TOC  |  Neurology

MIGRAINE   RX  |  Prophylactic Rx                                            

See Med Letter 2004  Migraine Treatment 
See Prevention of Migraine in Women throughout the life span (Mayo Clinic 2006)  


is a benign recurring headache and/or neurologic dysfunction usually attended by pain-free interludes and almost always provoked by stereotyped stimuli. It is more common in women, and has a hereditary predisposition toward attacks.

A Brief 3-item screening questions for migraine headache: Any associated

  1. disability
  2. nausea
  3. photophobia

If 2 of 3 positive answers, the positive predictive value for having migraine is 93%,
if all 3 positive answers, the positive predictive value for having migraine is 98%.

CLASSIC MIGRAINE with aura
denotes the syndrome of headache associated with characteristic premonitory visual, sensory, or motor symptoms.

International Headache Society Criteria for Migraine Without Aura
(Ref: Cephalagia 1988;8 Suppl 7;1-96)
A.  At least 5 attacks fulfilling criteria listed in B, C, D and E below.

B.  Headache lasts 4-72 h if untreated or unsucessfully treated.

C.  Headache has at least 2 of the following characteristics:
 - Unilateral location
-  Pulsating quality
-  Moderate to severe intensity
-  Aggravation by walking stairs or similar physical activity

D.  During headache, at least 1 of the following:

E.  History, physical, & neurologic examinations, & if appropriate, diagnostic tests exclude related organic disease.

The visual Sx of scotomas and/or hallucinations may last 20-25 minutes, always occur before the headache. It is from dysfunction of occipital lobe neurons.

COMMON MIGRAINE without aura
denotes one in which there is no focal neurologic disturbance preceding the occurrence of headache.

It is commonly described as benign periodic headache of several hours, with pain unilaterality, attendant N&V, positive family history, responsiveness to ergotamine, and scalp tenderness in varying combinations.

International Headache Society Criteria for Migraine With Aura
(Ref: Cephalagia 1988;8 Suppl 7;1-96)

A. At least 2 attacks that fulfill criteria in B and C

B. At least 3 of the 4 following characteristics:

  1. One or more fully reversible auro Sx indicating focal cerebral cortical or brain-stem dysfunction (or both)
  2. At least 1 aura Sx develops gradually over >4min or 2 or more Sx occur in succession.
  3. No single aura Sx lasts >60 min
  4. Headache begins during aura or follows aura with a Sx-free interval of 60 min (headache may begin before or with aura)

C.  History, physical & neurologic exam, and if appropriate, diagnostic tests exclude related organic disease.

BASILAR MIGRAINE
The Sx of a disturbance in brainstem function such as vertigo, dysarthria, and diplopia.

Bickerstaff called attention to a stereotyped sequence of dramatic neurologic events often comprising total blindness and sensorial clouding, accompanied or followed by admixtures of vertigo, ataxia, dysarthria, tinnitus, and distal and perioral paresthesia. In about 1/4 of pts, a confusional state supervenes. It usually persit for 20-30 min and are generally followed by a throbbing occipital headache. The sensorial alterations may last for as long as 5 days and may take the form of confusional states that may be mistaken for psychotic reactions.

CAROTIDYNIASYNDROME (Lower half headache or facial migraine)
The pain is usually at the jaw or neck, sometimes periorbital or maxillary pain. It may be continuous, deep, dull, and aching, & becomes pounding or throbbing episodically. , often superimposed by sharp, ice-picklike jabs. Attacks occur one to several times per week, lasting several minutes to hours. Tenderness and prominent pulsations of the cervical carotid artery, and soft tissue swelling overlying the carotid, are usually present homolateral to the pain. Dental trauma is a common precipitant of this syndrome.

MIGRAINE EQUIVALENTS or ACCOMPANIMENTS
denotes focal neurologic disturbances without headache or vomiting.

COMPLICATED MIGRAINE
denotes migraine with dramatic focal neurologic features that may persist as a residuum of a migraine attack.

ACUTE TREATMENT OF COMMON or CLASSIC MIGRAINE       Top  |  HomePage
Early Rx is critical to obtaining benefit
Rest in the dark & quiet enivronment
May need to try different medications to find 1 or more that are helpful.

