YOUR DIFFICULT PATIENT WITH RECURRENT SPELLS HAS MIGRAINE

1. David Lee Gordon, M.D., FAAN, FANA, FAHA Professor and Chair Department of Neurology The University of Oklahoma Health Sciences Center YOUR DIFFICULT PATIENT WITH RECURRENT SPELLS HAS MIGRAINE

2. DLG DISCLOSURES • FINANCIAL DISCLOSURE • I have nothing to disclose • UNLABELED/UNAPPROVED USES DISCLOSURE • I have nothing to disclose

3. MIGRAINE & RECURRENT SPELLSLEARNING OBJECTIVES • Relate a practical definition of migraine • Determine when the following symptoms are due to migraine: • Abdominal pain Confusion • Chest pain  Hemiparesis • Vertigo  Aphasia • Syncope  Headache • Name the three overarching considerations when prescribing migraine therapy • Describe the appropriate abortive and prophylactic therapies for migraine

4. CASE 1: PRESENTATION • 58-year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain • Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy • One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab • Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam

5. CASE 2: PRESENTATION • 28-year-old tearful woman with “pain all over,” unable to move L side due to pain and with bilateral blurred vision • Six weeks ago, had difficulty holding objects in L hand, then noted “waves of pain” in both shoulders radiating over minutes into both hands, L > R, followed by a lightning sensation into L thigh, radiating into L toes • Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month • One month ago, symptoms became constant without relief from daily Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid • Lost nursing job 3 weeks ago when she became bedbound with daily vertigo and occipital headache radiating to R temple & eye • For last week, severe R chest pain (R anterior axilla to upper back) • For last few days, blurred vision in both eyes, initially intermittent, then constant • For one day, nausea and vomiting

6. CASE 3: PRESENTATION • 80-year-old distraught man with intractable, intermittent, 12-hour episodes of vertigo, diplopia, ataxia, nausea, and vomiting occurring every 5-6 days that left him disabled and housebound • MRI brain normal • Symptoms became constant several months ago despite taking daily Voltaren, Protonix, and Zofran • Famous quaternary referral center #1 – no diagnosis • Famous quaternary referral center #2 – progressive, degenerative disease • On exam, he had gait ataxia

7. MIGRAINE: WHAT IT IS NOTMIGRAINE DOES NOT MEAN HEADACHE “Headache is never the sole symptom of migraine, nor indeed is it a necessary feature of migraine attacks.” Oliver Sacks, Migraine, Revised & Expanded, 1992 A book intended for laypersons with multiple descriptions of the varied symptoms (“phenomenology”) of migraine. Heavy reading, but very informative. Oliver Sacks also wrote the book Awakenings, later turned into a movie in which Robin Williams played the role of Oliver Sacks

8. HEADACHE VS. MIGRAINE:SYMPTOM VS. SYNDROME • Headache • Pain in the head • Migraine • A syndrome of episodic brain dysfunction with systemic manifestations (that may include headache) Migraine is by far the most common cause of recurrent, episodic headache without sequelae, but… migraine with NO headache is also very common.

9. MIGRAINE: WHAT IT ISPRACTICAL DEFINITION & DESCRIPTION Genetic condition in which a person has a predispositionto suffering recurrent transient episodes (attacks) of brain dysfunctionwith systemic manifestationsthat may include: • headache/neck pain – from mild to severe, variable location • focal neurologic symptoms – mimics stroke/TIA • GI symptoms (upper or lower) – equals IBS, mimics gallstones • chest pain – mimics heart attack, equals atypical noncardiac CP • autonomic dysfunction – BP, pulse, sinus congestion, etc. “triggered”by hormonal or environmental changes or other medical conditions, and consisting of 4 possible phases(prodrome, aura, pain, postdrome).

10. MIGRAINE TRIGGERS • Hormonal changes • Stress (esp. stress “letdown”), exercise, thyroid • Estrogen (menarche, pregnancy, hormonal contraceptives, menopause) • Environmental changes or exposures • Weather (barometric pressure), motion • Scents, smoke, fumes • Sleep changes • Deficiency or excess, change in shift • Diet changes • Hunger • Alcohol (all types, but esp. red wine) • Artificial foods (nitrates, MSG, sulfites, aspartame, sucralose) • Dehydration • Medical conditions • Head trauma, fever • Cerebral blood flow changes (AVM, endarterectomy/angioplasty)

