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Non-headache manifestations of Migraine


Non-headache manifestations of Migraine Dr Nicholas Silver Consultant Neurologist The Walton Centre for Neurology and Neurosurgery BASH HULL 2011 – PowerPoint PPT presentation

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Title: Non-headache manifestations of Migraine

Non-headache manifestations of Migraine
  • Dr Nicholas Silver
  • Consultant Neurologist
  • The Walton Centre for Neurology and Neurosurgery
  • BASH HULL 2011

Copies of slides anne.mccann_at_thewaltoncentre.n
Migraine Third National Morbidity Survey
  • Primary care consultations
  • gt 300,000 person-years
  • 9.5 of population consult GP each year re
    neurological symptom
  • Top 5 symptoms
  • Headache/migraine
  • Dizziness
  • Syndromes related to the cervical or lumbar spine
  • Faints or fits
  • Symptoms due to cerebrovascular disease.

Anthony Hopkins, JNNP 1989 Apr52(4)430-3
  • Episodic Migraine

Triggers additive effect
Hormone fluctuation
The 4 stages of acute migraine
  • Aura
  • (20)
  • Prodrome Postdrome
  • Headache
  • Associated
  • features
  • Hours Minutes Hours Usually 1-2
  • to hours to days

Acute Migraine Prodrome(premonitory features)
Mental State Neurological General
Fatigue Irritability Depressed mood Euphoria Hyperactivity Restlessness Depersonalisation Derealisation Yawning Somnolence Phonophobia Photophobia Osmophobia Restless Legs Lightheaded Food craving Dizziness Neck pain / stiffness Anorexia Frequent micturition Diarrhoea
prodrome seen in about 60 of patients
Migraine - Aura
A complex of focal neurological symptoms (positive or negative phenomena) that precede or accompany an attack
  • Only present in 20 of migraineurs
  • Symptoms usually evolve over time
  • Most commonly 20 to 30 minutes
  • May persist hours to months
  • cortical spreading depression
  • May occur without headache
  • acephalalgic migraine

Migraine - Aura
  • Motor
  • Weakness
  • True weakness is rare and always unilateral
  • Dysarthria
  • Ataxia
  • Chorea
  • Movement disorders
  • Cognitive
  • Dysphasia / aphasia
  • Apraxia
  • Agnosia
  • Disturbed consciousness / delusions
  • Acute confusional state
  • Multiple conscious trance-like states
  • Delirium
  • Coma
  • Déjà vu / Jamais vu
  • Visual
  • Scotoma
  • Photopsia, phosphenes
  • Teichopsia (fortification spectra)
  • Metamorphopsia, macropsia, zoom or mosaic vision
  • Sensory
  • unilateral or bilateral (lt50), slow migrating,
    positive phenomena
  • Cheiro-oral migrating paraesthesiae
  • Sensory ataxia
  • Often reported as weakness
  • Olfactory hallucinations

What are migrainous features of headache ?
  • Throbbing / pounding
  • Head, neck and / or face
  • Unilateral or bilateral
  • Tenderness
  • Nausea /- vomiting
  • Icepick (lt40)
  • (primary stabbing headache)
  • Stimulus Sensitivity
  • Movement exacerbation
  • Noise (photophobia)
  • Light (phonophobia)
  • Smell (osmophobia)
  • Touch (allodynia)
  • Relieving factors
  • Flat
  • Still
  • Vomit
  • Sleep

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Non-headache symptoms of acute migraine
Mental State Neurological General
Depression Dissociation Anxiety Fatigue Irritability Agitation Anger Rage Incapacity Confusion Exhilaration Hypomania constitutional and mental changes are almost universal Blurred vision Paraesthesiae Formication Vertigo Acute confusion Disorientation Word-finding difficulty Stuttering Dysphasia Autonomic Syncope Hemiplegia Coma Lightheadedness Flushing, Pallor, skin change, cold extremities Oedema / fluid retention Scalp / face oedema Hair loss Neck pain and stiffness Anorexia Gastroparesis Food craving Nausea (90) Vomit (30) Eructation Diarrhoea (16) Polyuria Epistaxis, Ecchymosis
Migraine postdrome
  • Resolution often associated with
  • Fatigue
  • Listlessness
  • Fragility
  • Scalp tenderness
  • Also, following may occur
  • Irritable
  • Impaired concentration
  • Muscle weakness and aching
  • Anorexia
  • Food cravings

Distortion of reality as a manifestation of
migraineAlice in Wonderland Syndrome
  • Visual aura
  • Teleopsia - zoom vision
  • Surroundings may appear very big or very small
  • Body image disturbances
  • body parts appear large, small, distorted,
    reduplicated or absent
  • Entomopia Insect eye - multiple copies of
    same image in grid-like pattern
  • Corona phenomena
  • Hallucinations
  • Visual
  • Auditory
  • Olfactory
  • Gustatory
  • Tactile
  • Cognitive deficit
  • apraxia, agnosia
  • acute confusional state
  • Delusions
  • Paranoid psychosis

Macrosomatognosia of head, neck, both arms and
hands. (Podoll and Robinson, Acta Neurolo
Scand 2000101413-416)

