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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 l.jpg

Migraine Headaches

Jim Ducharme MD CM FRCP

Professor, Emergency Medicine

Dalhousie University


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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?


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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


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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



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I.H.S. Diagnostic Criteria headache

  • 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


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Her physical exam is normal other than her obvious headache

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?


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Pathophysiology headache

  • 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


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Pathophysiology headache

  • Genetic predisposition

    • Deficient habituation during repetitive stimulation

    • Allows for surpassing or modification of threshold for migraine

      • External: prophylaxis, psychosocial

      • Internal: estrogen, stress response, foods


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Pathophysiology headache

  • Threshold surpassed:

    • Brainstem “generator” liberates CGRP

    • Activation of trigeminovascular system

  • CGRP also elevated with pulsating chronic tension-type headaches


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Pathophysiology headache

  • Nitric oxide

    • Vasodilator

    • Promotes central sensitization of trigeminal nociceptors

    • Sumatriptan decreases NO release in addition to inhibiting CGRP release


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Pathophysiology headache

  • 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


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Pathophysiology headache

  • Potentials for future abortive treatment:

    • Antagonists of: CGRP, NO, Glutamate

    • Agonists of adenosine A1 receptors


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Yeah, yeah and the moon is actually made of headache

Gruyère not Emmental….. My patient still has

her headache, so what do I give her?


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Effective Abortive Agents headache

  • Triptans

  • Dihydroergotamine

  • NSAIDs

  • Anti-emetics

  • Lidocaine?

  • Opioids?


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Triptans headache

  • 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


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Triptans headache

  • 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


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Dihydroergotamine headache

  • 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


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NSAIDs headache

  • 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


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Dopamine Antagonists headache

  • Phenothiazines

  • Butyrophenones

  • Metoclopramide


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Dopamine Antagonists headache

  • 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


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Lidocaine headache

  • 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


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Opioids headache

  • 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


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So back to that lady: what are you going to give her? headache

What should be your first choice?


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Analgesia-induced rebound headaches headache

  • 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


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Migraine: headache recurrence headache

  • 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


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Preventing recurrence headache

  • Innes et al: dexamethasone IV

  • Ducharme et al: complete elimination of pain before discharge

  • Choice of abortive agent

    • serotonin agonists have highest recurrence rate


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Preventing Future Headaches headache

  • Headache diary: identifying triggers

  • Prophylaxis

    • Diet

    • Exercise

    • Sleep

    • Stress modification


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Preventing Future Headaches headache

  • Medications:

    • Valproate: 45% patients more than placebo with 50% decrease in headache rate

    • Beta Blockers: 40%

    • Flunarazine: 42%

    • Pizotifen: 20%

    • Riboflavin: 37%


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Your patient is pain free, leaves your headache

ED with a smile, and you finish your shift

….

…..

With a throbbing headache of your own!