headaches: causes, cases, cures alexander mauskop, md [email protected] new york headache...
TRANSCRIPT
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Danger SignalsDanger Signals
New-severe headache
Worst headache ever
Headache with fever
Headache with stiff neck
Headache with weakness or numbness
Headache that wakes from sleep
Headache worsening over time
History of head trauma
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Migraine DiagnosisMigraine Diagnosis
Migraine is under-diagnosed
94% of patients seen by a primary care doctor with
recurrent headache suffer from migraine
Nearly 90% of “sinus headache” patients meet criteria
for migraine
Nearly 90% of “tension/stress” headache patients meet
criteria for migraine
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Migraine Diagnostic QuestionnaireMigraine Diagnostic Questionnaire
Has a headache limited your activities for
a day or more in the last three months?
Are you nauseated or sick to your stomach
when you have a headache?
Does light bother you when you have a headache?
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Approach to headachesApproach to headaches
History
Physical examination
Neurological examination
Differential diagnosis
Laboratory and imaging tests
Treatment
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Treatment of migraineTreatment of migraine
Establish correct diagnosis
Eliminate triggers
Lifestyle changes
Non-pharmacological approaches
Abortive and prophylactic drugs
Botulinum toxin
Devices
General principles
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Treatment of migraineTreatment of migraine
Sleep (sleep hygiene, treat sleep disorders, melatonin)
Exercise
Diet (low-carb, avoid trigger foods, gluten)
Biofeedback, neurofeedback, or meditation
Magnesium, CoQ10, riboflavin, omega-3, alpha-lipoic acid
Herbal: Feverfew, Boswellia, Butterbur, aromatherapy
Acupuncture
Music
Non-pharmacological treatments
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Physical activity and headache: results from the Nord-Trøndelag Health Study (HUNT). Varkey E, et al. Cephalalgia 2008.
A study of 46,648 subjects
“Low physical activity was associated with higher
prevalence of migraine and non-migraine headache. In
both headache groups, there was a strong linear trend
(P< 0.001) of higher prevalence of ‘low physical activity’
with increasing headache frequency”
Exercise and headaches
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Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Varkey E, Cider Å, J. Carlsson J, Linde M. Cephalalgia 2011;31:1428-1438.
91 patients divided into 3 groups:- aerobic exercise (40 minutes three times a week) - topiramate - relaxation training All three treatments equally effective. Only topiramate caused side effects, which occurred in 33% of patients
Exercise and headaches
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Treatment of migraineTreatment of migraine
Food
cheese, chocolate, sugar, wheat, dairy
Environmental
light, noise, air pollution, weather
Hormonal
Eliminate or reduce triggers
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CaffeineCaffeine
52% moderate or severe headache
11% depression
11% low vigor
8% anxiety
8% fatigue
235 mg (2.5 cups) a day235 mg (2.5 cups) a day
“Withdrawal syndrome after the double-blind cessation of caffeine consumption.”
(Silverman et al. NEJM 1992)
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Biofeedback & neurofeedbackBiofeedback & neurofeedback
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MeditationMeditation
Meditation-Based Treatment Yielding Immediate Relief for Meditation-Naïve Migraineurs. ME Tonelli, et al. Pain Management Nursing. 2014
A single intervention 33% decrease in pain and a 43% decrease in emotional tension
Meditation for Migraines: A Pilot Randomized Controlled Trial. RE Wells, et al. Headache, 2014.10 meditated, 9 were controls;
Meditators had significant improvement in disability and other measures.
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Low brain magnesium in migraine
N.M. Ramadan, et al. Headache 1989.
