Topics in migraine management: a survey of headache specialists highlights some controversies

Transient hemiplegia in a patient with migraine: A case of sporadic hemiplegic migraine

Hemiplegic migraine is a rare form of migraine characterized by aura with unilateral paralysis; however, studies on its treatment are limited. A 39-year-old man with migraine headaches and myofascial pain syndrome was referred to our hospital with transient right hemiplegia, after presenting to an outside emergency department with headache and right hemiplegia 2 days prior. Computed tomography, magnetic resonance imaging, and blood test results revealed no abnormalities. The symptoms resolved spontaneously; he was referred to our hospital. Based on the International Classification of Headache Disorders, Third Edition criteria, he was diagnosed with sporadic hemiplegic migraine. Propranolol was added to his regular regimen as prophylactic treatment, which resulted in reduction in his migraine frequency. Over the next 2 years, no recurrent paralysis occurred. Hemiplegic migraines should be considered in patients with migraine exhibiting transient hemiplegia without obvious intracranial abnormalities. Prophylactic treatment with propranolol could be effective in treatment of hemiplegic migraine.

The Perplexing Mental Health Comorbidity of Alice in Wonderland Syndrome (AIWS): A Case Study

The Alice in Wonderland Syndrome (AIWS) is an unusual and uncommon condition that falls under the umbrella of neurology and psychiatry. It is characterized by the presence of complex perceptual and visual discord. Additionally, there are visual hallucinations that are multi-dimensional. This syndrome was first described by John Todd in the 1950s, and it was loosely based on the book Alice in Wonderland. A man in his 30s arrived at his doctor’s appointment with a chief complaint of a pounding cluster headache that lasted over a full day. In addition, he mentioned that there was an aura preceding his headaches. The pain was so intense, it was debilitating him from routine activities. Before the headaches, he explained that he would sense bizarre physical and visual behaviors. During these episodes, he explained that things around him appeared distorted and of various sizes. Things in his room appeared to be more distant than they really were and larger in size (macropsia and micropsia). He described the fingers on his right hand to be much smaller compared to his left hand (micropsia). Objects around him were deformed and distorted (metamorphopsia). His symptoms lasted 45 minutes. He did not suffer from any previous headaches or hallucinations. He was a healthy man with a clean bill of health as per his medical records. Upon examination, the attending physician described the patient as alert, oriented to time and place, and under no obvious distress. All labs performed returned normal including a 10-panel drug test. These were tested to see if he was under the influence of any narcotic, stimulant, or other substances. The physician prescribed 500 mg of valproic acid to take daily. Three months later during his follow-up, he mentioned his symptoms had subsided but were still present. His dose was again increased to 1000 mg/day, eventually stopping all further symptoms from surfacing. He has not had another episode in three months. The Alice in Wonderland Syndrome is known to be associated with headaches with preceding auras. It is common in the pediatric and adult populations. In this paper, I introduce a case of a patient who displays migraines with preceding auras, indicative of AIWS.

Prevalence Rates of Primary Headache Disorders and Evaluation and Treatment Patterns Among Korean Neurologists

Background and Purpose

Several studies have found that the prevalence of migraine is higher among healthcare professionals than in the general population. Furthermore, several investigations have suggested that the personal experiences of neurologists with migraine can influence their perception and treatment of the disease. This study assessed these relationships in Korea.

Methods

A survey was used to investigate the following characteristics among neurologists: 1) the prevalence rates of migraine, primary stabbing headache, and cluster headache, and 2) their perceptions of migraine and the pain severity experienced by patients, diagnosing migraine, evaluation and treatment patterns, and satisfaction and difficulties with treatment.

Results

The survey was completed by 442 actively practicing board-certified Korean neurologists. The self-reported lifetime prevalence rates of migraine, migraine with aura, primary stabbing headache, and cluster headache were 49.8%, 12.7%, 26.7%, and 1.4%, respectively. Few of the neurologists used a headache diary or validated scales with their patients, and approximately half were satisfied with the effectiveness of preventive medications. Significant differences were observed between neurologists who had and had not experienced migraine, regarding certain perceptions of migraine, but no differences were found between these groups in the evaluation and preventive treatment of migraine.

