Migraines Mark Green, MD Clinical Professor Department of Neurology Columbia University New York, NY

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MigrainesMark Green, MDClinical
ProfessorDepartment of NeurologyColumbia
University New York, NY
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Patient History

• Patient is a 36-year old woman with a 10-year
  history of recurring headaches
• Average 2 headaches per month
• Headaches are left-sided, hemicranial, and
  associated with nausea and vomiting
• Attacks last 2 days, afterwards she is well

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Patient History

• Patient is a 38-year old woman with a long
  history of unilateral throbbing headaches
  associated with nausea and vomiting
• Headaches last 2 days and are particularly likely
  to occur while menstruating
• Over past 6 months, headaches have increased
  still unilateral but continuous
• Taking 50 Excedrin Migraine tablets each week for
  headache and getting only temporary relief

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Drug Overuse in Headache Patients

• Regular use of
• Analgesics
• Vasoconstrictors
• Decongestants
• Caffeine
• Triptans, NSAIDs (rare)

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Why is a migraine disabling?

• Pain
• Nausea, vomiting
• Photophobia and phonophobia
• Encephalopathy

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Common Comorbidities of Migraine

• Cardiovascular
• Hypertension or hypotension
• Raynauds disease
• Mitral valve prolapse
• Angina / myocardial infarction
• Stroke
• Respiratory
• Asthma
• Allergies

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Common Comorbidities of Migraine

• Gastrointestinal
• Irritable bowel disease
• Neurologic
• Epilepsy
• Psychiatric
• Depression
• Bipolar disorder
• Panic disorder
• Anxiety disorder

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Problems with Narcotic Analgesics

• Sedating
• Increases nausea and vomiting
• Vasodilator
• Rebound headaches
• Drug-seeking behavior

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Dopamine Antagonists

• Chlorpromazine
• Metoclopramide
• Prochlorperazine
• Droperidol

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Problems with Dopamine Antagonists

• Sedating
• Orthostatic hypotension
• Extrapyramidal effects

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NSAIDs

• Ketorolac (parenteral)
• Indomethacin (suppositories)

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Triptans in the ER

• Injectable sumatriptan most likely to work in a
  prolonged migraine
• Comorbidities
• Medications taken before ER

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Dihydroergotamine

• Intravenous or intramuscular
• Pretreat with an antiemetic
• Cannot mix with triptans/other ergots

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Corticosteroids

• Reduce rate of headache recurrence
• Little immediate relief

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Depacon

• 1 gram IV in 50 cc NS by rapid infusion over 5
  minutes
• Compatible with use of triptans/ergots same day
• No sedation
• Improvement in associated migraine symptoms
• Can begin prophylaxis immediately if desired

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Patient History

• Patient is a 37-year old woman who had abrupt
  onset of a severe occipital headache with mild
  nausea
• Had transient diplopia, which resolved before she
  arrived at the hospital
• Headache remained constant without any
  photophobia but with moderate nausea
• Her neurological examination was normal and her
  headache and nausea responded well to sumatriptan
  and she was discharged

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Patient History

• A 45-year old male presented to the emergency
  room in the evening. He had a long history of
  migraine without aura, which was treated with
  rizatriptan. This treatment has been generally
  successful in the past, but he did not respond on
  this occasion. He had taken it at 3am when he
  was awakened with a unilateral throbbing headache
  accompanied by nausea and vomiting. The rest of
  the evening and throughout the morning he
  continued to vomit frequently and did not appear
  to improve taking ibuprofen every 4 hours.

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When would you do a CT scan on this man?

• If his neurological examination is normal.
• If he does not respond to another dose of
  rizatriptan.
• If he does not have a pre-existing history of
  migraines.

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What would be your next treatment?

• Another dose of rizatriptan, in the MLT
  formation.
• Injectable sumatriptan.
• Intravenous prochlorperazine.
• Intravenous divalproex.

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Patient History

• Patient is a 37-year old woman who had abrupt
  onset of a severe occipital headache with mild
  nausea
• Had transient diplopia, which resolved before she
  arrived at the hospital
• Headache remained constant without any
  photophobia but with moderate nausea
• Her neurological examination was normal and her
  headache and nausea responded well to sumatriptan
  and she was discharged

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The response to medication is not diagnostic of
the problem.
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