Migraine Autonomic Symptoms
Migraine is the commonest cause of facial autonomic disturbance
  • Approx 20 of migraineurs
  • Localised facial disturbance
  • Conjunctival injection (red eye)
  • Lacrimation (tearing)
  • Eyelid / facial swelling
  • Periorbital swelling and apparent enophthalmos as
    opposed to ptosis
  • Nasal congestion / rhinorrhoea (less common)
  • Objective scalp or facial swellling (oedema)
  • Flushing (may be unilateral)
  • Fullness in ear
  • Ecchymosis (face or limbs)
  • ? Systemic oedema

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Differentiating Migraine from other pathology
with history
  • Acute Migraine may masquerade as
  • Stroke
  • SAH
  • Seizure / NEAD
  • Bells palsy

Differentiating Migraine from other pathology
with history
  • Aura vs Stroke
  • Premonitory phase
  • Evolution
  • Spread of symptoms
  • Type of deficit (eg scotoma vs hemianopia)
  • Positive symptoms with aura

Differentiating Migraine from other pathology
with history
  • Episodic migraine vs SAH
  • Often very difficult
  • Err on side of caution
  • Most useful question - ?Premonitory phase
  • Check true thunderclap, not just like aftermath
    of being hit by a baseball bat

Differentiating Migraine from other pathology
with history
  • Seizure vs Migraine Syncope
  • Is migraine syncope a common cause of blackout?
  • Premonitory phase often many minutes or hours
  • Often dissociated and light headed before
  • (eg 10 -15 minutes or more)
  • Symptoms may resemble panic attack or
  • May start with primary stabbing headache
  • Often presence of pain before LOC
  • Both often followed by migrainous headache

Differentiating Migraine from other pathology
with history
  • Bells Palsy vs Migraine
  • Migraine may cause facial drooping with apparent
  • Probable autonomic cause
  • Loss of frontalis corrugator appearance oedema
  • Apparent enophthalmos with periorbital oedema
  • Can close eye normally normal blink
  • Often with prominent numbness, tingling and
  • May have other autonomic disturbance

Chronic Migraine
Markers to suggest Chronic (vs episodic) Migraine
  • Loss of prior efficacy of
  • Acute attack medications (painkillers stopped
  • Preventative
  • Ask about number of crystal clear headache-free
    days per month and look for migrainous features
    in milder less specific headaches
  • Multisymptomatic patient, even if does not
    present with headache
  • i.e. presenting with
  • Fatigue
  • Other pain syndromes (neck pain, back pain,
    fibromyalgia, etc)
  • Vertigo / dizziness
  • Insomnia
  • Mood disturbance
  • Poor memory

Chronic Migraine
Frequent headaches with migrainous features lt 15 days per month headache-free
  • Gradual characteristic evolution from acute to
    chronic state
  • Frequency increases
  • Severity can increase or decrease
  • Gaps fill in with milder migrainous headaches
  • Acute attack medications lose efficacy
  • e.g. painkillers / triptans
  • Pervasive non-headache features
  • usually diminish / disappear on complete
    headache-free days

Medication Overuse
  • ? Main cause of lack of response to headache
  • All acute attack medications can cause medication
    overuse, as can caffeine
  • Usually motivated by patients desire to treat
    their headaches
  • Commonest cause of chronic daily headache (IHS
    ICHD II)
  • The interaction between a therapeutic agent and
    a susceptible patient
  • If co-morbid neck pain, back pain or
    fibromyalgia, still worth stopping painkillers,
    as central sensitisation may heighten other
    bodily pains.
  • Escalation of acute attack medications, with loss
    of effectiveness is a big alarm bell to MOH or
    caffeine overuse headache and chronic as opposed
    to acute migraine

Caffeine OveruseVirtues Household Physician
circa 1920
  • Tea and Coffee Headaches. In the nervous, and
    often the gouty and rheumatic person, the use of
    tea and coffee will cause violent headaches.
    These luxuries of life should be discontinued for
    at least one month. An extra strong cup of black
    coffee, to be sure, will stop the headache for
    the time being, but only adds fuel to the fire in
    the long run. We would strongly advise anyone
    that has constant or periodical headaches, if he
    uses either tea or coffee, and especially coffee,
    to leave them off entirely for three months. It
    may be the sole cause, and if caused by tea and
    coffee, there is no possibility of their cure by
    medicines while you continue their use

Chronic MigraineTriggers and Perpetuating
  • Triggers
  • Hormones
  • Pregnancy
  • Postpartum
  • OCP
  • Menopause
  • Viral infection
  • Head injury
  • Systemic illness
  • Neurological illness
  • Neurosurgery
  • Emotional stress
  • Idiopathic

Perpetuating Factors Painkillers Opioids
Paracetamol NSAIDS Triptans / Ergot Caffeine
Coffee Tea Cola Chocolate Lucozade
  • An Inherited
  • Predisposition
  • A genetic disorder
  • /- Family history
  • Travel sickness
  • Childhood
  • Adulthood with reading
  • /- previous migraine
  • Migrainous hangovers
  • Undeserved hangovers
  • Comorbid IBS