Conclusions

The high self-reported lifetime prevalence rates of migraine and other primary headache disorders among Korean neurologists may indicate that these rates are underreported in the general population, although potential population biases must be considered. From the perspective of neurologists, there is an unmet need for the proper application of headache diaries, validated scales, and effective preventive treatments for patients. While the past experiences of neurologists with migraine might not influence how they evaluate or apply preventive treatments to migraine, they may influence certain perceptions of the disease.

Alice in Wonderland syndrome as aura of migraine

Alice in Wonderland syndrome (AIWS), named for Lewis Carroll's titular character, is a disorder characterized by transient episodes of visual hallucinations and perceptual distortions, during which objects or body parts are perceived as altered in various ways (metamorphopsia), including enlargement (macropsia) or reduction (micropsia) in the perceived size of a form. Migraine aura is a transient neurological symptom that most commonly involves the visual fields and occurs before the headache phase. Aura symptoms include the perception of flashing lights that begin in the center of vision and expand in jagged patterns out into the periphery. Symptoms may be somatosensory, such as numbness and tingling in the lips or fingers. They may also involve a profound alteration of the perception of space and time (the "Alice in Wonderland" syndrome). In this article, we present a child had Alice in Wonderland syndrome as aura of migraine.

Child neurology: Migraine with aura in children

The differential diagnosis for an acute hemiparesis in a child includes stroke, Todd paralysis, and hemiplegic migraine. In the context of an illustrative case, this review highlights the differences in clinical presentation among these entities and an approach to the diagnostic workup. Migraine with aura in children is reviewed, including migraine equivalents such as abdominal migraine and the particular presentation of hemiplegic migraine. An approach to the prophylactic and acute treatment for children with migraine with aura is offered.

Pontine capillary telangiectasia as visualized on MR imaging causing a clinical picture resembling basilar-type migraine: a case report

A case of presumed pontine capillary telangiectasia in an 18-year-old woman with a clinical diagnosis of basilar-type migraine is reported. Since both are very rare diagnoses, this case provides some evidence to suggest that pontine capillary telangiectasia might cause a clinical picture resembling basilar-type migraine.

Migraine and stroke: current perspectives

OBJECTIVE

The purpose of this article is to review the latest concepts regarding migraine and ischemic stroke. In addition, focal neurological deficits and MRI changes in migraine patients will be reviewed.

METHODS

A PubMed search of neurological literature pertaining to this study was conducted using specific keyword search terms pertaining to migraine and ischemic stroke.

RESULTS

Migraine, especially with aura, is a relative risk factor for stroke. Neuroimaging demonstrates the posterior circulation as being most vulnerable, although the reason for this distribution is unclear. Factors that may contribute to stroke in migraine include changes during cortical spreading depression with hyper- or hypoperfusion of neural tissue, vasospasm and endothelial dysfunction. Estrogen affects migraine expression as well as cerebral circulation, yet most women with migraine without aura are not at increased risk. Co-morbidity with patent foramen ovale can be mechanism of both disorders via presumed lack of filtration of microemboli or toxic substances; however, closure with reversal of right to left shunt seems to be more beneficial for cryptogenic stroke than migraine. Migraine and stroke are found in specific genetic disorders such as CADASIL, HERNS and MELAS giving clues to genetic factors. Stroke associated with migraine treatments such as ergots or triptans is rare, and usually associated with special circumstances such as overuse or concomitant thrombogenic conditions.

CONCLUSION

Although true migrainous infarction is rare, our understanding of the subtle associations between migraine and cerebrovascular behavior is expanding.

Migraine prophylaxis

There is a wide array of options for migraine prophylaxis; many of the available drugs are clearly proven to be effective and yet are underused in Australia. "New" drugs which are gaining favour for migraine prophylaxis include topiramate, candesartan, gabapentin and botulinum toxin. The evidence for efficacy is excellent for topiramate and reasonably good but limited for candesartan and gabapentin. The use of botulinum toxin is controversial and has gained substantial popularity through anecdotal experience rather than convincing published evidence. Transformed or chronic migraine with medication overuse is a particularly difficult problem. New strategies to aid in medication withdrawal are reviewed. The approach to menstrual migraine and migraine with prominent aura may differ from that for typical migraine. Novel approaches are being explored for these problems.

