Outline Dr. Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC PsychMedEd for Advance 2012 Etiology, Stages & Classifications of Migraines Differential Pathophysiology from other Headaches Current Treatment Therapies Definition A migraine headache is a throbbing or pulsating headache that is often unilateral and associated with: nausea, vomiting sensitivity to light, sound, and smells sleep disruption depression Migraines are more common in menstruating women (onset~ 30; peak~ mid-life) with estrogen release, then withdrawal in the luteal phase Estrogen affects serotonin levels and may hail the onset Attacks are often recurrent and tend to become less severe as the migraine sufferer ages into natural menopause. General information Migraines can also be found in children, adolescents, and young women. They are often hailed by environmental factors and often have 4 stages associated: prodrome, aura, attack and postdrome Migraine attacks can cause significant pain for hours to days and be so severe that all you can think about is finding a dark, quiet place to lie down. Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots or tingling in your arm or leg. Etiology The cause of migraine is unknown, yet is associated with hormonal flux and vascular changes. The condition may result from a series of reactions in the central nervous system caused by changes in the body or in the environment. There is often a family history of the disorder, suggesting that migraine sufferers may inherit sensitivity to triggers that produce inflammation in the blood vessels and nerves around the brain and scalp, causing pain. Theory of Etiology Reacting to the reduced oxygen supply, certain arteries within the brain dilate to meet the brain's energy needs. This dilation spreads, finally affecting the neck and scalp arteries. The dilation of these arteries triggers the release of prostaglandins from various tissues and blood cells. Chemicals that cause inflammation and swelling and substances that increase sensitivity to pain are also released. The circulation of these chemicals and the dilation of the scalp arteries stimulate the pain-sensitive nociceptors. The result, according to this theory, is a throbbing pain in the head. 1
Theories Migraine pain starts with the release of inflammatory proteins from the dura, which envelops the brain, and from blood vessels and nerve endings in the brain. The release of these proteins over-sensitizes the trigeminal ganglion, located above the palate, which receives signals about conditions inside the skull. When over-sensitized, the ganglion interprets normal pressure inside the skull as the throbbing pain of migraine. Because the trigeminal ganglion seems to cause the primary pain of migraine, it is the target of current migraine drugs, which block serotonin receptors in sensory neurons connected to the dura. The drugs are often effective, but only if taken immediately after the headache begins. Nerve pain The over-sensitized trigeminal ganglion may, in turn, send signals to the nucleus caudalis, at the top of the spinal cord. Unlike the trigeminal ganglion, this group of nerves is connected to the skin, particularly near the eye, where the most dramatic skin sensitivity in migraine sufferers. Triggers A trigger is any stimulus that initiates a process or reaction. Commonly identified migraine triggers include the following: Alcohol (e.g., red wine) Environmental factors (e.g., weather, altitude, time zone changes) Exertion Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; used to enhance flavor in several processed foods and in Chinese food), nitrates (found in processed foods, hot dogs), artificial sweeteners (e.g., aspartame), and tyramine (e.g., yogurt, nuts, lima beans) Glare, contrasting patterns, flashing lights, Computer screen Hormonal changes in women Hunger Lack of sleep Medications (over-the-counter and prescription) Perfume or noxious odors Stress Classifications Migraines split into two major classifications with subtypes. They are classified according to the symptoms they produce. With aura Without aura Aura Migraine with aura is characterized by a neurological phenomenon (aura) that is experienced 10 to 30 minutes before the headache. Most auras are visual and are described as bright shimmering lights around objects or at the edges of the field of vision (called scintillating scotomas) or zigzag lines, castles (teichopsia), wavy images, or hallucinations. Others experience temporary vision loss. Nonvisual auras include motor weakness, speech or language abnormalities, dizziness, vertigo, and tingling or numbness (parasthesia) of the face, tongue, or extremities. Without Aura Migraine without aura is the most prevalent type and may occur on one (unilateral) or both sides (bilateral) of the head. Tiredness or mood changes may be experienced the day before the headache. Nausea, vomiting, and sensitivity to light (photophobia) often accompany migraine without aura. 2
