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Understanding Headaches. Grace Forde, M.D Assistant Professor of Neurology New York University Director of Neurological Services North Shore Pain Service. Migraine Epidemiology. Go Back to Main Menu. Migraine Prevalence.

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Understanding Headaches

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Understanding headaches l.jpg

Understanding Headaches

Grace Forde, M.D

Assistant Professor of Neurology

New York University

Director of Neurological Services

North Shore Pain Service

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Migraine Epidemiology

Go Back to Main Menu

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Migraine Prevalence

  • Approximately 26 million patients with migraine in the United States (> age 18)

  • One in 4 households has at least 1 migraine sufferer

Lipton RB, et al. Neurology. 2007; 68(5):343-349.

National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.

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Migraine Prevalence:Age and Gender

Migraine prevalence peaks in the 25-55 age range

Lipton RB, et al. Neurology. 2007;68(5):343-349.

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Migraine Economic Impact, Productivity, and Quality of Life

Go Back to Main Menu

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Economic Burden of Migraine in US

  • Lost productivity is the greatest contributor to migraine economic burden

  • Productivity losses cost US employers up to $13 billion annually

  • Direct costs of migraine per patient range from ~$500-$7000/year

  • Total medical costs in households with at least 1 member with migraine are 70% higher than families without a member with migraine

Hu XH et al. Arch Int Med. 1999;159(8):813-818.

Hawkins K et al. J Occup Environ Med. 2007;49(4):368-374.

Edmeads J and Mackell JA. Headache. 2002;42(6):501-509.

Stewart WF et al. JAMA. 2003;290(18):2443-2454.

Osterhaus JT et al. Pharmacoeconomics. 1992;2(1):67-76.

Etemad LR, et al. JMCP. 2005;11(2):137–44.

Pesa J and Lage MJ. Headache. 2004;44(6):562–70.

Lafata JE, et al. J Gen Intern Med. 2004;19(10):1005–12.

Hawkins K, et al. Value Health. 2006;9:A85.

Stang PE, et al. Am J Manag Care. 2004;10(5):313–20.

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Timing and Impact of Migraine

58% of Migraines Occurred During Typical Work Hours*

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.

*N=200 Full-Time Employees

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Impact of Migraine: Productivity

74% of Patients With Migraine* Reported Productivity Levels Below 80%

Productivity Levels

*N=157 Full-time employees

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.

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Migraine Diagnosis and Treatment

Go Back to Main Menu

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Any 2 of these pain qualities:

Any 1 of these associated symptoms:

  • unilateral pain

  • throbbing pain

  • pain worsened by movement

  • moderate or severe pain

  • nausea

  • vomiting

  • photophobia and phonophobia


International Headache Society Criteria for Migraine

Migraine Is an Episodic Recurrent Headache Lasting 4-72 Hours with:

Features such as osmophobia and posterior head and neck pain can also be present in a headache that meets IHS criteria for migraine.

Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

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Many Migraine Sufferers Remain Undiagnosed


Diagnosed Migraine


Undiagnosed Migraine

Diamond S et al. Headache. 2007;47(3):355-363.

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Patients with Recurrent Headache May Meet Criteria for Migraine

87% of patients presenting to PCP with recurrent headache

met IHS criteria for migraine

Episodic Tension-type Headache (n=1)0.4%

Other (n=3)1%

Probable Migraine (n=31)




Tepper SJ et al. Headache. 2004;44(9):856-864.

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Focusing on Migraine Diagnosis

  • Opportunities for accurate diagnosis of migraine patients still exist:

    • 80% of “sinus headache” patients met IHS criteria for migraine

    • 85% of “tension/stress” headache patients met IHS criteria for migraine

Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.

Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

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Phases of a Migraine Attack

Treatment Phase








Moderate to Severe


Migraine symptoms

occurring hours/days after headache resolution

Focal neurological symptoms preceding headache

(<1 hour)

Migraine symptoms

occurring hours/days prior

to headache

Migraine when headache is moderate to severe

Migraine when headache is mild

Migraine Intensity

  • Symptoms:

  • Sensitivity to light

  • Sensitivity to sound

  • Nausea

  • Pain in the back of the head and neck

  • Symptoms:

  • Same as mild but more intense

  • Symptoms:

  • Flashing lights or wavy lines

  • Numbness

  • Tingling in face

  • Disturbed senses

  • Symptoms:

  • Tiredness

  • Confusion

  • Lowered appetite

  • Stiff or sore muscles

  • Symptoms :

  • Food cravings

  • Mood changes

  • Yawning

  • Fatigue


Adapted from Cady RK.Headache. 2008;48(9):1415-1416.

Headache Classification Subcommittee of the International Headache Society. Cephalalgia. 2004;24(suppl 1):117-118.

Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone. 1999;1(6):21-32.

National Institutes of Health. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/headache/detail_headache.htm.

Accessed December 7, 2009.

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Food and food additives

Bright lights/glare



Loud noises/sounds

Changes in altitude/air travel


Weather changes


Alcoholic beverages

Changes in sleep habits

Hormonal fluctuations/ menstrual cycle

Possible Triggers of a Migraine Attack

Wober C et al. J Headache Pain.2006;7(4):188-195.

Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.

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Preventative Medications

May prevent or reduce the number of migraine attacks

Typically taken on a daily basis



Beta blockers

Calcium channel blockers

Acute Medications

May work quickly to relieve migraine pain and other symptoms

Usually taken during a migraine attack




Analgesics (Rx and OTC)





Medication Options Available for Migraine

Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.

