YOUR DIFFICULT PATIENT WITH RECURRENT SPELLS HAS MIGRAINE

YOUR DIFFICULT PATIENT WITH RECURRENT SPELLS HAS MIGRAINE David Lee Gordon, M. D. , FAAN, FANA, FAHA Professor and Chair Department of Neurology The University of Oklahoma Health Sciences Center OU Neurology

DLG DISCLOSURES n FINANCIAL DISCLOSURE I have nothing to disclose n UNLABELED/UNAPPROVED USES DISCLOSURE I have nothing to disclose OU Neurology

MIGRAINE & RECURRENT SPELLS LEARNING OBJECTIVES n n Relate a practical definition of migraine Determine when the following symptoms are due to migraine: n n Abdominal pain Chest pain Vertigo Syncope Confusion Hemiparesis Aphasia Headache Name three overarching considerations when prescribing migraine therapy Describe the appropriate abortive and prophylactic therapies for migraine OU Neurology

CASE 1: PRESENTATION n 58 -year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain n Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy n One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab n Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam OU Neurology

CASE 2: PRESENTATION n 28 -year-old tearful woman with “pain all over, ” unable to move L side due to pain and with bilateral blurred vision n Six weeks ago, had difficulty holding objects in L hand, then noted “waves of pain” in both shoulders radiating over minutes into both hands, L > R, followed by a lightning sensation into L thigh, radiating into L toes n Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month n One month ago, symptoms became constant without relief from daily Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid n Lost nursing job 3 weeks ago when she became bedbound with daily vertigo and occipital headache radiating to R temple & eye n For last week, severe R chest pain (R anterior axilla to upper back) n For last few days, blurred vision in both eyes, initially intermittent, then constant n For one day, nausea and vomiting OU Neurology

CASE 3: PRESENTATION n 80 -year-old distraught man with intractable, intermittent, 12 -hour episodes of vertigo, diplopia, ataxia, nausea, and vomiting occurring every 5 -6 days that left him disabled and housebound n MRI brain normal n Symptoms became constant several months ago despite taking daily Voltaren, Protonix, and Zofran n Famous quaternary referral center #1 – no diagnosis n Famous quaternary referral center #2 – progressive, degenerative disease n On exam, he had gait ataxia OU Neurology

MIGRAINE: WHAT IT IS NOT MIGRAINE DOES NOT MEAN HEADACHE n “Headache is never the sole symptom of migraine, nor indeed is it a necessary feature of migraine attacks. ” Oliver Sacks, Migraine, Revised & Expanded, 1992 A book intended for laypersons with multiple descriptions of the varied symptoms (“phenomenology”) of migraine. Heavy reading, but very informative. Oliver Sacks also wrote the book Awakenings, later turned into a movie in which Robin Williams played the role of Oliver Sacks OU Neurology

HEADACHE VS. MIGRAINE: SYMPTOM VS. SYNDROME n Headache Pain in the head n Migraine A syndrome of episodic brain dysfunction with systemic manifestations (that may include headache) Migraine is by far the most common cause of recurrent, episodic headache without sequelae, but… migraine with NO headache is also very common. OU Neurology

MIGRAINE: WHAT IT IS PRACTICAL DEFINITION & DESCRIPTION Genetic condition in which a person has a predisposition to suffering recurrent transient episodes (attacks) of brain dysfunction with systemic manifestations that may include: headache/neck pain – from mild to severe, variable location focal neurologic symptoms – mimics stroke/TIA GI symptoms (upper or lower) – equals IBS, mimics gallstones chest pain – mimics heart attack, equals atypical noncardiac CP autonomic dysfunction – BP, pulse, sinus congestion, etc. “triggered” by hormonal or environmental changes or other medical conditions, and consisting of 4 possible phases (prodrome, aura, pain, postdrome). OU Neurology

MIGRAINE TRIGGERS n Hormonal changes Stress (esp. stress “letdown”), exercise, thyroid Estrogen (menarche, pregnancy, hormonal contraceptives, menopause) n Environmental changes or exposures Weather (barometric pressure), motion Scents, smoke, fumes n Sleep changes Deficiency or excess, change in shift n Diet changes Hunger Alcohol (all types, but esp. red wine) Artificial foods (nitrates, MSG, sulfites, aspartame, sucralose) Dehydration n Medical conditions Head trauma, fever Cerebral blood flow changes (AVM, endarterectomy/angioplasty) OU Neurology