Other types of Migraines Some women experience migraines just prior to or during menstruation. These menstrual migraines may be related to hormonal changes and often do not occur or lessen during pregnancy. Other women develop migraines for the first time during pregnancy or after menopause. Abdominal migraine is most common in children with a family history of migraine. Symptoms include abdominal pain without a GI cause (may last up to 72 hours), nausea, vomiting, and flushing or paleness (pallor). Children who have abdominal migraine often develop typical migraine as they age. Other Migraines Basilar artery migraine involves a disturbance of the basilar artery in the brainstem. Symptoms include severe headache, vertigo, double vision, slurred speech, and poor muscle coordination. This type occurs primarily in young people. Carotidynia, also called lower-half headache or facial migraine, produces deep, dull, aching, and sometimes piercing pain in the jaw or neck. There is usually tenderness and swelling over the carotid artery in the neck. Episodes can occur several times weekly and last a few minutes to hours. This type occurs more commonly in older people. Doppler ultrasound studies of the carotid arteries are normal. Other Migraines Headache-free migraine is characterized by the presence of aura without headache. This occurs in patients with a history of migraine with aura. Ophthalmoplegic migraine begins with a headache felt in the eye and is accompanied by vomiting. As the headache progresses, the eyelid droops (ptosis) and nerves responsible for eye movement become paralyzed. Ptosis may persist for days or weeks. Signs & Symptoms Migraine headache pain is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head. The headache is often so severe that it interferes with daily activity and may awaken the person. The attack is debilitating, and migraine sufferers are often left feeling tired and weak once the headache has passed. Signs & Symptoms A migraine headache typically begins in a specific area on one side of the head, then spreads and builds in intensity over 1 to 2 hours and then gradually subsides. It can last up to 24 hours, and in some cases, several days. There may be accompanying symptoms such as nausea, vomiting, sensitivity to light (photophobia), or sensitivity to sound (phonophobia). Hands and feet may feel cold and sweaty and unusual odors may be intolerable. Diagnosis Diagnosis of migraine is based on the history of symptoms, physical examination, and neurological tests. The tests are performed to rule out other neurological and cerebrovascular conditions, including the following: Bleeding within the skull (intracranial hemorrhage) Blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis) Cerebral stroke (infarct) Dilated blood vessel in the brain (cerebral aneurysm) Excess cerebrospinal fluid in the brain (hydrocephalus) Inflammation of the membranes of the brain or spinal cord (meningitis) Low level of cerebral spinal fluid (CSF) Nasal sinus blockage Postictal headache, which occurs after a stroke or seizure Tumor 3
Treatment The goals of treatment are to prevent or reduce the number of migraines (called prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine (called abortive treatment). Preventative medication may be prescribed for patients who have frequent headaches (3 or more a month) that do not respond to abortive treatment. Studies have shown that as many as 40% of these patients may benefit from preventative treatment. Using one medication (monotherapy) is tried first, but a combination of medicines may be necessary. Many of these medications have adverse side effects. If migraines become controlled, the dosage is often reduced or the drug discontinued. Treatment A variety of drugs have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories: Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun. Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines. NSAIDs These medications, such as ibuprofen (Advil, Motrin, others) or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraines but aren't effective alone for severe migraines. If taken too often or for long periods of time, NSAIDs can lead to ulcers, gastrointestinal bleeding and rebound headaches. Triptans For many people with severe migraine attacks, triptans are the drug of choice. They are effective in relieving the pain, nausea and sensitivity to light and sound that are associated with migraines. Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), naratriptan (Amerge), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax). Side effects of triptans include nausea, dizziness and muscle weakness. They aren't recommended for people at risk for strokes and heart attacks. A new, single-tablet combination of sumatriptan and naproxen sodium (Treximet) became available in 2008. It's more effective in relieving migraine symptoms than either medication on its own Ergots Ergot. Ergotamine (Migergot, Cafergot) is much less expensive, but also less effective, than triptans. It seems most effective in those whose pain lasts for more than 48 hours. Dihydroergotamine (Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. Anti-nausea medications. Because migraine attacks are often accompanied by nausea with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or suppository). Prevention Drug therapy, biofeedback training, stress reduction, and the elimination of certain foods from the diet are the most common methods of preventing migraine headaches. Regular exercise (eg, swimming, vigorous walking) can also reduce the frequency and severity of migraines. Scientists estimate that a small percentage of these patients will benefit from a treatment program focused solely on eliminating headache-provoking foods and beverages. Finally, many specialists recommend that persons with migraines avoid oversleeping on weekends 4
Specific Prevention Treatment Beta blockers (e.g., propranolol [Inderal ], atenolol [Tenormin ]) are the preferred medications. These drugs produce an effect on heart rate. They should not be taken by patients with asthma and should be used with caution in patients with diabetes. Side effects include gastrointestinal upset, insomnia, low blood pressure (hypotension), slowed heart rate (bradycardia), and sexual dysfunction. Some beta blockers pass into breast milk and may cause problems in nursing infants. Antiseizure drugs such as valproic acid (Depakote ), topiramate (Topamax ), and gabapentin (Neurontin ) may be used to treat migraine. Side effects include nausea, gastrointestinal upset, sedation, liver damage, and tremors. Specific Prevention Treatment Calcium channel blockers (e.g., verapamil, amlodipine [Norvasc ]) inhibit artery dilation and block the release of serotonin. They should not be taken by patients with heart failure or heart block. Side effects include constipation, flushing, low blood pressure, rash, and nausea. Tricyclic antidepressants (TCAs; e.g., amitryptaline [Elavil ], nortryptaline [Pamelor ], desipramine [Norpramin ]) block serotonin reabsorption and take 2 3 weeks be effective. Side effects include the following: Constipation Dry mouth Low blood pressure (hypotension) Increased heart rate (tachycardia) Urinary retention Sexual dysfunction Weight gain Prevention Treatment Selective serotonin reuptake inhibitors (SSRIs; e.g., paroxetine [Paxil ], fluoxetine [Prozac ], sertraline [Zoloft ]) are usually better tolerated than TCAs, but may not be as effective. Side effects include nausea, insomnia, sexual dysfunction, and loss of appetite. Methysergide maleate (e.g., Deseril, Sansert ) may be prescribed for patients with frequent, severe migraines. Side effects include insomnia, drowsiness, lightheadedness, and hair loss. This drug should not be used by patients with coronary artery disease and must be discontinued for 3 4 weeks after 4 6 months of use because it can cause retroperitoneal fibrosis, a condition in which the blood vessels in the abdomen thicken, which reduces blood flow to organs. Botox Botulinum toxin type A (Botox). Botulinum toxin type A is sometimes used for treatment of chronic migraines. Studies have had mixed results with respect to effectiveness. Some headache specialists believe that it can be helpful for some people. Injections are made in muscles of the forehead and neck. When this is effective, the treatment typically needs to be repeated every three months. Complementary / Alternative Medicine Treatment Psychotherapy Relaxation Guided Imagry Medical Hypnosis Progressive Muscle Relaxation Diaphragmatic Breathing Biofeedback Acupuncture Physical Therapy Massage Therapy Cluster Headaches They are called cluster headaches because the attacks come in groups over prolonged periods. The pain arrives with little, if any, warning, and it has been described as the most severe and intense of any headache type. A single headache generally lasts from 30 to 45 minutes, although it might persist for several hours before it disappears. It can reoccur later in the day. Most sufferers experience one to four headaches a day during a cluster period. Cluster headaches frequently surface during the morning or late at night; the cluster cycle can last weeks or months and then can disappear for months or years. Clusters often occur during spring or autumn and, thus, are often incorrectly associated with allergies. 5
