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A neurologist’s overview
Date: 20 September 2013
Author: Dr Paul Masiowski
A neurologist’s overview
Outline and Objectives
Migraine: a neurologist’s overview
1.Briefly review the diagnosis and pathophysiology of migraine
2.Review red flags for diagnosis of headache
3.Consider the spectrum of migraine-related symptoms
4.Outline strategies for acute and preventive treatment
5.When to refer
A neurologist’s overview
Biography and disclosures
Migraine: a neurologist’s overview
•Queen’s Medicine, 2005
•USask Neurology residency, 2005-10
•FRCPC (Neurology) 2010
•Community practice at Lakeview Neurology
•Clinical Assistant Professor at USask
•SMA Section Rep
•Received honoraria from Allergan
•Interests: Migraine, Neuropsychiatry, Movement
A neurologist’s overview
Migraine is extremely common
Epidemiology of migraine
•Lifetime prevalence: 43% in women, 18% in
•Equal in boys and girls (4 - 5%)
•After puberty, increasingly prevalent in
females (role of estrogen)
•New diagnosis possible at any age
•Often hereditary (polygenic)
•Rare monogenic forms
•May be underdiagnosed
A neurologist’s overview
Migraine is a brain disorder
Pathophysiology of migraine
•Cortical spreading depression (CSD) -->
•Pain from dura, blood vessels, soft tissues
via trigeminal nerve (V3), upper cervical roots
•Connections in brainstem
•Projects up (pain signals to limbic areas, etc)
•Projects peripherally (autonomic activation)
•Produces a feedback loop
•Hypersensitization (allodynia, etc)
A neurologist’s overview
A neurologist’s overview
Diagnosis of migraine
A spectrum of related conditions
•Episodic migraine (with or without aura)
•Chronic migraine
•Acephalgic migraine (aura)
•Other periodic disorders:
•Hemiplegic migraine
•Migraine associated vertigo
•Cyclic vomiting syndrome
•Retinal migraine
A neurologist’s overview
Episodic migraine
Diagnostic criteria
A neurologist’s overview
Migraine aura
A sensory experience
•Aura can occur before or during the
headache... .
...or in the absence of a headache
•About 20% of patients with migraines get
auras (often unpredictable)
with a shimmering edge (fortification), stars, dots,
May also
or postdrome
wavy lines, complex patterns, visual distortions
•Sensory aura: paresthesia, usually unilateral, develop slowly and migrate, esp. in
hand and face
•Speech aura: dysphasia, often mild (hard to get words out, have to think about it)
•Motor aura: a sense of slowness and difficulty in movement (subjective only)
A neurologist’s overview
Migraine aura
Diagnostic criteria
A neurologist’s overview
Is this acute headache a migraine?
Red flags
•New after 50 years of age (temporal arteritis?)Sudden onset:
(SAH? AVM? pituitary apoplexy?)
•Worsening frequency and severity (mass lesion? subdural?)In
patient with systemic disease: (mets? chronic meningitis?
•With fever +/- stiff neck, altered LOC: (meningitis? encephalitis?)
•With focal signs or symptoms other than typical aura: (stroke?)
•With papilledema: (mass lesion? pseudotumor cerebri?)
•After trauma: (intracranial hemorrhage?)