11. Prodrome • Aura • Pain • Postdrome MIGRAINE PHASES:PRODROME/PREMONITORY* • Mood changes • Irritability, depression, euphoria/hyperactivity • Difficulty concentrating • Stiff neck • Fatigue, malaise, yawning • Autonomic/GI symptoms • constipation, diarrhea, urinary frequency • Anorexia or food cravings • esp. foods that increase serum serotonin and/or magnesium, e.g., chocolate, bananas, nuts, peanut butter, sweets, fatty foods *ICHD-3 suggests elimination of the term “prodrome” & substituting “premonitory” instead May begin hours to days before attack, persist through all 4 phases— likely related to serotonin, magnesium, hypothalamic changes

12. Prodrome • Aura • Pain • Postdrome MIGRAINE PHASES:AURA (1 of 2) • Transient neurologic symptoms • Due to cortical spreading excitation/depression • Symptoms referable to location of transient chemical changes in cerebral cortex • Pattern of symptoms • Recurrent & stereotypical (previous similar spells) • Gradual onset • Migratory (1 part of body to another) over mins to hrs • Progressive (1 type of symptom to another) • Duration minutes to hours Chemical chain reaction in the brain leads to focal symptoms that change during an attack

13. Prodrome • Aura • Pain • Postdrome MIGRAINE PHASES:AURA (2 of 2) • Types of symptoms • Visual—Usually “positive” (scintillation) followed by negative (scotoma) • Shimmering, scintillating, flashing lights • Spots, dots, bubbles, lines (zigzag, wavy, heat off pavement) • Any color, but often silver, gray, or clear • Usually associated w/ motion, e.g., moving, vibrating, coalescing • Sensory—Usually “positive” (tingling) followed by negative (numbness) • Motor—Hemiparesis • Cognitive—Aphasia, confusion, amnesia, olfactory hallucinations • Brainstem—Vertigo, ataxia, diplopia, tinnitus, dysarthria,  LOC • Autonomic • N/V, anorexia, dyspepsia, abdominal cramping, flatulence, diarrhea • Horner, sinus congestion/epistaxis, facial/scalp flushing (e.g., red ear) • Hypothermia, mild fever • Hypertension, hypotension, syncope, palpitations, arrhythmias *Migraine causes HA & HTN, but HA, per se, does not cause HTN

14. Prodrome • Aura • Pain • Postdrome MIGRAINE PHASES:PAIN • Headache characteristics—No specific pattern • Location variable • Unilateral, bilateral • Anterior (frontal, periorbital, etc.), posterior (occipital, neck) • Diffuse, focal (e.g., nummular = coin-shaped) • Throbbing, pulsating, pounding, pressure, squeezing, dull, aching • Severe, moderate, mild, absent • Onset usually gradual; duration hours, days, weeks • Associated symptoms • Sensory phobias – photo, phono, kinesio, thermo, osmo • Allodynia – pain due to light touch, breeze, hair moving, etc. • “Lightheadedness” – vibratory or buzzing paresthesia in head Trigeminal nerve (CN5) & cervical nerve root sensitization in the meninges results in headache, sensory phobias, neuropathic symptoms

15. Prodrome • Aura • Pain • Postdrome MIGRAINE PHASES:POSTDROME • Fatigue, malaise • Difficulty concentrating • Mood changes • Muscle aches • Scalp tenderness • Food cravings or anorexia The migraine hangover

16. Trigger Hypothalamic dysfunction & hyperexcitable cortex (esp. occiput) Prodrome Cortical spreading depression (excitation/depression w/ hyperemia/oligemia esp. occiput) Aura Spreading depression in insula or brainstem serotonergic & noradrenergic dysfunction Dysautonomia CN V/cervical root sensitization with pain receptor stimulation & release of neuropeptides (e.g., CGRP) Headache/ Arterial changes/ Sensory phobias MIGRAINE PATHOPHYSIOLOGYA JIGSAW PUZZLE WITH MISSING PIECES Platelet & serum serotonin levels decrease during attacks of migraine, tension headache, IBS, & PMS. Cerebral serotonin & magnesium decrease during a migraine attack.