Magnesium and Migraine
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IV MgSO4 for Acute MigraineIV MgSO4 for Acute Migraine
IMg2+
mmol/LIMg2+
mmol/L
0.58
0.56
0.54
0.52
0.50
0.48
0.46
0.44
0.42
0.58
0.56
0.54
0.52
0.50
0.48
0.46
0.44
0.42
xxxxxx oo
oooo
oo
xxxxxx
xxxxxxxx
xxxxxxxxxxxxxxxx
oooo
oooooooooooooooo
oooooooo
oooooo
x = non-respondersx = non-responders
o = responderso = responders
A. Mauskop et al, ClinScience 1995;89:633-6
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Magnesium and MigraineMagnesium and Migraine
Stress
Alcohol & caffeine
Genetics of absorption and renal excretion
Low dietary intake
Gastro-intestinal disorders (IBS, colitis, celiac)
Chronic illness
Potential causes of magnesium deficiencyPotential causes of magnesium deficiency
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NMDA receptorNMDA receptor
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Practical considerationsPractical considerations
Headaches
Leg muscle cramps
Coldness of extremities or body
PMS
Mental fog
Irritability, depression
Clinical symptoms of hypomagnesemia Clinical symptoms of hypomagnesemia
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Headache geneticsHeadache genetics
The effects of vitamin supplementation and MTHFR (C677T) genotype on homocysteine-lowering and migraine disability. Lea R, et al. Pharmacogenet Genomics. 2009.
Daily supplementation for 6 months with 2 mg of folic acid, 25 mg vitamin B6, and 400 mcg of vitamin B12 vs placebo.
1. Homocysteine – ↓ by 39%, p=0.0012. Prevalence of disability – ↓ from 60% to 30%, p=0.01 3. Headache frequency and pain severity ↓, p<0.051 and 2 were associated with MTHFRC677T genotype
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Alpha-lipoic acidAlpha-lipoic acid
A randomized double-blind placebo-controlled trial of thioctic acid in migraine prophylaxis Magis D et al. Headache 2007
44 patients; α-lipoic acid 600 mg vs placebo
50% responder rate for attack frequency – no difference
Improved: attack frequency, headache days, severity,
No adverse effects reported
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Coenzyme Q10Coenzyme Q10
Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraineHershey AD, et al. Headache 2007
1550 patients – 32.9% deficient Supplementation with 1-3 mg/kg/day CoQ10 levels improved, p<.0001 HA frequency improved from 19.2 to 12.5, p<.001 HA disability improved from 47.4 to 22.8, p<.001
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245 patients
Three groups: placebo, 100 mg & 150 mg
Attack frequency reduced by: 48% in 150 mg group, 36% in 100 mg, 26% in placebo
Petasites hybridus root (butterbur) is an effective preventive treatment for migraine.Lipton RB, Gobel H, Einhaupl KM, Wilks, K and Mauskop A.
Neurology 2004;63:2240-2244
Petasites hybridus root (butterbur) is an effective preventive treatment for migraine.Lipton RB, Gobel H, Einhaupl KM, Wilks, K and Mauskop A.
Neurology 2004;63:2240-2244
Butterbur (Petasites Hybridus)
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Boswellia serrataBoswellia serrata
Long-term efficacy of Boswellia serrata in 4 patients with chronic cluster headacheC. Lampl, et al. J Headache Pain. 2013
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Feverfew (Tanacetum Parthenium)Feverfew (Tanacetum Parthenium)
Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention – a randomized, double-blind, multicenter, placebo-controlled study.
Diener HC, et al. Cephalalgia 2005
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Botanical RemediesBotanical Remedies
Effect of peppermint and eucalyptus oil preparations on neurophysiological and experimental algesimetric headache parameters
Gobel H, al. Cephalagia 1994.
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ResultsResults
Analgesic effect
Muscle relaxing effect
Mentally relaxing effect
Combination of Peppermint Oiland EthanolCombination of Peppermint Oiland Ethanol
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“Music training may strengthen a child's brain for a lifetime”
Playing a musical instrument appears to have long-lasting brain benefits, particularly if a child starts practicing before age 7
“Music has the unique ability to go through alternative channels and connect different sections of the brain”
November 13, 2013Annual meeting of the Society for Neuroscience
Music and the brain
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Music therapyMusic therapy
Butterbur root extract and music therapy in the
prevention of childhood migraine: An explorative
study. Oelkers-Ax R et al. European Journal of Pain.
2008.
