MigrainesMigraines

Mark Green, MDMark Green, MD

Clinical ProfessorClinical ProfessorDepartment of NeurologyDepartment of Neurology

Columbia University Columbia University New York, NYNew York, NY

Mark Green, MD

Mark Green, MD

Patient HistoryPatient History

• Patient is a 36-year old woman with a 10-year history of recurring headaches

• Average 2 headaches per month

• Headaches are left-sided, hemicranial, and associated with nausea and vomiting

• Attacks last 2 days, afterwards she is well

Mark Green, MD

Mark Green, MD

Mark Green, MD

Mark Green, MD

Mark Green, MD

Patient HistoryPatient History

• Patient is a 38-year old woman with a long history of unilateral throbbing headaches associated with nausea and vomiting

• Headaches last 2 days and are particularly likely to occur while menstruating

• Over past 6 months, headaches have increased; still unilateral but continuous

• Taking 50 Excedrin Migraine tablets each week for headache and getting only temporary relief

Mark Green, MD

Mark Green, MD

Drug Overuse in Headache PatientsDrug Overuse in Headache Patients

Regular use of

• Analgesics

• Vasoconstrictors

• Decongestants

• Caffeine

• Triptans, NSAIDs (rare)

Mark Green, MD

Why is a migraine disabling?Why is a migraine disabling?

• Pain

• Nausea, vomiting

• Photophobia and phonophobia

• Encephalopathy

Mark Green, MD

Mark Green, MD

Common Comorbidities of MigraineCommon Comorbidities of Migraine

• Cardiovascular– Hypertension or hypotension– Raynaud’s disease–Mitral valve prolapse– Angina / myocardial infarction– Stroke

• Respiratory – Asthma– Allergies

Mark Green, MD

Common Comorbidities of MigraineCommon Comorbidities of Migraine

• Gastrointestinal – Irritable bowel disease

• Neurologic – Epilepsy

• Psychiatric – Depression– Bipolar disorder– Panic disorder– Anxiety disorder

Mark Green, MD

Mark Green, MD

Problems with Narcotic AnalgesicsProblems with Narcotic Analgesics

• Sedating

• Increases nausea and vomiting

• Vasodilator

• Rebound headaches

• Drug-seeking behavior

Mark Green, MD

Dopamine AntagonistsDopamine Antagonists

• Chlorpromazine

• Metoclopramide

• Prochlorperazine

• Droperidol

Mark Green, MD

Problems with Dopamine AntagonistsProblems with Dopamine Antagonists

• Sedating

• Orthostatic hypotension

• Extrapyramidal effects

Mark Green, MD

NSAIDsNSAIDs

• Ketorolac (parenteral)

• Indomethacin (suppositories)

Mark Green, MD

• Injectable sumatriptan most likely to work in a prolonged migraine

• Comorbidities

• Medications taken before ER

Triptans in the ERTriptans in the ER

Mark Green, MD

• Intravenous or intramuscular

• Pretreat with an antiemetic

• Cannot mix with triptans/other ergots

DihydroergotamineDihydroergotamine

Mark Green, MD

• Reduce rate of headache recurrence

• Little immediate relief

Corticosteroids Corticosteroids

Mark Green, MD

Depacon Depacon

• 1 gram IV in 50 cc NS by rapid infusion over 5 minutes• Compatible with use of triptans/ergots same day• No sedation• Improvement in associated migraine symptoms• Can begin prophylaxis immediately if desired

Mark Green, MD

Mark Green, MD

Mark Green, MD

Patient HistoryPatient History

• Patient is a 37-year old woman who had abrupt onset of a severe occipital headache with mild nausea

• Had transient diplopia, which resolved before she arrived at the hospital

• Headache remained constant without any photophobia but with moderate nausea

• Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

Mark Green, MD

Patient HistoryPatient History A 45-year old male presented to the emergency

room in the evening. He had a long history of migraine without aura, which was treated with rizatriptan. This treatment has been generally successful in the past, but he did not respond on this occasion. He had taken it at 3am when he was awakened with a unilateral throbbing headache accompanied by nausea and vomiting. The rest of the evening and throughout the morning he continued to vomit frequently and did not appear to improve taking ibuprofen every 4 hours.

Mark Green, MD

When would you do a CT scan on this man?When would you do a CT scan on this man?

A. If his neurological examination is normal.

B. If he does not respond to another dose of rizatriptan.

C. If he does not have a pre-existing history of migraines.

Mark Green, MD

What would be your next treatment?What would be your next treatment?

A. Another dose of rizatriptan, in the MLT formation.

B. Injectable sumatriptan.

C. Intravenous prochlorperazine.

D. Intravenous divalproex.

Mark Green, MD

Patient HistoryPatient History• Patient is a 37-year old woman who had abrupt

onset of a severe occipital headache with mild nausea

• Had transient diplopia, which resolved before she arrived at the hospital

• Headache remained constant without any photophobia but with moderate nausea

• Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

Mark Green, MD

Mark Green, MD

Mark Green, MD

The response to medication is not The response to medication is not diagnostic of the problem.diagnostic of the problem.

Mark Green, MD