Migraine Headache and Variants Flashcards
Why should a general dentist care
about headaches?
Because:
(2)
- The same nerve pathway (Trigeminal) is
involved and may show up as a toothache,
gingival pain or facial pain in your patient. - Being able to diagnose referred pain from
headaches will allow you to refer your patient
to the proper specialist AND AVOID
UNNECCESARY DENTAL TX (i.e. RCTs,
extractions, restorative)
Migraine pathways
Headaches occur Most
frequently on arising in
the morning therefore the
DDS must differentiate if
the head/facial pain is
from migraine, bruxism or
obstructive sleep apnea.
Dental Causes of Headache
(2)
Dr. Graff-Radford was the first dentist to become a board member
for the American Headache Society. He became world-renowned in
the headache community, and he helped to change the perception
of dentistry in the medical community as it relates TMD.
Steven was a trailblazer for dentists, expanding dental pain
management to treat the full spectrum of headaches, and
personally training many residents and dentists
Headaches can mimic acute dental disease
If located in the
(three) can mimic dental
disease and cause tooth pain
lower half of the face (V2-3)
Migraine, cluster headache, or paroxysmal hemicrania
Dental Pain vs Headache?
1. Acute dental pain may spread unilaterally but (unlike headache)
rarely crosses the midline of the face.
2. Dental pain clinical characteristics:
(3)
Intense, throbbing
Poorly localized
Generally provoked by stimulation of the offending tooth (i.e. pressure,
hot/cold)
Headache attributed to
temporomandibular disorder (TMD)
Diagnostic Criteria:
(3)
A.Any headache fulfilling criterion C
B. Clinical and/or imaging reveals evidence of TMD
C.Evidence of causation demonstrated by ≥2 of:
1.headache has developed in temporal relation to onset of TMD
2.either or both of:
a) headache has significantly worsened in parallel with progression of
TMD;
b) headache has significantly improved or resolved in parallel with
improvement in or resolution of TMD
3. headache produced or exacerbated by active jaw
movements, passive movements through range of motion of
jaw and/or provocative maneuvers such as pressure on TMJ
and surrounding muscles of mastication
4. headache, when unilateral, is ipsilateral to TMD
D. Not better accounted for by another ICHD-3 diagnosis
Primary
Headache
Disorders
(3)
- Migraine
- Tension-type
headache - Trigeminal-autonomic
cephalgias (TAC’s)
- Trigeminal-autonomic
cephalgias (TAC’s)
(4)
Cluster headache
Paroxysmal hemicrania
Hemicrania continua
SUNCT syndrome
- Orofacial pains resembling
presentations of primary headaches
(3)
5.1 Orofacial migraine:
5.1.1 Episodic orofacial migraine
5.1.2 Chronic orofacial migraine
5.1.1 Episodic orofacial migraine
Diagnostic criteria:
A. At least five
attacks fulfilling
criteria B–D
B. Facial and/or oral
pain, without head
pain, lasting
– hours
(untreated or
unsuccessfully
treated)
C. Pain has at least
two of the following
four
characteristics:
D. Pain is
accompanied by one
or both of the
following:
E. Not better
accounted for by
another ICOP or
ICHD-3 diagnosis
4–72
- unilateral location 2. pulsating quality 3. moderate or
severe intensity - aggravation by, or
causing avoidance
of, routine
physical activity
(e.g. walking or
climbing stairs) - nausea and/or
vomiting - photophobia (light
sensitivity)and
phonophobia (noise
sensitivity)
5.1.2 Chronic orofacial migraine
Diagnostic Criteria:
A. Facial and/or oral pain, without head pain, on 15
days/month for >3 months and fulfilling criteria B
and C below
B. Occurring in a patient who has had at least five
attacks fulfilling criteria B–D for 5.1 Episodic orofacial
migraine
C. On 8 days/month for >3 months, fulfilling either
of the following:
1. criteria C and D for 5.1.1 Episodic orofacial
migraine
2. believed by the patient to be orofacial migraine at
onset and relieved by a triptan or ergot derivative
D. Not better accounted for by another ICOP or
ICHD-3 diagnosis.