Chronic Migraine More Than Just a Headache
Migraine Vertigo Visual Vertigo Veering
Migraine-related dysequilibrium Dissociation,
lightheaded, Etc.
Evolving Aura
Stimulus Sensitivity Light, noise, smell
Chronic Fatigue
/- Frequent (/-severe) Headache
Coathanger Neck Pain
Sensory Disturbance (paraesthesiae / formication
Back Pain, Diffuse muscle tenderness
Reflex Syncope / POTS
Distortion of Reality AIWS
Restless Legs / PLMS / PLMW
Mood and Cognitive Disturbance Insomnia, poor
STM, word substitutions, irritability,
emotionalism, depression, anhedonia
Autonomic symptoms
Chronic Migraine Migraine associated symptoms
Ask about brilliantly crystal clear complete
headache-free days
  • e.g. Disappearance of
  • Post-natal depression
  • Chronic fatigue syndrome or ME
  • Fibromyalgia
  • Mood disturbance
  • Vertigo
  • Neck pain

Migraine and Fatigue
Migraine and Fatigue
  • Fatigue is common in chronic migraine1
  • 84 scored gt3 on Fatigue Severity Scale (FSS) 2
  • 67 met CDC3 criteria for Chronic Fatigue
  • Headache is commonly not volunteered by patients
    when presenting with other complaints
  • Chronic migraine should be considered in ALL
    patients presenting with chronic fatigue all
    such patients should also have detailed sleep
  • 1Peres et al (Cephalagia 200222720-724)
  • 2c.f. normal (lt2.8), MS (5-6.5), depression
    (4.5), CFS (6.1)
  • 3Center for Disease Control and Prevention

1994 CDC Criteria for Chronic Fatigue Syndrome
  • Primary symptoms
  • Clinically evaluated, unexplained, persistent or
    relapsing chronic fatigue that is
  • of new or definite onset
  • Not result of ongoing exertion
  • Not substantially alleviated by rest and
  • Results in substantial reduction in previous
    levels of function
  • Additional requirements
  • Concurrent occurrence of gt 4 of following
  • Self-reported impairment in short term memory /
  • Muscle pain
  • Joint pain without joint swelling or redness
  • Headaches of a new type, pattern, or severity
  • Unrefreshing sleep
  • Post-exertional malaise lasting more than 24
  • sore throat
  • tender cervical or axillary lymph nodes
  • Final requirement

  • Headaches attributed to the following disorders
    are not sufficiently validated
  • Chronic fatigue syndrome
  • Fibromyalgia

Migraine and
Migraine and Corpalgia
  • Cases of acute migraine of the legs
  • Cuadrado et al (Cephalalgia 2008)
  • 3 patients presenting with spontaneous body pain
    in association with migraine attacks. All
    patients had allodynia to mechanical stimuli over
    the painful areas.
  • Lovati et al (Expert Review of Neurotherapeutics
  • hypothesised that extracephalic allodynia
    mediated by mechanism of thalamic sensitization

Migraine and Fibromyalgia (FMS)
  • Comorbidities of Fibromyalgia Syndrome (FMS) 1
  • Depression
  • Anxiety
  • Headache migraine and tension-type
  • IBS
  • Chronic Fatigue Syndrome
  • Vertigo
  • Sinus problems
  • TMJ dysfunction
  • POTS
  • Peres (Neurology 2001) reported high rates of FMS
    in transformed (chronic) migraine patients

1 Waylonis and Heck, Am J Phys Med Rehab 1992
Migraine and Fibromyalgia (FMS)
  • Peres (Curr Neurol Neuroscience Rep 2003), and
    Centonze (Neurol Sci 2004)
  • suggest episodic migraine, chronic daily headache
    and FMS are continuum of same disorder.
  • Arguments based upon theories of central
  • Patients with FMS show increased sensitivity to
    mechanical, thermal and electrical stimuli, with
    abnormal central pain mechanisms and augmented
    pain experience.

Medication overuse and other bodily pains
  • Overuse of painkillers is a risk factor for
    developing chronic neck and back pain1. The study
    of 51,383 patients concluded
  • Overuse of analgesics strongly predicts chronic
    pain and chronic pain associated with analgesic
    overuse 11 years later, especially among those
    with chronic migraine
  • Reports of refractory neck and/or back pain in
    patients with migraine same or improved
    following AAM withdrawal

1 Zwart et al, Head Hunt study, 2003
Migraine and Fibromyalgia (FMS)
  • De Tommaso et al (Cephalalgia 2008)
  • FMS in 36 of patients with primary headache
  • Those with comorbid FMS had
  • Highest level of migraine severity
  • Poor sleep quality
  • Headache severity heightened intensity of diffuse
    pain and fatigue
  • Pamuk and Cakir (Clin Exp Rheumatol 2005)
  • Increased FMS symptoms with menses (pain /
  • Increased prevalence of FMS starting at menopause

FMS pathophysiology
  • Abnormal CNS function1
  • Supraspinal central sensitization
  • fMRI cortical and subcortical augmentation of
    pain processing
  • Evidence for role of autonomic nervous system
  • Best treatments antidepressant and
    anticonvulsant medications. NB One small trial of
    beta blockers suggested possible effect

1Thimineur and De Ridder, Pain Medicine 2007
Migraine and Restless Legs (RLS)
Chronic Migraine and RLS / PLM Personal view
  • Recognised in my clinic as major factor in CM (gt
    7 yrs)
  • Commonly comorbid with chronic migraine and
    caffeine/medication overuse (approx 80)
  • Also provoked by caffeine and painkillers
  • Disappears after full detox in approx 80
  • Frequently see CM in those that present with RLS
  • Disrupts normal sleep architecture and leads to
    sleep deprivation
  • Wake unrefreshed
  • Frequent wakening and dreaming
  • Diurnal variation of RLS symptoms (worst towards
  • PLMS often not obvious
  • ? Caused by or provokes migraine