•SNOOP: Systemic, Neurologic, Onset (new), Other (associated),
A neurologist’s overview
From episodic to chronic migraine
Risk factors for progression
A neurologist’s overview
Chronic migraine
Diagnostic criteria
•Headache fulfilling criteria C and D for migraine
without aura
•on ≥15 days/month for >3 monthsNot attributed to
another disorder
•Also includes ≥15 days of any headache,
•including ≥8 days of migraineExpect previous history
of episodic migraineMedication overuse is a confound
A neurologist’s overview
Medication overuse headache
Diagnostic criteria
•Headache ≥15 days/month
•meeting criteria C and D for migraine without auraRegular overuse for ≥3 months
of one or more drugs that can be taken for acute treatment of headacheHeadache
developed or markedly worsened during medication overuseHeadache resolves or
improves within 2 months of discontinuation of overused medication
A neurologist’s overview
Underrecognized migraine
chronic or recurring head and neck pain
•“sinus” headaches (dysautonomia)
•menstrual headaches
•occipitonuchal pain
•post-traumatic headache
•headaches related to psychiatric conditions
...also, associations with:
•stroke / TIA
•MRI changes (white matter lesions)
A neurologist’s overview
Other migraine-related conditions
Recurring paroxysmal disorders of the nervous system
•Cyclic vomiting syndrome
•Migraine associated vertigo
•Persistent positive visual phenomena
•Olfactory hallucinations
•“frequent TIAs”
A neurologist’s overview
Is it a migraine?
Three pillars to the diagnosis
1.RecurrenceStereotypic symptoms
The characteristics of a paroxysmal neurological
...of which migraine is by far the most common
A neurologist’s overview
Management of migraine
Trigger threshold theory
•Migraine has many characteristic
•change in sleep pattern
•change in eating pattern
•change in weather
•hormonal influences
•lights, noises, smells
•food & alcohol
A neurologist’s overview
Management of migraine
Trigger threshold theory
•Migraine may be viewed as the interaction of environmental triggers and a
susceptible host.
•Mechanism of triggers unknown, may involve nitric oxide (NO) signalling
A neurologist’s overview
Acute migraine therapy
Medications for migraine attacks
•Goal is to relieve pain and associated symptoms and reduce disability
•Response unpredictable, even for same patient to same drug
•Early treatment is best:
•interrupt the migraine build-up
•easier to prevent than reverse migraine physiology
•Medication choice depends on severity and patient, do not need to step up
•OTC analgesics --> NSAIDs --> triptans
•SC (sumatriptan) or nasal spray (sumatriptan) or wafers (rizatriptan) if early
•Fluids, caffeine, rest / sleep, ice packs, etc
•Avoid medication overuse (max 15 days per month of OTC, 10 per month of
•Avoid opioids if possible
A neurologist’s overview
Management of chronic migraine
Medications for migraine prevention
•Response can be gradual (over months)
•side effects worst first
•titrate up slowly
•Medication choice depends on severity, side effect profile
•HTN: beta-blocker, ARB;
•mood disorder: TCA, valproic acid
•insomnia: amitriptyline
•weight loss: topiramate
•But side effects also limit choices:
•asthma: avoid beta-blockers
•kidney stones: avoid topiramate
•elderly: avoid TCAs at higher doses (anticholinergic)
A neurologist’s overview
Management of chronic migraine
Strategies I use
•Milder symptoms, less disability
•nortriptyline (amitriptyline if insomniac)
•propranolol, flunarazine
•More severe symptoms and disability
•valproic acid
•TCA or beta blocker at higher dose
•Patient prefers not to take medications
•magnesium, riboflavin, coenzyme Q10, feverfew, butterbur
•In all cases:
•trigger management, education
•avoid medication overuse (caffeine too)
A neurologist’s overview
How about Botox?
Botulinum toxin injections for chronic migraine
•Clinical experience dates back >25 years
•PREEMPT trials (placebo-controlled RCT) published 2009-19
•Health Canada approved for chronic migraine prevention, 2011
•Used second-line or third-line in most cases
•Favorable side effect profile
•Injections usually well tolerated
•Cost is an issue
•Applying for new billing code for injections
•Many patients discontinue other preventive medications, and reduce use of acute
A neurologist’s overview
Multidisciplinary approach is best
The modern headache clinic
•Neurology, Family medicine
•Occupational therapy, Physiotherapy
•Social work, Psychology
.... strategies for acute and preventive treatment
Any questions?
Feel free to email me with questions:
[email protected]
A neurologist’s overview
Migraine is a primary headache disorder
Classification of primary headaches by frequency