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YOUR DIFFICULT PATIENT WITH RECURRENT SPELLS

HAS MIGRAINE

David Lee Gordon, M.D., FAAN, FANA, FAHAProfessor and Chair

Department of NeurologyThe University of Oklahoma Health Sciences Center

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DLG DISCLOSURES

FINANCIAL DISCLOSUREI have nothing to disclose

UNLABELED/UNAPPROVED USES DISCLOSUREI have nothing to disclose

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MIGRAINE & RECURRENT SPELLSLEARNING OBJECTIVES Relate a practical definition of migraine Determine when the following symptoms are due to

migraine: Abdominal pain Confusion Chest pain Hemiparesis Vertigo Aphasia Syncope Headache

Name the three overarching considerations when prescribing migraine therapy

Describe the appropriate abortive and prophylactic therapies for migraine

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CASE 1: PRESENTATION

58-year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain

Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy

One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab

Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam

OU Neurology

CASE 2: PRESENTATION

28-year-old tearful woman with “pain all over,” unable to move L side due to pain and with bilateral blurred vision

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

Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month One month ago, symptoms became constant without relief from daily

Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid Lost nursing job 3 weeks ago when she became bedbound with daily

vertigo and occipital headache radiating to R temple & eye For last week, severe R chest pain (R anterior axilla to upper back) For last few days, blurred vision in both eyes, initially intermittent,

then constant For one day, nausea and vomiting

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CASE 3: PRESENTATION

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

MRI brain normal Symptoms became constant several months ago despite

taking daily Voltaren, Protonix, and Zofran Famous quaternary referral center #1 – no diagnosis Famous quaternary referral center #2 – progressive,

degenerative disease On exam, he had gait ataxia

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MIGRAINE: WHAT IT IS NOTMIGRAINE DOES NOT MEAN HEADACHE

“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

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HEADACHE VS. MIGRAINE:SYMPTOM VS. SYNDROME

HeadachePain in the head

MigraineA syndrome of episodic brain dysfunction with

systemic manifestations (that may include headache)

Migraine is by far the most common cause ofrecurrent, episodic headache without sequelae, but…

migraine with NO headache is also very common.

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MIGRAINE: WHAT IT ISPRACTICAL DEFINITION & DESCRIPTION

Genetic condition in which a person has apredisposition 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).

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MIGRAINE TRIGGERS Hormonal changes

Stress (esp. stress “letdown”), exercise, thyroid Estrogen (menarche, pregnancy, hormonal contraceptives, menopause)

Environmental changes or exposures Weather (barometric pressure), motion Scents, smoke, fumes

Sleep changes Deficiency or excess, change in shift

Diet changes Hunger Alcohol (all types, but esp. red wine) Artificial foods (nitrates, MSG, sulfites, aspartame, sucralose) Dehydration

Medical conditions Head trauma, fever Cerebral blood flow changes (AVM, endarterectomy/angioplasty)

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MIGRAINE PHASES:PRODROME/PREMONITORY* Mood changes

Irritability, depression, euphoria/hyperactivity Difficulty concentrating Stiff neck Fatigue, malaise, yawning Autonomic/GI symptoms

constipation, diarrhea, urinary frequency Anorexia or food cravings

esp. foods that increase serum serotonin and/or magnesium, e.g., chocolate, bananas, nuts, peanut butter, sweets, fatty foods

1. Prodrome2. Aura3. Pain4. Postdrome

May begin hours to days before attack, persist through all 4 phases—likely related to serotonin, magnesium, hypothalamic changes

*ICHD-3 suggests elimination of the term “prodrome” & substituting “premonitory” instead

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MIGRAINE PHASES:AURA (1 of 2) Transient neurologic symptoms

Due to cortical spreading excitation/depressionSymptoms referable to location of transient chemical

changes in cerebral cortex Pattern of symptoms

Recurrent & stereotypical (previous similar spells)Gradual onsetMigratory (1 part of body to another) over mins to hrsProgressive (1 type of symptom to another)Duration minutes to hours

1. Prodrome2. Aura3. Pain4. Postdrome

Chemical chain reaction in the brain leads tofocal symptoms that change during an attack

