The Why & How of Migraine
Genetic hyperexcitability:
Lower threshold for activation
Longer retention of sensory information
Between episodes of migraine
During episodes of migraine
Hyper-vigilant 24/7
A sensitive brain that doesn’t like change
Always more than a headache!
Frequency is a product of Past/Current experiences interacting with the present environment

20. Patient Preferred Explanation
You are genetically predisposed to migraine because of abnormal hyperexcitability of neurons in certain regions of the brain.
We believe that this hyperexcitability is caused by in part mutations in channels on the surface of neurons that, when triggered, allow for the abnormal flow of sodium, calcium, and other brain chemicals in and out of the cell.

21. Staging Migraine Developed by Lipton, Cady, Farmer, & Bigal
First doctor/patient book
Based on frequency not severity of HA

22. Stage1: Episodic Migraine
Emphasis on acute abortive therapy
OTCs
Triptans
NSAIDs
Early intervention – complete response
Evaluation on mechanism of injury and pre-morbid biology of patient
Education focused on resuming normal function
Acute medication limits as headache progress
Preventive pharmacology
Behavioral interventions

23. Stage 2: Transforming Headache
Preventive pharmacology
Targeted use of abortives
Strong emphasis on behavioral intervention
Screen and treat co-morbidities
Perpetuating Factors > Precipitating Factors

24. Stage 3: Chronic Daily Headache
Behavioral intervention -- absolutely essential
Preventive pharmacology -- unavoidable
Screen & aggressively treat comorbidities
Educate, educate, educate
Establish reasonable goals and expectations
Targeted use of abortive medications
Emphasis of Quality of Life

25. Normal Neurological Function
Migraine Stages
Episodic
Chronic
Severe Impairment
Stage 3
Moderate Impairment
Stage 2
Mild Impairment
Stage 1
The concept of transformed migraine was first proposed by Ninan Mathew. He described how migraine patients developed a pattern of daily low grade headache on which is superimposed period of headache that have the clinical features of migraine. He like Raskin earlier noted a change in the threshold to headache and a failure to return to a normal baseline between headache. What is observed clinically is that as episodic migraine becomes chronic migraine there is a change is neurological function between headaches. Patients develop difficulty with sleep and often psychological disease use as generalized anxiety and or depression.
Normal Neurological Function
Cady RK, et al. Headache. 2004;44:

26. Risk Factors for Progression
Modifiable
Attack frequency
Poorly treated acute HA
Obesity
Snoring/OSA
Stressful life events
Medication overuse
Caffeine overuse
Not modifiable
Age
Female sex
Low education or socioeconomic status
Genetic factors
Head injury
Ashina S, et al. Curr Treat Options Neurol. 2008;10:36-43.

27. The Big Picture

28. Stop the Train Frame the condition – what are you trying to do?
Precipitating (Triggers) vs. Perpetuating factors
Perpetuating factors lower your threshold
Lower the threshold, easier to have a headache
Each Perpetuating factor as a locomotive engine

29. Expectations Patient No headaches
Less often, less intense, responding better to your “right-now” medication
Provider
Diaries
Appointments
Phone Calls
Must engage your life

30. Expectations There will be pain Focus on what’s important –
Prevention! You’re fighting a War, not a Battle!
Learning to Live (Well/Better) with the Pain
Have to use Behavioral Interventions
Start at the Beginning
Simple no longer an option!
Improves outcomes

31. Education Knowledge is Power!
What you know you can Master!
It is not enough to know that something “failed”
You must know why it failed
Headache Class
Written material
Web based resources
Nurse instruction
Pathophysiology
Self care
Abortive & Rescue care

32. “How can you have your pudding when you don’t eat your meat?”
All difficulties are easy when they are known
William Shakespeare
The man who is prepared, has half his battle fought
Miguel de Cervantes

33. Coach / Cheerleader Have to believe you can get better
Belief creates the actual fact
Where are you, Where do you want to be?
Who’s been where you at and gotten to where you want to be?
How’d they do that and what can I learn from them?
Have to be active -- How many people with a chronic condition get better by staying in bed?

