2/15/2019 Disclosures Recent Advances • Consultant for Eli Lilly – Emgality (FDA approved) in Neurology – Lasmitidan (phase 3 clinical trials) Case Presentation Rebecca L. Michael, MD February 15, 2019 Case #1 History • Onset at 55 y/o with visual aura • 78 y/o female referred to our clinic for further – Splintered glass, evolved over 30-45 minutes management of worsening migraine – Nausea afterwards, mild bilateral frontoparietal pain that would last 4-12 hours • Migraine onset 55 years old – Occurred 1-2 x/ year • Denies significant headaches prior to 55 – family hx of migraine (mother and sister) – +motion sickness, + cold-stimulus headaches, +prominent jet lag 1
2/15/2019 History History • Worsening at age 74 • Stopped wearing CPAP, headaches persisted – During a hike she developed severe bifrontal pain • Gradually increased in frequency radiated into her neck for 15-20 min – Daily with increases 18 days/month • Subsequent dull pain lasted 3-4 days – Occurred 2 days after PSG titration study after which she began wearing CPAP History Past Medical History • HTN- controlled • Pain primarily located in bilateral • DMII- controlled frontoparietal, face and neck • OSA- AHI 6.6 – crushing, pressure, squeezing, tightening • Sjogrens Disease – accompanied with N/V, fatigue, mild photophobia • Subacute cutaneous lupus erythematosus, lichen – worsened with movement or exertion sclerosis – headache similar to prior, more intense • Hypothyroid • Irritable Bowel Syndrome • Depression/anxiety • GERD 2
2/15/2019 Current Medications Prior Medication Trials • • advil 400mg - taking daily Prior Abortive Treatments: • ondansetron 8mg prn (had been using one of below daily) – Sumatriptan- would help temporarily, but pain would recur at 24 hours • Benadryl for headaches prn – Rizatriptan- some relief, but stopped because told in rebound • Zolpidem 10mg qhs • Prior Preventive Treatments: • Aspirin 81mg – Nortriptyline • Losartan 50mg – Gabapentin • Diltiazem 260mg – Zoloft • Levothyroxine 75mcg • Lansoprazole 30mg • Prior non-pharmacological and procedural trials: • januvia – Occipital nerve blocks - no relief • combivent 20mcg- only uses if goes to cold climate – Botox - made headaches worse • Clobetasol – CBD 8:1 - ineffective ROS Diagnostics • Shortness of breath with exertion • MRI brain wwo contrast • GERD Mild to moderate chronic deep white matter microvascular ischemic disease unchanged from prior • Joint pain comparison exam in November 2016. Otherwise • Low back pain normal MRI brain wwo contrast 3
2/15/2019 Initial Assessment/Plan Follow Up • Chronic Migraine • Saw cardiology • Migraine with aura • Cardiac stress test (limited left arm pain and • Medication overuse headache worsening headache) • Nuclear medicine cardiac scan 1. Limit ibuprofen to no more than 10 days/month • Found to have 2 vessel disease (70% LAD, 90% 2. For further prevention start memantine vs. right coronary), s/p cardiac cath with 3 stents switching losartan to candesartan 3. Follow up with PCP/cardiologist regarding shortness of breath (avoid triptans in interim) Follow Up Cardiac Cephalalgia • Headaches resolved after stenting • Lipton et al. first described 1997 • ICHD-3 10.6 description: – Migraine-like headache, usually but not always aggravated by exercise, occurring during an episode of myocardial ischaemia. It is relieved by nitroglycerine Lipton RB et al. Neurology 1997; 49:813-6 4
2/15/2019 Cardiac Cephalalgia Cardiac Cephalalgia • Rare headache disorder, considered a form of • Diagnostic criteria: A. Any headache fulfilling criterion C atypical angina B. Acute myocardial ischaemia has been demonstrated C. Evidence of causation demonstrated by at least two of the following: 1. headache has developed in temporal relation to the onset of acute • Pathophysiology myocardial ischaemia 2. either or both of the following: 1. Referred pain to head from vagal afferents 1. a) headache has significantly worsened in parallel with worsening of the myocardial ischaemia 2. b) headache has significantly improved or resolved in parallel with improvement in or 