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MIGRAINE PHASES:AURA (2 of 2)

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

1. Prodrome2. Aura3. Pain4. Postdrome

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MIGRAINE PHASES:PAIN

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

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

1. Prodrome2. Aura3. Pain4. Postdrome

Trigeminal nerve (CN5) & cervical nerve root sensitization in the meninges results in headache, sensory phobias, neuropathic symptoms

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MIGRAINE PHASES:POSTDROME

Fatigue, malaiseDifficulty concentratingMood changesMuscle achesScalp tendernessFood cravings or anorexia

1. Prodrome2. Aura3. Pain4. Postdrome

The migraine hangover

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MIGRAINE PATHOPHYSIOLOGYA JIGSAW PUZZLE WITH MISSING PIECES

Cortical spreading depression(excitation/depression w/hyperemia/oligemia esp. occiput)

Spreading depression in insula or brainstem serotonergic & noradrenergic dysfunction

Hypothalamic dysfunction &hyperexcitable cortex (esp. occiput)

Trigger

Aura

CN V/cervical root sensitization with pain receptor stimulation & release of neuropeptides (e.g., CGRP)

Prodrome

Headache/Arterial changes/Sensory phobias

Dysautonomia

Platelet & serum serotonin levels decrease during attacks of migraine, tension headache, IBS, & PMS.

Cerebral serotonin & magnesium decrease during a migraine attack.

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MIGRAINE WITH AURA:MRI BRAIN FINDINGS

Deep-white matter “UBOs” common in migraine w/ aura White on T2 & 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

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MIGRAINE WITHOUT AURA“OFFICIAL” DEFINITION PER ICHD-3 Frequency

> 5 episodes Duration

4-72 h untreated HA quality (> 2)

Unilateral Pulsating Moderate or severe w/ physical activity

Associated features (> 1) Nausea &/or vomiting Photo- & phonophobia

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, 3rd ed.

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MIGRAINE WITH AURA“OFFICIAL” DEFINITION PER ICHD-3

Frequency: > 2 attacks Aura: > 1 of the following

fully reversible aura sxs visual sensory speech &/or language motor brainstem retinal

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 No other cause of sxs

“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.”

Cephalalgia 2013;33(9):629-808

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MIGRAINE WITH AURATYPES PER ICHD-3

Migraine w/ typical aura Visual Sensory

Migraine w/ brainstem aura Dysarthria Vertigo Tinnitus Hypacusis Diplopia Ataxia level of consciousness

Hemiplegic migraine (HM) Familial HM type 1 (CACNA1A) Familial HM type 2 (ATP1A2) Familial HM type 3 (SCN1A) Familial HM other loci Sporadic hemiplegic migraine

Retinal migraine (monocular)

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MIGRAINE WITH “TYPICAL” AURADESCRIPTIONS PER ICHD-3

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

Migraine w/ sensory aura 2nd 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

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MIGRAINE GLASSES MAKE THE DIAGNOSIS MORE CLEAR

Symptoms that seemed vague and psychiatric are clearlydue to migraine when seen through the proper lenses

Diagnosis withoutmigraine understanding—things don’t make sense,

therefore patient is “crazy”

Diagnosis withmigraine understanding—

a pattern emerges

MIGRAINE MIGRAINE

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MIGRAINE IS A DISTINCT SYNDROME OF BOTHERSOME, BUT “BENIGN” SPELLS

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

Family history of spells similar to those suffered by pt

But obtaining accurate past & family histories is challenging

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WHY MIGRAINE IS REALLY, REALLY COMMON, BUT NOBODY KNOWS IT “Regular” / “ordinary” headaches are migraines Tension headaches are migraines

Frequent co-occurrence in patients and similar epidemiology, clinical features, & treatment responses

Actually migraines triggered by stress letdown 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

Not all migraine attacks include headache Aura without headache (visual, sensory, vertigo, etc.) Abdominal migraine (= irritable bowel syndrome) Precordial migraine (= noncardiac atypical chest pain)

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CONDITIONS LIKELY DUE TO(OR RELATED TO) MIGRAINE 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

