The Migraine World Summit: Day 4

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 Depression (30% of migraineurs) and anxiety (50% with migraine)

Comorbid disorders

Common wiring?

-        Serotonin

-        Peptides

-        Inflammation

-        Neurotransmitters

As migraine “chronifys”, mood disorders increase.

Brazilian study showed that if you experience one or less migraines a week (twice as likely depression). If you have daily headache you are seven times more likely to have depression.

Generalised anxiety:

-        Persistent daily worry (6 months)

-        Irritability

-        Poor sleep

-        Restless

-        5 fold greater in migraine patients

Panic disorder:

-        Severe scary intermittent surge

-        Fearful of next attack – alter behaviour

-        Anticipating panic- fearful

Migraine and panic:

Inherit some hyperexcitability in the nervous system

Bipolar disorder:

-        2.5-3-fold greater in migraine patients

-        Big spectrum

-        Diagnosis requires at least one manic or hyper manic episode

-        Often misdiagnosed with depression. Anti-depressants could make them worse.

OCD:

-        Not good data in migraine patients

-        Migraineurs tend to be highly efficient – making up for lost time

Suicidal thoughts:

-        Pain severity is a big indicator of this

-        Cluster headache & high frequency migraine

Important to treat mental health AND migraine. Co occurring disorders that require aggressive treatment.

Therapies?

-        Biofeedback (good evidence)

-        Relaxation therapy (diaphragmatic breathing)

-        CBT (decrease the cognition of threat), can be done online

-        Mindfulness/ meditation

Cyclical vomiting syndrome (CVS)- Occurs in both adults and children but we are unsure of the exact prevalence.

Tricky to diagnose: Confused with GI issues, metabolism issues. Lots of other disorders can look like CVS.

Symptoms?

-        Fatigue

-        Irritable

-        Vomiting

-        May have headache too

-        Nausea

-        Abdominal pain

Abdominal migraine Vs CVS?

-        Periodically: CVS tends to come in cycles for example if patient says every 6 weeks

-        Abdominal tends to have random frequency of attacks

-        What is the dominant symptom? Vomiting for CVS patients

CVS triggers?

-        Could be premonitory symptoms. Hard to tease out specific triggers

-        Not a lifestyle issue. Periodic nature of it.

Is it a neuro or GI disorder?

-        CVS is a neurological disease

-        Helpful to see gastro too to check nothing else has been missed.

CVS often predates migraine. Between 50% and 2/3 of CVS patients go on to develop migraine.

Treatment?

-        Acute: anti-nausea drugs

-        Prevention: tends to be the same for adults and children

-        CoQ10, Riboflavin and tricyclic antidepressants can all be used for prevention

How difficult is it to stop an attack?

-        Tricky working with oral treatments because of vomit

-        Nasal sprays and suppositories may be useful

-        Injections at home

-        IV in urgent care is sometimes necessary when patients are persistently vomiting

-        The earlier you treat the better, just like with migraine

Age of patients?

-        Youngest CVS patient she had seen was 2yrs old

-        5/6/7 typical start age

-        Can start mid 20’s

-        Possible link to infant colic

Prevent trip to ER?

-        Toolkit

-        Having a second rescue option if 1^st line attack does not work

-        Sometimes ER is inevitable because of dehydration concerns

CVS & CBD?

-        Not a good idea

-        Could trigger cannabinoid hyperemesis syndrome (CHS)

Advice for patients?

-        Find a good doctor who is interested in CVS

-        Take your toolkit with you wherever you go so that you are prepared and can treat early

-        Written documentation for ER can be useful to help bridge the gap in knowledge

Nausea can be even more disabling than headache

Strategies to help with Nausea?

-        Pharma (serotonin receptor antagonist, drugs that work on dopamine receptor, neurokinin receptor)

-        Acute meds (NSAID’s and triptans)

-        Non-Pharma (seabands, tens units, ginger chews/drops, frequent small sips of drink, graze on bland foods, aromatherapy lavender/peppermint)

Migraine meds and nausea?

-        Oral route (dissolving melts)

-        Nasal spray for triptans

-        Injectables (sumatriptan)

-        Per rectum suppositories

-        IV options at ER

Several options to bypass the GI tract. Even if no nausea, take anti-nausea tablets when treating migraine attack because stomach shuts down during migraine.