migren pdui 2015
TRANSCRIPT
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Curriculum Vitae• Nama : Muhammad Akbar
• Pendidikan :1. Dokter (dr) 1987, Unhas
. !"esia#is !ara$ (!".!) 199%, Unhas
&. Doktor (Ph.D) ''1, iroshima, e"an*.
+. Di"#oma in orensi- Medi-ine (DM) ''&, ronin*en, /e#anda.
%. 0onsu#tan erebro 2as-u#ar (!".!(0) '1&
Amanah :1. 0e"a#a Pusat 0a3ian Media dan !umber /e#a3ar, 4emba*a 0a3ian dan
Pen*emban*an Pendidikan UNA!, ''56'1'
. 0etua D i#aah !u#6!e# ''56''9
&. 0etua Perhim"unan Dokter !"esia#is !ara$ (P;D
Pusat, ''76'11 +. 0etua Perhim"unan Dokter mer*ensi ndonesia Pusat ''76'11
%. 0etua P
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HEADACHE AND MIGRAINEMANAGEMENT
Muhammad Akbar
NEUROLOGY DEPARTMENT
HASANUDDIN UNIVERSITY
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Introduction:
Headache is the most common problemneurologists encounter in their clinicalpractices
!i"etime pre#alence o" headache $allt%pes& is 96%
Although most o" these headaches are
benign $'()*&+ a small percentagere,uire urgent diagnostic studies and
treatment
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-#er .)) illnesses cause headache as as%mptom/
Temporal arteritis
0ubarachnoid1 subdural haemorrhage
Idiopathic intracranial h%pertension
Intracranial h%potension
Carotid1#ertebral arter% dissection
Cerebral #asculitis
Re#ersible cerebral #asospasm
Meningitis
Cerebral #ein thrombosis
Arnold chiari mal"ormation
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2hat to do 3rst4
Most important to 3nd out i" there is an%
red fag in this headache
Ta5e a good history: onset+ se#erit%+an% s%stemic "eatures6
Then+ tr% to identi"% i" %ou are dealing7ith primary or secondary headache
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Classi3cation o" Headache
Primary headaches (No underlying cause&MigraineTension-type TACs
-therSecondary headaches (Underlying cause)Medication o#eruseHead1nec5 in8ur%0pace9occup%ing lesion $ie brain tumour&Vascular cause $ie 0ubarachnoid hemorrhage+intracranial bleed&In"ectious cause $ie meningitis or upper respirator% tractin"ection& man% others
Headache Classi3cation Committee o" the International Headache Society+;(
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=rimar% HeadacheDisorders
More common Migraine+ 7ith or
7ithout aura Tension t%pe
Cluster
• Less commonLess common
• Paroxysmal hemicraniaParoxysmal hemicrania
• Idiopathic stabbingIdiopathic stabbing
• Cold-stimulusCold-stimulus
• Benign coughBenign cough• Benign exertionalBenign exertional
• Associated with sexual Associated with sexual
actiityactiity
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0econdar% HeadacheDisorders
• Associated with non- Associated with non-ascular intracranialascular intracranialdisorder disorder • Benign intracranialBenign intracranial
hypertensionhypertension• Intracranial in!ectionIntracranial in!ection
• Low CS" pressureLow CS" pressure
• Associated with Associated withnoncepalic in!ectionnoncepalic in!ection• #iral in!ection#iral in!ection
•Bacterial in!ectionBacterial in!ection
• Associated with ascular Associated with asculardisordersdisorders• SubarachnoidSubarachnoid
hemorrhagehemorrhage
• Acute ischemic Acute ischemiccerebroascular disorder cerebroascular disorder
• $nruptured ascular$nruptured ascularmal!ormationmal!ormation
• Arteritis Arteritis• Carotid or ertebral arteryCarotid or ertebral artery
painpain
• #enous thrombosis#enous thrombosis
• Arterial hypertension Arterial hypertension
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0econdar% HeadacheDisorders
Associated 7ithhead trauma Acute post9
traumatic headache
Associated 7ithsubstance use or7ithdra7al