17. MIGRAINE WITH AURA:MRI BRAIN FINDINGS Deep-white matter “UBOs” common in migraine w/ aura White on T2 & FLAIR Located at gray-white junction Small, round, indistinct borders Often confused with: Multiple sclerosis plaques Strokes (“small-vessel disease,” “arteritis,” “vasculitis”) Significance & cause unknown Further evaluation not necessary Reassure patient Kruit MC et al. JAMA 2004;291:427 “Unidentified Bright Objects” (UBOs) of migraine seen on FLAIR MRI

18. Frequency > 5 episodes Duration 4-72 h untreated HA quality (> 2) Unilateral Pulsating Moderate or severe  w/ physical activity Associated features (> 1) Nausea &/or vomiting Photo- & phonophobia No other cause of sxs “The diagnostic difficulty most often encountered among primary headache disorders is to discriminate between tension-type headache and mild migraine without aura.” Cephalalgia 2013;33(9):629-808 MIGRAINE WITHOUT AURA“OFFICIAL” DEFINITION PER ICHD-3 The ICHD-3 migraine criteria are useful for scientific studies, but are too restrictive & impractical for daily use & were written from perspective of physicians with focus on headache. ICHD-3 = International Classification of Headache Disorders, 3rd ed.

19. Frequency: > 2 attacks Aura: > 1 of the following fully reversible aura sxs visual sensory speech &/or language motor brainstem retinal Characteristics: > 2 of 4 following > 1 aura sx spreads gradually over > 5 min &/or > 2 sxs occur in succession each individual aura sx lasts 5-60 min (though motor sxs may last 72 h & “persistent aura without infarction” may last > 1 wk) > 1 aura sx is unilateral (incl. aphasia) aura accompanied, or followed w/in 60 min, by HA No other cause of sxs MIGRAINE WITH AURA“OFFICIAL” DEFINITION PER ICHD-3 “Recurrent attacks, usually lasting minutes, of unilateral fully reversible visual, sensory, or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.” Cephalalgia 2013;33(9):629-808

20. Migraine w/ typical aura Visual Sensory Migraine w/ brainstem aura Dysarthria Vertigo Tinnitus Hypacusis Diplopia Ataxia  level of consciousness Hemiplegic migraine (HM) Familial HM type 1 (CACNA1A) Familial HM type 2 (ATP1A2) Familial HM type 3 (SCN1A) Familial HM other loci Sporadic hemiplegic migraine Retinal migraine (monocular) MIGRAINE WITH AURATYPES PER ICHD-3

21. MIGRAINE WITH “TYPICAL” AURADESCRIPTIONS PER ICHD-3 • Migraine w/ visual aura • Most common (> 90%) aura • Fortification spectrum – zigzag figure that may gradually spread & assume laterally convex shape w/ angulated scintillating edge, leaving absolute or relative scotoma in its wake • Scotoma without positive phenomenon may occur • Migraine w/ sensory aura • 2nd most frequent aura • Pins & needles moving slowly from point of origin affecting 1 side of body, face, &/or tongue • Numbness may occur in its wake • Numbness may also be the only symptom

22. MIGRAINE GLASSES MAKE THE DIAGNOSIS MORE CLEAR Symptoms that seemed vague and psychiatric are clearly due to migraine when seen through the proper lenses Vague, unrelated symptoms MIGRAINE Probably psychiatric, manipulative MIGRAINE Diagnosis without migraine understanding— things don’t make sense, therefore patient is “crazy” Diagnosis with migraine understanding— a pattern emerges

23. MIGRAINE IS A DISTINCT SYNDROME OF BOTHERSOME, BUT “BENIGN” SPELLS • Lifelong (childhood through adulthood) history of multiple different types of similar “spells” • Main symptom headache, GI upset, chest pain, visual symptoms, tingling, vertigo, confusion, etc. • Associated with mood changes, food cravings, sensory phobias • Triggered by stress letdown, weather changes, estrogen changes, dehydration, hunger, etc. • Normal tests • Complete resolution between spells—though taking daily analgesic, triptan, decongestant, or muscle relaxant makes symptoms constant • Family history of spells similar to those suffered by pt But obtaining accurate past & family histories is challenging

24. WHY MIGRAINE IS REALLY, REALLY COMMON, BUT NOBODY KNOWS IT • “Regular” / “ordinary” headaches are migraines • Tension headaches are migraines • Frequent co-occurrence in patients and similar epidemiology, clinical features, & treatment responses • Actually migraines triggered by stress letdown • Sinus headaches are migraines • Respond to migraine prophylactic agents • Respond acutely to triptans (migraine abortive agents) • Do not respond to antibiotics • Sinus artery dilatation occurs in migraine • Not all migraine attacks include headache • Aura without headache (visual, sensory, vertigo, etc.) • Abdominal migraine (= irritable bowel syndrome) • Precordial migraine (= noncardiac atypical chest pain)

