Living with Living with HeadachesHeadaches

Bradford L Talcott, MD, PhDBradford L Talcott, MD, PhD

Common Headache Common Headache TypesTypes

What type of headache is this?What type of headache is this?

Acetaminophen does not helpMisses 1 day of work per monthMother had migraineDiagnosis???

26-year-old female with 26-year-old female with ten year history of ten year history of headacheheadache

Frequency: two per Frequency: two per month, each headache month, each headache lasts 24 hourslasts 24 hours

Bilateral temporal painBilateral temporal pain Throbbing, 9/10Throbbing, 9/10 Associated with nausea, Associated with nausea,

photophobia, photophobia, phonophobia, phonophobia, osmophobiaosmophobia

No vomiting or auraNo vomiting or aura Often goes into a dark Often goes into a dark

room and “sleeps it off”room and “sleeps it off”

Migraine without Migraine without AuraAura

What is this Headache?What is this Headache?

Four times a week she has an Four times a week she has an exacerbation of this continuous exacerbation of this continuous headache, rated 9/10headache, rated 9/10

Exacerbations are holocephalic, Exacerbations are holocephalic, throbbing, last 24 hours, and are throbbing, last 24 hours, and are associated with nausea, associated with nausea, phonophobia, osmophobia, and phonophobia, osmophobia, and increased photophobiaincreased photophobia

Currently taking six Excedrin Currently taking six Excedrin Migraine tablets per dayMigraine tablets per day

Diagnosis???Diagnosis???

A 36-year-old female presents with A 36-year-old female presents with worsening headacheworsening headache

Her headaches started at age 26, Her headaches started at age 26, initially occurred twice per month, initially occurred twice per month, associated with associated with N/V/photophobia/phonophobiaN/V/photophobia/phonophobia

Headache frequency has gradually Headache frequency has gradually increased over the last year, increased over the last year, associated with an increased use of associated with an increased use of Excedrin Migraine (acetaminophen, Excedrin Migraine (acetaminophen, aspirin, caffeine)aspirin, caffeine)

She has had a constant, She has had a constant, background, holocephalic, non-background, holocephalic, non-throbbing headache associated with throbbing headache associated with continuous photophobia for three continuous photophobia for three months, rated 6/10months, rated 6/10

Chronic Daily HAChronic Daily HA(Transformed migraine)(Transformed migraine)

ANDANDMedication overuse headacheMedication overuse headache

(Rebound Headache)(Rebound Headache)

What is this Headache?What is this Headache?

A 32-year-old male presents with A 32-year-old male presents with worsening headacheworsening headache

He has had headaches since 23, they He has had headaches since 23, they have always been under and around have always been under and around eyeseyes

He has a history of sinus troubleHe has a history of sinus trouble Headaches are associated with Headaches are associated with

photophobia/osmophobia/occasional photophobia/osmophobia/occasional loss of appetiteloss of appetite

Pain is a dull pulsing painPain is a dull pulsing pain Denies history of recent fevers, nasal Denies history of recent fevers, nasal

discharge or bleedingdischarge or bleeding Diagnosis???Diagnosis???

MigraineMigraine

Migraine vs. Sinus headacheMigraine vs. Sinus headache

Studies show that about 85% of people Studies show that about 85% of people with self described sinus headaches with self described sinus headaches actually have migraine headachesactually have migraine headaches

Sinus problems, like many other things Sinus problems, like many other things trigger migraine headachestrigger migraine headaches

Bottom line– the majority of headaches Bottom line– the majority of headaches severe enough to cause a person to severe enough to cause a person to seek medical attention are Migrainesseek medical attention are Migraines

More than you ever More than you ever wanted to know about wanted to know about

MigrainesMigraines

Migraine Burden in U.S.

Migraineur in one in four householdsMigraineur in one in four households 28 million migraineurs in the US28 million migraineurs in the US Estimated annual cost of labor lost to Estimated annual cost of labor lost to

migraine greater than $ 13 billion per yearmigraine greater than $ 13 billion per year Peak prevalence ages 25-55 Peak prevalence ages 25-55 Often ineffectively treatedOften ineffectively treated

Migraine Prevalence in U.S.

Headache 2001;41:646-657Headache 2001;41:646-657

18.2 % Women6.5% Men

Migraine Age-Specific Prevalence in U.S.

Headache 2001;41:646-657Headache 2001;41:646-657

Phases of MigraineMigraine are more than just pain

Migraine TriggersMigraine Triggers Missing a meal or dehydrationMissing a meal or dehydration Sleep (too little or too much)Sleep (too little or too much) CaffeineCaffeine StressStress Weather/Barometric Pressure ChangesWeather/Barometric Pressure Changes Menses/ Hormonal changesMenses/ Hormonal changes FatigueFatigue Exposure to environment (light, sound, smells)Exposure to environment (light, sound, smells) Head traumaHead trauma Dietary triggers (Chocolate, nitrates, MSG, Aged Dietary triggers (Chocolate, nitrates, MSG, Aged

cheeses, Alcohol , Nuts, Processed meats, Citrus)cheeses, Alcohol , Nuts, Processed meats, Citrus)

Migraine PathophysiologyMigraine Pathophysiology

Goadsby PJ et al. N Engl J Med. 2002.