1. 2. 3. 4. MIGRAINE PHASES: PRODROME/PREMONITORY* Prodrome Aura Pain Postdrome n Mood changes Irritability, depression, euphoria/hyperactivity n Difficulty concentrating n Stiff neck n Fatigue, malaise, yawning n Autonomic/GI symptoms *ICHD-3 suggests elimination of the term “prodrome” & substituting “premonitory” instead constipation, diarrhea, urinary frequency n Anorexia or food cravings esp. foods that increase serum serotonin and/or magnesium, e. g. , chocolate, bananas, nuts, peanut butter, sweets, fatty foods May begin hours to days before attack, persist through all 4 phases— likely related to serotonin, magnesium, hypothalamic changes OU Neurology

1. 2. 3. 4. MIGRAINE PHASES: AURA (1 of 2) Prodrome Aura Pain Postdrome n Transient neurologic symptoms Due to cortical spreading excitation/depression Symptoms referable to location of transient chemical changes in cerebral cortex n Pattern of symptoms Recurrent & stereotypical (previous similar spells) Gradual onset Migratory (1 part of body to another) over mins to hrs Progressive (1 type of symptom to another) Duration minutes to hours Chemical chain reaction in the brain leads to focal symptoms that change during an attack OU Neurology

MIGRAINE PHASES: AURA (2 of 2) 1. 2. 3. 4. Prodrome Aura Pain Postdrome n Types of symptoms Visual—Usually “positive” (scintillation) followed by negative (scotoma) § § Shimmering, scintillating, flashing lights Spots, dots, bubbles, lines (zigzag, wavy, heat off pavement) Any color, but often silver, gray, or clear Usually associated w/ motion, e. g. , moving, vibrating, coalescing Sensory—Usually “positive” (tingling) followed by negative (numbness) Motor—Hemiparesis Cognitive—Aphasia, confusion, amnesia, olfactory hallucinations Brainstem—Vertigo, ataxia, diplopia, tinnitus, dysarthria, LOC Autonomic § § N/V, anorexia, dyspepsia, abdominal cramping, flatulence, diarrhea Horner, sinus congestion/epistaxis, facial/scalp flushing (e. g. , red ear) Hypothermia, mild fever Hypertension, hypotension, syncope, palpitations, arrhythmias *Migraine causes HA & HTN, but HA, per se, does not cause HTN OU Neurology

1. 2. 3. 4. MIGRAINE PHASES: PAIN Prodrome Aura Pain Postdrome n Headache characteristics—No specific pattern Location variable § Unilateral, bilateral § Anterior (frontal, periorbital, etc. ), posterior (occipital, neck) § Diffuse, focal (e. g. , nummular = coin-shaped) Throbbing, pulsating, pounding, pressure, squeezing, dull, aching Severe, moderate, mild, absent Onset usually gradual; duration hours, days, weeks n Associated symptoms Sensory phobias – photo, phono, kinesio, thermo, osmo Allodynia – pain due to light touch, breeze, hair moving, etc. “Lightheadedness” – vibratory or buzzing paresthesia in head Trigeminal nerve (CN 5) & cervical nerve root sensitization in the meninges results in headache, sensory phobias, neuropathic symptoms OU Neurology

MIGRAINE PHASES: POSTDROME 1. 2. 3. 4. Prodrome Aura Pain Postdrome n Fatigue, malaise n Difficulty concentrating n Mood changes n Muscle aches n Scalp tenderness n Food cravings or anorexia The migraine hangover OU Neurology

MIGRAINE PATHOPHYSIOLOGY A JIGSAW PUZZLE WITH MISSING PIECES Trigger Hypothalamic dysfunction & hyperexcitable cortex (esp. occiput) Prodrome Cortical spreading depression (excitation/depression w/ hyperemia/oligemia esp. occiput) Aura Spreading depression in insula or brainstem serotonergic & noradrenergic dysfunction Dysautonomia CN V/cervical root sensitization with pain receptor stimulation & release of neuropeptides (e. g. , CGRP) Headache/ Arterial changes/ Sensory phobias Platelet & serum serotonin levels decrease during attacks of migraine, tension headache, IBS, & PMS. Cerebral serotonin & magnesium decrease during a migraine attack. OU Neurology

MIGRAINE WITH AURA: MRI BRAIN FINDINGS n Deep-white matter “UBOs” common in migraine w/ aura White on T 2 & FLAIR Located at gray-white junction Small, round, indistinct borders Often confused with: § Multiple sclerosis plaques § Strokes (“small-vessel disease, ” “arteritis, ” “vasculitis”) Significance & cause unknown Further evaluation not necessary Reassure patient Kruit MC et al. JAMA 2004; 291: 427 “Unidentified Bright Objects” (UBOs) of migraine seen on FLAIR MRI OU Neurology