Migraine and RLS
  • If disappears with detox, typically returns in
    acute episodic migraine attacks
  • If persists after detox, worth treating before
    adding migraine preventative
  • Pregabilin / Gabapentin restore normal sleep
  • Sinemet CR beware augmentation ? less likely
    if Rx breaks every 6/12
  • Dopamine agonist (beware impulse control disorder
    and counsel patient)
  • High remission rate with Rx
  • Beware RLS / PLM provoked by tricyclic
    antidepressants and SSRI drugs cause poor sleep
  • Full and prolonged replacement of iron if
    Ferritin lt50ng/ml
  • Replace B12 / folate and exclude renal impairment

Restless Legs Syndrome
  • Wherefore to some, when abed they betake
    themselves to sleep, presently in the arms and
    legs, leapings and contractions of the tendons,
    and so great a restlessness and tossing of their
    members ensue, that if the diseased are no more
    able to sleep, than if they were in the place of
    the greatest torture
  • Sir Thomas Willis, 1672

A medical condition?
  • On Hypochondria
  • Virtues Household Physician, a twentieth
    century medica
  • The skin will twitch in different parts, or
    feel numb, or have the sensation of spiders
    crawling on it
  • ? Associations with migraine
  • bright sparks are seen before the
    one time the person will feel as large as a
    barrel, at other times not larger than a
    whip-stock, the head will feel light or heavy,
    large or small. The smell becomes perverted the
    hypochondriac will smell odors where there are
    none,,,,the persons are subject to fainting
    turns..they are irritable, fretful, peevish and
  • Eminent Authorities Consulted included
    Frances Dercum, William Gowers, F Savary Pearce,
    Ludwig Hirt, Charles L Dana, early 1920s

  • 1800s Anxietas Tibiarum
  • sign of hysteria and/or neurosis
  • 1944 Ekbom Asthenia Crurum Paraesthetic
    (irritable legs) Acta Med Scand
  • Published observational review of 34 cases
  • Characterised salient features
  • Diurnal pattern of lower extremity paraesthesia
    coupled with compulsion to move, worsening with
    rest and alleviated by movement
  • NB not same as Ekboms syndrome referring to
    delusional parasitosis, same Ekbom though!

RLS - Diagnosis
  • 4 essential criteria
  • An urge to move the legs, usually accompanied by
    uncomfortable / unpleasant sensations /
  • Onset or worsening of symptoms at rest, not
    associated with any specific body position
  • Rapid relief by movement such as walking or
  • Marked diurnal / circadian pattern, worse in the
    evening or night. Note that patient may however
    wake in am with painful legs that disappears on
    getting up and moving

  • Ekbom
  • Considerable clinical morbidity
  • No objective evidence of neurological abnormality
  • Common 5 of population
  • Often family history
  • Noted associations with
  • Pregnancy
  • Iron deficiency anaemia
  • Blood donors
  • Carcinoma

RLS and sleep
  • RLS is a major cause of insomnia
  • Reduced time asleep
  • Frequent wakening
  • Fragmentation of normal sleep architecture

RLS clinical features
  • Characterised by unpleasant, deep within lower
    legs, most commonly distal to knees
  • May note sensations in thighs, feet, arms
  • If occur in arms, usually less severe there
  • Most commonly bilateral
  • May be unilateral
  • Only experienced after rest
  • Almost irresistible urge to move legs or stretch
  • May need to walk around to get relief
  • Most severe in late evening (diurnal)
  • May complain of true pain / dull ache

RLS - descriptions
  • Creeping
  • Crawling
  • Itching
  • Burning
  • Searing
  • Tugging
  • Drawing
  • Aching
  • Electric current
  • Want to take legs off

Supportive clinical features
  • Family history
  • 60-80 of cases are familial
  • autonomic dominant with variable penetrance
  • Response to dopaminergic Rx
  • PLMW or PLMS

Secondary causes and associations
  • Iron deficiency
  • Reduced ferritin, often normal Hb
  • Rx if ferritin less than 50ng/ml prolonged
  • Pregnancy - especially last trimester / ferritin
    lt 50ng/ml
  • Blood donation
  • Renal failure - effective Rx with IV Fe
  • Fibromyalgia
  • Migraine
  • Depression
  • Rheumatoid arthritis
  • B12 / folic acid deficiency (occasional)
  • Parkinsons disease, essential tremor

Restless Legs and Migraine
  • 17 of migraine vs 5 of controls had RLS1
  • RLS reported in 22 migraine subjects vs 8 of
  • gt 60 of RLS patients affected by MOH
  • Increased dopaminergic premonitory features in
    those with comorbid RLS3
  • RLS and PLMS recognised to be also associated
    with fibromyalgia4
  • Caffeine is the major aetiological factor in the
    causation of restless legs syndrome5

1 Rhode et al. Cephalalgia 200727(11)1255-60 2
dOnofrio et al. Neurol Sci 2008 May29
Suppl1S169-172 3 Cologno et al. Neurol Sci 2008
May 29 Suppl 1 S166-168 4 Yunus and Aldaq. BMJ
1996. May 25312(7042)1339 5 Lutz. J Clin
Psychiatry 197839(9)693-8
Periodic Limb Movements and migraine
  • Reported in association with migraine1
  • Other sleep disorders associated with migraine
  • OSA
  • Insomnia
  • Restless Legs
  • Circadian rhythm disorder
  • Hypersomnia

