8/23/2015 A PRACTICAL OPTOMETRIC HEADACHE APPROACH A PRACTICAL OPTOMETRIC HEADACHE APPROACH A PRACTICAL OPTOMETRIC HEADACHE APPROACH

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A Practical Optometric Approach

To

To Headaches

Headaches

Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO

Consultant, Department of Surgery Consultant, Department of Surgery Community Division of Ophthalmology Community Division of Ophthalmology Mayo

Mayo Clinic Health System in Albert Clinic Health System in Albert LeaLea Assistant

Assistant Professor of OphthalmologyProfessor of Ophthalmology Mayo Clinic College of

Mayo Clinic College of MedicineMedicine

A PRACTICAL OPTOMETRIC HEADACHE APPROACH

Ubiquitous symptom

73% of adults experienced headache in past year 10 million outpatient visits per year

Only 15% actually sought medical help

ESTIMATED PREVALANCE OF MIGRAINE SUFFERERS IN THE UNITED STATES

IMPACT OF MIGRAINE SOCIETAL COSTS

IMPACT OF MIGRAINE PERSONAL COSTS

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A PRACTICAL OPTOMETRIC HEADACHE APPROACH A PRACTICAL OPTOMETRIC HEADACHE APPROACH IMPACT OF MIGRAINE

HEALTH SURVEY SCORES FOR MIGRAINE AND OTHER CHRONIC CONDITIONS

HEADACHE CLASSIFICATION

International Headache Society criteria 1. Primary headache disorders

Migraine Tension-type Cluster

2. Secondary headache disorders

Headache is symptomatic of an underlying condition such as temporal arteritis, brain tumor, stroke

BASIS OF DIFFERENTIAL HEADACHE DIAGNOSIS

THOROUGH PATIENT INTERVIEW

APPROPRIATE GENERAL EXAMINATION

ADEQUATE NEUROLOGIC EXAMINATION

HEADACHE DIAGNOSIS P - Provokes, Palliates

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POTENTIAL TRIGGERS OF MIGRAINE: DRUGS HORMONES SENSORY STIMULI CARBON MONOXIDE EMOTIONAL STRESS FOODS AND BEVERAGES ENVIRONMENTAL CHANGES CHRONOBIOLOGIC CHALLENGES

MIGRAINE PREVALENCE BY AGE AND SEX

MIGRAINE CLASSIFICATION

Migraine without aura (common migraine)

Migraine with aura (classic migraine)

Complicated migraine

1. Ophthalmoplegic migraine 2. Basilar migraine 3. Migraine equivalents

MIGRAINE WITHOUT AURA (COMMON MIGRAINE)

MIGRAINE WITH AURA (CLASSIC MIGRAINE)

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OPHTHALMOPLEGIC MIGRAINE

ONSET BEFORE AGE 10

3RD, 6TH, OR 4TH NERVE PARESIS

POSITIVE FAMILY HISTORY

PERMANENT WITH REPEAT EPISODES

MIGRAINE EQUIVALENTS

ACEPHALGIC MIGRAINE

EPISODIC, TRANSIENT DYSFUNCTION OF AN ORGAN OR SYSTEM

NO ACCOMPANYING HEADACHE

MIGRAINE TREATMENT

Nonpharmacologic

1. Eliminate trigger factors 2. Stress management 3. Biofeedback 4. Acupuncture

Physical Techniques



Massage, acupressure



Acupuncture + OTC painkillers: 44% < HA



_{Trigger point injections}



Muscle stretching exercises



Osteopathic manipulation



_{Chiropractic spinal manipulation}

Peripheral Nerve Stimulation



Eon Mini IPG



Stimulation of occipital nerves for intractable chronic

Trigeminal Nerve Stimulation



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Homeopathic



Feverfew Feverfew –– herb, 50herb, 50--100 mg daily, (100 mg daily, (parthenolideparthenolide)) Can cause oral ulcers, tongue irritation, lip swelling. Can cause oral ulcers, tongue irritation, lip swelling.