MIGRAINE WITHOUT AURA “OFFICIAL” DEFINITION PER ICHD-3 n Frequency > 5 episodes n Duration 4 -72 h untreated n HA quality (> 2) Unilateral Pulsating Moderate or severe w/ physical activity n Associated features (> 1) Nausea &/or vomiting Photo- & phonophobia n No other cause of sxs “The diagnostic difficulty most often encountered among primary headache disorders is to discriminate between tension-type headache and mild migraine without aura. ” Cephalalgia 2013; 33(9): 629 -808 The ICHD-3 migraine criteria are useful for scientific studies, but are too restrictive & impractical for daily use & were written from perspective of physicians with focus on headache. ICHD-3 = International Classification of Headache Disorders, 3 rd ed. OU Neurology

MIGRAINE WITH AURA “OFFICIAL” DEFINITION PER ICHD-3 “Recurrent attacks, usually lasting minutes, of unilateral fully reversible visual, sensory, or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms. ” n Frequency: > 2 attacks n Aura: > 1 of the following fully reversible aura sxs visual sensory speech &/or language motor brainstem retinal n Characteristics: > 2 of 4 following > 1 aura sx spreads gradually over > 5 min &/or > 2 sxs occur in succession each individual aura sx lasts 5 -60 min (though motor sxs may last 72 h & “persistent aura without infarction” may last > 1 wk) > 1 aura sx is unilateral (incl. aphasia) aura accompanied, or followed w/in 60 min, by HA n No other cause of sxs Cephalalgia 2013; 33(9): 629 -808 OU Neurology

MIGRAINE WITH AURA TYPES PER ICHD-3 n Migraine w/ typical aura Visual Sensory n Migraine w/ brainstem aura Dysarthria Vertigo Tinnitus Hypacusis Diplopia Ataxia level of consciousness n Hemiplegic migraine (HM) Familial HM type 1 (CACNA 1 A) Familial HM type 2 (ATP 1 A 2) Familial HM type 3 (SCN 1 A) Familial HM other loci Sporadic hemiplegic migraine n Retinal migraine (monocular) OU Neurology

MIGRAINE WITH “TYPICAL” AURA DESCRIPTIONS PER ICHD-3 n Migraine w/ visual aura Most common (> 90%) aura Fortification spectrum – zigzag figure that may gradually spread & assume laterally convex shape w/ angulated scintillating edge, leaving absolute or relative scotoma in its wake Scotoma without positive phenomenon may occur n Migraine w/ sensory aura 2 nd most frequent aura Pins & needles moving slowly from point of origin affecting 1 side of body, face, &/or tongue Numbness may occur in its wake Numbness may also be the only symptom OU Neurology

MIGRAINE GLASSES MAKE THE DIAGNOSIS MORE CLEAR Symptoms that seemed vague and psychiatric are clearly due to migraine when seen through the proper lenses MIGRAINE Diagnosis without migraine understanding— things don’t make sense, therefore patient is “crazy” MIGRAINE Diagnosis with migraine understanding— a pattern emerges OU Neurology

MIGRAINE IS A DISTINCT SYNDROME OF BOTHERSOME, BUT “BENIGN” SPELLS n Lifelong (childhood through adulthood) history of multiple different types of similar “spells” Main symptom headache, GI upset, chest pain, visual symptoms, tingling, vertigo, confusion, etc. Associated with mood changes, food cravings, sensory phobias Triggered by stress letdown, weather changes, estrogen changes, dehydration, hunger, etc. Normal tests Complete resolution between spells—though taking daily analgesic, triptan, decongestant, or muscle relaxant makes symptoms constant n Family history of spells similar to those suffered by pt But obtaining accurate past & family histories is challenging OU Neurology

WHY MIGRAINE IS REALLY, REALLY COMMON, BUT NOBODY KNOWS IT n “Regular” / “ordinary” headaches are migraines n Tension headaches are migraines Frequent co-occurrence in patients and similar epidemiology, clinical features, & treatment responses Actually migraines triggered by stress letdown n Sinus headaches are migraines Respond to migraine prophylactic agents Respond acutely to triptans (migraine abortive agents) Do not respond to antibiotics Sinus artery dilatation occurs in migraine n Not all migraine attacks include headache Aura without headache (visual, sensory, vertigo, etc. ) Abdominal migraine (= irritable bowel syndrome) Precordial migraine (= noncardiac atypical chest pain) OU Neurology