1 Bokkala et al. Pediatr Neurol. 2008
Jul39(1)33-9 2 Rains and Poceta. Headache. 2006
Migraine and Dizziness
Migraine-related dizzinessPersonal view
  • Migraine-related disequilibrium commonest
  • Lightheaded
  • Dissociation - depersonalisation / derealisation
  • Hot, sweaty, flushed
  • Blurred, dim, or spotty vision
  • Mute and buzzy hearing
  • /- secondary panic
  • /- situation-specific hot, bright, noisy,
  • Migraine vertigo
  • Visual vertigo
  • Unexplained veering

Migraine-related dizziness
  • 0.89 of population has migraine vertigo
  • Total 1 year prevalence of vertigo 4.9
  • Prevalence of BPPV 1.6 1
  • Motion sickness may be treated effectively with
    Rizatriptan in migraineurs with migraine vertigo2
  • NB Motion sickness often associated with stimulus
    sensitivity to noise, light and smell
  • Migraine vertigo presents usually as attacks of
    spontaneous or positional vertigo lasting seconds
    to days and usually with accompanying migrainous
  • Treat with standard approaches for chronic
    migraine lifestyle, preventative (topiramate,
    beta blocker, flunarizine, etc,)

1 Neuhauser. Current Opin Neurol 2007 2 Eggers.
Curr Neurol Neurosci Rep 2006
FMS and neurotologic symptoms
  • Fibromyalgia (FMS) (Bayazit et al, 2002)
  • 50 otologic symptoms, predominant dizziness
  • Rosenhall et al (1996)
  • Vertigo / dizziness in 72
  • Auditory evoked potentials suggested brainstem

Considering Migraine in Differential
DiagnosisThe Chameleon in the Neurology Clinic
  • Dizziness and Vertigo
  • Blackouts / Syncope
  • Sensory disturbance
  • Fatigue
  • Insomnia
  • Panic Attacks (/- panic)
  • Depression / anxiety
  • Chronic Pain
  • Neck pain / Brachalgia
  • Facial pain
  • Fibromyalgia
  • ? MS
  • ? Epilepsy
  • ? NEAD
  • ? TIA
  • ? Stroke
  • Chronic Fatigue Syndrome
  • ME
  • ? Conversion disorder
  • Dementia
  • Psychosis

Approaches tosuccessful management of chronic
Selling the conceptBehaviour modification
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Chronic Migraine - Rx
  • The foundation
  • No painkillers
  • No caffeine
  • Good fluids
  • Regular meals
  • Regular sleep
  • Acute abrupt withdrawal
  • All acute attack medication (long term)
  • triptans, analgesics, NSAIDS
  • All caffeine
  • Warn headaches typically worsen for 5-7 days
  • Lifestyle sleep, hydration, meals
  • Rx Restless Legs / Periodic Limb Movements if
    persist after detox (disappear in most patients)
  • After withdrawal, add preventative for 1 year
  • Beta blocker (eg propranalol)
  • AED (eg valproate, topiramate, gabapentin
  • Tricyclic antidepressant
  • Change preventative if no response at 4/12
  • Aim for maximum tolerated dose reduce if
    persistent sedation

Migraine PreventativesReasons for failure
  • Ineffective
  • Acute attack drugs still used
  • Caffeine
  • Not used to high enough dose
  • Aim for maximum tolerated dose
  • Used at too high dose
  • Often ineffective if patient persistently sedated
  • Fatigue with migraine distinguished by
    pre-existing before drug started or absence of
    fatigue on headache-free day
  • Not used for long enough, i.e. 4 months at top
    level reached
  • Underlying sleep disorder RLS, PLM, OSA

Chronic Migraine Preventatives
  • Poor evidence for many traditionally used
    preventative drugs
  • Best evidence for topiramate and propranalol
  • Licensing varies between countries
  • Poor evidence for any individual approaches to Rx
    for migraine variants
  • Much anecdotal advice

Rationale in Clinical Situations
  • Poor sleep insomnia, RLS, PLMS, wake
  • Gabapentin to 900-1200mg tds, Pregabilin to
    300-400mg bd
  • AVOID tricyclics and SSRI drugs
  • Obesity, weight gain on preventatives
  • Topiramate
  • Eating disorder
  • Use most weight-neutral drugs
  • Pregnancy / planning pregnancy
  • Avoid all preventatives if possible
  • Consider GON Block
  • If necessary, amitryptilline or propranalol
  • Females of reproductive age
  • Avoid Sodium Valproate and other anticonvulsants
    if possible
  • Counsel all patients who intend to use
    anticonvulsants to take good contraceptive
    measures, take regular folate 5mg, and beware
    induction of OCP (eg topiramate)
  • Major Depression
  • Consider avoiding beta blockers
  • Agitated psychiatric state and/or suicidal
  • Consider short term olanzepine
  • Severe migraine vertigo short term help
  • Consider olanzepine short term
  • Severe anxiety or hypertension
  • Consider beta blocker
  • Hemiplegic Migraine
  • Consider topiramate, acetazolamide
  • Flunarizine
  • Migraine vertigo
  • Consider topiramate, flunarizine