• Migraines are triggered by internal (dehydration, lack of sleep, stress) or external stimuli (smell, light, food)• Deep nuclei in the brainstem begin to malfunction (trigeminal nucleus and Magnus raphe nucleus) • Energy failure allows the nerves surrounding vascular structures in the brain (which are part of the trigeminal nerve) to propagate the problem and malfunction (throbbing pain)• These malfunctioning nerves trigger thalamic dysfunction (nausea, severe pain)

Migraine Genes

Migraines are a Genetic conditionMigraines are a Genetic condition- 3 genes discovered in past year3 genes discovered in past year

- EAAT2 affects glutamate removal from EAAT2 affects glutamate removal from synapsesynapse

- TRSK is a potassium channel in nervesTRSK is a potassium channel in nerves

–Gene discoveries support the concept Gene discoveries support the concept that migraine is caused by nerves that are that migraine is caused by nerves that are hypersensitive hypersensitive

Treatment of Migraines:Treatment of Migraines:A brief history of natural and A brief history of natural and

homoeopathic homoeopathic time-honored therapiestime-honored therapies

TreatmentTreatment

Aretaeus A.D. 81?Aretaeus A.D. 81?

For the treatment of For the treatment of headache, Aretaeus headache, Aretaeus recommended inducing recommended inducing sneezing by placing testicle sneezing by placing testicle of beaver powder intranasally of beaver powder intranasally to “bring off phlegm” to “bring off phlegm”

940-1010 AD940-1010 AD

“For the effective treatment of long-standing headache the patient may bind over his head a mole long dead and putrid”

Willis 1685Willis 1685

““the use of Millepedes ought not the use of Millepedes ought not here to be omitted, or set lightly here to be omitted, or set lightly by, in regard that their express’d by, in regard that their express’d Juice, distill’d Water, and also Juice, distill’d Water, and also the Powder prepar’d of them, the Powder prepar’d of them, often contribute egregiously to often contribute egregiously to the Cure of ancient and the Cure of ancient and obstinate Head-achs.” obstinate Head-achs.”

Other Interesting Headache Other Interesting Headache TreatmentsTreatments

Drilling a whole in the skullDrilling a whole in the skull BloodlettingBloodletting Placing a hot iron on the headPlacing a hot iron on the head Spinning a patient in a centrifugeSpinning a patient in a centrifuge

Historical Figures with Historical Figures with MigrainesMigraines

Thomas JeffersonThomas Jefferson Joan of ArcJoan of Arc Vincent Van GoghVincent Van Gogh Julius CaesarJulius Caesar Ulysses S GrantUlysses S Grant Sigmund FreudSigmund Freud

Headache Treatment: Headache Treatment: A More Modern ApproachA More Modern Approach

Five Principles of Five Principles of Migraine ManagementMigraine Management

Treat occipital neuralgia and Treat occipital neuralgia and trigeminal nerve dysfunctiontrigeminal nerve dysfunction

Avoid Rebound headacheAvoid Rebound headache Abortive therapyAbortive therapy Preventative therapyPreventative therapy Lifestyle IssuesLifestyle Issues

Treat Occipital NeuralgiaTreat Occipital Neuralgia

Trigeminal NerveTrigeminal Nerve

Avoid Rebound HeadacheAvoid Rebound Headache(medication overuse headache) (medication overuse headache) In general if acute meds are used more the 3 days In general if acute meds are used more the 3 days

per week they will cause rebound headache. per week they will cause rebound headache. This HA is usually a dull constant HAThis HA is usually a dull constant HA Treatment: Tough love- stop taking meds Treatment: Tough love- stop taking meds

completelycompletely Things might get worse for 2 weeks but then will Things might get worse for 2 weeks but then will

improveimprove The worst offenders: Narcotics, Excedrin, Fioricet, The worst offenders: Narcotics, Excedrin, Fioricet,

butalbital containing medsbutalbital containing meds This may also keep headache preventive This may also keep headache preventive

medications from working well.medications from working well.

Acute (abortive) migraine Acute (abortive) migraine treatment principlestreatment principles

Treat early, while headache is buildingTreat early, while headache is building Use correct dose and formulationUse correct dose and formulation Limit to 3 days per week (with exceptions)Limit to 3 days per week (with exceptions) Try drug with at least 2 headaches to see if it Try drug with at least 2 headaches to see if it

works before moving on to another agentworks before moving on to another agent Use drug combinations often work when a Use drug combinations often work when a

single agent won’t worksingle agent won’t work

Acute treatment optionsAcute treatment options

NonspecificNonspecific

– NSAIDsNSAIDs

– simple analgesicssimple analgesics

– combination analgesicscombination analgesics

– Anti-Nausea medsAnti-Nausea meds

SpecificSpecific

– Triptans, e.g., Triptans, e.g., Imitrex, Maxalt, Imitrex, Maxalt, Zomig, Relpax, Zomig, Relpax, ectect

