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By Dr. David Greene, CEO
Nevada Pain Network
NevadaPainNetwork.com
THE BASICS OF MIGRAINES
• Chronic headaches that affect people from a few hours up to 72 hours straight.
• Complicated, recurrent headache disorder.
• Most common in women and those between 15 and 55.
• Most become less severe and less frequent with age.
WHAT IS A MIGRAINE?
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• Affects 18% of women, 8% of men.
• 30 million in US have at least one migraine per year.
• Every 10 seconds, someone in the United States goes to the emergency room with a headache or migraine.
• 70% have a 1st degree relative who suffers.
• If one parent suffers from migraine, there is a 40% chance a child will suffer. If both parents suffer, the chance rises to 90%.
• More than 90% of sufferers are unable to work or function normally during their migraine.
HOW COMMON ARE MIGRAINES?
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• There’s a LOT we don’t know.
• Genetics and Environment
• Imbalances in brain chemicals – serotonin levels drop during migraines.
• Low serotonin, a pain management chemical, levels can trigger a migraine by letting too much blood flow through vessels that should be constricted—inducing a throbbing sensation.
WHAT CAUSES MIGRAINES?
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• Foods – aged cheese, red wine (tyramine), beer, whisky, food additives (nitrates), cold foods, citrus fruits, MSG, caffeine.
• Elevated Stress
• Weather changes – barometric
• Strong scents – perfume, paint
• Hair accessories – ponytail
• Exercise – e.g. sex
• Poor Posture
• Skipping Meals
• Smoking
WHAT ARE TYPICAL MIGRAINE TRIGGERS?
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CHOCOLATE
Small silver lining – NO evidence to clearly substantiate that chocolate is a trigger of
migraine headaches. It’s a myth!
Nevada Pain http://wwwpainmanagementlasvegas.com (702) 323-0553
• Often unilateral head pain that is throbbing and aggravated by activity.
• Aura – visual or sensory symptoms prior to the onset of the headache (photophobia, visual scintillations).
• 80% of migraines have no aura.
SYMPTOMS OF MIGRAINES
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• No objective testing available.
• CT or MRI can rule out badness causing similar symptoms.
• Diagnosed on patient history and pattern of symptoms.
• Migraine diary can be very helpful.
DIAGNOSING MIGRAINES
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• International Headache Society requires pt to have at least 5 attacks fulfilling 3 criteria:
1. 4-72 hour duration
2. At least 2 of these:
1. Unilateral
2. Pulsating
3. Moderate to severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity
3. At least one of these:
1. Nausea +/- Vomiting
2. Photophobia and phonophobia
MAKING THE DIAGNOSIS OF MIGRAINE
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• Triptans – target Serotonin
• Almotriptan (Axert)
• Eletriptan (Relpax)
• Frovatriptan (Frova)
• Naratriptan (Amerge, Naramig)
• Rizatriptan (Maxalt)
• Sumatriptan (Alsuma, Dosepro, Imitrex, Sumavel, Treximet, Zecuity)
• Zolmitriptan (Zomig)
ABORTIVE TREATMENT OPTIONS
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• Acetaminophen-isometheptene-dichloralphenazone (Midrin)
• Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
• Ergotamine tartrate (Cafergot)
• Over- the-counter medications such as Advil Migraine (containing ibuprofen), Excedrin Migraine (containing aspirin, acetaminophen, caffeine), and Motrin Migraine Pain (containing ibuprofen)
ABORTIVE TREATMENT OPTIONS
Nevada Pain http://wwwpainmanagementlasvegas.com (702) 323-0553
• Narcotics
• Barbiturates
• Nausea
• Metoclopramide (Reglan)
• Prochlorperazine (Compazine)
• Promethazine (Phenergan)
ABORTIVE TREATMENT OPTIONS
Nevada Pain http://wwwpainmanagementlasvegas.com (702) 323-0553
• Goal is to lessen the frequency and severity of migraines.
• High blood pressure medications
• Beta blockers
• Calcium Channel Blockers
• Antidepressants
• Amitriptyline (Elavil)
• Nortriptyline (Pamelor)
• Antiseizure medications
• Gabapentin
• Topamax
• Depakote
• Pizotifen (Sanomigran)
• Serotonin antagonist
PREVENTIVE TREATMENT OPTIONS
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INTERVENTIONAL TREATMENTS
• FDA has approved Botox injections for chronic migraines.
• 3 month intervals
• Injected into 32 sites in a 10 minute procedure.
• Covered if certain medications have been tried and failed.
• For chronic migraines = “distinct and severe neurological disorder characterized by patients who have a history of migraine and suffer from headaches on 15 or more days per month with headaches lasting four hours a day or longer.”
• Patients treated with BOTOX® (onabotulinumtoxinA) averaged 8 to 9 fewer headache days per month compared to baseline (vs 6 to 7 days with placebo) as demonstrated in the Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) study.1
Nevada Pain http://wwwpainmanagementlasvegas.com (702) 323-0553
• Occipital Nerve Blocks
• Cervical Facet Injections
• Cervical Epidural Injection
• Sphenopalatine Ganglion Blocks
• Supratrochlear Nerve Blocks
• Supra/ Infraorbital Nerve Blocks
• Pulsed radiofrequency energy of Occipital Nerves
INTERVENTIONAL TREATMENTS
Nevada Pain http://wwwpainmanagementlasvegas.com (702) 323-0553
NERVE BLOCKS• Study of 100 pts.receiving GON blocks (Migrainetrust.org) - 53% achieved pain
relief averaging 3 weeks.
• Retrospective study on the efficacy of GON block in refractory migraine patients. [5] A mixture of lidocaine and methylprednisolone was used for nerve blockade. Fifty-four percent of migraine patients reported on being "significantly better" after the blocks, and the duration of response lasted up to 6 months. (Gawel and Rothbart 1992, Cephalalgia)
• Caputi and Firetto examined the benefit of PNBs in the treatment of migraine. [6] They assessed 27 migraine patients before and after GON and supraorbital nerve (SON) blocks. Maximum of 10 injections with 85% effectiveness rate for 6 months.
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