Comment: A Pain Diary must be kept to track headache frequency
Pain sensitive
intracranial
structures
Include:
the skin and blood
vessels of the scalp; the
head and neck muscles;
the venous sinuses; the
arteries of the meninges;
the larger cerebral
arteries; the pain-carrying
fibers of the fifth, ninth,
and tenth cranial nerves;
and parts of the dura
mater at the base of the
brain.
The brain itself is
insensitive to pain
Impact of
Migraines
American Migraine Foundation is
fundraising for research on
migraines
– million Americans are estimated
to have severe migraine
headaches.
Migraine will affect –% of women
over a lifetime.
Annual lost productivity in the U.S.
due to migraine costs over $ 1
billion per year.
36
30
Severe type of headache that affects
approximately –% of the world
population or 1 Billion
Gender Prevalence:
Episodes may occur at any time of the
10
2-3:1 W, M
day or night
Onset of migraine occurs in the first — life decades,
then the frequency decreases. — gender
distribution is equal.
four
Childhood
Introduction
Clinical Characteristics
Scalp tenderness occurs in – of the
patients during or after the headache
A — factor or familial history
is present in most migraineurs
More than –% of migraineurs have
less than two attacks per month.
2/3
genetic
50
Pathophysiology
Migraines & trigeminal autonomic cephalgias cause activation of the
— system causing release of inflammatory chemical
mediators in the brain known as —.
The — receptor (5-HT) gets activated. — acts as a
neurotransmitter in the CNS & is a potent —. It is found in
the brain, platelets & intestine.
— is believed to play a MAJOR role in
migraine pathogenesis
Trigeminovascular
neuropeptides
serotonin
vasoconstrictor
Calcitonin gene related peptide (CGRP)
Introduction
A small group of migraineurs transform into CHRONIC
daily headache which is now classified as …
(Previous classification was Medication
Overuse or Rebound Headache since use
of analgesics and migraine abortive
medications >2days/week can trigger
daily headaches in some individuals)
— is effective for treatment
of daily persistent migraines.
daily
persistent migraine- Headaches occur ≥ 15 times per
Month
Onabotulinum A
Family History
Familial tendency:
–% of migraineurs have a parent
with the disorder and up to –% have
at least one first-degree relative with
migraine
chromosome – is linked to migraines
– headaches rarely occur within
the same family
—% of tension-type headaches
sufferers have family members with
similar headaches
50-60, 80
19
cluster
40
Comorbidity of Migraine
Migraine is Comorbid with:
(4)
- stroke
- epilepsy
- depression
- anxiety disorders
In patients with migraine, anxiety disorders & major
depression, the onset of — generally precedes
the onset of migraine, whereas the onset of major
— usually follows the onset of migraine
anxiety
depression
skipped
Psychiatric Comorbidity of
Migraine
Odds Ratio
Major depression –
Manic episode –
Anxiety disorder –
Panic disorder –
4.5
6.0
3.2
6.6
International Headache Society
(IHS) Classification of Migraine
(4)
- Migraine with aura (Classic Migraine)
- Migraine without aura (Common Migraine)
Many patients have both forms
Aura can precede, accompany, or follow the actual
headache attack.
Aura prevalence is: Male-female ratio of 1:2
3. EPISODIC MIGRAINE < 15 migraine days/month
4. CHRONIC MIGRAINE >15 migraine days/month
1.1 Migraine without aura
Diagnostic Criteria
(A-E)
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully
treated)
C. Headache has 2 of the following characteristics:
D. During headache 1 of the following:
E. Not better accounted for by another ICHD-3 diagnosis
C. Headache has 2 of the following characteristics:
(4)
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (i.e., walking, climbing
stairs)
- aggravation by or causing avoidance of routine physical activity (i.e., walking, climbing
D. During headache 1 of the following:
(2)
- nausea and/or vomiting
- photophobia and phonophobia
Migraine Attack
Phases
(4)
- Prodrome - occurs hours
to days before the
headache. - Aura - immediately
precedes or
accompanies the
headache. - Headache
- Headache Resolution-
may take days
Prodrome
(3)
Change in mood or behavior (i.e. depressed,
hyperactive, euphoric, talkative, drowsy,
restless, or irritable).
