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Teshamae Monteith, MD, FAHSUniversity of Miami, Miller School of MedicineMiami, FL
Migraine and Cluster Headache Misconceptions
Teshamae Monteith, MD, FAHS
Research/Grants: Allergan Inc.;; Site principal investigator Eli Lilly and Company (funds do not go directly to Dr. Monteith)Other Financial or Material Support: Received travel funds from Teva
Disclosures
Cluster headache (ICHD-3 Beta)
A. At least 5 attacks fulfilling criteria B-DB. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 min (when untreated)C. Either or both of the following:
1. ³1 of the following ipsilateral symptoms or signs: – a) conjunctival injection and/or lacrimation;; b) nasal congestion and/or rhinorrhoea;; c) eyelid oedema;; d) fore-head and facial sweating;; e) forehead and facial flushing;; f) sensation of fullness in the ear;; g) miosis and/or ptosis
2. A sense of restlessness or agitation (90%)D. Frequency from 1/2 d to 8/d for > half the time when activeE. Not better accounted for by another ICHD-3 diagnosis
Cluster Headache (ICHD-3 Beta)
1. Episodic cluster headacheA. Attacks fulfilling criteria for Cluster headache and occurring in
bouts (cluster periods)B. ³2 cluster periods lasting 7 d to 1 y (when untreated) and
separated by pain-free remission periods of ³1 mo2. Chronic cluster headacheA. Attacks fulfilling criteria for Cluster headache and criterion B
belowB. Occurring without a remission period, or with remissions lasting
<1 mo, for ³1 y
Cluster: Just a Headache? Cluster headache- episodic (80%) and chronic (20%) Occurs in 0.4% of the general population Onset usually 20-40 years of age (80%) Positive family history in 7% of cases (14% risk in first degree relatives) Male predominates but female rates may be rising Hallmark by periodicity of bouts (often starts during shortest and longest day of the year in Jan/July)
Can be associated with migraine symptoms Peripheral: trigeminal activation, cranial parasympathetic fibers from superior salivatory nucleus, carotid sympathetic plexus (Horner’s syndrome)
Central: circadian, circannual, and seasonal rhythmicity/hormones
Misconceptions and Delays
Bahra A, Goadsby P. Acta Neurol Scand. 2004;;109(3):175-9.
Specialist Seen By Procedures
Dentist 46%
Tooth extraction
Splint
Braces
Filing
Maxillo-facial surgery
ENT 32%
Sinus washout
Nasal spectral surgery
Antibotics
Optician 26%Spectacles
Eye exercises
Ophthalmologist 23% None
Cluster Headache PathophysiologyHypothalamic dysfunction Circadian peridiocity of attacks Neuroendocrine changes (altered levels of melatonin, cortisol, luteinizing hormone, testosterone)
Activated areas seen in PET scan and voxel based morphometry in patients during cluster pain
Migraine: Just a Headache?
Migraine without aura Migraine with aura Migraine with typical aura Typical aura without headache Migraine with brainstem aura Hemiplegic migraine (1-3) Sporadic hemiplegic migraine Retinal migraine Chronic migraine (+aura)
Complications of migraine– Status migrainous– Persistent aura without infarction– Migrainous infarction– Migraine aura-triggered seizure
Probable migraine (with, without aura) Episodic syndromes
– Recurrent GI disturbance– Cyclical vomiting syndrome– Abdominal migraine– Benign paroxysmal vertigo– Benign paroxysmal torticollis
International Headache Society. International Classification of Headache Disorders. Third Edition 2013.
Diagnosis of Migraine
A. At least five attacks1 fulfilling criteria B–DB. Headache attacks lasting 4-72 hours
(untreated or unsuccessfully treated)2,3
C. Headache has at least 2 of the following 4characteristics:1. Unilateral location2. Pulsating quality3. Moderate or severe pain intensity4. Aggravation by or causing avoidance of
routine physical activity (e.g. walking or climbing stairs)
D. During headache at least one of the following:1. Nausea and/or vomiting2. Photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis.
Chronic migraine defined as > 15 headache days/month, 8 migraine days (for over 3 months) Rizzoli P, et al. The Migraine Solution: A Complete Guide to Diagnosis, Treatment, and Pain Management. Harvard University. St Martin’s Press, New York, NY. 2012
Migraine Phases
Migrainetalkblog @ https://migrainetalkblog.wordpress.com/2014/09/14/the-5-possible-stages-of-a-migraine-attack-2/ Published September 14, 2014. Accessed September 15, 2016.
It’s All in Your Head!Vascular Theory?
Afridi SK, et al. Arch Neurol 2005;;62(8),1270-1275Matharu MS, et al. Brain 2004;;127(Pt 1):220-230
Chronic Episodic
Obermann M, et al.Cephalalgia 2006;;26(6):763-766
Weiller C, et al.Nat Med 1995;;1(7):658-660
Chronic Migraine with Medication Overuse
Grazzi L, et al. Headache. 2010;;50(6):998-1004.
Control Subjects
Chronic migraine and medication overuse
Chronic migraine and medication overuse 6
months after withdrawal
Questions Answers &
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