CONDITIONS LIKELY DUE TO (OR RELATED TO) MIGRAINE n n n Tension-type headache Sinus headache Regular/ordinary headache Cervicogenic headache Premenstrual syndrome Irritable bowel syndrome Functional dyspepsia Infantile colic Motion sickness Chronic pelvic pain Recurrent vertigo/Meniere n Panic attacks n Atypical noncardiac chest pain n Intermittent headache w/ transient hypertension n Transient global amnesia n Episodic confusion n POTS (postural orthostatic tachycardia syndrome) n Syncope of unknown cause n Postconcussion/posttraumatic headache n Stroke-like spells (TIA mimic) These conditions cause temporary symptoms that are said to be of unknown cause, but which may be explained by migraine OU Neurology

NOT DIAGNOSING MIGRAINE LEADS TO WASTED DOLLARS & LIVES n Imaging studies (CT, MRI, endoscopy, colonoscopy, etc. ) n Medications Antibiotics (bacterial resistance) Decongestants (chronic nasal congestion, HTN, chronic symptoms) Anxiolytics, antidepressants (social consequences of false diagnosis) Antithrombotic agents (hemorrhage) Narcotics (chronic symptoms, drug-seeking behavior caused by docs) n Surgeries Gallbladder Uterus and ovaries Sinus and ear n Disability, retirement, divorce OU Neurology

WHY DON’T MORE DOCTORS KNOW ABOUT MIGRAINE? n Migraine training is often inadequate n Physicians have limited time to spend with patients Diagnosis is based on history; with limited time, history is cursory and important details are missed Exam & tests are normal, leading to assumption of psychiatric illness n Physicians have limited confidence beyond their specialty Neurologists deal with headaches GI doctors deal with stomach and intestine symptoms Ob-Gyn doctors deal with woman issues ORL / ENT doctors deal with ear, nose, sinus symptoms Cardiologists deal with cardiac causes of chest pain Pain specialists deal with peripheral (not CNS) pain OU Neurology

MIGRAINE THERAPY: THE TWO KINDS Prophylactic and Abortive Agents n Prophylactic agents (preventers) If a patient takes certain medications every day, s/he is likely to have less frequent and less severe migraines n Abortive agents (stoppers) If a patient takes certain medications as soon as possible at the start of a migraine attack, s/he may either stop the attack or make it less severe OU Neurology

MIGRAINE THERAPY: THE 3 OVERARCHING CONSIDERATIONS n Avoid medication-overuse syndrome Limit use of all combined abortive agents to < 2 d/wk (except prescription naproxen) Use prophylactic therapy to enable patient to use abortive therapy < 2 d/wk n Kill 2 birds with 1 stone Choose prophylactic agent(s) that treat other conditions pertinent to the patient n Aim to prevent ALL migraine symptoms—not just headache OU Neurology

MEDICATION-OVERUSE SYNDROME/ ANALGESIC REBOUND HEADACHE Near-daily use of certain drugs—esp. migraine abortive agents—causes migraine symptoms to be constant n Caused by: Analgesic, triptan, decongestant, muscle relaxant use > 2 days/week Any analgesic (over-the-counter to narcotic) other than prescription naproxen Note: ondansetron & PPIs may also trigger migraine n Relationship to migraine: More common in migraineurs Changes migraine symptoms from intermittent to chronic (incl. headache, GI, chest pain, tingling, vertigo, etc. ) Common cause of chronic migraine & status migrainosus Renders all migraine therapies ineffective OU Neurology

MIGRAINE PROPHYLACTIC THERAPY: GENERAL PRINCIPLES n Kill 2 birds with 1 stone No agent initially developed for migraine; when choosing an agent, address concurrent conditions (e. g. , hypertension, depression, anxiety, patient weight, seizures, osteoarthritis, insomnia, stool consistency) n Different patients respond differently to different drugs n Each agent/dose change takes > 4 wk to take full effect n Start low, go slow Start one med, low-dose q 2 -4 wks to maximize efficacy vs. toxicity, but do NOT make automatic increases May eventually need more than one med OU Neurology

