frederick t strobl md azmn neurology migraines ...az-ns.org/presentations/migraines.pdf ·...
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Frederick T Strobl MDAZMN Neurology
Migraines:
Classification, Management and Effects on Cognition
Arizona Neuropsychological Society
June 21, 2014
© 2014 Frederick Strobl
Learning Objectives:
1.Understand the general classification of headaches with particular attention to migraines.
2.Learn how migraine headaches can affect cognition.
3.Learn how treatment of headaches may improve/impair cognition
© 2014 Frederick Strobl
Curriculum Vitae - 1
College:
1967 – 1968 Rensselaer Polytechnic Institute (RPI), Troy,
New York
1968 – 1971 University of Minnesota, Minneapolis
BS Electrical Engineering; Minors in
Computer Science and Control Systems
1970-1971 Worked part time for Honeywell Systems and
Guidance Group. This group was in charge of the design
of control systems for Apollo Spacecrafts, X-15 rocket
planes, 747’s
Curriculum Vitae - 2
Medical School:
1972 – 1975 University of Minnesota, Minneapolis
Internship (PGY-1):
1975 – 1976 Hennepin County Medical Center (HCMC, the
Level I Trauma Center for Minneapolis)
Curriculum Vitae - 3
Residency (PGY-2 through PGY-4):
1976 – 1979 University of Minnesota Neurology Program
(at the time the largest in the United States) with
rotations at HCMC and St. Paul Ramsey (now Regions
Medical Center) – all Level I Trauma
Chief Resident at University of Minnesota and HCMC
Curriculum Vitae - 4
1977
Scholarship to study Electromyography (EMG) at the
National Hospital for Nervous Disease, Institute of
Neurology, Queen Square, London, UK
Fellowship Training:
1979 Mayo Clinic, Rochester, MN, Electroencephalography
Curriculum Vitae - 5
NATIONAL BOARD CERTIFICATIONS
American Board of Psychiatry and Neurology
(Neurology)
American Board of Electrodiagnostic Medicine (EMG)
American Board of Neurologic Rehabilitation
Diplomate of National Board of Medical Examiners
Curriculum Vitae - 6
Minneapolis Clinic of Neurology
(Largest Private in US)
AZMN Neurology
Curriculum Vitae - 8
1977 – Present: American Academy of Neurology
(AAN – the dominant professional Neurology
association in the world)
AAN was founded by the Chief of Neurology at the
University of Minnesota, Dr. A. B. Baker, who was
also was my Chief in training.
The idea for AAN came from Joseph Resch, MD, a
founder and past President of my clinic, The
Minneapolis Clinic of Neurology
It is VERY cold & dark in Minnesota in Winter
Headache Classification
Many Classifications
Generally Not Helpful Clinically
For most – dichotomy
Vascular – sounding
Non-vascular
© 2014 Frederick Strobl
Headache Classification: Non-vascular
Muscle-contraction
Stress
Cervical spine diseases
Tumor, ICH, Infection
© 2014 Frederick Strobl
Headache Classification: Vascular
Inflammatory
Lupus, GCA/TA, Vasculitis, Lyme
Migraine
Many forms
Grossly underdiagnosed
Prominent among Neurologists
© 2014 Frederick Strobl
Migraine - Pathophysiology
Primary brain disease
Spreading depolarization
Prominent Trigeminal/Brainstem Involvement
Role of Hypothalamus?
© 2014 Frederick Strobl
Migraine - Statistics
18% of Females >1 attack/year
6% of Males (likely underdiagnosed)
35 – 45 years old
Increased risk of seizures
© 2014 Frederick Strobl
Case Study
27 yo Neurology Resident walking in hall feels lightheaded. He notices
that his thinking is unclear. This all passes within a few minutes.
Over next few months the resident will have repeated identical episodes without any clearcut precipitants.
© 2014 Frederick Strobl
Case Study 1
As a resident, he had been asked to be a test subject normal for EEG at
three institutions.
All are read as normal.
MRI is normal.
© 2014 Frederick Strobl
Case Study 2
Routine bloods, including glucose during an attack, are normal.
Attacks become more common and longer.
He reports his cognition is slower during these attacks.
He can read but not comprehend.
© 2014 Frederick Strobl
Case Study 3
Almost never has headaches.
Occasionally sees visual scotomasand flashing lights.
Can’t read in car – nausea.
Since childhood he has had episodic attacks of severe abdominal pain, being rushed to ER for appy once.
© 2014 Frederick Strobl
Case Study 4
His four-year old daughter has similar
attacks of abdominal pain.
Suspecting migraines, he calls his mother who never reported them to
him because she didn’t want to trouble him, has identical symptoms plus severe HA’s as does her mother.
© 2014 Frederick Strobl
Case Study 5
Ibuprofen relieves his symptoms within 30’.
Daily aspirin 81 – 325 mg have markedly reduced frequency.
© 2014 Frederick Strobl
Acute Confusional Migraine (ACM)
Up to 8% of children w Migraine
Affects adults as well-under diagnosed
Alice-in-Wonderland syndrome (AIWS)
Micropsia, macropsia, or size distortion of other sensory modalities
© 2014 Frederick Strobl
Acute Confusional Migraine (ACM) 1
Amnesia
Inability to concentrate
Disorientation
Agitation
Exhaustion or Hyperalertness
Speech impairment
© 2014 Frederick Strobl
Migraine - Diagnosis
History
Family History
Exclude other etiologies
No direct test
MRI, MRA
EEG may be positive
© 2014 Frederick Strobl
Migraine - Treatment
Interventional
NSAIDs, Triptans (eg, Imitrex)
Preventive
Anti-epileptics, (eg, Depakote ER)
Calcium channel blockers
Beta blockers
Tricyclics
© 2014 Frederick Strobl
Questions & Answers