Migraine For Psychiatrist, Mae Hong Sorn, 54

Migraine
“Solving the problem”

Surat Tanprawate, MD, MSc(Lond.), FRCP(T)
Division of Neurology
Chiang Mai University
4.2.11
Sunday, 6 February 2011
Why psychiatrist need to
know about headache?
Vise versa
Why neurologist treating headache need to

know psychological conditions?

Headache and
psychological conditions

Headache and
1. Psychological conditions are highly co-
morbid of primary headache disorder
• ex. migraine vs depression

Headache and
1. Psychological conditions are highly co-
morbid of primary headache disorder
• ex. migraine vs depression
2. Headache can be caused by psychiatric
disorder
• ICHD-II: Headache attributed to
psychiatric disorder

ICHD-II 2004
Migraine
• Epidemiology and problematic
concern
• Clinical and pathophysiological
ground
• Management strategies
International Classification of
Headache Disorder-2004
Part 1. The primary headaches

- Migraine, TTH, CH and other
TACs, and other primary headache
disorder
Part II. The secondary headaches International Classification of
Headache Disorder 2004
-Headache attributed to ....
Part III. Cranial neuralgias,
central and primary facial pain and
other headaches http://ihs-classification.org

Prevalence of Migraine
Incidence of migraine by age and sex Adjusted prevalence of migraine by

geographic area and meta-analysis of
studies using IHS criteria
Steewart WF. Am J Epidemiol.1991;134:1111-1120

Leading causes of years of life lived with a
disability (YLDs)
Leonardi M. J Headache Pain (2003) 4:S12–S17

Clinical
manifestation/
Diagnostic criteria

Early migraine
description
"He seemed to see something
shining before him like a light,
usually in part of the right eye; at
the end of a moment, a violent pain
supervened in the right temple,
then in all the head and neck....
vomiting, when it became
possible, was able to divert the
pain and render it more moderate."
Hippocrates (c.460-c.370 B.C.)
JMS Pearce. JNNP 1986;49:1097-1103

Migraine with aura =
“Classic migraine”
"He seemed to see something
shining before him like a light,
usually in part of the right eye; at
the end of a moment, a violent pain
supervened in the right temple,
then in all the head and neck....
vomiting, when it became
possible, was able to divert the
pain and render it more moderate."

Population-based study
Only migraine without aura
Only migraine with aura
Both types
14%
19%
67%
Migraine without aura is more common

(previously called common migraine)
Launer LJ et al. Neurology 1999;53:537-42

ICHD-II: Migraine
Migraine with/without Migraine variant

aura (migraine equivalent)
Migraine with prolonged aura Childhood periodic syndromes that

Migraine aura without headache are commonly precursors of migraine
Hemiplegic migraine -Cyclic vomiting syndrome
Basilar-type migraine -Abdominal migraine
Retinal migraine -Benign paroxysmal vertigo of childhood
Migraine classification
ICHD-II 2004
Description and Criteria
http://ihs-classification.org
Description
Criteria

Clinical Picture
Genetic
Trigger
factors
Environmental
factors
Migraine attack

The “Classic” Migraine =
Migraine with aura

Typical aura
• Typical aura consisting of visual and/or

sensory and/or speech symptoms.
Gradual development, duration no
longer than one hour, a mix of
positive and negative features and complete
reversibility characterize the aura which is
associated with a headache.

Migraine Aura Typical aura:
-Visual
99% 31% -Sensory
-Speech
6%
18%
n=163
Michael B. R. et al. Brain 1996: 119, 355-361
Visual aura
Typical visual aura is simple

ʻʻTeichopsiaʼʼ
(Greek for ʻʻtown
wall visionʼʼ)
ʻʻOn a distinct form of

transient hemiopsiaʼʼ by
Dr. Hubert Airy in 1870.

Visual Aura
Zig-zag lines (fortification)
Zig-zag lines in migraine aura
Olomouc (c.1757) bastion fortress in Table of Fortification, from the 1728

today's Czech Republic
Alice in Wonderland
Syndrome (AWS)
Somesthetic metamorphopsia.
Distortion of body and space
Did Lewis Carroll draw inspiration
from migraine auras?
Alice in Wonderland. By Lewis Carroll
Cortical spreading
depression(CSD) and Aura
Spreading suppression of cortical activation during migraine aura.