Acute use ore>posure Chronic use or
e>posure
Associated 7ithmetabolicdisorders
H%po>ia H%percapnia
Mi>ed h%po>ia ?h%percapnia
Dial%sis
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0econdar% HeadacheDisorders
Associated 7ith head trauma Acute post9traumatic headache
Headache o" "acial pain associated 7ithdisorder o" cranium+ nec5+ e%es+ ears+nose+ sinuses+ teeth+ mouth or other
"acial or cranial structures
Cranial neuralgias+ ner#e trun5 pain and
dea@erentation pain
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Clues to Secondaryeadache
"e#er+ seiure+ beha#ioral change+ etc
age 'BB
posterior location
neurological de3cit
abrupt onset1se#ere intensit%:thunderclap
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Meningococcal rash
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attleFs sign
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Temporal arteritis
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Headache Histor%
Is this %our 3rst or 7orst headache4Ho7 bad is %our pain on a scale o" ;9;)4 Do%ou ha#e headaches on a regular basis4 Isthis headache li5e the ones %ou usuall%
ha#e4
2hat s%mptoms do %ou ha#e be"ore o"during the headache4 2hat s%mptoms
do %ou ha#e no74
2hen did this headache begin4 Ho7did it start $graduall%+ suddenl%&4
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Headache Histor%
• %here is your pain&%here is your pain&'oes the pain spread to any other area& %here&'oes the pain spread to any other area& %here&
• %hat (ind o! pain do you hae%hat (ind o! pain do you hae )throbbing*)throbbing*stabbing* dull* others+stabbing* dull* others+&&
• 'o you hae other medical problems&'o you hae other medical problems&• 'o you ta(e medicines&'o you ta(e medicines&
• Hae you recently hurt your head or had aHae you recently hurt your head or had a
medical or dental procedure&medical or dental procedure&
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Essential Questions
Headache duration+ location+ ,ualit%+se#erit%+ e>acerbating1relie#ing "actors+associated s%mptoms+ speci3c timing inthe da%6
!hy did the patient come to the ER4 2as the onset sudden or gradual4 Does the patient ha#e an% underl%ing
medical conditions+ eg+ are the%immunosuppressed4 An% recent head trauma4 An% medications4
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lue lag Headaches
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Red lag Headaches
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-ther Red lag Headaches
Associated 7ith rash Ma% indicate !%me disease or meningococcemia
Non9migraine headache in pregnanac% or post9
partum Ma% indicate cerebral thrombosis
Associated 7ith changes in posture Ma% indicate lo7 C0 pressure due to spontaneous C0
lea5
Associated 7ith pressing #isual disturbances Ma% be due to glaucoma or optic neuritis
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Headache Red lags: 09N9-9-9=90
S%stemic s%mptoms: "e#er+ 7eight loss Neurological s%mptoms or abnormal signs:
con"usion+ impaired alertness or consciousness
"nset: suddent+ abrupt or split9second "lder: ne7 onset or progressi#e headache+
speciall% in patients ' B) %o Pre#ious headache histor%: 3rst o ne7 or
di@erent headache Secondar% ris5 "actors: s%stemic cancers+
HIV
David Dodick, MD
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Tests for secondary causes
CT scan $mass lesion+ 0AH&
M#$M#&M#' $mass lesion+ dissection+AVM+ aneur%sm+ AVM+ #enous thrombosis&
umar puncture $meningitis+ 0AH+intracranial h%pertension&
&ngiography $aneur%sm+ AVM+ #asculitis+
#enous thrombosis+ dissection& as: E0R+ CC+ T0H+ drug screens+
electrol%tes
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International Classi!ication o! Headache),.+
