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Headaches

Ninety percent of persons who seek medical advice for headache have migraine or tension-type headaches, and only 10% of all people have anything else wrong with them. Although there are many types of headaches, the overwhelming majority of people fit into only a very small category of headache.

Letís discuss what doesnít cause headaches, because these are things which are commonly blamed on causing headaches, which arenít very important. The first is: refractive errors of the eye. Whether you need glasses or you donít need glasses is nice, but usually doesnít have a whole lot to do with why you have chronic recurring headaches.

Now the IHS, International Headache Society, classified headaches a number of years ago and they put out a very, very long doctrine about hundreds and hundreds and causes of headache. Hereís the Green simplification of the IHS classification, which is probably all itís worth - one slide. Itís basically worth dividing headaches into primary.

The other thing is, it seems that if you have a previous history of headaches and you develop a brain tumor, you are more likely to develop headaches than if you didnít have a previous history of headaches. Itís very common that what youíve got now, with your brain tumor, is simply more of what you used to have. Now migraine being with a prodrome. Very often migraine begin with a prodrome and thatís not very often spoken about. We talk about auras - Iíll talk about auraís a little bit too - but prodromes are very common. Prodromes occur up to a day before a migraine begins, and Iíll give you some examples of what prodromes are like. There are often changes in mentation. Many people feel depressed before their migraine.

What really happens is that the generator of a migraine is in the brain stem. Itís located in an area called the periaqueductal gray in the midbrain, and that seems to generate the attack. There are neurons that are called raphe neurons, which are serotonergic and these neurons get stimulated and they cause release of, not just serotonin. Now we know that migraine is a genetically mediated condition and so somebody said, "Okay, we know that there is some relationship of migraine to some behavioral disturbances, could there be a relationship of migraine to some of the genetic serotonin neurotransmission abnormalities that psychiatrists see?" Well, the answer is yes. If you have

Now there are antiemetics, and these are very effective in the emergency room. Now antiemetics are fine at home for nausea but they donít really exert much migraine effect. But in the emergency room intravenous chlorpromazine and prochlorperazine are very effective in not just reducing the nausea but the migraine. They work, probably through the dopaminergic system, but these are very effective. Now they are not very good in the sense of migraine disability because no one is going to run home after theyíve been given such drugs. Theyíll be tired. But they are very effective and we see people who were given a specific anti-migraine drug, they come into the emergency room on their death bed. These are wonderful drugs, they are very, very effective.

Then there are nonsteroidals. The nonsteroidals are useful for mild, occasionally moderate attacks. They have the advantage of not increasing nausea in general, not making you tired, so they work very well in this migraine disability issue. But they are only effective in mild attacks in general. The parenteral one of Toradol, ketorolac, 60 mg IM has shown to be effective, 30 is actually not more effective than placebo. Then these ergots, and there are really two ergots which are totally different. Thereís ergotamine tartrate and dihydroergotamine and ergotamine tartrate is really, in my opinion, an outmoded drug. I causes a tremendous amount of rebounding, which Iíll tell you what that means in a minute, and they really increase nausea and that becomes a problem. But occasionally they are useful. Dihydroergotamine is a much better drug, itís much more effective, it doesnít tend to increase nausea to the degree that ergotamine tartrate does. Itís available by intravenous or intramuscular form and most recently marketed as Migranal, which is a nasal spray. And itís effective about 50% of the time.

Then there are the triptans. These are the agents that are certainly very exciting. They are the cleanest anti-migraine drugs in that they are fairly specific 5HT1 agonists. The first one on the market was sumatriptan, thatís marketed as Imitrex. Available as an injectable drug - which is the most effective thing we have - a nasal and an oral form.

Then thereís naratriptan, thatís marketed as Amerge. And naratriptan is a little less effective than sumatriptan but has a long half life and a low recurrence rate. Recurrence is a big issue with these drugs because migraines, as  naratriptan or dihydroergotamine perhaps are better choices.

Zolmitriptan, marketed as Zomig, is very similar. Itís an oral drug. Itís very, very similar to 50 mg of Imitrex. Thereís no substantial difference in efficacy. But the good news was - which is what we were hoping - that if you donít respond to one, you still might respond to the other. The triptans are not all alike. So people who failed on one, itís well worth trying the other agent. Then there is rizatriptan, which will be marketed as Maxalt, that will be on the market in July. Itís also very similar to Imitrex and zolmitriptan in efficacy. Maxalt will come out as an oral form, as a table, and also as a wafer, a quick dissolving wafer which has the advantage of your being able to not just treat your migraine but to take communion at the same time.

Now, prophylactically there are a variety of drugs. What I think you have to understand is that prophylactic drugs are not that effective. I think that this kind of gets lost. That prophylactic drugs, statistically, a good drug may provide 50% relief in 50% of the patients. I mention that because in the world of managed care I get these nasty letters saying, "You know, you gave this person 12 sumatriptans last month and thatís bad care. If you had only

Antidepressants: basically, amitriptyline, dioxyline, doxepin, and protriptyline and nortriptyline are the ones that we use the most. The SSRIís are up for grabs. There are just a few studies. Some show that they are somewhat effective, others show that they are ineffective, but they are clearly not major anti-migraine drugs. And then there are

How do you treat them? Well, sumatriptan injectable is FDA approved and probably the most effective drug we have. Oxygen, however, is the drug of choice. Inhalant oxygen, which is not effective in migraine, is often effective in cluster and is very safe. They need 8-12 liters a minute for half-an-hour or so, early on in the attack. What I do is I

Valproate, Depakote which is useful in both can be added to the lithium. Corticosteroids - now, corticosteroids work on everything, you know that. Thatís what you learn in neurology school and those of you who know

Now we treat those people with certain anticonvulsants, basically drugs which seem to involve polysynaptic reflexes like carbamazepine, phenytoin. Baclofen is not an anticonvulsant but chemically very similar to carbamazepine. Valproate is very effective. And if a drug doesnít work, we often use some type of procedure. We know what

Now, how do you treat it surgically? Iím going to show you a great way of treating it, but a more dangerous way. Most of the time when we treat them surgically we use either something called the glycerol rhizotomy or a radiofrequency rhizotomy. Which is