Migraine and ischaemic heart disease and stroke: potential mechanisms and treatment implications

The migraine-ischemia relationship is best understood in the context of the pathophysiology of migraine. Potential mechanisms of migrainous infarction (stroke occurring during migraine) include vasospasm, hypercoagulability, and vascular changes related to cortical spreading depression. Stroke occurring remote for the migraine attack may be related to arterial dissection, cardioembolism, and endothelial dysfunction. Endothelial dysfunction, a process mediated by oxidative stress, may be a cause or a consequence of migraine, and explain the relationship of migraine to vascular factors and ischemic heart disease. It remains uncertain whether stroke or myocardial infarction can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition, or a combination of these strategies. Although triptans are generally considered safe for use in migraine, caution is warranted in those with multiple vascular risk factors. Known vascular disease is a contraindication to triptan use.

Answers to frequently asked questions about migraine

Migraine is a common primary headache disorder associated with pronounced disability and hence marked economic and public health Implications. Appropriate treatment is warranted to limit the associated disability migraineurs experience. Because of the heterogeneity of migraine, treatment plans must be individualized. The purpose of this article is to provide answers to frequently asked questions regarding the management of migraine.

Stroke and chest pain in young people with migraine

BACKGROUND

Cerebrovascular and cardiovascular complications in migraineurs may be part of the migraine process and also consequent to triptan treatment.

AIM

To determine the frequency, subtypes and associations of migraine-associated stroke and angina in young people (18-49 years).

METHODS

Patients were derived from a tertiary referral migraine and stroke registry. Migraine-associated stroke was classified according to the four groups described by Welch and by the TOAST etiological stroke classification. A clinical description of angina during a migraine attack was required for the diagnosis of cardiac migraine without concomitant triptan or other vasoactive medications.

RESULTS

Of the young patients with stroke (349/1316; 26.5%), there were 30 (30/349; 8.6%) who had migraine at the time of stroke when categorized by the Welch classification type II to IV (type II n = 5, type III n = 2, type IV n = 3). Comparison of type I (n = 20) versus types II-IV (n = 10) showed significant difference (P = .03). Topographically the lesions were distributed into the partial anterior circulation (n = 8) and posterior circulation (n = 2) (P = .04). Comparison of anterior and posterior circulation territories of infarction indicated significant difference (n = 26/30 and 4/30; P = .01). The stroke etiological subtypes included cardiogenic (n = 5), atherogenic (n = 15), other (n = 5), and unknown (n = 5), with none diagnosed with small-vessel cerebrovascular disease. Traditional stroke mechanistic entities (cardiac and atherogenic) differed significantly in comparison to the other and unknown categories P = .05. Cardiovascular patients with angina during a migraine attack (n = 9/1040; 0.9%), included IHS subtypes; migraine without aura (n = 4), migraine with aura (n = 4), and complicated migraine (n = 1). One patient required cardiac catheterization on account of significant ECG changes, with documented, reversible vasospasm.

CONCLUSION

(i) Migraine-induced stroke remains controversial, with only two probable cases of type Welch III A+B in a large registry. (ii) Cardiac migraine may be a distinct entity requiring careful differentiation from triptan-induced chest pain.

Prophylaxis of migraine

Migraine is a common primary headache disorder often associated with significant disability. While many individuals are able to limit therapy to acute treatment of attacks, others need medication to reduce the attack frequency and/or severity. Evidence-based guidelines exist regarding indications and goals for migraine preventive treatment. The specific prophylactic approach needs to be individualized taking into account multiple variables. Medications used in this task vary widely in proven efficacy and presumed mechanisms of action. This review's goal is to discuss the issues that guide the decision-making process in migraine preventive treatment.

Headache

The patient who presents with headache can be diagnosed quickly and efficiently once the correct pattern has been identified. Most patients will have migraine, and treatment is based on the severity and disability. If the identified patient has significant disability, a medication that treats comorbidity should be prescribed. Patients who have a serious underlying disorder can be recognized by a thoughtful history and careful examination and can be worked up accordingly. Patients who have an acute new onset headache problem that requires immediate attention can be triaged and treated once their pattern and history are clear. Hopefully, increasing comfort levels with diagnosing headaches will allow the primary care practitioner to treat headache patients more effectively and efficiently.