Silberstein SD. Neurol Clin. 2009;27(2):429-443.

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Differences in Patients with Migraine

  • Migraine patient’s brain is in a state of hyperexcitability

    • Reduced threshold for stimuli

    • Everyday things can trigger a migraine attack

  • Migraine patient’s gut is slowed

    • Gastric stasis is common and can delay tablet absorption

    • Conventional tablets rely on surface erosion and gastric motility for dissolution in the stomach, which must occur before being absorbed

Hargreaves RJ and Shepheard SL.Can J Neurol Sci. 1999;26(suppl 3):S12-S19.

Aurora S et al. Headache. 2006;46(1):57-63.

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The Triptans

  • Sumatriptan

  • Zolmatriptan

  • Naratriptan

  • Rizatriptan

  • Almotriptan

  • Frovatriptan

  • Eletriptan

  • Sumatriptan and Naproxen sodium

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Triptan Prescribing Information:Contraindications and Precautions for ALL Triptans

  • Ischemic cardiac disease

  • Cerebrovascular disease

  • Uncontrolled hypertension

  • Hypersensitivity

  • Use within 24 hours of other 5-HTs/ergots

  • Hemiplegic/basilar migraine

  • History of risk factors for CAD

  • SSRI precaution

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Case Scenario 2

  • 29-year-old single woman, sales clerk; history of 8-9 migraines / month lasting for 12-14 hours, frequent recurrence

  • HA associated with nausea and sensitivity to light and sound

  • Currently taking an oral triptan tablet

  • Says that current treatment takes too long to act and does not fully relieve headache pain

  • Looking for a way to prevent attacks

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β-adrenergic blockers



Calcium channel antagonists

Serotonin antagonists


Botulinum toxin A*

coenzyme Q10





Preventive Medication Groups

*Approved by FDA for this use.

SSRI = selective serotonin reuptake inhibitor

TCA = tricyclic antidepressant

  • Silberstein SD. Lancet. 2004;363:381-391.

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Nonpharmacologic Therapies Tested in Clinical Trials

  • Behavioral Treatments

  • Relaxation training*

    • Hypnotherapy

    • Thermal biofeedback training*

    • Electromyographic biofeedback therapy*

    • Cognitive / behavioral management therapy*

Physical Treatments


Transcutaneous electrical nerve stimulation (TENS)

Occlusal adjustment

Cervical manipulation

*Proven effective in clinical trials

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

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Case Scenario #3

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Migraine Is Often Overlooked

Sinus headache is the most common misdiagnosis

  • Sinus pain caused by inflammation induced allergens or by infection occurs when exudate in inflamed, blocked sinuses exerts pressure that stimulates local trigeminal nerve fibers

  • Chronic sinusitis is not validated as a cause of headache unless it relapses into an acute stage

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Major factors

Purulence in nasal cavity on exam

Facial pain/pressure/congestion**

Nasal obstruction/blockage/ discharge

Fever (in acute only)


Minor factors


Fever (chronic)



Dental pain


Ear pain/pressure/fullness

Headache: A Minor Criteria in AAO-HNS Sinusitis

Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*

** Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign.

* American Academy of Otolaryngology-Head and Neck Surgery

Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.

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Sinus Features May Hide the Presence of Migraine

Headache Symptoms at Screen Among IHS Diagnosed Migraineurs












IHS Migraine Symptom Criteria

Sinus Like Features




% of Subjects

Schreiber et al. Poster Presented at: American Headache Society Meeting; June 21-23, 2002: Seattle, WA.

Data on file, GlaxoSmithKline.

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Why do so many Americans think they have Sinus Headache?

  • In his 1988 review, “Sinus Headache: A Neurologist’s Viewpoint,” Couch writes:

    • In my experience and in that of others, “sinus headache,” as reported by patients, is a popular conception that is often erroneous. Patients reason that, since the sinuses are close to the eyes (as depicted in advertisements in popular magazines), headaches located in the frontal, supraorbital, or infraorbital region are sinus headaches… [These] headaches frequently are associated with some gastrointestinal symptomatology, photophobia, and phonophobia, and may have some visual or neurologic symptoms. In short, these “sinus headaches” are usually migraine headaches, most often of the common migraine type.

Couch, J. Seminars in Neurology. 1988;8(4):298-302.

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Migraine Is Often Overlooked (cont’d)

  • Tension headache is another common misdiagnosis

  • Symptoms include

    • Dull steady ache

    • Physical activity does not worsen pain

    • Nausea, photo/phonophobia are not usually present

    • Vomiting never present

    • Patients have likely tried OTCs and failed

Cady et al. Headache Free. 1993;36-38.

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Migraine Pain Can Be Felt in Peripheral Locations Such as the Neck

  • In Kaniecki’s study of 144 patients with migraine

  • 75% reported neck pain with their migraine

  • 43% described neck pain as bilateral and 57% as unilateral

  • 69% described the neck pain as “tightness” and 17% as stiffness”


reported neck pain with their migraine

Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.

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Activation of the TNC May Result in Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Network

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Case Scenario 5

  • 26-year-old man, computer programmer, married with 2 children

  • Has severe, stabbing pain behind his right eye

  • Headaches are accompanied by lacrimation and nasal congestion

  • Pain lasts 30 to 45 minutes; attacks occur daily for several weeks, then stop for months at a time

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Treatment of Hypnic Headach

  • Lithium Carbonate (200-600mg)

  • Indomethacin

  • Verapamil (160my QHS)

  • Methysergide

  • Caffeine (60mg)

  • Lamotrigene

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