Primary Headaches
Migraine 7ithout aura Migraine 7ith aura
Tension t%pe headache
Trigeminal Autonomic Cephalgias $TACs& Cluster headache =aro>%smal hemicrania
0NCT
-ther primar% headaches
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tension9t%pe headache
0imple analgesics paracetamol+ N0AIDs+ aspirin
=re#ention tric%clics+ gabapentin+ topama>+ epilim
Management o" stress and tension
E>ercise
2atch "or M-H
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cluster headache and other
trigeminal autonomic cephalgias
Cluster headache $episodic or chronic& Intermittent+ e>cruciating+ sharp1stabbing
Ipsilateral autonomic sign $con8uncti#al in8+ lacrimation+ nasalcongestion+ rhinorrhea+ e%elid oedema+ "orehead and "acials7eating+ miosis or ptosis&
;B9;
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other primary headaches
=rimar% stabbing headache
=rimar% cough headache
=rimar% e>ertional headache
=rimar% headache associated 7ith se>ual acti#it% H%pnic headache
Hemicrania continua
Ne7 dail%9persistent headache
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=rimar% stabbing headache
=aro>%smal + #er% short $o"ten less than ; sec& pain attac5s7hich occur as single or as repetiti#e pain stabs
A@ect a circumscribed area+ usuall% in VI 0tabbing+ mild to mod intensit%
; a %ear to ;)) a da% More common in patients 7ith other headache disorders 0pontaneous or triggered eg Cold ice or drin5s+ ice9pic5 li5e
pain No cranial autonomic s%mptoms
=athoph%siolog% un5no7n suall% no treatment Indomethacin i" #er% "re,uent JB to B) mg bd Tr% melatonin+ ni"edipine+ gabapentin
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=rimar% cough headache
0udden onset and lasts one second to .) minutes
Triggered b% coughing or #alsal#a
;; to B) * o" cases cough ha is s%mptomatic+ most commonis Arnold9Chiari t%pe ;+ other causes incl post "ossa mass+
craniocer#ical abnormalities+ non9ruptured aneur%sms Mean age o" onset BB to LB and men .9B > more common
than 7omen
-"ten spontaneous remission+ usuall% J months to J %ears
suall% no treatment+ a#oid coughing
Indomethacin B)mg bd range JB to J))mg+ mean duration
o" treatment L mths to K %ears Alternati#e isacetaolamide+ or topama>+ !=
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=rimar% e>ertional headache
Triggered b% di@erent t%pes o" ph%sical e>ercise eg 7eightli"ting+ s7imming and running
=ulsating headache lasting B mins to K< hours JJ to K.* o" cases are secondar% 0AH+ cer#ical arter%
dissection+ Arnold9Chiari mal"ormation+ post "ossa lesions+intracranial #enous anomalies or stenoses
suall% in earl% adult %ears Co9morbidit% 7ith primar% ha associated 7ith se>ual
acti#it% in about K)* and KL* ha#e migraine
0pontaneous remission is common A#oid e>ercise or slo7 increase esp in heat or high altitude Indomethacin or propranolol or short term proph%la>is 7ith
indomethacin JB to B) mg ; hour be"ore e>ercise
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=rimar% headache associated 7ith se>ualacti#it%
• Not assoc 7ith other sorts o" ph%sical acti#it% but pts can also ha#ee>ertional or cough headache Independent to the 5ind o" se>ualpractice
• -rgasmic$.9K > more common& or pre9orgasmic
• =ain is bilateral+ di@use or occipital
• suall% about .) mins and up to JK hours
• E>clude secondar% headache $;;* o" 0AH occur during se>ual acti#it%&
• Mechanism o" disorder is un5no7n
• su spontaneousl% remit but can last da%s to %rs and recur
• Men . to K > more "re,uent
• 0pontaneousl% remit
• Treatment is to stop as soon as headache starts
• =anadol+ #oltaren+ aspirin or nuro"en ine@ecti#e+ triptans can settle ha+B)9Bmg indomethacin is recommended proph%lacticall% $