The risk of stroke in patients with migraine and implications for migraine management

Assessing the risk of stroke in persons with migraine is complicated by the intricate relationship between these two conditions. Both migraine and stroke are common and co-morbidity may, in some cases, be coincidental. Given the overlap of clinical symptoms in stroke and migraine, each condition may also mimic the other. Numerous studies have, however, shown that migraine is an independent risk factor for stroke both during, and remote from, the migraine attack. Women of childbearing age and those with aura are at greatest risk of migraine-related stroke. Additional risk of stroke in migraineurs occurs in those using oral contraceptive pills and who smoke cigarettes. Elevated blood pressure, an important stroke risk factor, is less common in migraineurs. Acquired antiphospholipid antibodies, not clearly a cause of migraine per se, may raise the risk of infarction in migraineurs. Hereditary conditions, including CADASIL (cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy), MELAS (mitochondrial myopathy, encephalopathy, lactacidosis and stroke) and hereditary haemorrhagic telangiectasia, appear to predispose to both migraine and stroke. Purported mechanisms for migraine-associated stroke include involvement of the vasculature (including vasospasm, arterial dissection and small vessel arteriopathy), hypercoagulability (elevated von Willebrand Factor, platelet activation) and elevated risk of cardioembolism (patent foramen ovale, atrial septal aneurysm). Triptans and ergotamines, used to treat acute migraine attacks, appear to be safe in low-risk populations. These medications should be avoided in persons with haemiplegic migraine, basilar migraine, vascular risk factor and prior cerebral or cardiac ischaemia.

Adverse reactions related to drugs for headache treatment: clinical impact

OBJECTIVE

To assess the clinical impact of adverse reactions related to drugs for primary headache treatment.

METHODS

We examined the adverse reactions to 360 medications prescribed by the specialists of the Headache Centre of the University of Modena and Reggio Emilia to 256 consecutive outpatients (214 female, 42 male; mean age: 38.88 +/- 14.06 years; range 10-72 years). Adverse reactions were reported by patients during scheduled follow-up visits, classified by specialists and reassessed by a clinical pharmacologist.

RESULTS

Adverse reactions with a causal relationship classified as definite/probable/possible were 202 (56%): 62% (80/129) were due to acute treatments and 53% (122/231) to prophylactic treatments (chi2 test, P = 0.115 ns). More than 90% of the adverse reactions were of limited intensity [mild (58%) or moderate (36%)]. Only 5% were severe, and two reactions (1%) were serious. The most affected apparatus was the nervous system (41%). Of these adverse reactions, 43% caused the discontinuance of the treatment, especially of prophylaxis (54%). Patients evaluated 70% of the medications as effective, but, at the same time, they considered most of the adverse reactions (69%) unacceptable.

CONCLUSION

Adverse reactions related to headache medications have a strong impact on patients' management, even if their real intensity and severity are usually very limited. Drugs for headache treatment are still far from being ideal drugs. To prevent the discontinuance of effective medications, the physician, prior to prescribing, should assess, together with the patient, the acceptability of the more common adverse drug reactions.

Management of menstrual migraine

BACKGROUND

Migraine is more prevalent in women than men. Hormonal changes can influence the occurrence of migraine, particularly related to the menstrual cycle. Menstrual migraine may require both acute and preventive treatment.

REVIEW SUMMARY

Gender differences in migraine may be a result of variations in the central nervous system of men and women as well as the effects of estrogen. Migraine attacks occurring in the perimenstrual period respond well to acute treatment with triptans. Hormonal manipulation may reduce migraine occurrence, especially when related to hormonal fluctuations in the perimenstrual period.

CONCLUSIONS

Effective migraine management requires an understanding of the unique epidemiologic and pathophysiological factors affecting women. An understanding of associated hormonal influences facilitates development of individualized treatment plans.

Migraine prophylactic medication usage patterns in The Netherlands

This study aims to investigate usage patterns of specific migraine prophylactic medications in ergotamine and triptan patients commencing this treatment for the first time during 1 January 1992 until 31 December 1998. Usage patterns of specific migraine prophylactic drugs were evaluated for each patient by accessing data from a large prescription database and were characterized as continued, switch or stop use during the patient observation period. Several patient and medication-related factors were explored in order to identify a possible relationship with the specific usage pattern defined. Approximately 75% of the study population (n = 729) had terminated (stop or switch) prophylactic treatment after 1 year. Age < 40 years (relative risk (RR) 1.9; 95% confidence interval (CI) 1.2-3.2) and the concomitant use of non-steroidal anti-inflammatory drugs (RR 3.2; 95% CI 1.2-5.5) or specific abortive migraine drugs resulted in a faster onset of treatment modification (switch). Overall, migraine prophylactic treatment is used for a relatively short period, probably attributable to the common limitations associated with migraine prophylaxis, such as poor compliance and/or limited therapeutic efficacy. Patterns of use can be influenced by a variety of factors, including age, type of prescriber and certain co-medication. Patient interview studies are required to clarify these issues further.