Riboflavin Riboflavin –– Vitamin BVitamin B22–– 400 mg daily400 mg daily Increases energy efficiency of mitochondria. Increases energy efficiency of mitochondria.



Vitamin B Complex Vitamin B Complex –– BB6625 mg, B25 mg, B1212400 mcg, 400 mcg, folic acid 2 mg: 50% < HA

folic acid 2 mg: 50% < HA



Butterbur Butterbur –– herb, 75 mg BID x 4 months: 50% <HAherb, 75 mg BID x 4 months: 50% <HA Use the brand

Use the brand PetadolexPetadolex..



Magnesium 600 mg daily: 50% < HAMagnesium 600 mg daily: 50% < HA

Start with 200 mg daily, slowly increase to 600 mg. Start with 200 mg daily, slowly increase to 600 mg.

Botulinum Toxin Injection



Peripheral effect

Peripheral effect –

– muscle relaxant

muscle relaxant



_{Central effect}

_{Central effect –}

_{– inhibits release of trigeminal}

_{inhibits release of trigeminal}

cell

cell--mediated neurotransmitters

mediated neurotransmitters

MIGRAINE TREATMENT

Symptomatic (Abortive)

1. Over-the-counter medication a. Aspirin

b. Acetaminophen

c. Non-steroidal anti-inflammatory drugs Motrin Migraine Pain

Advil Migraine

d. Combination drugs: Excedrin Migraine

MIGRAINE TREATMENT

Symptomatic (Abortive) 2. Prescription medication

a. Combination drugs with narcotic b. Ergotamine tartrate

c. Dihydroergotamine: Migranal d. Narcotics: Stadol NS e. Midrin

Selective Serotonin Receptor Agonists



Imitrex

Imitrex ((sumatriptan

sumatriptan))



_Zomig

_{Zomig ((zolmitriptan}

_{zolmitriptan))}



Amerge

Amerge ((naratriptan

naratriptan))



_Maxalt

_{Maxalt ((rizatriptan}

_{rizatriptan))}



Axert

Axert ((almotriptan

almotriptan))



_Frova

_{Frova ((frovatriptan}

_{frovatriptan))}



Relpax

Relpax ((eletriptan

eletriptan))

Selective Serotonin Receptor Agonists



Efficacy: if first triptan does not work, try

another

another –

– may require trial and error

may require trial and error



Onset: injection

Onset: injection –

– 10

10--15 minutes

15 minutes

nasal spray

nasal spray –

– 15 minutes

15 minutes

troche

troche –

– no faster than oral tablets

no faster than oral tablets



_{Route: nasal spray or injection for N/V}



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MIGRAINE TREATMENT

Prophylactic (Preventive) a. Beta blockers

b. Tricyclic antidepressants

c. Nonsteroidal anti-inflammatory drugs d. Calcium channel blockers

e. Monoamine oxidase inhibitors: Nardil

f. Anticonvulsants: Depakote, Depakene, Topamax Topamax 50% < HA by 6 weeks

Prophylactic Therapy

Prophylactic Therapy -- Anticonvulsants

Anticonvulsants



TopiramateTopiramate ((TopamaxTopamax))



50% reduction of headache by 6 weeks50% reduction of headache by 6 weeks



Adverse effects: Adverse effects: paresthesiaparesthesia, weight loss, weight loss



Acute angle closure glaucoma within one month of Acute angle closure glaucoma within one month of starting therapy. Edema and forward rotation of starting therapy. Edema and forward rotation of ciliary

ciliary body body –– txtx: atropine and : atropine and prednisoloneprednisolone



Acute myopia: forward movement of irisAcute myopia: forward movement of iris--lens lens diaphragm

diaphragm



Reversible visual field defects independent of Reversible visual field defects independent of elevated intraocular pressure

elevated intraocular pressure