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H%pnic headache
Almost e#er% night $at least e#er% 7ee5& a occursheadache during sleep t%picall% at the same time eachnight
=ulsating or dull+ moderate+ .) mins to . hours+ bilateral"rontotemporal or di@use
No assoc autonomic s%mptoms
suall% starts o#er the age o" B)
Main problem is disturbed sleep
-nl% treat i" impaired ,ualit% o" li"e
0trong co@ee or oral ca@eine at bedtime+ or lithium+indomethacin
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=rimar% thunderclap headache
0udden headache o" ma>imal intensit% similar to that o" aruptured aneur%sm 7ith normal imaging and C0
In the acute headache phase+ di@use+ segmental or multi"ocal#asospasms in all #essel territories 7ithout e#idence o"aneur%sm or bleeding
Vasospasm is completel% re#ersible
Re#ersible cerebral #asoconstriction s%ndrome
suall% once in a li"etime
Can be triggered b% heat
-ther disorders can cause sudden se#ere headache and needto be considered
No data on pre#alence+ 7omen'men+ mean age KB $JB9L&
Treat acutel% 7ith paracetamol and opioids
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Hemicrania Continua
irst described in ;(
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Ne7 dail% persistent headache
irst described in J))K
DiOcult to distinguish "rom chronic tension9t%pe ha
Acute or subacute onset 7ithin . da%s and then continuous
Resembles chronic t9t ha but can ha#e migrainous "eatures
su bilateral+ mostl% not pulsating+ dull and mild to modintensit%
No preceding episodic ha 7ith increasing "re,uenc%
Consider medication o#eruse
=ost in"ectious occurrence considered
MP+ onset ;) to .) or B) to L) %rs
No e#idence based treatment recommendation but e>pert
consensus agrees treatment is #er% diOcult Treatment choicedepends on primar% "eatures
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headache management
Good 7or5ing relationship 7ith the patient
Trial and error rarel% a simple 3>/
Manage e>pectations Diar% o" headache and medication use
Regular consultations
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Headache diar% 777migraineclinicorgu5
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Chronic 'aily Headache
=rimar% headache occurring on at least ;B da%s o" themonth
. to B* o" the population
suall% a mi>ture o" tension9t%pe headache and migraine About ;)* o" this group ha#e ne7 dail% persistent
headache
-"ten complicated b% head in8ur% and medication o#eruse
-"ten accompanied b% mood disorder Increased ris5 o" chroni3cation o" migraine also occurs
7ith obesit%+ ca@eine inta5e and stress Q
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Medication o#eruse headache
• An% analgesic can cause M-H/
• A neurobeha#ioural disorder / =h%sical receptor alterations / eha#ioural e>cessi#e1obsessi#e drug9ta5ing+
anticipator% an>iet%+ "ear o" pain
Man% use drugs to cope 7ith li"e and stress+ e#en7hen not #aluable "or pain
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Treatment o" M-H
Multidimensional approach
Discontinuation o" dail% medication
=re#enti#e therap% to limit headache occurenceand1or se#erit%
Diar% $the !ondon Migraine Clinic Headache
Diar%& Ma% need i# dih%droergotamine protocol as
inpatient
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0%mptomatic Therap%
As aborti#e therap% Goal: to abort+ reduce or stop a
headache+ head pain or s%mptoms
accompan%ing a headache
=urpose:
"or acute attac5s that are in"re,uent "or brea5through attac5s 7hile onpre#enti#e therap%
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0%mptomatic Therap%
Notes: etter used at onset o" headache
re,uentl% combined 7ith pre#enti#e therap% Can cause rebound headaches