Rizatriptan: an update of its use in the management of migraine

Rizatriptan is an orally active serotonin 5-HT(1) receptor agonist that potently and selectively binds to 5-HT(1B/1D) subtypes. Earlier clinical trials demonstrated that rizatriptan 5 or 10mg is more effective than placebo at providing pain relief and a pain-free state, relieving associated symptoms of migraine, normalising functional ability and improving patient quality of life, and showed that rizatriptan provides faster freedom from pain and reduces nausea to a greater extent than oral sumatriptan. More recently, rizatriptan 10mg was shown to be more effective than zolmitriptan 2.5mg or naratriptan 2.5mg at producing a pain-free state 2 hours postdose. Furthermore, compared with naratriptan, significantly more patients who received rizatriptan were pain free or had pain relief from 1 hour onwards. The number of patients with normal functional ability at 2 hours was significantly higher after rizatriptan than after naratriptan or zolmitriptan. Rizatriptan was also generally more effective than zolmitriptan or naratriptan at relieving migraine-associated symptoms. Rizatriptan is generally well tolerated and adverse events are usually mild and transient. The most common adverse events associated with rizatriptan in recent randomised trials were asthenia/fatigue, dizziness, somnolence and nausea. There was a trend towards a lower incidence of adverse events with rizatriptan compared with zolmitriptan (31.2 vs 38.8%). However, rizatriptan was associated with a significantly higher incidence of adverse events than naratriptan (39 vs 29%). The incidence of chest pain was similar after the administration of rizatriptan, zolmitriptan or naratriptan (2 to 4%).

CONCLUSION

Rizatriptan is an effective drug for the acute treatment of moderate or severe migraine. Oral rizatriptan 5 and 10mg have shown greater efficacy than placebo in providing pain relief, an absence of pain, relief from associated symptoms, normal functional ability and an improvement in patient quality of life. Earlier results showed that rizatriptan provides faster freedom from pain and reduces nausea to a greater extent than oral sumatriptan. More recent studies have shown that rizatriptan 10mg provides faster pain relief and a higher percentage of patients with an absence of pain and normal functional ability at 2 hours than naratriptan 2.5mg or zolmitriptan 2.5mg. The efficacy of rizatriptan is retained when used in the long term and the drug is generally well tolerated. Although well designed studies comparing rizatriptan with almotriptan, eletriptan and frovatriptan would further define the position of rizatriptan, current data suggest rizatriptan should be considered as a first-line treatment option in the management of migraine.

Integrating the triptans into clinical practice

The triptans (selective serotonin agonists) are becoming the first-line alternatives in the acute pharmacological treatment of migraine, at least for attacks of moderate-to-severe intensity. Although clinical trials demonstrate significant differences in efficacy between triptan tablets, they often appear similar in efficacy when used in clinical practice, particularly after dose adjustments. Most patients with migraine consider drugs that can be administered orally to be the most user-friendly. However, gastrointestinal absorption may be impaired during migraine attacks because gastric motility is inhibited, and there is a risk that nausea during the attack will culminate in vomiting. Furthermore, in addition to their antimigraine properties, triptans may prolong the gastric emptying time. For this reason the absorption of any triptan taken orally during the migraine attack will be erratic and treatment effects inconsistent. Despite these barriers to good efficacy and high reliability, the tablet is the most commonly used triptan formulation.

Management of peripheral pain generators in fibromyalgia

Fibromyalgia is a widespread chronic pain disorder that is characterized in part by central sensitization and increased pain response to peripheral nociceptive and non-nociceptive stimuli. Part of the comprehensive pain management of patients with fibromyalgia should include a thoughtful evaluation and search for peripheral pain generators that either are associated with fibromyalgia or are coincidentally present. The identification and treatment of these pain generators lessens the total pain burden, facilitates rehabilitation and decreases the stimuli for ongoing central sensitization.