  • Chronic Migraine accounts for more than 90 of
    referrals to a specialist headache clinic
  • It is frequently misdiagnosed in hospital and
    primary care
  • Chronic migraine may present with features other
    than headache
  • Always consider sleep disorders in your history
  • It is highly worthwhile taking full migraine
    history in patients presenting with unexplained
    neurological symptoms
  • It is worth treating chronic migraine with
    lifestyle strategies, attention to sleep quality
    / disorder, and rational approach to drug use and
    preventative strategies, even if headache is not
    a main presentation

Copies of slides anne.mccann_at_thewaltoncentre.n Patient info sheets - http//www.thewaltonce
  • Alice in Wonderland syndrome
  • Migraine postdromal features
  • Migraine Variants (basilar migraine, FHM,
    ophthalmoplegic migraine etc)
  • Fatigue
  • PLMS
  • Medication and caffeine overuse
  • Walton Centre Audit of non headache symptoms of
  • Guides for detoxification

Alice in Wonderland Syndrome
  • Lippman 1952 Certain Hallucinations peculiar to
  • 1 patient with left ear ballooning out 6 inches
    or more
  • Body split in 2 halves as if by vertical line,
    with right size twice the size of left.
  • Syndrome named by Todd, 1955, in relation to
    migraine and epilepsy
  • Characterised by body schema disturbances and
    facultative symptoms, including
    depersonalisation, derealisation, visual
    illusions and illusory alterations in the passage
    of time
  • Bizarre visual illusions and spatial distortions
  • Macropsia world appears larger than normal /
    subject appears smaller
  • Micropsia opposite of macropsia
  • Metamorphosia - sensation of formed body
  • Zoom vision (e.g. teleopsia)
  • Sense of time speeding up or slowing down
  • More commonly reported in children
  • Often before the headache
  • Also reported with infectious mononucleosis,
  • and drugs

Migraine Variants
  • Migraine variant or migraine equivalent are terms
    applied to migraine exhibiting itself
    predominantly in form other than head pain
  • Characterized by paroxysmal episodes of
  • prolonged visual auras,
  • atypical sensory, motor or visual aura,
  • confusion, dysarthria, focal neurological
  • gastrointestinal symptoms,
  • other constitutional symptoms
  • with or without headache
  • Many migraine variants recognised in IHS IHCD-II,
  • hemiplegic migraine
  • basilar migraine
  • childhood periodic syndromes
  • retinal migraine
  • complicated migraine
  • ophthalmoplegic migraine

Migraine Variants
  • Basilar Migraine
  • Ophthalmoplegic Migraine
  • Hemiplegic Migraine
  • Episodic ataxia
  • Vertiginous Migraine
  • Alternating Hemiplegia of Childhood
  • Cyclical Vomiting Syndrome
  • Confusional Migraine
  • Abdominal Migraine
  • Benign paroxysmal vertigo of childhood
  • Retinal migraine
  • Migraine infarction
  • ? Migraine-triggered seizures (Migralepsy)

Migraine VariantsBasilar Migraine
  • Aura usually lt 1 hour, headache typically follows
  • Typical hemianopia expands to all visual fields,
    sometimes temporary blindness
  • Many neurological features are bilateral
  • Visual deficit typically followed by one or more
  • Vertigo
  • Tinnitus
  • Decreased hearing
  • Diplopia
  • Ataxia
  • Bilateral paraesthesiae, weakness
  • Impaired cognition
  • confusion

Migraine Variants Confusional Migraine
  • Boys gt girls
  • Usually in children
  • Aura
  • Headache (may be insignificant)
  • Confusion
  • Inattention
  • Distractibility
  • Difficulty maintaining speech / activities
  • Sedation
  • Agitation / violent behaviour
  • Usually relieved by sleep

Migraine Variants Ophthalmoplegic Migraine
  • At least 2 attacks with ocular palsy
  • Typically IIIrd nerve with dilated pupil and
    unilateral eye pain
  • IV and VI palsy (occasional)
  • Ophthalmoplegia hours to months
  • Differential diagnosis includes
  • Tolosa-Hunt
  • Aneurysm
  • Cavernous sinus / middle cranial fossa lesion
  • Sphenoid sinusitis
  • Lyme, syphilis, coccidiomycosis, HIV
  • Sarcoid, Leukaemia, CNS inflammatory disorder
  • Needs intensive investigation
  • MRIGd and MRA
  • DSA
  • LP
  • Bloods

Migraine Variants Hemiplegic Migraine
  • Sporadic or Familial
  • Often starts in childhood
  • Attacks frequently precipitated by minor head
  • Change in conscious level often seen (confusion
    to coma)
  • Differential diagnosis includes
  • Focal seizure
  • Stroke
  • Homocystinuria
  • FHM
  • Autosomal Dominant with variable penetration
  • Includes episodes with or without motor aura
  • Episodes
  • Days to weeks

Migraine Variants Episodic Ataxia type 2
  • Autosomal dominant
  • Paroxysmal ataxia
  • Provocation
  • Physical, emotional stress, alcohol, caffeine
  • Interictal nystagmus
  • Responds to acetazolamide
  • Chr 19 (CACNA1A)

Migraine Variants Vertiginous Migraine
  • Vertigo present in approx 1/3 of migraineurs
  • Recurrent vertigo episodes with or without other
    migraine features, e.g.
  • Prodromal symptoms
  • Nausea
  • Stimulus sensitivity to noise, light, smell
  • Autonomic disturbance, etc.