25. Tension-type headache Sinus headache Regular/ordinary headache Cervicogenic headache Premenstrual syndrome Irritable bowel syndrome Functional dyspepsia Infantile colic Motion sickness Chronic pelvic pain Recurrent vertigo/Meniere Panic attacks Atypical noncardiac chest pain Intermittent headache w/ transient hypertension Transient global amnesia Episodic confusion POTS (postural orthostatic tachycardia syndrome) Syncope of unknown cause Postconcussion/posttraumatic headache Stroke-like spells (TIA mimic) CONDITIONS LIKELY DUE TO(OR RELATED TO) MIGRAINE These conditions cause temporary symptoms that are said to be of unknown cause, but which may be explained by migraine

26. NOT DIAGNOSING MIGRAINE LEADS TO WASTED DOLLARS & LIVES • Imaging studies (CT, MRI, endoscopy, colonoscopy, etc.) • Medications • Antibiotics (bacterial resistance) • Decongestants (chronic nasal congestion, HTN, chronic symptoms) • Anxiolytics, antidepressants (social consequences of false diagnosis) • Antithrombotic agents (hemorrhage) • Narcotics (chronic symptoms, drug-seeking behavior caused by docs) • Surgeries • Gallbladder • Uterus and ovaries • Sinus and ear • Disability, retirement, divorce

27. WHY DON’T MORE DOCTORS KNOW ABOUT MIGRAINE? • Migraine training is often inadequate • Physicians have limited time to spend with patients • Diagnosis is based on history; with limited time, history is cursory and important details are missed • Exam & tests are normal, leading to assumption of psychiatric illness • Physicians have limited confidence beyond their specialty • Neurologists deal with headaches • GI doctors deal with stomach and intestine symptoms • Ob-Gyn doctors deal with woman issues • ORL / ENT doctors deal with ear, nose, sinus symptoms • Cardiologists deal with cardiac causes of chest pain • Pain specialists deal with peripheral (not CNS) pain

28. MIGRAINE THERAPY:THE TWO KINDS Prophylactic and Abortive Agents • Prophylactic agents (preventers) • If a patient takes certain medications every day, s/he is likely to have less frequent and less severe migraines • Abortive agents (stoppers) • If a patient takes certain medications as soon as possible at the start of a migraine attack, s/he may either stop the attack or make it less severe

29. MIGRAINE THERAPY: THE 3 OVERARCHING CONSIDERATIONS • Avoid medication-overuse syndrome • Limit use of all combined abortive agents to < 2 d/wk (except prescription naproxen) • Use prophylactic therapy to enable patient to use abortive therapy < 2 d/wk • Kill 2 birds with 1 stone • Choose prophylactic agent(s) that treat other conditions pertinent to the patient • Aim to prevent ALL migraine symptoms—not just headache

30. MEDICATION-OVERUSE SYNDROME/ ANALGESIC REBOUND HEADACHE Near-daily use of certain drugs—esp. migraine abortive agents—causes migraine symptoms to be constant • Caused by: • Analgesic, triptan, decongestant, muscle relaxant use > 2 days/week • Any analgesic (over-the-counter to narcotic) other than prescription naproxen Note: ondansetron & PPIs may also trigger migraine • Relationship to migraine: • More common in migraineurs • Changes migraine symptoms from intermittent to chronic (incl. headache, GI, chest pain, tingling, vertigo, etc.) • Common cause of chronic migraine & status migrainosus • Renders all migraine therapies ineffective

31. MIGRAINE PROPHYLACTIC THERAPY:GENERAL PRINCIPLES • Kill 2 birds with 1 stone • No agent initially developed for migraine; when choosing an agent, address concurrent conditions (e.g., hypertension, depression, anxiety, patient weight, seizures, osteoarthritis, insomnia, stool consistency) • Different patients respond differently to different drugs • Each agent/dose change takes > 4 wk to take full effect • Start low, go slow • Start one med, low-dose •  q2-4 wks to maximize efficacy vs. toxicity, but do NOT make automatic increases • May eventually need more than one med