Butterbur (n=19) and music (n=20) groups did better
than placebo (n=19) at 6 months follow-up. Only music
group did better immediately after 12-week treatment
period
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Music therapyMusic therapy
Emotional valence contributes to music-induced
analgesia. Roy M, et al. Pain. 2008.
18 volunteers subjected to pleasant music,
unpleasant music and silent period;
Thermally-induced pain was reduced only by
pleasant music.
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Music therapyMusic therapy
Both happy and sad melodies modulate tonic human heat
pain. Zhao H, et al. The Journal of Pain. 2009.
20 volunteers subjected to: baseline pain tolerance,
pleasant sad music, pleasant happy music and, a lecture
Both happy and sad music resulted in significantly lower
pain ratings.
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Music therapyMusic therapy
Music modulation of pain perception and pain-related
activity in the brain, brain stem, and spinal cord: A
functional magnetic resonance imaging study. CE Dobek, et
al. The Journal of Pain. 2014.
Conclusion: Music modulates pain responses in the
brain, brain stem, and spinal cord, and neural activity
changes are consistent with engagement of the
descending analgesia system.
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AcupunctureAcupuncture
Acupuncture in routine care. Jena S, Melchart D et al. 15,056 patients with migraine and tension-type
headaches randomized to receive over three months
either:conventional treatment (1,569) or conventional treatment plus up to 15 acupuncture
treatments (1,613)the third group received acupuncture
Significant difference in QOL and in headache days per
month:
two acupuncture groups – drop from 8.4 to 4.7 days
control group – 8.1 to 7.5 days
Improvement persisted for subsequent 3 months
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Migraine:Symptomatic TreatmentMigraine:Symptomatic Treatment
PainIbuprofenNaproxenAcetaminophen
NauseaGingerSea-BandsZofran
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MigralexMigralex
A patented, rapidly dissolving combination of:
Aspirin – 500 mg
Magnesium oxide – 75 mg
A patented, rapidly dissolving combination of:
Aspirin – 500 mg
Magnesium oxide – 75 mg
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MigralexMigralex
The usual dose is two tablets
(Aspirin – 1,000 mg and magnesium oxide – 150 mg)
Both magnesium and aspirin relieve headaches
Magnesium reduces GI side effects of aspirin
Rapidly dissolving formulation
Works for migraine, menstrual, tension, stress, sinus,
allergy, neck-related, & hangover headaches
The usual dose is two tablets
(Aspirin – 1,000 mg and magnesium oxide – 150 mg)
Both magnesium and aspirin relieve headaches
Magnesium reduces GI side effects of aspirin
Rapidly dissolving formulation
Works for migraine, menstrual, tension, stress, sinus,
allergy, neck-related, & hangover headaches
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Prescription drugsPrescription drugs
Cafergot - ergotamine/caffeine
Migranol – dihydroergotamine nasal spray
Fioricet, Esgic – butalbital/caffeine/APAP
NSAIDs, COX-2
codeine, hydrocodone, oxycodone
Stadol NS – butorphanol nasal spray
Non-triptans
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Prescription drugsPrescription drugs
Imitrex (Treximet) – sumatriptan (+naproxen)
Zomig – zolmitriptan
Maxalt – rizatriptan
Amerge - naratriptan
Axert - almotriptan
Frova - frovatriptan
Relpax - eletriptan
TriptansTriptans
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Consider prevention when:Consider prevention when:
Migraine significantly interferes with patient’s daily
routine despite acute treatment
Frequency attacks >2/week with risk of acute
medication overuse
Contraindication to, failure, adverse events, or acute
medication overuse
Patient preference
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Preventive TreatmentPreventive Treatment
Choice is based on:
Patient’s preferences
Headache type
Drug side effects
Presence of coexisting conditions
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Preventive drugsPreventive drugs
-blockers: Inderal (propranolol)
Antidepressants: Elavil (amitriptyline) Cymbalta (duloxetine)
Epilepsy drugs: Depakote (divalproex) Topamax (topiramate)
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History of Botox usein migraineHistory of Botox usein migraine
Anecdotal reports of reduced migraines from
patients receiving BTX-A treatment for other
indications
A retrospective review of patient charts suggested
migraine relief was associated with certain injection
sites
This information was used in designing early clinical
studies
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Botox for chronic migraine:Phase III trialsBotox for chronic migraine:Phase III trials
Botulinum neurotoxin type A for treatment of chronic migraine
Aurora et al. Cephalalgia 2009
Botulinum neurotoxin type A for treatment of chronic migraine.
