Headache School2013

Norton Headache and Concussion Center

Why Headache School?

• Headache is one of the most common reasons for patients to seek medical attention

• Of patients seeking medical attention for headache, the majority will be diagnosed with migraine

• Migraine affects approximately 12% of the population

Why Headache School?

• Formal educational programs have been shown to produce better outcomes for patients with headache

• Opportunity for patients to interact with physicians and other patients in an informal setting

What Can You Do?

• Come to classes• Bring a friend, spouse, etc.• Come with questions• Share your story

– Interact with those around you– Migraine is a lot more common than you think– You are NOT the only one

Upcoming Classes

• Medication Maze– April 11

• How Diet Affects Headaches– May 16

• Women and Headaches– June 13

What Is Migraine?

A Common Problem

• 45 million Americans with headache disorders• 30 million Americans with migraine, the most

common disabling form of headache• 12% of the US population has migraine• 18% of women, 6% of men are affected by

migraine

One Year Prevalence of Migraine

Lipton R B et al. Neurology 2007;68:343-349

Migraine is more common than diabetes and asthma combined!

1%

7%

6%

7%

13%

0% 5% 10% 15% 20%

Migraine

Osteoarthritis

Diabetes

Asthma

RheumatoidArthritis

Commonly Mis- / Un-Diagnosed

Diagnosed Migraine

Undiagnosed Migraine

39%

61% 52%

48%

19891999

Lipton et al., 2001

American Migraine Study II

A Costly Problem

• Chronic headache disorders are among the top 20 causes of disability in the US according to the World Health Organization (WHO)

• 4% of Americans experience 4 hours of headaches per day, at least 15 days per month

• Headache disorders are responsible for more than $31B in economic costs in the US annually

Diagnosis of Migraine Without Aura

• No single feature required or sufficient for diagnosis• Characteristics (2/4)

– Unilateral (40% bilateral or generalized)– Throbbing (50% non-pulsating)– Moderate-severe intensity (~20% mild)– Pain worsened by exertion (>95%)

• Associated symptoms (1/2)– Nausea (86% – 95%) or vomiting (47% – 62%)– Photophobia (82% – 95%), phonophobia (61% – 98%)

Russell MB et al. Cephalalgia. 1996.Pryse-Phillips WEM et al. Can Med Assoc J. 1997.

Additional Features of Migraine

• Predictable timing around menstruation and ovulation

• Stereotyped prodromal symptoms• Characteristic triggers• Improves with sleep (more effective in young pts)• Positive family history• Childhood precursors (cyclic vomiting, abdominal

“migraine”, episodic vertigo, probably motion sickness)

• Osmophobia (smell sensitivity)

“I have sinus headaches”

Eross E, Dodick D, Eross M. The sinus, allergy and migraine study (SAMS)

86% Migraine

3% Sinus related headache

Patients self diagnosing “sinus headaches”

What Causes Migraine?

• The Vascular Theory

• Blood vessels constricting (aura)Followed by

• Blood vessels dilating

The Vascular Theory

• Does not explain prodrome• Not supported by blood flow studies• There are effective nonvascular drugs, such as

NSAIDs• Most patients do not have aura

• THIS IS NOT CORRECT

The Neurovascular Theory

• Referred pain from dura mater and blood vessels

• Peripheral Neural Processing• Central Neural Processing

Pain Perceiving Structures Inside the Skull

The most important structures that register pain in the head are the large cranial vessels, proximal cerebral vessels and dural arteries and the large veins and venous sinuses

A More Sensitive Brain

Pain control mechanisms are partially defective in migraine patients

Wang, Schoenen. Cephalalgia. 1998.

People with migraine process visual and auditory stimulation differently that people without migraine. In this example with repeated stimulation non-migraine patients have decreased response with repeated stimulation whereas migraine patients have an increased response.

Migraine Triggers

• Most frequently reported triggers– Stress– Menstruation– Changes in sleep– Skipping meals– Changes in weather– Diet (alcohol most frequent)

• Time from trigger to onset of headache can be up to 72 hours - hard to track

Migraine Triggers

If summation of triggers are greater than threshold – a headache happens

Migraine Aura

Migraine Aura

• A reversible focal neurological deficit– Most commonly visual

• Cortical spreading depression– Think a wave of activity moving across the brain

followed by decreased activity– The part of the brain inactivated causes the

neurological deficit• Occipital lobes = vision

Spreading Depression of Leão

EEG activity is suppressed and moves in a wave, correlates with symptoms

Aura is from brain cells (neurons)

The Pain

Neuropeptides

• Cranial levels of both substance P and calcitonin gene-related peptide (CGRP) are increased by stimulation of the trigeminal ganglion in humans

• In migraine CGRP is elevated in external jugular vein blood, whereas substance P is not

• CGRP infusions can trigger headache and migraine

A Growing Snowball• Trigeminal nerve and its blood supply (neurovascular)

– Release of neuropeptides• CGRP• Substance P• 5-HT (serotonin) --> “triptans”• Nitric oxide

– Vasodilatation (CGRP) leads to further activation, and the process spreads

– Brainstem, thalamus, cortex become activated leading to “central sensitization”

• Amplified pain signaling in the central nervous system– Allodynia: pain due to a non-noxious stimulant

Cutaneous Allodynia

Migraineurs develop increased sensitivity to stimuli as a result of increased nerve excitability

80% of migraine patients had cutaneous allodynia during attacks

Non painful stimuli perceived as painful

After allodynia occurs, triptans lose effectiveness

Burstein R, et al. Brain. 2000.