32. Antihypertensive agents candesartan (Atacand) lisinopril (Prinivil, Zestril) nadolol (Corgard) propranolol (Inderal) Tricyclic antidepressants nortriptyline (Pamelor) amitriptyline (Elavil) Serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine ER Antiepileptic drugs topiramate (Topamax) divalproex (Depakote) NSAID naproxen (Naprosyn)* Over the counter magnesium oxide vitamin B2 (riboflavin) melatonin MIGRAINE PROPHYLACTIC THERAPY:TOP CHOICES BY MECHANISM There is no “class effect”—a patient may respond well to a drug after not responding to a different drug in the same category

33. MIGRAINE PROPHYLACTIC THERAPY:SIDE EFFECTS Side effects that may influence agent choice All antihypertensives hypotension Beta blockers depression, sedation, asthma Tricyclic antidepressants weight gain, sedation, constipation Divalproex weight gain, hair loss, polycystic ovaries Topiramate weight loss, abnl cognition, nephrolithiasis Naproxen ulcers, renal disease Magnesium loose stools

34. MIGRAINE PROPHYLACTIC THERAPY:TOP CHOICES BY AGE • Children & Young Adults • topiramate • nortriptyline / amitriptyline • nadolol / propranolol • Older Adults • candesartan (Atacand) / lisinopril • nortriptyline / amitriptyline • divalproex (Depakote) • venlafaxine (Effexor) • All Ages—primary or adjunct • naproxen  peri-predictable triggers / other pain • magnesium oxide  constipation • melatonin  insomnia

35. MIGRAINE ABORTIVE THERAPY:GENERAL PRINCIPLES • Triptans—migraine-specific serotonin agonists—are most effective (bind to subsets of serotonin 1 receptor—1D & 1B) • Triptans may cause vasospasm; safety uncertain if: • Migraine associated w/ aphasia, hemiplegia, or vertigo • Vascular disease or risk factors (including hypercoagulability) • Patient < 12 or > 65 years of age • Analgesics may also be effective as abortive therapy • Narcotics are generally NOT indicated for headache—limit their use to pregnant women and those with vascular disease, esp. the elderly • Take all abortive therapy early, e.g., triptan efficacy 2/3 when HA mild, 1/3 when HA moderate • Take analgesics and triptans < 2 d/wk to avoid medication-overuse headaches

36. TRIPTANS Selective 5-HT1D/1B agonists Fast onset/Short half-life eletriptan (Relpax) rizatriptan (Maxalt & Maxalt MLT) zolmitriptan (Zomig & ZomigZMT) almotriptan (Axert) sumatriptan (Imitrex PO, PN ,SC) Slow onset/Long half-life frovatriptan (Frova) naratriptan (Amerge) ERGOTS Nonselective 5-HT1D agonists Cafergot (PO, PR) DHE DHE-45 IV, IM Migranal PN TRIPTAN + NSAID sumatriptan/naproxen sodium (Treximet) MIGRAINE ABORTIVE THERAPY:SEROTONIN (5-HT) AGONISTS In most cases, start with the highest recommended triptan dose, e.g., sumatriptan 100 mg, eletriptan 40 mg, rizatriptan 10 mg. Take as early as possible at onset; may repeat x 1 after 2 h; do not exceed 2 tabs / 24 h; do not exceed 2 d / week.

37. MIGRAINE ABORTIVE THERAPY:NON-NARCOTIC ANALGESICS While all these agents can be effective when used as early as possible at migraine onset, they all cause medication-overuse syndrome if used > 2 days per week • Nonspecific single-agent analgesics • Aspirin, acetaminophen (Tylenol), NSAIDs • Nonspecific combination analgesics • Excedrin Migraine (acetaminophen, aspirin, caffeine) • BC Powder (acetaminophen, aspirin, caffeine) • Goody’s Headache Powder (aspirin, salicylamide, caffeine) • Midrin, Amidrine, Duradrin, Epidrin (acetaminophen, dichloralphenazone, isometheptene) • Fiorinal (aspirin, butalbital, caffeine) • Fioricet, Esgic (acetaminophen, butalbital, caffeine)

38. MIGRAINE ABORTIVE THERAPY:PARENTERAL AGENTS IN HOSPITAL/ED • Normal saline – 1 L IV bolus • Magnesium sulfate – 1 g IV • Valproic acid (Depacon) – 500 mg IV • Prochlorperazine (Compazine) – 10 mg IV • Metoclopramide (Reglan) – 10 mg IV • Chlorpromazine (Thorazine) – 25 mg IV • Dihydroergotamine (DHE) – 0.5-1.0 mg IV or IM These agents may be repeated q8h PRN. Note there are many options for migraine abortive therapy in the ED or inpatient setting that are not analgesics—and narcotics, per se, are RARELY necessary Avoid reflexively giving PRN Tylenol or narcotics! These IV agents are preferable to oral, IV, or transdermal analgesics for ED & hospitalized patients with headache