Cluster Headache Symptoms The cluster headache was once considered a type of migraine, because it is vascular. Unfortunately, it is possible for a person to suffer from both migraines and clusters, although it is rare. The headache is strictly unilateral and rarely switches sides from one attack to another. You might feel the pain begin around one eye, "like a nail or knife stabbing or piercing" your eye, or as if someone "were pulling out" your eye; it may be accompanied by a tearing or bloodshot eye and a runny nose on the side of the headache. It can radiate from the eye to the forehead, temple and cheek on the same side. The pain of a cluster headache has been described as piercing, burning, throbbing, pulsating, and so excruciating that most victims cannot sit still and feel compelled to rock in a chair, walk back and forth, or bang their heads against something. Cluster Headache Treatment (*acute tx) Sumatriptan injection* (side effects: N/V, fatigue, parasthesias, chest/throat tightness) Zolmitriptan intranasal* (N/V, fatigue, parasthesias, chest/throat tightness) Oxygen inhalation* via non-rebreather mask x 15-20 min Ergotamine/Dihydroergotamine Lidocaine intranasal for moderate adjunctive help Somatostatine & Octreotide Maintenance Prophylaxis These medications are gnerally discontinued after the resolution of the cluster period and restarted at the onset of the next cluster period. Monotherapy is optimal. Calcium channel blockers (Verapamil) (hypotension, constipation, peripheral edema) First-line Lithium (diarrhea, tremor, polyuria, kidney/liver damage) Second-line. Topiramate (parasthesias, wight loss, cognitive dysfunction, fatigue, dizziness, taste alteration) Second-line. Valproic acid (weight gain, fatigue, tremor, hair loss, nausea) Third-line. Gabapentin (somnolence, fatigue, dizziness, weight gain, peripheral edema, ataxia) Third-line Baclofen (drowsiness, dizziness, ataxia, muscle weakness) Third-line. Non-medicinal Treatments Peripheral Nerve & Sphenopalatine Ganglion Block Block (lidocaine, betamethasone)given ipsilateral to head pain or in suboccipal area Significant, temporary relief (~4 weeks) Peripheral Nerve & Sphenopalatine Ganglion For people refractory to meds Occipital nerve stimulation Benefits in minutes StimulationDeep Brain (hypothalamic) Stimulation Watch for intracerebral hemorrhage Ablative procedures Done strictly for unilateral, side-locked headaches No longer popular Trigeminal nerve often ablated Moderately good results Tension-Type Headaches (TTH) Signs and symptoms of a tension headache include: Dull, aching head pain The sensation of tightness or pressure across your forehead or on the sides and back of your head Tenderness on your scalp, neck and shoulder muscles Occasionally, loss of appetite A tension headache can last from 30 minutes to an entire week. You may experience these headaches only occasionally, or nearly all the time. Common in males or females Tension Headaches: Differential A tension-type headache, as it's medically known is the most common type of headache, and yet its causes aren't well understood. May be caused by teeth clenching which creates a chronic contraction of the temporalis muscle. May be caused by a malfunctioning pain filter which is located in the brain stem (hyperexcitability of central nociceptive neurons) TTH is generally a diffuse, mild to moderate pain that many people describe as feeling as if there's a tight band/constant pressure around the head. The pain can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. 6
TTH Precipitators Various precipitating factors may cause TTH in susceptible individuals: Stress: usually occurs in the afternoon after long stressful work hours or after an exam Sleep deprivation Uncomfortable stressful position and/or bad posture Irregular meal time causing hunger One half of patients with TTH identify stress or hunger as a precipitating factor Eye strain TTH Treatment Ibuprofen, acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. The first-line treatment for chronic tension type headache is amitriptyline (e.g., Elavil) Other medication options include topiramate (e.g., Topamax) and valproic acid (e.g., Depakote) Biofeedback, accupuncture, and cranio-sacral pressure techniques may also help. Dr Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC PsychMedEd 7