1-Peripheral Trigeminal Sensitization

1-Peripheral Trigeminal Sensitization

2-Central Trigeminal Sensitization

2-Central Trigeminal Sensitization

3-Forehead Allodynia3-Forehead Allodynia

4-Extracephalic Allodynia

4-Extracephalic Allodynia

Importance of treating earlyNo Allodynia Allodynia

Pain free @2hrs 28 (93%) 5 (15%)

Not pain free @2hrs 2 (7%) 29 (85%)

30 34

R Burstein, 2003

Allodynia is a risk factor for developing chronic migraine

Earliest Possible Treatment to Stop Migraine Progression and Chronification

Inherited threshold for

trigeminal activation

Triggers or stressors

Episodic migraine

Ineffectivepain

control

Ineffectivepain

control

Medicationoveruse

Medicationoveruse

Increasedheadache frequency

Increasedheadache frequency

Chronic migraineChronic

migraine

Graphic adapted from: Calhoun AH. In: Headache Newsletter: American Headache Society Committee for Headache Education; Veteran’s Day, 2010.

Medication Overuse Headache

• Headache present on ≥15 days/month• Regular overuse for ≥3 months of one or more drugs

that can be taken for acute and/or symptomatic treatment of headache

• Headache has developed or markedly worsened during medication overuse

• Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication

Chronification of MigraineMedication Overuse Headache

The Cleveland Clinic Manual of Headache Therapy p. 156

Bigal ME, et al. Headache. 2008;48:1157-1168.

Bigal ME, et al. Pain. 2009;142:179-182.

Medication Overuse Headache

• Simple analgesics:• Acetaminophen (Tylenol)• Ibuprofen (Advil, Motrin)• Aspirin (Bayer)• Naproxen (Aleve)

• Combination products:• Fioricet• Excedrin

• Opiates:– Lortab (hydrocodone)– Percocet (oxycodone)– Many others

• Triptans:– Imitrex, Maxalt, Relpax,

Zomig, Frova, Amerge, Axert, Treximet

• DHE

Why opiates are bad

Other Associated Symptoms

Nausea• Gastroparesis occurs frequently,

both during and outside of acute migraine attacks1-3

– May correlate with intensity ofheadache, nausea, and photophobia4

• Absorption of orally administered drugs used to treat migraine may be delayed by gastroparesis, postponing the drug’s onset of action1,5-7

1. Krymchantowski AV, et al. Cephalalgia. 2006;26(7):871-874; 2. Aurora SK, et al. Headache. 2006;46(1):57-63; 3. Aurora S, et al. Headache. 2007;47(10):1443-1446; 4. Boyle R, et al. Br J Clin Pharmacol. 1990;30(3):405-409; 5. Thomsen LL, et al. Cephalalgia. 1996;16(4):270-275; 6. Volans GN. Br J Clin Pharmacol. 1975;2(1):57-63; 7. Tokola RA and Neuvonen PJ. Br J Clin Pharmacol. 1984;18(6):867-871; 8. Tfelt-Hansen P. Headache. 2007;47(6):929-930; 9. Dahlöf C. Curr Opin Neurol. 2002;15:317-322; 10. Lychkova AE. Bull Exp Biol Med. 2004;138(2):127-130.

Other Associated Symptoms

• Blurry vision (29%)• Neck pain (31%)• Nasal congestion (28%)• Sweating (30%)• Dizziness (16%)

Why is it important to understand the science of migraine?

• Treatment– Prevention of triggers– Preventative medications– Rescue medications

Triggers

• We now understand that patients with migraine have an “excitable” brain– Need to be careful with:

• Sleep• Diet• Medication overuse• Stress management

Preventative Medications

• Antiseizure drugs– Topamax– Depakote

• Antidepressants– Amitriptyline (Elavil)– Effexor

• Blood pressure medications– Propranolol (Inderal)– Verapamil

Rescue Medications

• Triptans• NSAIDs• DHE

Triptans

Selective agonists (activators) of serotonin blocking the release of other inflammatory chemicals during a migraine attack

Triptans work here

Triptans

• Prevent release of neuropeptides• Once enough activation has occurred the

process of central sensitization begins– Manifested by allodynia– Remember 15% vs. 93% chance of success

NSAIDs

• Ketorolac infusion has been shown to reverse central sensitization

• IV ketorolac is not practical in the outpatient setting

• Further discussed next month

DHE

• Can also reverse central sensitization• More side effects• A little less convenient to give in the home

setting

• Will be discussed further next month

Summary

• Hyperexcitable brain: more susceptible to triggers

• Aura: spreading excitation and depression• Throbbing head pain: trigeminal inflammation• Allodynia: common, important and due to

central sensitization

Future Classes

• Medication Maze– April 11

• How Diet Affects Headaches– May 16

• Women and Headaches– June 13

Questions?

Thanks

NortonHealthcare.com/HeadacheandConcussion