Dodick et al. Cephalalgia 2009
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Safety Summary Safety Summary
Botox was very well tolerated
All treatment-related adverse events were local and transient
Most common were
Headache
Neck pain
Ptosis (droopy eyelid)
Injection site weakness
Skin tightness
There were no serious treatment-related adverse events
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Peripheral nerve stimulationPeripheral nerve stimulation
Cefaly - TENS
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TMS for migraine TMS for migraine
Cerena TMS by eNeura Therapeutics
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Vagus nerve stimulationVagus nerve stimulation
Gammacore Acute treatment of up to 4 migraine
attacks Treatment consisted of two, 90-
second doses, at 15-minute intervals. Of 30 enrolled, 26 treated 79
migraines headaches. At 2 hours, 46 of 79 headaches (58%)
responded, and in 22 out of 79 (28%) pain was completely gone.
Of 26 patients 20 (77%) reported mild or nor pain at 2 hours, for at least one treated headache
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Approach to migraine patients at the NYHCApproach to migraine patients at the NYHC
aerobic exercise, neck exercise
biofeedback / neurofeedback / meditation
magnesium
CoQ10
dietary approaches
Botox
acupuncture
medications: abortive, prophylactic
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Case 1Case 1
Chief Complaint: Severe headaches.
History of Present Illness: 35-year-old woman,
headaches since age 15. Headaches: frontal and
periorbital, severe, pulsatile, with nasal congestion, at
times nausea, often with sensitivity to light, but not
noise; and made worse by light physical activity.
Occur once a month and last three days. No aura or
other neurological symptoms. She has been seeing an
ENT and takes decongestants, and at times antibiotics
or steroids with some relief; Sinus surgery suggested
by ENT, despite normal CT scan
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Case 1Case 1
Review of Organ Systems: anxiety, occasional insomnia
Past Medical History: negative
Social History: no tobacco use or alcohol abuse; married with 3 children; works full time
Family History: Positive for headaches.
Physical Examination: Normal
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Case 1Case 1
Assessment:
Migraine headaches (nasal congestion is not an uncommon occurrence in migraines)
Treatment:
Sumatriptan, 100 mg – excellent relief with disability score dropping from severe to none.
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Case 2Case 2
Chief Complaint: Severe headaches.
History of Present Illness: 40-year-old woman, headaches since age 8. Headaches: unilateral, severe, pulsatile, with nausea, sensitivity to light and noise, not made worse by light physical activity. Occur four times a week and last one day.
No aura or other neurological symptoms. Triggers: stress and menstrual cycle. Rx: Imitrex, 100 mg: good, but incomplete relief. Excedrin Migraine, 2-4 tablets almost daily
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Case 2Case 2
Review of Organ Systems: constipation, decline in memory, cold hands, PMS, back and neck pains.
Past Medical History: negative
Social History: no tobacco use or alcohol abuse, 4 cups of coffee; married with 2 children; works full time
Family History: Positive for headaches.
Physical Examination: Neck muscle spasm
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Case 2Case 2
Assessment:
Intractable chronic migraine headaches
Severe disability (MIDAS -22, over 20 - severe disability).
Excessive caffeine consumption - major contributor.
Presence of coldness of extremities and PMS suggestmagnesium deficiency
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Case 2Case 2
Plan: Stop all caffeine (coffee and Excedrin)Regular aerobic exerciseBiofeedback Magnesium oxide, 400 mg and CoQ10, 300 mg
For abortive therapy: rizatriptan (Maxalt), 10 mg PRN If ineffective, try other triptans with an NSAID.
If headaches persist consider:Botox injections or prophylactic medications
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Alexander Mauskop, MDNew York Headache Center [email protected]