PNAS 2001 98(8): 4687–4692
Cortical Spreading
Depression (CSD)
“CSD is a wave of neuronal and
glial depolarization, followed by
long-lasting suppression of
neural activity”

Changes in cerebral blood flow in relation to the
occurrence of the aura and the headache in
migraine with aura
Olesen J et al. Ann Neurol. 1990;28:791–798.
Cortical spreading depression
“the cortical process”
• The spreading of a self-propagating wave of

cellular depolarization in the cerebral cortex
• The spreading of a wave of ischemia passing

through an area of cortex
• The spreading of a wave of vasoconstriction

following vasodilation of contiguous cortical
arterioles

The Mechanism
of Head Pain

Neuroanatomical Processing of
Vascular Head Pain
Goadsby P. J. Headache 2005; 45[Suppl 1]: S14-S24

Mechanism of head pain
“Trigeminovascular system”

Genetic
Trigger
factors
Environmental
factors
Migraine attack

Migraine triggers
Chronobiologic Physical
Diet
• Sleep (too much or too exertion
• Hunger little)
• Exercise
• Alcohol • Schedule change
• Sex
• Additives
Environmental
• Certain foods factors
Stress and
• Light glare anxiety
Hormonal • Odors
change
• Altitude Head
• Menstruation
• Weather change trauma

Hypothesis
“Trigger factors”
Periaqueductal gray matter (PAG), Cortical spreading depression [CSD]

Nucleus raphe magnus (NRM)
Geoffrey A. Headache 2008.
Clinical Picture
Genetic
Trigger
factors
Environmental
factors
Migraine attack

Genetic factor and
migraine brain
• Migraine: hyperexcitability of brain network
• Twin studies
• Familial hemiplegic migraine(FHM)
• 3 genes: CACNA1A, SCN1A, ATP1A2
• disturb ion transportation
Russell M. Hum Genet 1995; 96: 726–30
Wessman M. Lancet Neurol 2007; 6: 521–32
Functional roles of the proteins coded by known FHM genes within a glutamatergic synapse
Lancet Neurol 2007; 6: 521–32

Migraine
management

Migraine
diagnosis IHS criteria
Disability
assessment
Patient
communication
Assessments of
and education migraine impact
Individualised •Attack frequency

management •Attack severity
•Degree of disability
•Non-headache symptoms
•Patient participation:
preference, prior response, co-
Stratified care existent conditions
The US Headache Consortium Guideline

Matchar DB. Neurology 2000; 54
Comprehensive
treatment plan
• Education, reassurance and life style
modification
• Avoiding triggers to prevent attack
• Non-phamacologic treatment
• Treating the acute attack
• Long-term preventive therapy
• Physical and alternative medicine
Silberstein SD. Wolff ’s headache. 2008
Education, reassurance
and life style modification
• The simple fact that a headache patient
desires attention for his/her
headaches signals that advice regarding
lifestyles should be offered.
• Initially, it may be beneficial to remind the
headache sufferer that his/her nervous
system is highly sensitive, which
includes changes in their environment and
routines.

Education, reassurance
and life style modification
• Thus, regularity and predictable

lifestyles are to be considered
behavioral headache management
keystones to success.
• All patients are informed and
counseled about the A-H of
behavioral life support for headache

A-H for prevention by behavioral lifestyles
A = Apnea and Assessing psychophysiologic insomnia
B = Biofeedback and other behavioral relaxation
C = Caffeine: reduction of this and other substances; but most
importantly caffeine
D = Diet: eating regularly as fresh and unprocessed an eating plan as
feasible
E = Exercise (cardiovascular) with increased non-exercise activity
(walking)
F = Fluids: adequate hydration at all times
G = Groups: to enhance the benefits of social connectedness
H = Habits of all of the above leading to Happiness with improved
well-being
Taylor, FR.Techniques in Regional Anesthesia and Pain Management (2009) 13, 28-37

Living as
natural life

Medication
• Ionic channels: Ca, Na
• Neurotransmitter system:
• Serotonergic system(5-HT),
Dopaminergic system(DA)
• Inflammatory process
Acute Medication
Medication
• Non-specific vs specific medication
Treatment strategies
• Step-care vs staged care vs stratified
care
Lipton RB. Cephalalgia 1998; 18 (suppl 22):40-6

Pharmacotherapy of
acute migraine attack
Non-specific Specific
• Acetaminophen, • Dihydroergotamine
• NSAIDs • Ergotamine
• butalbital • Triptan
• caffeine,
• opioids
• neuroleptic

Analgesics with evidence of efficacy
EFNS migraine treatment guideline 2009
Evers, S et al. European Journal of Neurology 2009, 16: 968–981

Triptans
Evers, S et al. European Journal of Neurology 2009, 16: 968–981

Choice and route of
therapy
• severity and frequency of attack
• associated symptoms
• coexistent disorders
• previous treatment response
• drug’s efficacy
• potential for overuse
• adverse events
Step-care
First series of attack Second series of attack Third series of attack
Treatment
Migraine First-line Rx strategies
Second-line Rx
(combination
Third-line Rx
(specific
diagnosis (simple analgesic)
therapy) antimigraineous)
Staged care
0h 2h 4h
Second-line Rx Third-line Rx
Migraine First treatment
(combination (combination
therapy) therapy)
Stratified care High need

