Understanding Headaches

Grace Forde, M.D

Assistant Professor of Neurology
New York University
Director of Neurological Services
North Shore Pain Service

Migraine Epidemiology

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Migraine Prevalence
Approximately 26 million patients with
migraine in the United States (> age 18)
One in 4 households has at least 1
migraine sufferer

Lipton RB, et al. Neurology. 2007; 68(5):343-349.

National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.

Migraine Prevalence:
Age
and
Gender
Migraine prevalence peaks in the 25-55 age range

Lipton RB, et al. Neurology. 2007;68(5):343-349.

Migraine Economic Impact,

Productivity, and Quality of Life

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Economic Burden of Migraine in

US
Lost productivity is the greatest contributor to migraine economic
burden
Productivity losses cost US employers up to $13 billion annually
Direct costs of migraine per patient range from ~$500-$7000/year
Total medical costs in households with at least 1 member with
migraine are 70% higher than families without a member with
migraine
Hu XH et al. Arch Int Med. 1999;159(8):813-818.
Hawkins K et al. J Occup Environ Med. 2007;49(4):368-374.
Edmeads J and Mackell JA. Headache. 2002;42(6):501-509.
Stewart WF et al. JAMA. 2003;290(18):2443-2454.
Osterhaus JT et al. Pharmacoeconomics. 1992;2(1):67-76.

Etemad LR, et al. JMCP. 2005;11(2):13744.

Pesa J and Lage MJ. Headache. 2004;44(6):56270.
Lafata JE, et al. J Gen Intern Med. 2004;19(10):100512.
Hawkins K, et al. Value Health. 2006;9:A85.
Stang PE, et al. Am J Manag Care. 2004;10(5):31320.

Timing and Impact of Migraine

58% of Migraines Occurred During Typical Work Hours*

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting,
June 26-29, 2008; Boston, MA.

N=200 Full-Time Employees

Impact of Migraine: Productivity

Productivity Levels

74% of Patients With Migraine* Reported

Productivity Levels Below 80%

N=157 Full-time employees

Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.

Migraine Diagnosis
and Treatment

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International Headache Society

Criteria for Migraine
Migraine Is an Episodic Recurrent Headache
Lasting 4-72 Hours with:
Any 2 of these pain
qualities:

Any 1 of these
associated symptoms:

unilateral pain
throbbing pain
pain worsened by
movement
moderate or severe pain

nausea
vomiting
photophobia and
phonophobia

Features such as osmophobia and posterior head and neck pain can also be present in a
headache that meets IHS criteria for migraine.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders.
2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

Many Migraine Sufferers Remain

Undiagnosed

56%
Diagnosed Migraine

44%
Undiagnosed Migraine

Diamond S et al. Headache. 2007;47(3):355-363.

Patients with Recurrent Headache May

Meet Criteria for Migraine

87% of patients presenting to PCP with recurrent headache

met IHS criteria for migraine
Episodic Tension-type Headache (n=1)

0.4%
Probable Migraine
(n=31)

Other (n=3)

1%

11%
Migraine
(n=237)

87%

Tepper SJ et al. Headache. 2004;44(9):856-864.

Focusing on Migraine Diagnosis

Opportunities for accurate diagnosis of migraine
patients still exist:
80% of sinus headache patients met IHS criteria for
migraine
85% of tension/stress headache patients met IHS criteria
for migraine

Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.

Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

Phases of a Migraine Attack

Treatment Phase

Pre-HA

Migraine Intensity

Premonito
ry/
Prodrome
Migraine
symptoms
occurring
hours/days prior
to headache

Headach
e

PostHA

Aura
Focal
neurological
symptoms
preceding
headache
(<1 hour)

Symptoms:
Flashing lights
Symptoms :
or wavy lines
Food cravings Numbness
Mood changes Tingling in face
Yawning
Disturbed
Fatigue
senses

Moderate
to Severe

Mild

Migraine when
headache is mild

Symptoms:
Sensitivity to light
Sensitivity to sound
Nausea
Pain in the back of
the head and neck

Migraine when
headache is moderate
to severe

Symptoms:
Same as mild but
more intense

Postdrom
e

Migraine
symptoms
occurring
hours/days
after headache
resolution

Symptoms:
Tiredness
Confusion
Lowered appetite
Stiff or sore
muscles

Time
Adapted from Cady RK. Headache. 2008;48(9):1415-1416.
Headache Classification Subcommittee of the International Headache
Society. Cephalalgia. 2004;24(suppl 1):117-118.
Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone.
1999;1(6):21-32.

National Institutes of Health. National Institute of Neurological

Disorders and Stroke.
http://www.ninds.nih.gov/disorders/headache/detail_headache.htm.
Accessed December 7, 2009.

Possible Triggers of a Migraine

Attack

Food and food additives

Bright lights/glare
Smells/odors
Dieting/hunger
Loud noises/sounds
Changes in altitude/
air travel

Wober C et al. J Headache Pain. 2006;7(4):188-195.

Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.

Stress
Weather changes
Caffeine
Alcoholic beverages
Changes in sleep habits
Hormonal fluctuations/
menstrual cycle

Medication Options Available

for
Migraine
Acute Medications
Preventative Medications

May work quickly to relieve

migraine pain and other symptoms
Usually taken during a migraine
attack
Triptans
NSAIDs
Opioids
Analgesics (Rx and OTC)
Ergotamine/DHE
Antiemetics
Neuroleptics
Corticosteroids

Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.

Silberstein SD. Neurol Clin. 2009;27(2):429-443.