0hould not e>ceed . da%s17ee5
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=re#enti#e Therap%
As proph%la>is or pre#ention o" recurrence Goal: reduce "re,uenc%+ se#erit% and
duration o" attac5s
=urpose: or "re,uent attac5s o" headache or moderate to se#ere headaches or those on e>cessi#e use o" s%mptomatic
medication 7ithout relie"
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=re#enti#e Therap%
Notes: Gi#en dail% "or at least .9L months
egin at lo7er dose 7ith up7ard titration Reassess e#er% L months 0ome medications need tapering be"ore
discontinuation
Encourage e@ecti#e birth control in "ertile7omen 7hile on pre#enti#e therap%
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The pre#enti#ealphabet Antidepressants: nortript%line+
amitript%line+ C%mbalta
9bloc5ers: propranolol+ atenolol+nadolol
Calcium channel bloc5ers: #erapamil
Depa5ote $#alproic acid&
Epileps% meds $other than
Depa5ote&: gabapentin+ topiramate+!%rica
Misc: tianidine+ Namenda
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oto> Treatment
oto> In8ections9 Appro#ed b% DA in -ctJ);)/
Appro#ed "or chronic migraine $migraine
headaches happening more than ;Bda%s1 month&
.J in8ection sites in "orehead+ temples+shoulders and nec5
Man% insurance companies are still3ghting not to co#er this
!i"est%le
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!i"est%leManagement 0leep < hours consistent schedule
Eat . regular meals $or more& per da% Drin5 lots o" uids Get Aerobic e>ercise regularl% !imit ca@eine $or better %et a#oid
completel%& Identi"% your triggers Seep a headache diar% Manage stress se correct posture and pause during
repetiti#e acti#ities
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Nonpharmacologic
Treatments io"eedbac5io"eedbac5 Rela>ation therap%Rela>ation therap%
Cogniti#e eha#ioral Therap%Cogniti#e eha#ioral Therap% AcupressureAcupressure
AcupunctureAcupuncture
=h%sical Therap%=h%sical Therap% Chiropractic treatmentChiropractic treatment
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Additional Treatment
Measures -ccipital Ner#e 0timulators TEN0 units
Transcranial Magnetic 0timulator
0pecial Diets
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2hat Is Migraine4
A chronic disorder 7ith episodicattac5s
Comple> changes in the brain
• During attac5s / Headache
/ 0e#eral associated
s%mptoms / unctional disabilit%
• In9bet7een attac5s Enduring predisposition to
"uture attac5s
Anticipator% an>iet%
TG0 P trigeminal s%stem TNC P trigeminal nucleus candalis
igal ME et al Neurology J))
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Migraine:A Continuum o" 0%mptoms
Cad% R et al Headache. J))JKJ:J)KJ;L!inde M Acta Neurol Scand J))L;;K:;
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Migraine:Headache Not Al7a%s Gradual
Cad% R et al Headache. J))JKJ:J)KJ;L!inde M Acta Neurol Scand J))L;;K:;
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migraine
Migraine 7ithout aura K to J hrs duration
nilateral+ pulsing ,ualit%+ mod to se#ere pain+aggra#ated b% usual ph%sical acti#it%
At least one o" :nausea and1or #omiting+ photophobia and phonophobia
Migraine 7ith aura
ull% re#ersible #isual and1or sensor% and1or speech s>sbut no motor 7ea5ness
Headache begins during the aura or "ollo7s aura 7ithinL) mins
T i 0 t Th t Mi i
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Triggers 0uggest That MigraineIs a Disorder o" the brain $CN0&
The case orthe sensiti*emigraine rain
Normal lie
e*ents trigger orare associated.ith attac/s inthosepredisposed
CN0 P central ner#ous s%stemCoppola G et al Cephalalgia J))J:;KJ(;K.( Selman ! Cephalalgia J)) J:.(KK)J =ietrobon D et al
Nat )e Neurosci J)).K:.