Migraine Variants Retinal Migraine
  • Not uncommon cause of transient monocular
    blindness in young adults
  • Recurrent attacks of unilateral visual
    disturbance / loss with minimal or no headache
  • Gradual enlarging scotoma enlarging to total
    monocular visual loss
  • ? Due to transient vasospasm of choroidal or
    retinal arteries
  • Need to exclude vascular (carotid) disease and
    other ocular conditions

Fatigue Severity Scale
During the past week, I have found that Score Score Score Score Score Score Score
    1. My motivation is lower when I am fatigued. 1 2 3 4 5 6 7
    2. Exercise brings on my fatigue. 1 2 3 4 5 6 7
    3. I am easily fatigued. 1 2 3 4 5 6 7
    4. Fatigue interferes with my physical functioning. 1 2 3 4 5 6 7
    5. Fatigue causes frequent problems for me. 1 2 3 4 5 6 7
    6. My fatigue prevents sustained physical functioning. 1 2 3 4 5 6 7
    7. Fatigue interferes with carrying out certain duties and responsibilities. 1 2 3 4 5 6 7
    8. Fatigue is among my three most disabling symptoms. 1 2 3 4 5 6 7
    9. Fatigue interferes with my work, family, or social life. 1 2 3 4 5 6 7
MOH - How much is overuse?Limitations of IHS
  • Dietary caffeine not included as component of
    overuse in IHS guidance
  • Increased caffeine consumption has been
    associated with increased risk of developing
    chronic daily headache1
  • Literature on detoxification from AAM does not
    take account of dietary caffeine
  • How much is overuse according to IHS2?
  • Simple analgesics gt 15 days per month
  • Triptans or combination analgesics3 gt 10 days per
  • Opioids or ergotamine gt 10 days per month
  • ? Depends on individual pharmacogenetics

1 Sholz et al, 1988 2 Mathew et al, 1990,
Diamond and Dalessio 1982, Mathew 1990, Saper
1987, Wilkinson 1988, 3 i.e. with caffeine
How much is overuse?
  • All types of analgesic and acute attack
    medications reported to be associated with MOH
  • Paracetamol, NSAIDS, Opioids
  • All known triptans
  • Ergotamine
  • Rebound headache may occur acutely in single
  • stopping AAM recognised use in first line Rx of
    status migrainosus
  • Stop acute attack drugs
  • Rehydration
  • Treatment of nausea and vomiting
  • (/- later IV steroid, neuroleptic, IV
  • Anecdotally, patients who stop using analgesics
    or triptans often report shorter attacks of acute
    migraine following detox

Clinical Features of rebound headache
  • Analgesic rebound headache - No
    placebo-controlled trials
  • Caffeine rebound headache
  • stopping low dose caffeine frequently results in
    withdrawal headache1
  • Double blind placebo-controlled short-term
    caffeine withdrawal study
  • N 64, subjects with low to moderate caffeine
  • 32 placebo 32 continued caffeine
  • 50 of those given placebo had headache by day 2
  • 6 of those continuing caffeine had headache by
    day 2
  • Nausea, depression, flu-like symptoms common in
    placebo (detox) group
  • Does not indicate long term consequences of

1 Silverman et al 1992
Caffeine Overuse
  • Not proven, but long recognised to cause
    headaches, especially on withdrawal
  • Caffeine regarded as acute attack medication
  • Often in combined analgesics
  • Mild headaches (e.g. regarded as TTH) almost
    always disappear with complete elimination of
    acute medication and caffeine
  • Caffeine withdrawal - first line for
    treatment-resistant depression

Caffeine content in drinks
  • 12 oz drink mg
  • Red Bull (8oz) 80
  • Lucozade 46
  • Diet coke 46
  • Dr Pepper 41
  • Pepsi 38
  • Diet pepsi 36
  • Coca cola 34
  • 8 oz drink mg
  • Coffee 70-135
  • Tea 40-60
  • Cocoa 14
  • Decaf coffee 2-3

Horlicks, sprite etc are caffeine free

Walton Centre Audit on Non-headache
manifestations of migraine
Retrospective review of 50 consecutive patients
at WCNN with chronic migraine
Retrospective review of 50 consecutive patients
at WCNN with chronic migraine
AppendixMigraine treatment preventatives
Approach to successful treatment of chronic
  • The withdrawal
  • Warn of possible severe worsening for 1-2 weeks
  • Worsening is a good sign and usually heralds
    reverse to acute migraine
  • Admit for in-patient detoxification if elderly,
    diabetes, severe triptan or opioid overuse,
    severe depression and/or suicidal ideation
  • May assist withdrawal with
  • Fluids (/- IV)
  • Oral / rectal domperidone up to 120mg per day
  • 5/7 - Naproxen 500mg 8am 4pm
  • Clonidine (if opiates )
  • 5/7 - IM Chlorpromazine _at_ 10pm
  • IV Dihydroergotamine
  • Steroids
  • Combined pain syndromes
  • Advise that other pains often eventually improve
    off painkillers (especially neck and back), due
    to cessation of central sensitisation
  • Consider other measures for other pains
  • Back pain Pilates, Extensor stretch exercises,
    swimming, pain clinic epidurals etc
  • Neck Pain usually improves
  • Arthritis glucosamine, large joint revision