Neurological (i.e. sensitivity to light & noise,
difficulty concentrating, yawning,&
hypersomnia).
General (i.e. stiff neck, food cravings, cold
feeling, anorexia, sluggish & thirsty)
Aura
Approximately –% of migraine attacks
are “with aura”.
Many patients have both forms
The aura consists of gradually
spreading neurological symptoms that
usually precede the headache by –
minutes
Most common symptoms are (2)
30
5-60
visual
disturbances such as flashing lights
(scotoma) or a zigzag pattern
(fortification spectra)
Sensory Auras
motor symptoms (i.e. weakness or atonia) - –%
prevalence
hyperkinetic movement disorders (i.e. chorea)
speech abnormalities (i.e. aphasia- absence of language
or dysarthria- poorly articulated speech) –%
prevalence
18
17-20
1.2.1 Migraine with typical aura
(4)
A. At least 2 attacks fulfilling criteria B and C
B. Aura of visual, sensory and/or speech/language
symptoms, each fully reversible, but no motor,
brainstem or retinal symptoms
C. 2 of the following 4 characteristics:
1. 1 aura symptom spreads gradually over ≥5 min,
and/or 2 symptoms occur in succession
2. each individual aura symptom lasts 5-60 min
3. 1 aura symptom is unilateral
4. aura accompanied or followed by headache
in <60 min
D. Not better accounted for by another ICHD-3 diagnosis,
and TIA excluded
1.2.1.2 Typical
aura
without headache
(2)
A. Fulfils criteria for 1.2.1
Migraine with typical aura
B. No headache accompanies
or follows the aura within
60 min
Headache Phase
Location:
Pain:
— is common although food cravings
may occur
nausea (–%), vomiting (–%)
— cause patient to seek a
dark, quiet room
— will typically worsen migraine
may be bilateral (40%) or start on
one side and become generalized
intensity varies ,however, average
rating reported is 5/10 on Numeric Rating
Scale (0=no pain, 10=worst pain)
anorexia
90, 33
photo/phonophobia
Exercise
Headache Phase
Systemic Symptoms
(11)
blurry vision
nasal stuffiness
anorexia
hunger
diarrhea
abdominal cramps
polyuria
pallor
sensations of hot / cold
sweating
scalp tenderness
Headache Phase
Affective Alterations Include:
(7)
impairment of concentration (common)
impairment of memory (less common)
depression
fatigue
anxiety
nervousness
irritability
Resolution
Phase
pain —
… may occur
some migraine sufferers
report —
following an attack
while others report
— and —
diminishes
fatigue, irritability,
listlessness, impairment
of concentration, or
mood change
euphoria
depression and malaise
Aggravating or Precipitating
Factors for Headache
Menstruation or pregnancy due to
estrogen level changes
Stress
Alcohol (esp. red wine)
Caffeine
Smoking
relaxation after stress
fatigue
inadequate or excessive sleep
missing a meal
weather change (i.e. high
humidity)
high altitude
perfumes or chemical fumes
food triggers
physical activity
coughing
exposure to glare or flickering
lights
loud noise
Past Headache History
Ask patient about:
(4)
Previous medications prescribed (dose
& length of time taken)
Non-pharmacological therapies
(biofeedback, psychotherapy,
acupuncture & chiropractic)
Current medications
Withdrawal or rebound headache -
produced by excessive use of NSAIDS,
barbiturates, triptans, narcotics &
ergots. Limit usage to 2 days/week.