Panic attacks Atypical noncardiac chest pain Intermittent headache w/

transient hypertension Transient global amnesia Episodic confusion POTS (postural orthostatic

tachycardia syndrome) Syncope of unknown cause Postconcussion/posttraumatic

headache Stroke-like spells (TIA mimic)

These conditions cause temporary symptoms that are said to beof unknown cause, but which may be explained by migraine

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NOT DIAGNOSING MIGRAINE LEADS TO WASTED DOLLARS & LIVES

Imaging studies (CT, MRI, endoscopy, colonoscopy, etc.) 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) Surgeries

Gallbladder Uterus and ovaries Sinus and ear

Disability, retirement, divorce

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WHY DON’T MORE DOCTORS KNOW ABOUT MIGRAINE?

Migraine training is often inadequate 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 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

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MIGRAINE THERAPY:THE TWO KINDS

Prophylactic and Abortive Agents Prophylactic agents (preventers)

If a patient takes certain medications every day, s/he is likely to have less frequent and less severe migraines

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

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MIGRAINE THERAPY: THE 3 OVERARCHING CONSIDERATIONS

Avoid medication-overuse syndromeLimit 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 Kill 2 birds with 1 stone

Choose prophylactic agent(s) that treat other conditions pertinent to the patient

Aim to prevent ALL migraine symptoms—not just headache

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MEDICATION-OVERUSE SYNDROME/ ANALGESIC REBOUND HEADACHENear-daily use of certain drugs—esp. migraine abortive

agents—causes migraine symptoms to be constant 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 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

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MIGRAINE PROPHYLACTIC THERAPY:GENERAL PRINCIPLES 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)

Different patients respond differently to different drugs Each agent/dose change takes > 4 wk to take full effect Start low, go slow

Start one med, low-dose q2-4 wks to maximize efficacy vs. toxicity, but do NOT

make automatic increases May eventually need more than one med

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MIGRAINE PROPHYLACTIC THERAPY:TOP CHOICES BY MECHANISM

Antihypertensive agents candesartan (Atacand) lisinopril (Prinivil, Zestril) nadolol (Corgard) propranolol (Inderal)

Tricyclic antidepressants nortriptyline (Pamelor) amitriptyline (Elavil)

Serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine ER

Antiepileptic drugs topiramate (Topamax) divalproex (Depakote)

NSAID naproxen (Naprosyn)*

Over the counter magnesium oxide vitamin B2 (riboflavin) melatonin

There is no “class effect”—a patient may respond well to a drug after not responding to a different drug in the same category

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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

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MIGRAINE PROPHYLACTIC THERAPY:TOP CHOICES BY AGE Children & Young Adults

topiramate nortriptyline / amitriptyline nadolol / propranolol

Older Adults candesartan (Atacand) / lisinopril nortriptyline / amitriptyline divalproex (Depakote) venlafaxine (Effexor)

All Ages—primary or adjunct naproxen peri-predictable triggers / other pain magnesium oxide constipation melatonin insomnia

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MIGRAINE ABORTIVE THERAPY:GENERAL PRINCIPLES Triptans—migraine-specific serotonin agonists—are most effective

(bind to subsets of serotonin 1 receptor—1D & 1B) 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

Analgesics may also be effective as abortive therapy Narcotics are generally NOT indicated for headache—limit their use to

pregnant women and those with vascular disease, esp. the elderly Take all abortive therapy early, e.g., triptan efficacy 2/3 when HA mild,

1/3 when HA moderate Take analgesics and triptans < 2 d/wk to avoid medication-overuse

headaches

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MIGRAINE ABORTIVE THERAPY:SEROTONIN (5-HT) AGONISTSTRIPTANSSelective 5-HT1D/1B agonistsFast onset/Short half-life eletriptan (Relpax) rizatriptan (Maxalt & Maxalt MLT) zolmitriptan (Zomig & Zomig ZMT) almotriptan (Axert) sumatriptan (Imitrex PO, PN ,SC)Slow onset/Long half-life frovatriptan (Frova) naratriptan (Amerge)

ERGOTSNonselective 5-HT1D agonists Cafergot (PO, PR) DHE

DHE-45 IV, IM Migranal PN

TRIPTAN + NSAID sumatriptan/naproxen sodium

(Treximet)

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.