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Causes o" Migraine
Increased excitability of CNS
Meningeal blood vessel dilation
Activation of perivascular sensory trigeminal nerves
Pain impulses Vasoactive neuropeptides contain:
substance P
calcitonin gene-related peptide C!"P#
neuro$inin A
combination of increased pain sensitivity% tissue and
vessel s&elling% and inflammation
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K 0tages o" Migraine
'( Prodrome
)( Aura
*( +eadac,e
( Postdrome
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=rodrome -ccurs hours to da%s be"ore
migraine 7ithout headache Aura
Neurological phenomenasuch as disturbance o"#ision 8ust be"ore headache
=ain phase Headache on one side o"
head 7ith nausea+photophobia and other
classic migraine s%mptoms =ostdrome
E>haustion+ irritabilit%+depression
The K phases o" a migraine
=hases o" Migraine
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=hases o" MigraineMigraine are more than 8ust pain
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Prodrome
0tage o" Migraine that is characteriedb% diOcult% concentrating+ %a7ning+"atigue and1or sensiti#it% to light and
noise Duration: A "e7 hours to a "e7 da%s
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Aura
0tage o" migraine that is characteriedb% #isual illusions o" spar5s and lights+o"ten "ollo7ed b% blind or dar5 spots in
the same place as the brighthallucinations
Duration: J)9L) minutes
http:11777health8oc5e%com1J))1;;1J)1brain9di@erences9detected9in9migraine9su
@erers1
http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/http://www.healthjockey.com/2007/11/20/brain-differences-detected-in-migraine-sufferers/
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d h
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Headache
0tage characteried b%e>cruciating or throbbingpain along 7ith sensiti#it%to light and sound
Ma% be accompanied b%nausea and #omiting
0ometimes onl% hal" o" the
head or part o" the head isin pain
Duration: K J hours
P d
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Postdrome
Characteried b%: sensiti#it% to light and
mo#ement
!etharg%
atigue DiOcult% "ocusing
Also called a ombie phase
Duration: A "e7 hours to a
"e7 da%s
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Menstrual Migraine
Da% 9J to .
Migraine 7ithout aura
Estrogen patches poor result
Mini9proph%la>is 7ith N0AIDs and1or sumatriptan
Tric%cle coc pill or reduced pill9"ree inter#al orsupplemental estrogen
0top o#ulation 7ith ceraette or depo pro#era
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2 t T t Mi i
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2a%s to Treat Migraines
A#oiding Trigger actors
0imple Non9Drug Treatment
=ain Medications
=roph%lactic Medications Aborti#e Medications
$acute+ speci3c medications&
Magnesium
A idi T i t
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A#oiding Trigger actors
or reasons un5no7n+ migraines can beset o" b% man% "actors li5e alcohol+per"ume+ deh%dration+ e>cessi#e
e>ercise+ menstruation+ stress+ 7eatherchanges+ seasonal changes+ allergies+lac5 o" sleep+ altitude+ ic5ering lightsand hunger
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8/18/2019 Migren Pdui 2015
74/99
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8/18/2019 Migren Pdui 2015
75/99
Acute Therap% "or Migraine
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76/99
Clinical Pracic! Guid!lin! "#r h! Dia$n#%i% and Mana$!m!n #" Mi$rain!& IEHP& N#'!mb!r ()*)
Acute Therap% "or Migraine$=harmacolog%&
&orti*e(symptomatic)
Pre*enti*e(prophylactic)
=ain9"ree response at J hours$IH0+J);)&
Nonspecific Specific
Aborti#e Medications
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Aborti#e Medications
Triptans Current Triptans in use:
Sumatriptan Naratriptan olmitriptan
Riatriptan Almotriptan ro#atriptan Eletriptan
Ergots Current ergots in use
0, Ergotamine Tartrate Ca"ergot Isomethaheptane
WHY THE NEED FOR PROPHYLAXIS ?
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WHY THE NEED FOR PROPHYLAXIS ?
