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Teshamae Monteith, MD, FAHSUniversity of Miami, Miller School of MedicineMiami, FL

Migraine and Cluster Headache Misconceptions

Teshamae Monteith, MD, FAHS

Research/Grants: Allergan Inc.;; Site principal investigator Eli Lilly and Company (funds do not go directly to Dr. Monteith)Other Financial or Material Support: Received travel funds from Teva

Disclosures

Cluster headache (ICHD-­3 Beta)

A. At least 5 attacks fulfilling criteria B-­DB. Severe or very severe unilateral orbital, supraorbital and/or

temporal pain lasting 15-­180 min (when untreated)C. Either or both of the following:

1. ³1 of the following ipsilateral symptoms or signs: – a) conjunctival injection and/or lacrimation;; b) nasal congestion and/or rhinorrhoea;; c) eyelid oedema;; d) fore-­head and facial sweating;; e) forehead and facial flushing;; f) sensation of fullness in the ear;; g) miosis and/or ptosis

2. A sense of restlessness or agitation (90%)D. Frequency from 1/2 d to 8/d for > half the time when activeE. Not better accounted for by another ICHD-­3 diagnosis

Cluster Headache (ICHD-­3 Beta)

1. Episodic cluster headacheA. Attacks fulfilling criteria for Cluster headache and occurring in

bouts (cluster periods)B. ³2 cluster periods lasting 7 d to 1 y (when untreated) and

separated by pain-­free remission periods of ³1 mo2. Chronic cluster headacheA. Attacks fulfilling criteria for Cluster headache and criterion B

belowB. Occurring without a remission period, or with remissions lasting

<1 mo, for ³1 y

Cluster: Just a Headache? Cluster headache-­ episodic (80%) and chronic (20%) Occurs in 0.4% of the general population Onset usually 20-­40 years of age (80%) Positive family history in 7% of cases (14% risk in first degree relatives) Male predominates but female rates may be rising Hallmark by periodicity of bouts (often starts during shortest and longest day of the year in Jan/July)

Can be associated with migraine symptoms Peripheral: trigeminal activation, cranial parasympathetic fibers from superior salivatory nucleus, carotid sympathetic plexus (Horner’s syndrome)

Central: circadian, circannual, and seasonal rhythmicity/hormones

Misconceptions and Delays

Bahra A, Goadsby P. Acta Neurol Scand. 2004;;109(3):175-­9.

Specialist Seen By Procedures

Dentist 46%

Tooth extraction

Splint

Braces

Filing

Maxillo-­facial surgery

ENT 32%

Sinus washout

Nasal spectral surgery

Antibotics

Optician 26%Spectacles

Eye exercises

Ophthalmologist 23% None

Cluster Headache PathophysiologyHypothalamic dysfunction Circadian peridiocity of attacks Neuroendocrine changes (altered levels of melatonin, cortisol, luteinizing hormone, testosterone)

Activated areas seen in PET scan and voxel based morphometry in patients during cluster pain

Migraine: Just a Headache?

Migraine without aura Migraine with aura Migraine with typical aura Typical aura without headache Migraine with brainstem aura Hemiplegic migraine (1-­3) Sporadic hemiplegic migraine Retinal migraine Chronic migraine (+aura)

Complications of migraine– Status migrainous– Persistent aura without infarction– Migrainous infarction– Migraine aura-­triggered seizure

Probable migraine (with, without aura) Episodic syndromes

– Recurrent GI disturbance– Cyclical vomiting syndrome– Abdominal migraine– Benign paroxysmal vertigo– Benign paroxysmal torticollis

International Headache Society. International Classification of Headache Disorders. Third Edition 2013.

Diagnosis of Migraine

A. At least five attacks1 fulfilling criteria B–DB. Headache attacks lasting 4-­72 hours

(untreated or unsuccessfully treated)2,3

C. Headache has at least 2 of the following 4characteristics:1. Unilateral location2. Pulsating quality3. Moderate or severe pain intensity4. Aggravation by or causing avoidance of

routine physical activity (e.g. walking or climbing stairs)

D. During headache at least one of the following:1. Nausea and/or vomiting2. Photophobia and phonophobia

E. Not better accounted for by another ICHD-­3 diagnosis.

Chronic migraine defined as > 15 headache days/month, 8 migraine days (for over 3 months) Rizzoli P, et al. The Migraine Solution: A Complete Guide to Diagnosis, Treatment, and Pain Management. Harvard University. St Martin’s Press, New York, NY. 2012

Migraine Phases

Migrainetalkblog @ https://migrainetalkblog.wordpress.com/2014/09/14/the-­5-­possible-­stages-­of-­a-­migraine-­attack-­2/ Published September 14, 2014. Accessed September 15, 2016.

It’s All in Your Head!Vascular Theory?

Afridi SK, et al. Arch Neurol 2005;;62(8),1270-­1275Matharu MS, et al. Brain 2004;;127(Pt 1):220-­230

Chronic Episodic

Obermann M, et al.Cephalalgia 2006;;26(6):763-­766

Weiller C, et al.Nat Med 1995;;1(7):658-­660

Chronic Migraine with Medication Overuse

Grazzi L, et al. Headache. 2010;;50(6):998-­1004.

Control Subjects

Chronic migraine and medication overuse

Chronic migraine and medication overuse 6

months after withdrawal

Questions Answers &

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