  1. Aspirin/Excedrin or
    Fiorinal (ASA+Butalbital+caffeine) or Fioricet (Tylenol+Butalbital+caffeine) 1-2 tab q4 h PO
  2. NSAID as ibuprofen/Motrin 600-800mg, naproxen 375-750mg.
  3. Rizatriptan(Maxalt-MLT) 5-10 mg PO, may repeat after 2 hrs (Max 30 mg/day) .
    Sumatriptan/Imitrex 6 mg subc     (Max two 6 mg subc injection/day separated by at least 1 h)
    or 25-50-100 mg tab PO, may repeat after 2 hrs (Max 200 mg PO/day), or intranasal 2 sprays  -may repeat x 1.
    Zolmitriptan (Zomig) 2.5 - 5 mg PO - may repeat x 1 after 4 hrs (Max 5 mg/day).
    Naratriptan  (Amerge) 2.5 mg PO - may repeat x1
    Almotriptan (Axert) 6.25 - 12.5 mg PO tab ,may repeat in in 2 hours prn (Max 25 mg/day)
    Eletriptan (Relpax) 20-40 mg tab, may repeat in >2 hours prn (Max 80 mg/day)
    Frovatriptan (Frova) 2.5 mg, may repeat in 2 hours prn (Max 7.5 mg/day).
  4. Isometheptene/Midrin 2 cap at once, followed by 1 cap q1h until relieved, up to 5 cap within 12h.
    (Check the contraindication list)   Max 6/d & 24/wk.
  5. Ergotamine tartrate/Ergomar/Ergostat 2 mg tab sublingual, then another tab at 1/2 h intervals
    (max 3 tab in 24h; 5 tab in 1 week)
    Cafergot (ergotamine tartrate +caffeine) 1 mg tab q 30 min until relieved. Ave. dose is 3 tab of 1 mg PO or 1/2 tab of 2 mg supp.  (Max 6 tab/attack, 10 tab/week, or 2 supp/attack, 5 supp/week)
  6. Dihydroergotamine/DHE-45. give 0.5 - 1 mg (1 ml) subc or IM/IV, may repeat at 1 h to a total of 3 ml.
    (Max 6 ml/wk).
    Migrainal DHE nasal spray (Migranal)     each nostril at onset, may repeat x 1 in 24 h.
    A common IV protocol is the mixture of 5 mg of prochlorperazine/Compazine + 0.5 mg of dihydroergotamine/DHE-45 over 2 min.
  7. Corticosteroid as Dexamethasone or Prenisone for refractory migraine
  8. ? 4% Lidocaine aqueous solution for nasal instillation 0.5 mL to nostril over 30 seconds, repat after 2 min as needed
  9. Meperidine (Demerol) 50-100 mg + Vistaril 25 mg IM  for severe disabling pain.
  10. Ketorolac  (Toradol) 15-30 mg IM or IV q6h as needed for severe pain.
  11. Compazine (Prochlorperazine) 10 mg IM, Reglan (Metoclopramide) 10 mg PO or IV for nausea & vomiting.

PROPHYLAXIS RX of COMMON or CLASSIC MIGRAINE      Top  |  HomePage

  1. Propranolol (Inderal) 40-240 mg/day or Atenolol (Tenormin) 50-100 mg tab qd
  2. Verapamil/Calan 160-480 mg/day
  3. NSAID as Ibuprofen 400-600 mg, Naprosyn 375-500 mg, etc.
  4. Valproate/Depakene 125-250 mg tid, up to 500 mg tid as needed
  5. Prozac start with 10 mg, up to 80 mg daily PO
    Amitriptyline/Elavil  start with 10 mg, then increase up to 25-100mg/day     or
    Nortriptyline/Pamelor 40-120mg/day (Supplied: 10-25-50-75mg cap)
    Desipramine (Norpramin) 10-50 mg hs
  6. Neurontin (Gabapentin) 300 mg 2-4x/day
  7. Topamax (Topiramate) initial 15-25 mg, typical daily dose 75-200mg/day
  8. Phenelzine/Nardil 45-90mg/day.
  9. Bellergal (Ergotamine/belladonna/phenobarbital) 1 tab bid
  10. Phenelzine/Nardil 45-90 mg/day
  11. Methysergide/Sansert 4-12 mg/day; cyproheptadine
  12. Riboflavin (Vit. B2) 400 mg daily ? (Neurology 1998;50:466 - Schoenen J)
  13. Magnesium oxide 400-800 mg/day ?
  14. In this study, the angiotensin II receptor blocker one 16-mg candesartan cilexetil tablet daily provided effective migraine prophylaxis, with a tolerability profile comparable with that of placebo. JAMA. Jan. 1, 2003;289:65-69

CLUSTER MIGRAINE HEADACHE               Top  |  HomePage

The episodic type is characterized by 1-3 short-lived attacks of periorbital or less commonly temporal pain per day over a 4-8 week period, followed by a pain-free interval. The pain begins without warning and reaches a crescendo within 5 min. It is often excruciating in intensity and is deep, nonfluctuating, and explosive in quality; only rarely is it pulsatile. Pain is strictly unilateral & usually affects the same side in subsequent months. Attacks last from 30 min to 2 h; there are often the associated Sx of homolateral lacrimation, reddening of the eye, nasal stuffiness, lid ptosis, and nausea. Alcohol provocation of attacks occurs in about 70% of pts & ceases when the bout remits. This on-off vulnerability to alcohol is pathognomonic of the cluster headache syndrome.

The chronic form of cluster headache may begin de novo or several years after an episodic pattern has become established. Men are affected more commonly than women in a proportion of 7-8:1.

Hypothalamus may be the site of activation.

TREATMENT of CLUSTER HEADACHE:

  1. O2 inhalation 10 L/min via tight mask for 10 minutes or 15 min inhalation of 100% O2 is often necessary to stop attacks.
    Ref:  JAMA Dec 9,2009;302(22):2451
  2. Intranasal lidocaine (4% topical or 2% viscous) to the most caudal aspect of the inferior nasal turbinate).
  3. Prednisone begin at 40-60 mg x 7d & rapidly taper off in 3 days (total 10d).
  4. Sumitriptan/Imitrex 6 mg subc.
  5. Ergotamine 3mg PO or 1mg supp 1-2h before the expected attacks.
  6. Lithium 600-900 mg/d as prophylaxis or in chronic cluster headache.
  7. Verapamil/Calan for prophylaxis Rx
  8. Baclofen
  9. Methysergide/Sansert 4-12 mg/d
  10. Smoking cessation
  11. ? Microvascular decompression of the trigeminal nerve
  12. ? Radiofrequency lesions of the sphenopalatine ganglia
  13. ? Glycerol injection to the sphenopalatine ganglia (Cleveland Clinic)


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