39. CASE 1: PRESENTATION • 58-year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain • Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy • One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab • Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam

40. CASE 1: CLARIFICATION & OUTCOME • Clarification of “pseudoseizure” episodes: • First lightheadedness, then loss of consciousness and tone • Rapid awakening with vertigo, nausea, vomiting, headache, confusion • Final diagnoses: • Syncopal migraine • Migraine with vertigo aura • Abdominal migraine • Precordial migraine • Medication overuse syndrome • Functional overlay (aphasia) • Outcome: • On topiramate, all symptoms markedly improved & the patient went to the ED only four times in the next four years • The patient does NOT have pseudoseizures, gastroparesis, or anxiety-induced chest pain.

41. CASE 2: PRESENTATION • 28-year-old tearful woman with “pain all over,” unable to move L side due to pain and with bilateral blurred vision • Six weeks ago, had difficulty holding objects in L hand, then noted “waves of pain” in both shoulders radiating over minutes into both hands, L > R, followed by a lightning sensation into L thigh, radiating into L toes • Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month • One month ago, symptoms became constant without relief from daily Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid • Lost nursing job 3 weeks ago when she became bedbound with daily vertigo and occipital headache radiating to R temple & eye • For last week, severe R chest pain (R anterior axilla to upper back) • For last few days, blurred vision in both eyes, initially intermittent, then constant • For one day, nausea and vomiting

42. CASE 2: CLARIFICATION & OUTCOME • Blurred vision = whitish-tan wavy lines or “heat-off-the-pavement” throughout her vision in both eyes • Since early childhood • Intermittent headaches, bioccipital, radiating to right temple and eye with nausea, vomiting, sensory phobias, photopsia (star bursts), tingling (head, neck, both hands), & vertigo (saw multiple doctors for vertigo) • For the last few years, episodes of intermittent severe Rabdominal pain with bloating, nausea, vomiting, and diarrhea occurring daily for a week, followed by constipation for a few days, then recurrent abdominal pain; no gallstones; cholecystectomy did not help • Diagnoses: Status migrainosus due to medication overuse syndrome, migraine with aura (visual, sensory, vertigo), abdominal migraine, precordial migraine, depression with anxiety • Management: All analgesics discontinued except prescription naproxen; topiramate & venlafaxine begun; 3 weeks later, patient markedly improved, started new RN job, &, after 3 days promoted to manager

43. CASE 3: PRESENTATION • 80-year-old distraught man with intractable, intermittent, 12-hour episodes of vertigo, diplopia, ataxia, nausea, and vomiting occurring every 5-6 days that left him disabled and housebound • MRI brain normal • Symptoms became constant several months ago despite taking daily Voltaren, Protonix, and Zofran • Famous quaternary referral center #1 – no diagnosis • Famous quaternary referral center #2 – progressive, degenerative disease • On exam, he had gait ataxia

44. CASE 3: FAMILY HX & OUTCOME • His sister has similar episodes • With candesartan and magnesium oxide, symptoms markedly improved—over next 6 months, patient had no vertigo, diplopia, nausea, or vomiting; he had persistent, mild, 1-hour episodes of gait ataxia upon awakening two days a week that resolved by late morning and did not interfere with his activities of daily living

45. OTHER CASES • The 2 women (ages 60 & 20) with intractable nausea, vomiting, abdominal pain, & diarrhea on TPN, Fentanyl patch, & oral narcotics • The 65 yo woman with daily HA x 50 years • The 50 yo woman with retinal infarction & daily diarrhea • The 4 yo boy with post-social debilitating GI pain • The 63 yo tearful woman with schizophrenia, diabetes mellitus type II, hypertension, obesity, & past history of TIAs; now with acute aphasia & left hemiparesis for which she received IV tPA

46. MIGRAINE & RECURRENT SPELLSLEARNING OBJECTIVES • Relate a practical definition of migraine • Determine when the following symptoms are due to migraine: • Abdominal pain Confusion • Chest pain  Hemiparesis • Vertigo  Aphasia • Syncope  Headache • Name the three overarching considerations when prescribing migraine therapy • Describe the appropriate abortive and prophylactic therapies for migraine

47. THE END