Social History
(6)
- Identify source of stress
- Recent major life changes
- Job satisfaction
- Exposure to drugs/toxins in workplace
- Habit history (i.e. alcohol, tobacco, caffeine &
recreational drugs) - Sleep habits (i.e. keep bedtime and awakening
time the same each day. Depression, anxiety,
sleep apnea produces morning headaches)
Migraine Management
(3)
Psychotherapy: Patient education, stress reduction and
trigger avoidance
Non-pharmacologic methods
Pharmacologic methods
Pharmacologic methods
(2)
Abort the migraine
Prevent the migraine
Non-Pharmacologic
Methods (Behavioral
Modifications)
May Help:
(8)
Less likely to help:
(2)
Regular sleep
Regular exercise
Regular meals
Avoid chocolate
Avoid tyramine/MSG
in foods
Limit caffeine
Eliminate alcohol
Biofeedback/stress
management
Avoid milk products
Avoid citrus products
Non-pharmacologic
Methods
Encourage good —
Patients should …
Same schedule should be
maintained even on the
—.
Migraine attacks frequently
begin in the — hour of sleep
when sleep has been
lengthened
Stress management
Decreases — nervous
system responsiveness
sleep hygiene
go to sleep and
arise in the morning at the same
time each day
weekends
last
autonomic
Non-pharmacologic Methods
Psychotherapy:
(4)
- Relaxation training
- Biofeedback
- Hypnosis
- Cognitive behavior therapy
Migraine Medications
1. Abortive medications:
2. Prophylactic medications:
treat
Acute phase.
preventive- recommended if
headache frequency is 2 or more
headaches per week.
Pharmacologic Methods
Migraines that occur less than twice a
week are managed with —
medications
Treatment is provided during the onset
of the attack (within – minutes of
onset for optimal outcome)
Migraines that occur more frequently
should be managed with — medications
abortive
20
both preventive
and abortive
skipped
Abortive migraine
medications
(9)
Acetaminophen
Aspirin
Butalbital, caffeine & analgesics
Caffeine adjuvant
Isometheptene
Narcotics
NSAIDs
Ergotamine
TRIPTANS:
skipped
TRIPTANS:
5-HT 1B/1D Agonists:
(6)
Sumatriptan (Imitrex)
Zolmitriptan (Zomig)
Naratriptan (Amerge)
Rizatriptan (Maxalt)
Eletriptan (Relpax)
skipped
Abortive Medications
Examples of Ergot derivatives
(5)
Cafergot suppositories / tablets
Wigraine suppositories / tablets
Ergostat sublingual tablets
Dihydroergotamine: DHE-45 SC
and IV
Migranal nasal spray
Abortive Medications
All ergotamine preparations
are capable of producing
(6)
Frequent use of
ergotamine tartrate–more
than — days per week–
can result in ergot dependency
- Nausea, vomiting, paresthesias,
muscle cramps, HTN and angina in
sensitive individuals
two
Abortive
Medications:
Analgesics
In a small number of
patients analgesic
medications (i.e. aspirin,
acetaminophen, and
NSAIDs) can be useful in
aborting migraine
When these medications
are helpful they should be
used because of their
low
toxicity and side effects
Generally safe when used
infrequently
Potential for overuse
skipped
Other
treatments
(5)
Rimegepant (PO)
CGRP Receptor
Antagonist
Both preventative and
acute pain reilief
Take 75mg q 2 days
Lasmotodine
Abortive Medications:
Triptans
Sumatriptan (Imitrex)
(3)
- Available in nasal spray, tablet and
subcutaneous injection - Has the shortest half life
- Response for recurrence of headache pain 12-
24 hours after administration
Naratriptan hydrochloride (Amerge)
5-6 hour half life
(2)
- Slower onset of action
- Longest half life (5-6 hours)
Triptans: Abortive Medications
(3)
Zolmitriptan (Zomig) (more rapid Tmax)
Rizatriptan (Maxalt) (more rapid Tmax)
Eletriptan (Relpax)
Zolmitriptan (Zomig) (more rapid Tmax)
(2)
Fast onset of action and early efficacy
Available in tablet and nasal spray
Rizatriptan (Maxalt) (more rapid Tmax)
(2)
Available in tablet and wafer oral
disintegrating tablet
Fast onset of action and early efficacy
Eletriptan (Relpax)
(2)
