Headache Mary D. Hughes, MD Neuroscience Associates

Case 1 22 year old female presents with recurrent headaches. She has had headaches for the past 3 years. They start on the right side of her head and spread across her forehead. She gets queasy and notes that the light bothers her eyes during a headache. She doesn t drink Margaritas because she has noticed that they trigger her headaches.

A bad headache makes her lay her head down on her desk at work. She gets milder ones about once a week that she treats with Tylenol. PmHx Normal Soc Hx: rare etoh, Recently separated Fam Hx: Mother has migraines PE: Normal

Adapted IHS Criteria for Migraine with Typical Aura A At least 2 attacks fulfilling criteria B B Aura consisting of at least one of the following, but no motor weakness: -Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) -Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness) -Fully reversible dysphasic speech disturbance C At least two of the following: -Homonymous visual symptoms and/or unilateral sensory symptoms -At least one aura symptom develops gradually 5 minutes or more and/or different aura symptoms occur in succession over 5 or more minutes D Headache fulfilling criteria for migraine without aura beginning during the aura or follows the aura within 60 minutes

Alice in Wonderland Syndrome Lewis Carroll Migraineur? Or addict? Distorted images

I m pretty brave, generally, only today I happen to have a headache. Tweedledum

Visual Scotoma

Adapted from IHS Criteria for Migraine without Aura* Headache Descriptions (Any 2) Unilateral Pulsatile quality Moderate to severe pain intensity Aggravation by or causing avoidance of routine physical activity Associated Symptoms (Any 1) Nausea and/or vomiting Photophobia and phonophobia *Must have 5 attacks fulfilling the above criteria and no signs of a secondary headache disorder. The headaches last 4 72 hours

Triggers Anxiety Stress Lack of food or sleep Exposure to light Hormonal changes (in women)

Genetics

Case 2 22 year old female presents with sinus headaches. She gets pressure over her eyes and lights bother her. She admits to being irritable during a headache. The sinus pressure gets worse when she climbs stairs. PmHx negative SocHx: Student, No tobbacco or alcohol Fam Hx: Negative for migraines PE: Normal

Adapted IHS Criteria for General Diagnosis of Episodic TTH* Headache Description (Any 2) Associated Symptoms (Any 1) Pressing or tightening Mild to moderate intensity Bilateral location No worsening with exertion No nausea or vomiting Photophobia or phonophobia (1 allowed) *Must have had >10 previous headache episodes and no evidence of a secondary headache disorder. Episodic TTH occur <15 days/month and CTTH occur >15 days/month. CTTH also allows the presence of mild nausea

Life Cycle of Migraines

Case 3 31 year old male presents with a severe headaches that wake him from sleep for the last two weeks. The pain is so intense that he cries and paces the room. His girlfriend states that he hits his head the pain is so severe. He remembers having headaches like this 2 years ago which lasted about a month and then disappeared. PmHx: Neg SocHx: Smokes 1ppd, 1-2 beers/night FamHx: Remembers his father having bad headaches PE: normal

Adapted IHS Criteria for the General Diagnosis of Cluster Headache* Headache Description (All 4) Severe headache Unilateral Duration of 15 180 min Orbital, periorbital, or temporal location Autonomic Symptoms (Any 2) Rhinorrhea Lacrimation Facial sweating Miosis Eyelid edema Conjunctival injection Ptosis *No evidence of a secondary headache disorder. Episodic cluster headaches occur for <1 year and chronic headaches occur for >1 year.

Characteristics of Primary Headache Disorders Migraine Tension-Type Cluster Location Unilateral Bilateral Strictly Unilateral Intensity Mod/Severe Mild/Moderate Severe Duration 4-72 hrs 30 min-7 days 15 90 min Quality Throbbing Pressing/Tightening Severe Assoc. Symptoms Yes No Yes - autonomic Gender F > M F > M M > F

MSQ

Red Flags for a Secondary Headache Disorder A new or different headache "Thunderclap" headache (peak intensity within seconds to minutes) Worst headache ever Focal neurologic signs or symptoms, such as papilledema, motor weakness, memory loss, papillary abnormalities, or sensory loss Change in existing headaches New onset headache after age 50 Headache associated with systemic symptoms (fever, weight loss, jaw claudication)

Migraine Comfort Signs Positive family history of migraine Headache related to menstrual cycle Headaches preceded by typical aura Headaches remaining periodic and stable over time Normal physical and neurologic findings

Pain Relief

Pain Free

Risk of Reocurrance

MRM = menstrual related migraine Class A Established Efficacy Divaloproex sodium Sodium valproate Topiramate Metoprolol Propranolol Timolol Class B Probable Efficacy Amitriptyline Venlafaxine Atenolol Naldolol Naratriptan(MRM) Zolmitriptan (MRM) Frovatriptan (MRM)

ED algorthim http://effectivehealthcare.ahrq.gov/

Institute of Medicine and Comparative Effectiveness Research Compare the effectiveness of different treatment strategies on the frequency and lost productivity in people with chronic, frequent migraine headaches

Background GHS employee claims data Appropriate anti-migraine medication use is associated with 26% decreased annual total health care costs GHS employee survey 40% with mild to severe headache 45% not satisfied with headache treatment

Utilization and treatment outcomes Utilization Have you ever seen a health care provider in the last year for your 259 (62.1) headaches? Yes, n(%) Have you ever gone to emergency room in the last year because of your 46 (8.6) headaches? Yes, n(%) Have you had a CAT scan or MRI in the last year because of your 68 (12.7) headache? Yes, n(%) Has a health care provider ever told you that you have migraines? Yes, n(%) 339 (63.1) Medication use, n(%) Yes 415 (77.3) OTC 329 (61.3) Prescription drugs 247 (46.0) High utilizers 89 (16.6) Treatment optimization, n(%) Yes 146 (27.2) No 269 (50.0) N/A 122 (22.7)

Impacts of Headache on Treatment Optimization and Productivity Migraine/headache 18% of women and 6% men Most active employment period 25-55 years old Lost work productivity(absenteeism) Reduced efficiency (presenteeism)

Impacts of Headache on Treatment Optimization and Productivity Total costs for migraine: 60%: indirect costs due to lost productivity 40%: direct medical costs

Acknowledgements The study was funded by IAHC seed grant