MIGRAINE

AND
CLUSTER HEADACHE

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RSUP SANGLAH/FK UNUD
 MIGRAINE

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 INTRODUCTION
The core features of migraine are headache, which is usually
throbbing and often unilateral, and associated features of
nausea, sensitivity to light, sound, and exacerbation with head
movement.(American Headache Society)

The most common type of headache that leads patients to

seek medical care
- PREVALENCE  between 2.6% and 21.7%, with an average
of ~12%. 1
- Major cause of disability and is among the top 10 causes of
years lived with disability in the world (Global Burden of
Disease Study, 2015)
- Familial link.1
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Yeh WZ, Blizzard L, Taylor BV. What is the actual prevalence of migraine? Brain Behav. 2018;8:e00950
1
 PATHOPHYSIOLOGY

CORTICAL
Genetic AURA
SPREADING Oligemia
predisposition
DEPRESSION

Increase in MMP (3-

6h after CSD)
- vasodilation of the Activates the
Sterile Trigeminal
middle meningeal
inflammatory Nociceptive
artery
- Plasma leakage response Pathway

Pro-inflammatory
peptides (CGRP)

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 PATHOPHYSIOLOGY

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 CLINICAL MANIFESTATIONS

PRODORMAL
(hours or a day or two AURA HEADACHE POSTDROMAL
before the other symptoms)

- Fatigue - Visual (95%) most commonly

- Thirst - sensory fatigue and elated
- Anorexia - speech and/or or depressed
- Food cravings language mood
- Emotional - motor
- Nausea
- Blurred vision

AURA : focal neurologic symptoms, most commonly visual (>95% of all auras), that typically evolve and then
regress over minutes before headache onset

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 PRECIPITATING FACTORS

• Skipping meals
• Sleeping disturbances
• Menstruations
• Light
• Stress

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 DIAGNOSTIC CRITERIA
(The International Classification of Headache
Disorders 3rd edition)
A. Migraine with out aura = common migraine.
A. Recurrent headache (5 X).
B. Headache last with in 4 – 72 hours (untreated or
unsuccessfully treated)
C. Headache has at least two of the following
characteristic:
1. Unilateral.
2. Throbbing or pulsating headache.
3. Moderate or severe pain intensity.
4. Aggravated by routine physical activity such
as bending, climbing stairs.
D. During headache at least one of:
1. Nausea and vomiting
2. Photophobia and phonophobia
3. Not attributed to another disorders
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 DIAGNOSTIC CRITERIA
(The International Classification of Headache
Disorders 3rd edition)
A. Migraine with aura = common migraine.
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
1.visual
2.sensory
3.speech and/or language
4.motor
5.brainstem
6.retinal
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 DIAGNOSTIC CRITERIA
(The International Classification of Headache
Disorders 3rd edition)
A. Migraine with aura = common migraine.
C. At least three of the following six characteristics:
1.at least one aura symptom spreads gradually over ≥5 minutes
2.two or more aura symptoms occur in succession
3.each individual aura symptom lasts 5-60 minutes1
4.at least one aura symptom is unilateral2
5.at least one aura symptom is positive3
6.the aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another disease.
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 MANAGEMENT

A. General principles.
Avoid precipitating factors, sleep hygiene, self monitoring

B. Two primary steps in the care of migraine patients: treatment of the

acute headache and prevention of subsequent events.
• Acute headache  relief pain  ABORTIVE TREATMENT
• Frequent headache, other specific indications  PROPHYLACTIC

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 ABORTIVE TREATMENT
Considerations: Rapid and constant effect of the drug, minimal/ with out side effect, long term effect
to prevent recurrent headache, drug effectiveness that help patients return back to normal activity,
unexpensive and available

Choices:
1) Analgesic  NSAID, aspirin, acetaminophen
2) Serotonin 1B/1D receptor agonist (“triptan”)  Sumatriptan 30mg
3) Ergotamin

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 PROPHYLACTIC TREATMENT
Considerations:
1) Recurrent migraine, disturb daily avtivities.
2) More than 2 times attack/week.
3) Failure abortive treatment or exceed abortive treatment.
4) Side efect with abortive treatment.
5) Patient choise.
6) Uncommon migraine ( hemiphlegic migraine, basilar migraine, migraine with
prolonged aura, aura infarct migraine).

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 PROPHYLACTIC TREATMENT
Choices:
1) Beta blocker (propanolol, metoprolol, timolol)
2) Antidepresant (amitriptilin, flouxetin)
3) Calcium chanel blocker (nimodipin, nipedipin, verapamil)
4) Anti convulsant (sodium valproate, gabapentine)
5) Serotonon antagonis (metisergid, pizotifen)
6) Botox (botolinum toxin)

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 CLUSTER
HEADACHE

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 INTRODUCTION

Cluster headaches is much less common than

migraines, to which they are unrelated, affecting
only 0.1% of adults (third decade, men > women =
2-4 : 1).
Cluster headache is usually more severe and
debilitating and have been referred to as the
“suicide headache.”

Underlying mechanism: activation of

a trigeminal-autonomic loop in the
brainstem

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 PATHOPHYSIOLOGY

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 CLINICAL MANIFESTATIONS

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 CLINICAL MANIFESTATIONS

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 DIAGNOSTIC CRITERIA
(The International Classification of Headache Disorders 3rd edition)

A. At least five attacks fulfilling criteria B–D

B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
C. Either or both of the following:
1. at least one of the following symptoms or signs, ipsilateral to the headache:
a) conjunctival injection and/or lacrimation
b) nasal congestion and/or rhinorrhoea
c) eyelid oedema
d) forehead and facial sweating
e) forehead and facial flushing
f) sensation of fullness in the ear
g) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is
active
E. Not better accounted for by another ICHD-3 diagnosis.
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 DIAGNOSTIC CRITERIA
(The International Classification of Headache Disorders 3rd edition)
A. EPISODIC CLUSTER HEADACHE
• Cluster headache attacks occurring in periods lasting from 7 days to one year, separated by pain-free periods lasting at
least 3 months.
Diagnostic criteria:
• Attacks fulfilling criteria for Cluster headache and occurring in bouts (cluster periods)
• At least two cluster periods lasting from 7 days to 1 year (when untreated) and separated by pain-free remission periods of
≥3 months.

A. CHRONIC CLUSTER HEADACHE

• Cluster headache attacks occurring for one year or longer without remission, or with remission periods lasting less than 3
months.
Diagnostic criteria:
• Attacks fulfilling criteria for Cluster headache and occurring in bouts (cluster periods)
• At least two cluster periods lasting from 7 days to 1 year (when untreated) and separated by pain-free remission periods of
≥3 months.
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 MANAGEMENT
ABORTIVE TREATMENT PREVENTIVE TREATMENT

1. Oksigen 100%, 7 lt/minutes (10-15 minutes).

1. Verapamil 360-480mg
2. Triptan  sumatriptan (6 mg SC; 5-15mg),
Zolmatriptan 5 mg. 2. Ergotamine 1-2 mg

3. Ergotamin 3. Metisergid 1-2 mg( 3-4 time/day).

4. Analgetic and narcotic. 4. Kortiokosteroid (prednisolon 60-80 mg).
5. Lithium carbonate.
6. Sodium valproate.

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 THANK
YOU

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