34. Headache Provider Toolbox
Patient Identification
Measures
HIT, MIDAS
Headache Self Efficacy
Headache Disability Index
Headache Fear
Pain Catastrophizing Scale

35. Headache Providers Toolbox
The Headaches
Wolff’s Headaches
Marcus Library -- Headaches Simplified, Pregnancy & Lactation, Emergency Department
The Cleveland Clinic Headache Manuel
The Jefferson Headache Manuel
Advanced Headache Therapy - Robbins
Headache and Facial Pain Levin/Newman

36. Headache Treatments Framing the Foundations
Preventive –reduce frequency, intensity, and improve response to acute meds
Abortive – pain freedom in 2 hours
Rescue – when the stop medicine didn’t

37. Saves You Money! 18-month comparison study
Acute vs acute/preventive therapies
Office visits  51%
ED visits  82%
CT scans  75% MRI scans  88%
Medication costs  $48 -$138/month/patient
Silberstein SD et al. Headache

38. AAN Preventive Recommendations
Level A
Level B
Divalproex Sodium
Sodium valproate
Topiramate
Metoprolol
Propranolol
Timolol
Frovatriptan (MRM)
Amitriptyline
Venlafaxine
Atenolol
Nadolol
Naratriptan (MRM)
Zolmitriptan(MRM)

39. Prevention Pearls Pick the low hanging fruit
Start with supplements online/local vendor
Pick a med that helps a perpetuating factor.
Start low and go slow.
Consider “Re – Challenging”
you never step in the same river twice.

40. Migraine preventive therapy Possible reasons for lack of efficacy
Inadequate duration (<6-8 wk) at suboptimal dose
Poor Pt adherence (side effects, half-life, unrealistic expectations)
Concomitant drug-induced headache – Prevention unlikely to work in MOH
Newly developed medical condition causing a secondary headache
Failure to appreciate a migraine brain

41. Behavioral Interventions
Biofeedback
Thermal Biofeedback
Relaxation Response
Heart Rate Variability
Guided Imagery
DawnBuse.com

42. Stress Management They Can’t Find Anything Wrong
If you only read one book this year
It Will Change Your Practice
Mary Jo Rapini – Psychotherapist

43. Making Plans

44. Abortive – pain freedom in 2 hours
Headache Treatments
Preventive –reduce frequency, intensity and improve response to acute meds
Abortive – pain freedom in 2 hours
Rescue – when the stop medicine didn’t

45. Abortive Therapy Goal is pain freedom in 2 hours
Treat at mild pain (prior to central sensitization)
May use polypharmacy

46. Oral Therapies Non-triptan NSAIDS Combinations
APAP/ASA/caffeine
Analgesics
Antiemetics
Triptans
Ergotamines
When to consider
First-line therapy
Adjunctive therapies
There is no medication that is perfect for all migraine attacks or all circumstances in which treatment is needed.
First line therapy especially for treating early while pain is mild. Would add to slide.

47. Step Care 1st Choice Treatment NSAIDs 2nd Choice Treatment NSAID
Combination Drugs
3rd Choice Treatments
Other Analgesics
Combination Drugs
Last Choice Treatment
Triptans

48. Stratified Care Disability Low Disability NSAIDs Moderate
High or Severe
NSAIDs
NSAIDs + neuroleptics
or triptans
Triptans

49. What I do Soooooo Off-Label & Remember my patients aren’t yours
3 tablets Effervescent ASA + Mg 500mg or
Ibuprofen mg + Mg
Naproxen 500mg + Mg
Augment /c Metoclopramide or Prochlorperazine
Triptan – Suma & Nara generic. Generic Suma $3/pill Online pharmacy

50. Rescue – when the stop medicine didn’t
Headache Treatments
Preventive –reduce frequency, intensity and improve response to acute meds
Abortive – pain freedom in 2 hours
Rescue – when the stop medicine didn’t

51. Why should I treat Acute Headaches?
Have to keep these people out of the ED
Primary HAs are not an emergency
Not the best place – too bright, too loud, often ignored
Can’t risk exposure to opiates
More likely to V.O.M.I.T. in ED

52. No Opiates for Headaches
Major risk factor for Medication Overuse HA
Once established it’s a self fulfilling prophesy
Jakubowsk,et al Wolfe Award paper
64%-71% Migraine pts pain-free 1’ /p ketoralac iv
Only factor that predicted ketorolac failure: hx of opioid txt in the non-responders
Rewires the brain to perpetuate the HA state by inhibiting the breakdown of glutamate