Ab#ri'! dru$% %h#uld n# b! u%!d m#r! han (+, im!% a
-!!k
L#n$+!rm .r#.h/la0i% im.r#'!% 1uali/ #" li"! b/ r!ducin$
"r!1u!nc/ and %!'!ri/ #" aack%
2)3 #" mi$rain!ur% ma/ r!1uir! .r#.h/la0i%
=roph%lactic Medications
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=roph%lactic Medications
or those patients 7ho e>perience se#ere andcomplicated migraines more than J times a month
Three categories
Anticon#ulsants
Topiramate $Topama>& Antidepressants
Verapamil or Nortript%line
Antih%pertensi#es
=ropranolol or Venla"a>ine I" one doesnFt 7or5 then it is gi#en in combination
7ith the others
acute treatment o" migraine
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acute treatment o" migraine
Triptan is the treatment o" choice "or migraine Contraindications include pregnanc%+ age+ cardiac
histor%+ pre#ious ad#erse e@ects o" triptans
A number o" patients 7ill respond to simple analgesicsearl% in the course o" the headache
I" no contraindications to use o" a triptan+ then 7hichmight be the most suitable triptan and 7hich route o"deli#er%4
Is nausea present4 -ral #s subcutaneous #s nasal spra%
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81/99
acute treatment o! migraine
ri1atiptan(ma2alt) ;)mg
sumatriptan B)9;)) mg
1olmitriptan(1omig) Bmg intranasal spra%
$recurrence+ triptan9speci3c side e@ects and cardio#ascularsa"et%&
9 0tudies con3rm earl% treatment produces greatereOcac% $0TART stud% J);)+ LJ* J hr pain9"ree #s .B*&
9 In non9responders to sumatriptan+ riatriptan 7as "oundto be e@ecti#e $J hr pain relie" B;*+ pain "reedom JJ*&
$J);)+Cephalalgia&
$ca"ergot or codeine phosphate or tramadol&
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acute treatment o! migraine
=aracetamol rapid ;g W9 N0AID
parama> J tabs W9 N0AID Napro>en sodium BB)mgtra+ co@ee+ co5e
anti9emetics ma>olon+ buccastem+ ondansetron Q
=re#enti#e treatment
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B)* reduction in B)* o" patients
=ropranolol use ;) or K)mg tabs and increase to B9;))mg1da%+ ma>imum J))mg1da%
Epilim use J))mg tabs and increase graduall% to L)) to
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8/18/2019 Migren Pdui 2015
84/99
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8/18/2019 Migren Pdui 2015
85/99
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8/18/2019 Migren Pdui 2015
86/99
Adances in the preentie treatment o! migraine
Topiramate is currentl% one o" the best studied pre#enti#edrugs
It can be e@ecti#e "or migrainous #ertigo e#en at a small
dose o" B)mg1da% Cannot stop the de#elopment o" chronic dail% ha but
reduces o#erall ha da%s
Its e@ecti#eness ma% be due to augmentation o" the
GAAa receptor+ modulation o" sodium channels+glutamate receptor antagonism+ carbonic anh%draseprotein 5inase inhibition+ possible serotonin acti#it% oralteration o" neuroinammator% "actors
Special areas in treatment o! migraine
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Special areas in treatment o! migraine
• Menopause i" go in 7ith episodic better than CDH• =regnanc%
/ TcaFs+ beta9bloc5ers / =aracetamol+ diclo"enac JB9B)mg $ not 3rst trimester
and not "or more than or . consecuti#e da%s&+ codeine
• Complementar% and alternati#e treatments / Riboa#in $#itamin J& K)) mg1da% / Magnesium
/ Coen%me X;) / Vitamin D / Iron supplements
Special areas in treatment o! migraine
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Special areas in treatment o! migraine
Diet Dair% "ree diet minimum o" . 7ee5s
Gluten "ree diet minimum o" . months
E>ercise #er% important////
Massage and acupuncture
Ice to Head
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!i"est%le Modi3cation "or
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90/99
!i"est%le Modi3cation "orMigraine Eat health"ull% and regularl% do not s5ip meals
Get enough sleep+ but do not o#ersleep
Seep a regular sleep schedule
Seep 7ell h%drated
E>ercise regularl%
Rest during a migraine+ and do not o#ere>ert
a"ter7ard
Reduce %our stress
Identi"% %our triggers and a#oid 7hen possible
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8/18/2019 Migren Pdui 2015
91/99
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8/18/2019 Migren Pdui 2015
92/99
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8/18/2019 Migren Pdui 2015
93/99
-
8/18/2019 Migren Pdui 2015
94/99
-
8/18/2019 Migren Pdui 2015
95/99
-
8/18/2019 Migren Pdui 2015
96/99
-
8/18/2019 Migren Pdui 2015
97/99
-
8/18/2019 Migren Pdui 2015
98/99
-
8/18/2019 Migren Pdui 2015
99/99