Impact questionnaire
Moderate
Migraine Assessment of need
diagnosis illness severity Stratification
Low need
Step-care
Migraine First-line Rx
(combination (specific
Staged care
0h 2h 4h
therapy) therapy)

Moderate
Low need
Step-care
Staged care
0h 2h 4h
therapy) therapy)

Moderate
Low need
Step-care
Staged care
0h 2h 4h
therapy) therapy)

Moderate
Low need
Stratified care and
migraine assessment
Factors need to be considered
• Frequency
• Severity
• The present and level of disability
• Associated non-headache symptoms
US Headache Consortium Guideline 2007
MIDAS and HIT-6

Criteria for assessing migraine
patient severity
Moderate to severe
Mild to moderate migraine
migraine
Headache are almost mild-to- Headache that frequently develop
moderate intensity to moderate or severe in intensity
Non-headache associated Significant non-headache associated

symptoms, if present are not symptoms, which may be severe in
severe in intensity intensity
The impact of the headache on the The impact of the headache on the
patient’s lifestyle is not significant: patient’s lifestyle is significant:
MIDAS Gr. 1 or 2, HIT Gr. I or 2 MIDAS Gr. III or IV (moderate or
severe impact)
Non-triptan Triptan or DHE

Curr Med Res Opin 2002.
Early vs Late
intervention
• Early intervention prevents

escalation and can increase the
effectiveness of the treatment.
Cady RK, Clin Therap 2000; 22: 1035–48.

Successful treatment of
migraine attack
• Pain free after 2 hours
• Improvement of headache from moderate
or severe to mild or none after 2 hours
• Consistent efficacy in two of three attacks
• No Headache recurrence and no further
drug intake within 24 hours successful
treatment (so-called sustained pain relief or
pain free)

When the drug is
ineffective
• at least two attacks should be treated
• inadequate response
• change the dose
• change the route
• add adjuvant therapy
• change medication
SD Silberstein Lancet 2004; 363: 381–91
Prevent medication overused
headache (MOH)
Simple analgesics:
no more than 15 days/month
Combined analgesics:
no more than 10 days/month

Preventive Medication
Aim
• Reduce attack frequency, severity, and
duration
• Improve responsiveness to acute headache

therapies
• Improve function and reduce disability
• Reduce overall cost associated with migraine

treatment

Indication for preventive
treatment in migraine
• Recurring migraine that significantly interferes with
quality of life
• Frequency of migraine attacks > 1/weeks
• Frequency of acute medication use>2/week
• Failure of, contraindication to, or trouble AE from acute

medication
• Uncommon migraine: hemiplegic migraine, basilar

migraine, prolonged, disabling or frequent aura, or
migrainous cerebral infarction
Pract Neurol 2007; 7: 383–393

Estimated 1-year incidence rate of:
(a) chronic daily headache (180+ headaches/year) (b) increased headaches (105–179)
in an episodic headache population by baseline headache frequency.
Concept
Right Preventive medication that
drug was proven the efficacy
Right Consider patient profiles,

person and co-morbidities
Right Titrate into the appropriated

dose dose
Right On the preventive therapy

duration long enough
Migraine Comorbid disease
Cardiovascular
• Hyper- or hypotension, Raynaud’s disease, mitral valve
prolapse, angina/myocardial infarction, stroke
Psychiatric
• Depression, mania, panic disorder, anxiety disorder
Neurologic
• Epilepsy, positional vertigo
Gastrointestinal
• Functional bowel disorder
Other
• Asthma, allergy
Wolff ’s headache and other head pain 2009
Group of medication used for migraine prevention based
on levels of evidence for efficacy (AAN)
5 Groups
Group 1: medications with proven high efficacy based on at least
two Class-I trials (should be used).
Group 2: medications probably effective based on one Class-I or
at least two Class-II trials (should be considered).
Group 3: medications possibly effective based on one Class-II
trial or at least two Class-III trials, or conflicting studies (may be
considered).
Group 4: medications cannot be recommended based on
inadequate or conflicting data (Class-IV trials or no trials) (we
cannot recommend these drugs one way or the other but some are
clearly used frequently—for example, nortriptyline).
Group 5: medications probably ineffective (based on one Class-I
or at least two Class-II trials (should not be considered).