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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

Nonspecific single-agent analgesics Aspirin, acetaminophen (Tylenol), NSAIDs

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)

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MIGRAINE ABORTIVE THERAPY:PARENTERAL AGENTS IN HOSPITAL/ED

Normal saline – 1 L IV bolus Magnesium sulfate – 1 g IV Valproic acid (Depacon) – 500 mg IV Prochlorperazine (Compazine) – 10 mg IV Metoclopramide (Reglan) – 10 mg IV Chlorpromazine (Thorazine) – 25 mg IV Dihydroergotamine (DHE) – 0.5-1.0 mg IV or IM

These agents may be repeated q8h 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!

These IV agents are preferable to oral, IV, or transdermal analgesics for ED & hospitalized patients with headache

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CASE 1: PRESENTATION

58-year-old woman with history of pseudoseizures, gastroparesis, and anxiety with noncardiac chest pain

Admitted 18 times to 3 different hospitals in last 6 months with normal EEGs, video EEGs, cardiac catheterizations, EGD, & colonoscopy

One year of constant headache and lower abdominal cramping pain and daily diarrhea for which she takes daily Reglan & Lortab

Now transferred from outside hospital for acute stroke and found to have psychiatric aphasia on exam

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CASE 1: CLARIFICATION & OUTCOME

Clarification of “pseudoseizure” episodes: First lightheadedness, then loss of consciousness and tone Rapid awakening with vertigo, nausea, vomiting, headache, confusion

Final diagnoses: Syncopal migraine Migraine with vertigo aura Abdominal migraine Precordial migraine Medication overuse syndrome Functional overlay (aphasia)

Outcome: On topiramate, all symptoms markedly improved & the patient went to

the ED only four times in the next four years

The patient does NOT have pseudoseizures, gastroparesis, or anxiety-induced chest pain.

OU Neurology

CASE 2: PRESENTATION

28-year-old tearful woman with “pain all over,” unable to move L side due to pain and with bilateral blurred vision

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

Lyrica caused intolerable lethargy, Cymbalta ineffective after 1 month One month ago, symptoms became constant without relief from daily

Fentanyl patch, Tylenol, ibuprofen, Lortab, and Dilaudid Lost nursing job 3 weeks ago when she became bedbound with daily

vertigo and occipital headache radiating to R temple & eye For last week, severe R chest pain (R anterior axilla to upper back) For last few days, blurred vision in both eyes, initially intermittent, then

constant For one day, nausea and vomiting

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CASE 2: CLARIFICATION & OUTCOME

Blurred vision = whitish-tan wavy lines or “heat-off-the-pavement” throughout her vision in both eyes

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)

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

Diagnoses: Status migrainosus due to medication overuse syndrome, migraine with aura (visual, sensory, vertigo), abdominal migraine, precordial migraine, depression with anxiety

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

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

MRI brain normal Symptoms became constant several months ago despite

taking daily Voltaren, Protonix, and Zofran Famous quaternary referral center #1 – no diagnosis Famous quaternary referral center #2 – progressive,

degenerative disease On exam, he had gait ataxia

OU Neurology

CASE 3: FAMILY HX & OUTCOME

His sister has similar episodes 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

The 2 women (ages 60 & 20) with intractable nausea, vomiting, abdominal pain, & diarrhea on TPN, Fentanyl patch, & oral narcotics

The 65 yo woman with daily HA x 50 years The 50 yo woman with retinal infarction & daily diarrhea The 4 yo boy with post-social debilitating GI pain 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 tPA

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MIGRAINE & RECURRENT SPELLSLEARNING OBJECTIVES Relate a practical definition of migraine Determine when the following symptoms are due to

migraine: Abdominal pain Confusion Chest pain Hemiparesis Vertigo Aphasia Syncope Headache

Name the three overarching considerations when prescribing migraine therapy

Describe the appropriate abortive and prophylactic therapies for migraine

OU Neurology

THE END