10/13/17. Christy M. Jackson, MD Director, Dalessio Headache Center Scripps Clinic, La Jolla Clinical Professor, Neurosciences UCSD

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1 Christy M. Jackson, MD Director, Dalessio Headache Center Scripps Clinic, La Jolla Clinical Professor, Neurosciences UCSD } Depomed Consultant 2014 to present } Avanir Consultant 2014 to present } Amgen Consultant Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalalgias 4. Other primary headache disorders Cephalalgia 33(9) International Headache Society

2 Welch M et al. Headache Apr; 45 Suppl 1:S Van den Maagdenberg AM et al. Neuron. 2004;41: Double click image to play video Lauritzen M. Brain. 1994;117: } Kinins start the process leading to prostaglandin synthesis Kinins facilitate the production of cyclooxygenases Cyclooxygenases convert arachidonic acid to prostaglandins Woolf CJ. Ann Intern Med. 2004;140:

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4 } Topamax/Trokendi } Namenda XR use in pregnancy } Propranolol ER } Amitriptyline } Amlodipine } Depakote ER } Lisinopril } Cyproheptadine- children and pregnancy } Topamax mental fog, paresthesias, anorexia, emotional lability } Namenda XR dizziness } Propranolol LA hypotension, fatigue } Amitryptyline- sedation, dry mouth, weight gain } Amlodipine hypotension, LE edema, constipation } Depakote ER leucopenia, LFTs, tremor, weight gain STHeitiSC-Light } Chronic Migraine is a defined condition 1-3* 15 or more headache days per month Headaches lasting 4 hours per day or more At least 8 headache days that are linked to migraine or that respond to migraine-specific medication 2,3 With or without medication overuse } *Multiple headache phenotypes are possible. 1,2 1. Headache Classification Committee. Cephalalgia. 2004;24(suppl 1): Headache Classification Committee; Olesen J et al. Cephalalgia. 2006;26: Lipton RB. Headache. 2011;51(S2):

5 } Proven in PREEMPT trial to be effective in lowering HA days by 50% } Diagnosis of Chronic Migraine necessary } Approved by insurance of pt has failed trials of 2-3 prophylactic meds over 6 months } Injections every 3 months } Medication Overuse Headache included } May reduce pericranial muscular tension and contractions } May directly affect sensory nerves possibly reducing neuropeptide release (CGRP) 5

6 } Neurology May 25;62(10): Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Bendtsen L, Jensen R. Danish Headache Center, University of Copenhagen, and Department of Neurology, Glostrup University Hospital, Copenhagen, Denmark. 6

7 Acute: NSAIDS Tramadol Local heat/ cold Valium Preventive: TCA NSAIDS Physical Therapy } Side Locked } Originates at base of skull and travels up over scalp to eye } May become pulsatile } Does not meet criteria for migraine } Responds to occipital nerve blocks, indomethacin } ICHD Criteria revised 2006 } Daily headache, diffuse and bilateral } Waking with headache } Headache when medication is withdrawn } Tolerance to abortive medication } No response to preventive medication } International Headache Society (2004). "The International Classification of Headache Disorders: 2nd edition". Cephalalgia 24 (Suppl 1):

8 } Step 1: Prophylaxis of med, botox } Step 2: Prednisone taper Day 1 } Step 3: D/c analgesic Day 2 } Step 4: days 3-10 Rescue with promethazine, prochlorperazine, DHE nasal spray } Elavil, trazodone } 5 day taper 60mg-20mg } If fioricet, may need phenobarb added } May allow return to 2 days weekly at day 11 } Preventive CGRP receptor antibody injection Occipital nerve stimulator Cefaly } Abortive Sumatriptan air injector Occipital nerve blocks Trigeminal nerve blocks DHE inhalation apparatus } Double blind, placebo controlled randomized pilot study } 41 pts age with Chronic Migraine (CM) }.3 cc of.5% Bupivacaine or saline twice weekly for 6 weeks 8

9 } Repetitive SPG blocks showed a statistically significant decrease in numeric rating pain scores at 15, 30 min and 24 hours } Follow up at 6 months showed significant decrease in overall disability Cady, Saper et al. Headache 2015;55: } CGRP is a 37 amino acid neuropeptide } Targeting CGRP with small molecule antagonists has been effective but unsafe } TEV is one of four monoconal antibodies targeting CGRP or receptors } Six Phase I studies complete } Phase IIb underway } Early results show decrease by 50% in high frequency episodic migraine and chronic migraine with few SAEs } TEV-48125: a Review of a monoclonal CGRP antibody: Bigal, M : Curr Pain Headache Rep (2015) 19:6 9

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11 } Acute Therapy High Flow Oxygen Triptan DHE } Suppressant Therapy Steroids Indomethacin Ca Channel Blocker Lithium Topiramate 11

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