2. Transient rise in ICP secondary to decreased cerebral resolution of the myocardial ischaemia 3. headache has at least two of the following four characteristics: venous drainage from reduced cardiac output 1. a) moderate to severe intensity 2. b) accompanied by nausea 3. Proinflammatory mediators released during cardiac 3. c) not accompanied by photophobia or phonophobia ischemia leads to vasodilation of cerebral vessels 4. d) aggravated by exertion 4. headache is relieved by nitroglycerine or derivatives of it D. Not better accounted for by another ICHD-3 diagnosis. Lazari J et. Al Pract Neurol 2018 Question Acute treatment options in CAD patients Triptans are contraindicated in patients with risk • Consensus is that triptans should be avoided factors for coronary artery disease? in patients with significant coronary artery disease • Risk factors for arterial disease A. True 61% – Poorly controlled HTN, HLP, DM, premature CAD B. False 39% family hx (men <55, women <65), postmenopausal women • 1 risk factor: EKG suggested • > 1 risk further work-up suggested such as stress test recommended e e u s l r a T F Dodick et. al Headache. 2004 :01 44(5): 414-25 5
2/15/2019 Acute treatment options in CAD patients Acute treatment options in CAD patients • Transcutaneous Supraorbital Nerve Stimulator (Cefaly) • Acetaminophen -level A evidence • Single pulse Transcranial Magnetic Stimulator (eNeura) • Antiemetics (metoclopramide, – Contraindications: certain cardiac stents prochlorperazine, promethazine)- level B • Gammacore (non-invasive vagus nerve stimulator) evidence – Contraindications: Carotid atherosclerosis, clinically significant hypertension, hypotension, bradycardia or • Butalbital/acetaminophen/caffeine- level C tachycardia contraindications evidence • Lasmitidan (5HT1-F)- not FDA approved yet • Hydroxyzine (recent MI relative • Gepants (CGRP receptor antagonists) - not FDA approved yet contraindication, prolonged QTc?) Question Acute treatment options in CAD patients • Prevention Arterial disease is listed as a contraindication for novel CGRP monoclonal antibodies • Prevention • Prevention! A. True 91% B. False 9% e e u s l r a T F :01 6
2/15/2019 Case #2 However…. Organ Systems Where CGRP and Receptor is Presen t 90 y/o female referred to our clinic for further management of new onset positional headache Deen M et. Al J Headache Pain. 2017; 18(1): 96. Case #2 History continued • Triggers include cooking, being active • Began 5 months prior, no clear precipitant • Associated with mild lightheadedness, but • Gradual progression to current frequency of denies migrainous features of photophobia, daily phonophobia, nausea • Located in right occipital radiated to parietal • Denies prior significant headache history • Dull, but with increases sharp, shooting • Duration is minutes to hours or until she can lay down on her right side (pain would dissipate within 5 minutes) 7
2/15/2019 Current Medications Past Medical History • Lisinopril 12.5mg • Arthritis • Hydralazine 25mg • Atrial fibrillation • Carvedilol 25mg • CHF- s/p ICD • Furosemide 20mg • HTN • Amlodipine 5mg • Mild sensorineural hearing loss • Eliquis 5mg • Cervicalgia • Atorvastatin 10mg • Potassium • Calcium Prior Medication Trials Diagnostics • Prior Abortive Treatments: – Tylenol- doesn't help • CT brain - unremarkable – celebrex- doesn't help • Prior to referral spontaneous CSF hypotension • Prior Preventive Treatments: was the working diagnosis. However patient – none could not get an MRI brain given her ICD • Prior non-pharmacological and procedural • 2 non targeted blood patches trials: – Acupuncture- didn't help much – No improvement 8
2/15/2019 Question Back to our case… What percentage of patients with CSF hypotension have a normal MRI brain? A. 5% 56% B. 10% C. 20% 28% D. 40% 13% 4% % % % % 5 0 0 0 1 2 4 :01 CT Cervical Spine CT Cervical Spine Right Left Multilevel moderate degenerative changes. Notable changes with erosions at the C1-C2 lateral masses on the right the adjacent base of the odontoid 9
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