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Migraine Headaches. Jim Ducharme MD CM FRCP Professor, Emergency Medicine Dalhousie University. A 34 year-old woman arrives with 24 hours of pulsating frontal headache. She has vomited twice, and wants the lights off. What questions do you want answered?. Previous headache history

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migraine headaches

Migraine Headaches

Jim Ducharme MD CM FRCP

Professor, Emergency Medicine

Dalhousie University

slide2

A 34 year-old woman arrives with 24 hours of

pulsating frontal headache. She has vomited twice,

and wants the lights off.

What questions do you want answered?

slide3
Previous headache history
  • Onset of headache
  • Analgesic use
  • Any identified trigger
  • Allergies/Medication intolerance
risk factors suggesting a serious underlying cause of headache
Risk factors suggesting a serious underlying cause of headache
  • First or worst headache, especially if abrupt onset
  • Change in pattern of normal headaches
  • New progressive persistent headache

CMAJ 1997

risk factors suggesting a serious underlying cause of headache5
Risk factors suggesting a serious underlying cause of headache
  • Headache brought on by Valsalva
  • Accompanying systemic symptoms:
    • myalgia, fever, malaise, weight loss, jaw claudication, tender scalp
  • Focal neurological signs or symptoms
  • Altered mental status

CMAJ 1997

i h s diagnostic criteria
I.H.S. Diagnostic Criteria
  • Migraine without aura
    • > 5 episodes
    • Duration 4-72 hours
    • 2/4 of: increase with activity, moderate to severe intensity, pulsatile at some point, visual complaints
    • 1 of 2 of: photo/phonophobia, nausea/vomiting
    • Normal exam
slide8

Her physical exam is normal other than her obvious

pain. You would like to treat her headache. What

therapeutic endpoints do you establish before starting:

  • complete headache abolition?
  • reduction of her headache to a mild level?
  • avoidance of significant adverse effects?
  • avoidance of headache recurrence?
pathophysiology
Pathophysiology
  • Aura
    • Spreading cortical depression, not ischemia
  • Brainstem
    • Migraine “generator” in dorsal raphe, locus ceruleus and periaqueductal gray matter
    • PET scans show increased blood flow, even after cessation of headache
pathophysiology10
Pathophysiology
  • Genetic predisposition
    • Deficient habituation during repetitive stimulation
    • Allows for surpassing or modification of threshold for migraine
      • External: prophylaxis, psychosocial
      • Internal: estrogen, stress response, foods
pathophysiology11
Pathophysiology
  • Threshold surpassed:
    • Brainstem “generator” liberates CGRP
    • Activation of trigeminovascular system
  • CGRP also elevated with pulsating chronic tension-type headaches
pathophysiology12
Pathophysiology
  • Nitric oxide
    • Vasodilator
    • Promotes central sensitization of trigeminal nociceptors
    • Sumatriptan decreases NO release in addition to inhibiting CGRP release
pathophysiology13
Pathophysiology
  • Trigeminal Stimulation
    • Ca channel activation: substance P release
    • Feedback to DRG: NMDA & AMPA release, leading to wind up
    • Release of prostaglandins, kinins that induce perivascular inflammation
    • NO and CGRP further capillary leakage
pathophysiology14
Pathophysiology
  • Potentials for future abortive treatment:
    • Antagonists of: CGRP, NO, Glutamate
    • Agonists of adenosine A1 receptors
slide15

Yeah, yeah and the moon is actually made of

Gruyère not Emmental….. My patient still has

her headache, so what do I give her?

effective abortive agents
Effective Abortive Agents
  • Triptans
  • Dihydroergotamine
  • NSAIDs
  • Anti-emetics
  • Lidocaine?
  • Opioids?
triptans
Triptans
  • 5-HT1B action: vasoconstriction by acting against NO
  • 5-HT1D action: inhibit CGRP release
  • Should be very effective, yet only 70-80% effective, with 50% headache recurrence.
    • Cardiac risk, side effects further limit use
triptans18
Triptans
  • PO versions require 60-90 minutes to effect
  • 50% success rate PO vs. 75-80% s/c
  • Newer triptans offer no real advantage over original
  • Subset of patients do respond well to this abortive agent in home setting
dihydroergotamine
Dihydroergotamine
  • Same 5-HT action, but slower binding
    • Impact of IM may require 2 hours
    • Nasal version requires up to 4 hours
  • If given IV may initially increase CGRP release, producing dramatic headache increase
  • Does not increase N&V
  • Most initial research success probably due to adjunctive anti-emetics
nsaids
NSAIDs
  • Excellent for mild to moderate migraines
  • No effect on neurotransmitters
  • Direct inhibition of most perivascular inflammation
  • Ketorolac at best 50-60% success as abortive for severe migraines
dopamine antagonists
Dopamine Antagonists
  • Phenothiazines
  • Butyrophenones
  • Metoclopramide
dopamine antagonists22
Dopamine Antagonists
  • High adverse event rate
    • Need to treat prophylactically: benztropine, lorazepam, diphenhydramine
  • Low headache recurrence rate
  • Only droperidol as effective IM as IV
  • Dysphoria cannot be treated, found to be horrible by some patients
lidocaine
Lidocaine
  • Intranasal lidocaine found effective in two studies, but of very short duration, 70% headache recurrence
  • Mechanism of action uncertain as blocks Na+ channels not Ca++ ones
opioids
Opioids
  • At best 50% effective, high recurrence rate
  • Often required in combination for complex cases
  • Biggest effect: allows patient to enter REM sleep, which shuts down dorsal raphe activity
slide26

Prochlorperazine 5 mg IV plus 1 mg benztropine

  • Droperidol 2.5 mg IM or IV plus benztropine
  • Sumatriptan 6 mg s/c
analgesia induced rebound headaches
Analgesia-induced rebound headaches
  • Obtain good headache medication history
  • May occur with simple analgesics or with opioids
  • If cessation of medication may take 3 months to return to baseline headache frequency
  • DHE IV q8h x 2-3 days resolves problem
migraine headache recurrence
Migraine: headache recurrence
  • First identified 1989
  • As high as 50-60% at 24 hours in some trials
  • Often as debilitating as original headache
  • Need to distinguish from analgesia rebound headache
preventing recurrence
Preventing recurrence
  • Innes et al: dexamethasone IV
  • Ducharme et al: complete elimination of pain before discharge
  • Choice of abortive agent
    • serotonin agonists have highest recurrence rate
preventing future headaches
Preventing Future Headaches
  • Headache diary: identifying triggers
  • Prophylaxis
    • Diet
    • Exercise
    • Sleep
    • Stress modification
preventing future headaches31
Preventing Future Headaches
  • Medications:
    • Valproate: 45% patients more than placebo with 50% decrease in headache rate
    • Beta Blockers: 40%
    • Flunarazine: 42%
    • Pizotifen: 20%
    • Riboflavin: 37%
slide32

Your patient is pain free, leaves your

ED with a smile, and you finish your shift

….

…..

With a throbbing headache of your own!

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