Preventative Drugs for MigraineLicensed
  • Beta Blockers
  • Propranalol (best evidence for use)
  • Timolol, Metoprolol
  • Antiepileptic Drugs (AED)
  • Topiramate
  • Others
  • Clonidine (antihistamine and serotonin
    antagonist) of no proven efficacy (BNF states
    Clonidine is not recommended and may aggravate
    depression and cause insomnia)
  • Pizotifen - evidence for effectiveness is poor
    adverse effects severely limit use
  • Methysergide considered very effective but
    concerns about about ergot side effects
    (retroperitoneal fibrosis etc)
  • Beta Blockers
  • Atenolol (not licensed, but commonly used)
  • Nadolol
  • Tricyclic antidepressants
  • Amitriptyline (best studied)
  • Dosulepin (commonly used potentially better
    tolerated beware cardiac arrhythmias)
  • Nortryptilline (often better tolerated)
  • Antiepileptic Drugs (AED)
  • Sodium Valproate
  • Gabapentin (limited evidence of efficacy 1
  • Zonisamide
  • Neuroleptics
  • Olanzepine
  • amisulpiride
  • Calcium Antagonists

Partial agonists unhelpful ideal beta
blocker is hydrophilic and cardioselective
Unlicensed, but recommended for use in BNF!
Hospital Supervision or Specialist Introduction
  • First Line
  • Nortryptilline / Amitryptilline / Dosulepin
  • Propranalol (Inderal LA)
  • Second Line
  • Epilim Chrono
  • Topiramate
  • Third Line
  • Gabapentin (first line if sleep disorder)
  • Paroxetine
  • Refractory cases
  • Flunarizine
  • Olanzepine
  • Methysergide
  • Botulinum toxin
  • GON Block / GON stimulator

  • First Line
  • Dosulepin
  • 25mg 7-8pm, increase 25mg each 2/52, aim 1mg/kg
    or maximum tolerated dose reduce dose if
    persistent side effects other than dry mouth
  • Consider ECG
  • Beware, may exacerbate restless legs syndrome and
    poor sleep and be counterproductive
  • Propranalol (Inderal LA)
  • 80mg, increase 160-240mg
  • Avoid if severe depression
  • Second Line
  • Epilim Chrono
  • 200mg, increase 200mg / week, aim 400-800mg bd
  • Folic acid and contraception if young female
  • Warn side effects weight gain, hair loss,
    tremor (10), polycystic ovaries
  • Beware teratogenic (learning disabilities etc)
  • Topiramate
  • 25mg, increase each week 25mg, aim 50-150mg bd

  • Third Line
  • Gabapentin
  • Some evidence of benefit
  • Well tolerated in most
  • Useful if comorbid restless legs
  • my first line if RLS persists after detox
  • 600-1200mg tds
  • Paroxetine
  • SSRIs not likely to be as useful as tricyclic
  • 10mg, increase 20mg after 1 week
  • Warn side-effects (dizzy, nausea, drowsy)
    typically last only 2/52
  • May exacerbate poor sleep

  • Refractory cases
  • Flunarizine
  • Off licence calcium antagonist
  • Licensed in some European countries where may be
    one of first line drugs
  • Anecdotal benefits in prolonged aura and
    migraine-related dizziness
  • Useful in refractory patients
  • Beware tardive (extrapyramidal) side effects,
    weight gain and severe depression
  • Olanzepine
  • Very helpful in emergency situations
  • very resistant cases (in specialist clinics only)
  • Short term for important time
  • Beware weight gain, diabetes and tardive movement
  • Methysergide
  • Good anecdotal evidence
  • Useful for refractory cases
  • Safe if lt12mg daily dose, drug holidays (1 month
    off every 5 months)

  • Alternative agents
  • Pizotifen
  • Very poorly tolerated weight gain and sedation
  • If tolerated, works reasonably
  • Rarely used in headache clinics
  • Lisinopril, Candesartan
  • Small evidence, small effect
  • Clonidine
  • Licensed, but never been studied
  • Lamotrigine, verapamil, carbamazepine
  • Unlikely to work as migraine preventatives
  • Alternative drugs butterbur, coenzyme Q10,
    riboflavin, feverfew
  • Small studies, some evidence

  • Alternative treatments
  • Greater Occipital Nerve (GON) Blocks
  • Not proven
  • Appear very effective for lt3-4/12 in approx
  • Useful as stopgap strategy
  • IV Dihydroergotamine
  • Not proven
  • Appear very effective for lt3-4/12 in approx
  • Useful as stopgap strategy
  • Botulinum toxin
  • ? Role in chronic migraine (ineffective in acute
  • Studies have blinding issues
  • Occipital Nerve Stimulation
  • Experimental
  • Anecdotal benefit in number of primary headache
    disorders including migraine, cluster headache,
    SUNCT and hemicrania continua

Migraine PreventativesReasons for failure
  • Ineffective
  • Acute attack drugs still used
  • Caffeine
  • Not used to high enough dose
  • Aim for maximum tolerated dose
  • Used at too high dose
  • Often ineffective if patient persistently sedated
  • Fatigue with migraine distinguished by
    pre-existing before drug started or absence of
    fatigue on headache-free day
  • Not used for long enough, i.e. 4 months at top
    level reached
  • Underlying sleep disorder RLS, PLM, OSA