MIGRAINE PROPHYLACTIC THERAPY: TOP CHOICES BY MECHANISM There is no “class effect”—a patient may respond well to a drug after not responding to a different drug in the same category n Antihypertensive agents candesartan (Atacand) lisinopril (Prinivil, Zestril) nadolol (Corgard) propranolol (Inderal) n Antiepileptic drugs topiramate (Topamax) divalproex (Depakote) n Tricyclic antidepressants nortriptyline (Pamelor) amitriptyline (Elavil) n Serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine ER n Over the counter magnesium oxide vitamin B 2 (riboflavin) melatonin n NSAID naproxen (Naprosyn)* OU Neurology

MIGRAINE PROPHYLACTIC THERAPY: SIDE EFFECTS Side effects that may influence agent choice All antihypertensives hypotension Beta blockers depression, sedation, asthma Tricyclic antidepressants weight gain, sedation, constipation Divalproex weight gain, hair loss, polycystic ovaries Topiramate weight loss, abnl cognition, nephrolithiasis Naproxen ulcers, renal disease Magnesium loose stools OU Neurology

MIGRAINE PROPHYLACTIC THERAPY: TOP CHOICES BY AGE n Children & Young Adults topiramate nortriptyline / amitriptyline nadolol / propranolol n Older Adults candesartan (Atacand) / lisinopril nortriptyline / amitriptyline divalproex (Depakote) venlafaxine (Effexor) n All Ages—primary or adjunct naproxen peri-predictable triggers / other pain magnesium oxide constipation melatonin insomnia OU Neurology

MIGRAINE ABORTIVE THERAPY: GENERAL PRINCIPLES n Triptans—migraine-specific serotonin agonists—are most effective (bind to subsets of serotonin 1 receptor— 1 D & 1 B) n Triptans may cause vasospasm; safety uncertain if: Migraine associated w/ aphasia, hemiplegia, or vertigo Vascular disease or risk factors (including hypercoagulability) Patient < 12 or > 65 years of age n Analgesics may also be effective as abortive therapy n Narcotics are generally NOT indicated for headache—limit their use to pregnant women and those with vascular disease, esp. the elderly n Take all abortive therapy early, e. g. , triptan efficacy 2/3 when HA mild, 1/3 when HA moderate n Take analgesics and triptans < 2 d/wk to avoid medication-overuse headaches OU Neurology

MIGRAINE ABORTIVE THERAPY: SEROTONIN (5 -HT) AGONISTS TRIPTANS ERGOTS Fast onset/Short half-life n eletriptan (Relpax) n rizatriptan (Maxalt & Maxalt MLT) n zolmitriptan (Zomig & Zomig ZMT) n almotriptan (Axert) n sumatriptan (Imitrex PO, PN , SC) n Cafergot (PO, PR) n DHE Slow onset/Long half-life n frovatriptan (Frova) n naratriptan (Amerge) n sumatriptan/naproxen sodium (Treximet) Selective 5 -HT 1 D/1 B agonists Nonselective 5 -HT 1 D agonists DHE-45 IV, IM Migranal PN TRIPTAN + NSAID In most cases, start with the highest recommended triptan dose, e. g. , sumatriptan 100 mg, eletriptan 40 mg, rizatriptan 10 mg. Take as early as possible at onset; may repeat x 1 after 2 h; do not exceed 2 tabs / 24 h; do not exceed 2 d / week. OU Neurology

MIGRAINE ABORTIVE THERAPY: NON-NARCOTIC ANALGESICS While all these agents can be effective when used as early as possible at migraine onset, they all cause medication-overuse syndrome if used > 2 days per week n Nonspecific single-agent analgesics Aspirin, acetaminophen (Tylenol), NSAIDs n Nonspecific combination analgesics Excedrin Migraine (acetaminophen, aspirin, caffeine) BC Powder (acetaminophen, aspirin, caffeine) Goody’s Headache Powder (aspirin, salicylamide, caffeine) Midrin, Amidrine, Duradrin, Epidrin (acetaminophen, dichloralphenazone, isometheptene) Fiorinal (aspirin, butalbital, caffeine) Fioricet, Esgic (acetaminophen, butalbital, caffeine) OU Neurology

MIGRAINE ABORTIVE THERAPY: PARENTERAL AGENTS IN HOSPITAL/ED n n n n These IV agents Normal saline – 1 L IV bolus are preferable to Magnesium sulfate – 1 g IV oral, IV, or transdermal Valproic acid (Depacon) – 500 mg IV analgesics for ED Prochlorperazine (Compazine) – 10 mg IV & hospitalized patients with Metoclopramide (Reglan) – 10 mg IV headache Chlorpromazine (Thorazine) – 25 mg IV Dihydroergotamine (DHE) – 0. 5 -1. 0 mg IV or IM These agents may be repeated q 8 h PRN. Note there are many options for migraine abortive therapy in the ED or inpatient setting that are not analgesics—and narcotics, per se, are RARELY necessary Avoid reflexively giving PRN Tylenol or narcotics! OU Neurology