– Ergotamine/DHE; Ergotamine/DHE; MigranolMigranol

Rational polytherapyRational polytherapy

NSAID plus TriptanNSAID plus Triptan Antiemetic (metoclopramide 10 mg) Antiemetic (metoclopramide 10 mg)

plus NSAID (Naproxen sodium 550 mg)plus NSAID (Naproxen sodium 550 mg) Antiemetic plus triptanAntiemetic plus triptan Antiemetic plus NSAID plus triptanAntiemetic plus NSAID plus triptan

Preventive med principlesPreventive med principles

No set rule on when to use, but consider No set rule on when to use, but consider use when severe headache occurs once a use when severe headache occurs once a weekweek

In order for preventive meds to be most In order for preventive meds to be most effective, limit acute meds to 3 days per effective, limit acute meds to 3 days per weekweek

Make sure to use an appropriate doseMake sure to use an appropriate dose At least a 2 month trial at a proper dose is At least a 2 month trial at a proper dose is

requiredrequired Goal is to decrease headache freq by 50%Goal is to decrease headache freq by 50%

Preventive med principlesPreventive med principles

Prepare for side effects first, benefit Prepare for side effects first, benefit laterlater

Reliable birth controlReliable birth control Keep trying until you find one that Keep trying until you find one that

worksworks Preventives are not always lifelong Preventives are not always lifelong

treatments-can be tapered off after treatments-can be tapered off after several months when frequency of several months when frequency of headache decreasesheadache decreases

Natural PreventativesNatural Preventatives

ButterBurr Root (be careful of source)ButterBurr Root (be careful of source) FeverfewFeverfew Magnesium Magnesium Alpha-linolenic acid and Gamma-linolenic acid Alpha-linolenic acid and Gamma-linolenic acid Vitamin D, E, B12, B2Vitamin D, E, B12, B2 alpha lipoic acid alpha lipoic acid L-CarnatineL-Carnatine Fish oil Fish oil Co Q10Co Q10

The preventive alphabetThe preventive alphabet

AAntidepressants: nortriptyline, ntidepressants: nortriptyline, amitriptyline, Cymbaltaamitriptyline, Cymbalta

BB-blockers: propranolol, atenolol, -blockers: propranolol, atenolol, nadololnadolol

CCalcium channel blockers: verapamilalcium channel blockers: verapamil DDepakote (valproic acid)epakote (valproic acid) EEpilepsy meds (other than Depakote): pilepsy meds (other than Depakote):

gabapentin, topiramate, Lyricagabapentin, topiramate, Lyrica Misc: tizanidine, NamendaMisc: tizanidine, Namenda

Botox TreatmentBotox Treatment

Botox Injections- Approved by FDA in Botox Injections- Approved by FDA in Oct 2010!Oct 2010!

Approved for chronic migraine Approved for chronic migraine (migraine headaches happening more (migraine headaches happening more than 15 days/ month)than 15 days/ month)

32 injection sites in forehead, temples, 32 injection sites in forehead, temples, shoulders and neckshoulders and neck

Many insurance companies are still Many insurance companies are still fighting not to cover thisfighting not to cover this

Lifestyle ManagementLifestyle Management Sleep 8 hours consistent scheduleSleep 8 hours consistent schedule Eat 3 regular meals (or more) per dayEat 3 regular meals (or more) per day Drink lots of fluidsDrink lots of fluids Get Aerobic exercise regularlyGet Aerobic exercise regularly Limit caffeine (or better yet avoid completely)Limit caffeine (or better yet avoid completely) Identify Identify youryour triggers triggers Keep a headache diaryKeep a headache diary Manage stressManage stress Use correct posture and pause during Use correct posture and pause during

repetitive activitiesrepetitive activities

Nonpharmacologic TreatmentsNonpharmacologic Treatments

BiofeedbackBiofeedback Relaxation therapyRelaxation therapy Cognitive Behavioral TherapyCognitive Behavioral Therapy AcupressureAcupressure AcupunctureAcupuncture Physical TherapyPhysical Therapy Chiropractic treatmentChiropractic treatment

Additional Treatment Additional Treatment MeasuresMeasures

Occipital Nerve StimulatorsOccipital Nerve Stimulators TENS unitsTENS units Transcranial Magnetic StimulatorTranscranial Magnetic Stimulator Special DietsSpecial Diets

Transcranial Magnetic Transcranial Magnetic Stimulator (TMS)Stimulator (TMS)

Graham’s rulesGraham’s rules There is no magic medicine that “cures” There is no magic medicine that “cures”

migrainemigraine The patient is not to “blame” for having The patient is not to “blame” for having

inherited the migraine traitinherited the migraine trait The pain of the migraine attack is very The pain of the migraine attack is very

real and not “imaginary”real and not “imaginary” Getting Headaches under control Getting Headaches under control

sometimes requires a considerable sometimes requires a considerable period of timeperiod of time

There is definite hope for improvement There is definite hope for improvement through conscientious effort by both through conscientious effort by both patient and physician, but that complete patient and physician, but that complete freedom from migraine is rarely achieved freedom from migraine is rarely achieved by any therapeutic programby any therapeutic program

•Graham, Treatment of Migraine, 1955

Questions?Questions?