May prevent or reduce the number

of migraine attacks
Typically taken on a daily basis
Antiepileptics
Antidepressants
Beta blockers
Calcium channel blockers

Differences in Patients with

Migraine
Migraine patients brain is in a state of hyperexcitability
Reduced threshold for stimuli
Everyday things can trigger a migraine attack
Migraine patients gut is slowed
Gastric stasis is common and can delay tablet
absorption
Conventional tablets rely on surface erosion and gastric
motility for dissolution in the stomach, which must occur
before being absorbed
Hargreaves RJ and Shepheard SL. Can J Neurol Sci. 1999;26(suppl 3):S12-S19.
Aurora S et al. Headache. 2006;46(1):57-63.

The Triptans

Sumatriptan
Zolmatriptan
Naratriptan
Rizatriptan
Almotriptan
Frovatriptan
Eletriptan
Sumatriptan and Naproxen sodium

Triptan Prescribing Information:

Contraindications and Precautions for ALL
Triptans
Ischemic cardiac disease
Cerebrovascular disease
Uncontrolled hypertension
Hypersensitivity
Use within 24 hours of other 5-HTs/ergots
Hemiplegic/basilar migraine
History of risk factors for CAD
SSRI precaution

Case Scenario 2
29-year-old single woman,
sales clerk; history of 8-9
migraines / month lasting
for 12-14 hours, frequent
recurrence
HA associated with nausea and
sensitivity to light and sound
Currently taking an oral
triptan tablet
Says that current treatment
takes too long to act and does
not fully relieve headache pain
Looking for a way to
prevent attacks

Preventive Medication Groups

Anticonvulsants
valproate*
topiramate*

Antidepressants
TCAs
SSRIs

-adrenergic blockers
propranolol*
timolol*
SSRI = selective serotonin reuptake inhibitor
TCA = tricyclic antidepressant

Calcium channel
antagonists
Serotonin antagonists
Others

Botulinum toxin A*
coenzyme Q10
NSAIDs
Petasites
Riboflavin
Magnesium

*Approved by FDA for this use.

Silberstein SD. Lancet. 2004;363:381-391.

Nonpharmacologic Therapies
Tested in Clinical Trials
Behavioral Treatments
Relaxation training*
Hypnotherapy
Thermal biofeedback
training*
Electromyographic
biofeedback therapy*
Cognitive / behavioral
management therapy*
*Proven effective in clinical trials

Physical Treatments
Acupuncture
Transcutaneous
electrical nerve
stimulation (TENS)
Occlusal adjustment
Cervical manipulation

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

Case Scenario #3

Migraine Is Often Overlooked

Sinus headache is the most common

misdiagnosis

Sinus pain caused by

inflammation induced
allergens or by infection
occurs when exudate in
inflamed, blocked sinuses
exerts pressure that
stimulates local trigeminal
nerve fibers
Chronic sinusitis is not
validated as a cause of
headache unless it
relapses into an acute

Headache:
A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS*
Major factors
Purulence in nasal cavity on
exam
Facial pain/pressure/congestion**
Nasal obstruction/blockage/
discharge
Fever (in acute only)

Minor factors
Headache
Fever (chronic)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness

Hyposmia/anosmia
** Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the
absence of another major nasal symptom or sign.

Sinus Features May Hide the Presence of

Migraine
Headache Symptoms at Screen Among IHS Diagnosed Migraineurs
96%
87%
84%
84%
82%
70%
65%
57%

n=2257

42%
38%

IHS Migraine Symptom Criteria

28%

Sinus Like Features

27%
23%

% of Subjects
Schreiber et al. Poster Presented at: American Headache Society Meeting; June 21-23, 2002: Seattle, WA.
Data on file, GlaxoSmithKline.

Why do so many
Americans think they
have Sinus
Headache?

In his 1988 review, Sinus Headache: A Neurologists Viewpoint, Couch writes:

In my experience and in that of others, sinus headache, as reported
by patients, is a popular conception that is often erroneous. Patients
reason that, since the sinuses are close to the eyes (as depicted in
advertisements in popular magazines), headaches located in the
frontal, supraorbital, or infraorbital region are sinus headaches
[These] headaches frequently are associated with some gastrointestinal
symptomatology, photophobia, and phonophobia, and may have some
visual or neurologic symptoms. In short, these sinus headaches are
usually migraine headaches, most often of the common migraine type.

Couch, J. Seminars in Neurology. 1988;8(4):298-302.

Migraine Is Often Overlooked

(contd)
Tension headache is another common
misdiagnosis
Symptoms include
Dull steady ache
Physical activity does not worsen pain
Nausea, photo/phonophobia
are not usually present
Vomiting never present
Patients have likely tried OTCs and failed

Cady et al. Headache Free. 1993;36-38.

Migraine Pain Can Be Felt in Peripheral

Locations Such as the Neck
In Kanieckis study of 144 patients with
migraine
75% reported neck
pain
with their migraine

43% described neck

pain as bilateral and
57% as unilateral

69% described the

neck
pain as tightness and

75%
reported neck pain
with their migraine

Activation of the TNC May Result in

Referred Pain that Could be Perceived
Anywhere along the Trigeminocervical
Network

Case Scenario 5
26-year-old man, computer programmer,
married with 2 children
Has severe, stabbing
pain behind his right eye
Headaches are
accompanied by
lacrimation and nasal
congestion
Pain lasts 30 to
45 minutes; attacks
occur daily for several
weeks, then stop for
months at a time

Treatment of Hypnic Headach

Lithium Carbonate
(200-600mg)
Indomethacin
Verapamil (160my
QHS)
Methysergide
Caffeine (60mg)
Lamotrigene

TRIGEMINAL NEURALGIA