CASE 1: PRESENTATION n 58 -year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain n Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy n One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab n Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam OU Neurology

CASE 1: CLARIFICATION & OUTCOME n Clarification of “pseudoseizure” episodes: First lightheadedness, then loss of consciousness and tone Rapid awakening with vertigo, nausea, vomiting, headache, confusion n Final diagnoses: Syncopal migraine Migraine with vertigo aura Abdominal migraine Precordial migraine Medication overuse syndrome Functional overlay (aphasia) The patient does NOT have pseudoseizures, gastroparesis, or anxiety-induced chest pain. n Outcome: On topiramate, all symptoms markedly improved & the patient went to the ED only four times in the next four years OU Neurology

CASE 2: PRESENTATION n 28 -year-old tearful woman with “pain all over, ” unable to move L side due to pain and with bilateral blurred vision n Six weeks ago, had difficulty holding objects in L hand, then noted “waves of pain” in both shoulders radiating over minutes into both hands, L > R, followed by a lightning sensation into L thigh, radiating into L toes n Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month n One month ago, symptoms became constant without relief from daily Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid n Lost nursing job 3 weeks ago when she became bedbound with daily vertigo and occipital headache radiating to R temple & eye n For last week, severe R chest pain (R anterior axilla to upper back) n For last few days, blurred vision in both eyes, initially intermittent, then constant n For one day, nausea and vomiting OU Neurology

CASE 2: CLARIFICATION & OUTCOME n Blurred vision = whitish-tan wavy lines or “heat-off-the-pavement” throughout her vision in both eyes n Since early childhood Intermittent headaches, bioccipital, radiating to right temple and eye with nausea, vomiting, sensory phobias, photopsia (star bursts), tingling (head, neck, both hands), & vertigo (saw multiple doctors for vertigo) n For the last few years, episodes of intermittent severe R abdominal pain with bloating, nausea, vomiting, and diarrhea occurring daily for a week, followed by constipation for a few days, then recurrent abdominal pain; no gallstones; cholecystectomy did not help n Diagnoses: Status migrainosus due to medication overuse syndrome, migraine with aura (visual, sensory, vertigo), abdominal migraine, precordial migraine, depression with anxiety n Management: All analgesics discontinued except prescription naproxen; topiramate & venlafaxine begun; 3 weeks later, patient markedly improved, started new RN job, &, after 3 days promoted to manager OU Neurology

CASE 3: PRESENTATION n 80 -year-old distraught man with intractable, intermittent, 12 -hour episodes of vertigo, diplopia, ataxia, nausea, and vomiting occurring every 5 -6 days that left him disabled and housebound n MRI brain normal n Symptoms became constant several months ago despite taking daily Voltaren, Protonix, and Zofran n Famous quaternary referral center #1 – no diagnosis n Famous quaternary referral center #2 – progressive, degenerative disease n On exam, he had gait ataxia OU Neurology

CASE 3: FAMILY HX & OUTCOME n His sister has similar episodes n With candesartan and magnesium oxide, symptoms markedly improved—over next 6 months, patient had no vertigo, diplopia, nausea, or vomiting; he had persistent, mild, 1 -hour episodes of gait ataxia upon awakening two days a week that resolved by late morning and did not interfere with his activities of daily living OU Neurology

OTHER CASES n The 2 women (ages 60 & 20) with intractable nausea, vomiting, abdominal pain, & diarrhea on TPN, Fentanyl patch, & oral narcotics n The 65 yo woman with daily HA x 50 years n The 50 yo woman with retinal infarction & daily diarrhea n The 4 yo boy with post-social debilitating GI pain n The 63 yo tearful woman with schizophrenia, diabetes mellitus type II, hypertension, obesity, & past history of TIAs; now with acute aphasia & left hemiparesis for which she received IV t. PA OU Neurology

MIGRAINE & RECURRENT SPELLS LEARNING OBJECTIVES n n Relate a practical definition of migraine Determine when the following symptoms are due to migraine: n n Abdominal pain Chest pain Vertigo Syncope Confusion Hemiparesis Aphasia Headache Name three overarching considerations when prescribing migraine therapy Describe the appropriate abortive and prophylactic therapies for migraine OU Neurology

THE END OU Neurology