The Quality Standards
Subcommittee of the AAN
Recommended
medication for
migraine prevention
“EFNS guideline
2009”
Evers, S et al.
European Journal of Neurology 2009, 16: 968–981

Indications, contraindications, and adverse effects of conventional migraine preventive drugs
Relative
Drugs Relative indications Adverse effect
contraindication
Amytriptiline (TCA) Other pain disorders, Mania, urinary Drowsiness, dry
depression, anxiety, retention, heart blocks, mouth, increase
insomnia glaucoma appetite, weight gain
Propranolol (B-blocker) Hypertension, angina Asthma, depression, Fatique, lethargy,

CHF, Raynaud’s disease nausea, depression,
dizziness
Flunarizine (CCB) Hypertension, vertigo Obesity, depression, PD Drowsiness, weight

gain, depression, PD
Valproic acid (AED) Epilepsy, mania, anxiety Liver disease, bleeding Nausea dyspepsia,
disorder sedation, increase
appetite, weight gain
Topiramate (AED) Epilepsy, mania, anxiety Renal calculosis, liver Paresthesia, weight
disease loss, alter taste,
language disturbance
F. Galletti et al. Progress in Neurobiology 89 (2009) 176–192

Anti-epileptic drug
• AEDs that act on multiple mechanism of

actions are the best candidate (Topiramate,
Valproic acid, Gabapentin)
• Action: Glutamiatergic/ GABA, Ion channels

Clinical trials-Topiramate
Silberstein SD. Headache 2005; 45[Suppl 1]: S57-S65

Incident of most common adverse events
Adverse events in multicenter clinical trials (MIGR-001/-002/-003 and CAPSS-155) that occurred in at least
10% of subjects, and at a greater incidence in the topiramate 100 mg per day and 200 mg per day groups
Silberstein SD. Headache 2005; 45[Suppl 1]: S57-S65

Topiramate: Recommended
Migraine Prophylaxis dose and
titration
Brandes, J. L. Headache 2005;45[Suppl 1]:S66-S73

Continue preventive
medication for 4-6 months

Comprehensive
treatment plan
• Education, reassurance and life style
modification
• Avoiding triggers to prevent attack
• Non-phamacologic treatment
• Treating the acute attack
• Long-term preventive therapy
• Physical and alternative medicine
Silberstein SD. Wolff ’s headache. 2008
Conclusion
• Migraine is common and high disable
disease
• Migraine: various symptoms
• Pathophysiology links to symptoms
• Treatment plan: select right person,
medication, dose, and duration

THANK YOU FOR
YOUR ATTENTION
DOWNLOADABLE AT
WWW.OPENNEURONS.COM

Migraine For Psychiatrist, Mae Hong Sorn, 54

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Migraine

“Solving the problem”

Why neurologist treating headache need to

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

Part 1. The primary headaches

Sunday, 6 February 2011

Incidence of migraine by age and sex Adjusted prevalence of migraine by

Steewart WF. Am J Epidemiol.1991;134:1111-1120

Leonardi M. J Headache Pain (2003) 4:S12–S17

Sunday, 6 February 2011

Sunday, 6 February 2011

JMS Pearce. JNNP 1986;49:1097-1103

Sunday, 6 February 2011

Migraine without aura is more common

Sunday, 6 February 2011

Migraine with/without Migraine variant

Migraine with prolonged aura Childhood periodic syndromes that

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

• Typical aura consisting of visual and/or

Sunday, 6 February 2011

Typical visual aura is simple

Sunday, 6 February 2011

ʻʻOn a distinct form of

Sunday, 6 February 2011

Zig-zag lines in migraine aura

Olomouc (c.1757) bastion fortress in Table of Fortification, from the 1728

Spreading suppression of cortical activation during migraine aura.

Sunday, 6 February 2011

• The spreading of a self-propagating wave of

• The spreading of a wave of ischemia passing

• The spreading of a wave of vasoconstriction

Sunday, 6 February 2011

Sunday, 6 February 2011

Goadsby P. J. Headache 2005; 45[Suppl 1]: S14-S24

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

Periaqueductal gray matter (PAG), Cortical spreading depression [CSD]

Sunday, 6 February 2011

Lancet Neurol 2007; 6: 521–32

Sunday, 6 February 2011

Sunday, 6 February 2011

Individualised •Attack frequency

The US Headache Consortium Guideline

Sunday, 6 February 2011

• Thus, regularity and predictable

Sunday, 6 February 2011

Sunday, 6 February 2011

Sunday, 6 February 2011

Lipton RB. Cephalalgia 1998; 18 (suppl 22):40-6

Sunday, 6 February 2011

Evers, S et al. European Journal of Neurology 2009, 16: 968–981

Evers, S et al. European Journal of Neurology 2009, 16: 968–981

Sunday, 6 February 2011

Stratified care High need

Stratified care High need

Stratified care High need