Onset of action is 1 hour
Half-life is 5 hours
Abortive
Medications:
Triptans
Therapeutic effect:
Triptans- come in many different dosage
forms
Have particular beneficial influence in
controlling — as well as —
For patients with early or significant nausea
or vomiting select a non-oral route of
administration
nausea
headache
Therapeutic effect:
* Restores
* Inhibits
* Restores
vascular integrity
neuropeptide release/inflammation
central inhibition of pain pathway
Triptans
(5-HT Serotonin Agonists)
Cause:
(2)
Contraindications:
(3)
Cranial vasoconstriction
Coronary vasoconstriction
Coronary artery disease
Heart disease & uncontrolled
hypertension
Stroke
skipped
Preventive Migraine
Medications
Beta-blockers: (propranolol,
andosol, atenolol)
Calcium channel blockers:
(verapamil)
Antidepressants:
Tricyclic
SSRI
MAOI
(5)
- Serotonin antagonists:
(methergine, methysergide) - Anticonvulsants: (valproic
acid, gabapentin,
topiramate)) - CGRP Antagonists (Aimovig,
Emgality) – injected 2x first
month then monthly - NSAIDs
Preventive
Medications
Frequent migraine attacks are best
managed with medications that, when
taken regularly, decrease the likelihood of
the …
Provide antagonist activity at the — receptors
Drugs effective for preventing migraine
attacks include:
next attack
5-HT2 and the 5-HT1c
Beta adrenergic Blockers
Beta blocker effect on the 5-HT
receptors
Act centrally to inhibit the
central beta receptors and
decrease the enhancing
adrenergic pathways
Calcium channel blockers
* Act on — receptors
* Inhibit
* Inhibit
* Prevent — of cerebral neurons
5-HT
contraction of vascular smooth
muscle
prostaglandin formation
hypoxia
Serotonin antagonists
* Examples(two)
* * Blocks the development of
- Methysergide (Sansert)
- Periactin
neurogenic
inflammation
Divalproex (Depakote)
(2)
- Inhibits firing of 5-HT neurons
- Enhanced post-synaptic response to
GABA (gamma-aminobutyric acid)
Topiramate (Topamax)
Blocks
* Does not affect
* Causes
voltage-dependent sodium and calcium
channels
reuptake or binding of
neurotransmitters
weight loss
Gabapentin (Neurontin)
(2)
- Structurally related to GABA but does not interact
with GABA receptors - Identify and function remain to be elucidated
Preventive
Migraine
Medications
INDICATIONS :
(4)
- 2 or more attacks per
month that produce
disability > 3 days - Abortive medications
not effective - Use of abortive
medications > 2x/week - Special circumstances
i.e. hemiplegic migraine
Calcitonin Gene
Related Peptide
(CGRP)Receptor
Inhibitors
is widely expressed in the
peripheral and central nervous
systems
αCGRP is highly expressed in
— neurons
Inhibits — pathways
These Monclonal Antibodies Used
for cancer treatment do Not cause
—.
For prevention of — migraine
ONLY (prophylaxis)
sensory
inflammatory
immunosuppression
acute
Calcitonin Gene Related
Peptide Antagonists
Marketed
Name AIMOVIG® EMGALITY® AJOVY® TBD
Generic
name Erenumab Galcanezum
ab
Fremanezu
mab
Eptinezumb
†† Produced
in yeast.
provide …
effective, differentiated therapy for acute migraine
treatment and prevention of frequent episodic and chronic
migraine
Onabotulinum toxin type A
Potent —
Weakens —
Inhibits —
FDA treatment option for Chronic
Migraines >– days/month
Interrupts pain cycle & may alter
neurotransmitter secretory function in
both afferent & efferent motor nerves
Therapeutic injections have an average
duration of – weeks before re-injection is
necessary
neurotoxin
painful muscles
muscle contractions
15
12
Onabotulinum A Toxin
1. Used for — NOT responsive to medications
2. Injected at – sites
3. Repeated every – Months
4. Research has demonstrated effectiveness in treatment of
headaches and muscle pain
5. Advantages:
6. Potential Side Effects:
Chronic Migraine Headache
32
3
no drug-drug interactions and no systemic side effects
are risk of weakness at injection site