53. Clinical Headache Rescue
Assoc. Neurologist of S. CT AHS SA Poster
Drop in HA Clinic – Prevent ED visits
9/05 - 8/ pts
Time to Present = 104 hours (8-240h)
VAS pain: Entry 8.5 Discharge 1.5
Txt: IVF (94%), Ketoralac (84%), Suma sq (78%), Prochlorperazine (52%), Metoclopromide (21%), DHE (8%), Mg (4%)
Average charge $426 Average payment $272.64

54. Clinical Headache Rescue UAB experience
200 pts. Randomized Optimal Self Care or Optimal Self Care + Optional in-clinic Headache rescue
Optimal Self Adm
Clinic Rescue
423 visits
33.6K ($80) 73
ED Visits 27
147.9K($2027)
ED Direct Cost
45.3K ($1609)
79% no d/a > 24’

55. Clinical Headache Rescue UAB experience
89% very satisfied
Drug #
Drug Cost
Droperidol 2.75mg
218
3.00
Diphenhydramine 50mg
201
1.25
DHE 1mg
167 42
Prochlorperazine 5-10mg
141
11.5
Promethazine 50mg 68 4.
Ketoralac 30mg 38
(saline)

56. Acute Headache Interventions
IV >> IM >> PO
Sumatriptan 6mg IM/SC
Dihydroergotamine 1mg IM/SC/IV
Ketorolac 30mg IV / 60mg IM
Neuroleptics – Dopamine Antagonists (Droperidol, Metoclopramide, Prochlorperazine)
Steroids
Others – Mg++, Valproic Acid, Diphenhydramine
Procedures – Occipital Nerve Block, Lower Cervical Intramuscular Injections

57. DHE vs. Suma Are you Ready 2 Rumble?
DHE 1mg SQ vs sumatriptan 6mg SQ
At 2 hours could receive second dose of same medication
Two hour relief: 85% Suma Vs. 73% DHE (p=0.002)
24 hour relief: 77% Suma Vs. 90%DHE (p=0.004)

58. DHE Pearls Patients want it for rescue
May mix with lidocaine to reduce injection site pain
When given IV, need to use the highest sub-nauseating dose
May be infused over 8 – 24 hours

59. Ketorolac Dose: 30mg IV or 60mg IM Cautions/ Contra-indications:
Typical Non-steroidal risk
What to expect:
IM shots cause localized burning pain

60. Case 1 – 27yo C♀ ICU Nurse Dexamethasone 4mg BID X 7d
Magnesium, CoQ10, Tizanidine, B ONB
Metoclopramide to augment acute meds.
No improvement placed on DHE for 10d
Ketorolac 60mg IM rescue
F/U HAs ↓ 3/7 days started Topirmate
HAs reduced to 1/7 days /c severe 1-2/30d
Titrated off Topirmate after 9m of stability

61. Books You Should Know The Woman’s Migraine Toolkit Dawn Marcus, MD
Disclosure
The Best
****1/2 – 9 reviews

62. Books You Should Know Nov 2008 ****1/2 (10 reviews)
The Keeler Migraine Method Robert Cowan, MD
Nov 2008
****1/2 (10 reviews)

63. Books You Should Know 4.7/5 - reviews UnlearnYourPain.com
Expands Sarno’s work
Youtube
Search “Sarno” & “20/20”

64. Books You Should Know The Great Pain Deception
4.8/5 – 161 reviews
Patient of Sarno
PainDeception.com

65. Books You Should Know Neuroplastic Transformation
4.4/5 – 21 reviews
Neuroplastix.com
Focuses on rewiring the brain in pain

66. Books You Should Know Migraines Be Gone ***** --28 reviews
Personalized Biofeedback
Author Sponsored Website

67. Books You Should Know Chocolate & Vicodin Pt. Memoir NDPH
Best description of the relentlessness of daily headache
May be painful for docs

68. Books You Should Know Trigger Point Therapy for Headaches & Migraine
Valerie DeLaune
***** – 46 reviews

69. Our Role as Healers
Stress related complaints – Especially in chronic illness
Use care with a mechanical (acute) model
Limbic Augmented Pain
The sorrow that hath no vent in tears ...
Acknowledge Limits “I can’t fix this”
Only thing you can cure is a ham.

70. AHS Choosing Wisely
Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine
Don’t perform CT imaging for headache when MRI is available, except in emergency settings
Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial
Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders
Don’t recommend prolonged or frequent use of over- the-counter pain medications for headache