frederick t strobl md azmn neurology migraines ...az-ns.org/presentations/migraines.pdf ·...

Frederick T Strobl MDAZMN Neurology

Migraines:

Classification, Management and Effects on Cognition

Arizona Neuropsychological Society

June 21, 2014

© 2014 Frederick Strobl

Learning Objectives:

1.Understand the general classification of headaches with particular attention to migraines.

2.Learn how migraine headaches can affect cognition.

3.Learn how treatment of headaches may improve/impair cognition

© 2014 Frederick Strobl

Curriculum Vitae - 1

College:

1967 – 1968 Rensselaer Polytechnic Institute (RPI), Troy,

New York

1968 – 1971 University of Minnesota, Minneapolis

BS Electrical Engineering; Minors in

Computer Science and Control Systems

1970-1971 Worked part time for Honeywell Systems and

Guidance Group. This group was in charge of the design

of control systems for Apollo Spacecrafts, X-15 rocket

planes, 747’s

Curriculum Vitae - 2

Medical School:

1972 – 1975 University of Minnesota, Minneapolis

Internship (PGY-1):

1975 – 1976 Hennepin County Medical Center (HCMC, the

Level I Trauma Center for Minneapolis)

Curriculum Vitae - 3

Residency (PGY-2 through PGY-4):

1976 – 1979 University of Minnesota Neurology Program

(at the time the largest in the United States) with

rotations at HCMC and St. Paul Ramsey (now Regions

Medical Center) – all Level I Trauma

Chief Resident at University of Minnesota and HCMC

Curriculum Vitae - 4

1977

Scholarship to study Electromyography (EMG) at the

National Hospital for Nervous Disease, Institute of

Neurology, Queen Square, London, UK

Fellowship Training:

1979 Mayo Clinic, Rochester, MN, Electroencephalography

Curriculum Vitae - 5

NATIONAL BOARD CERTIFICATIONS

American Board of Psychiatry and Neurology

(Neurology)

American Board of Electrodiagnostic Medicine (EMG)

American Board of Neurologic Rehabilitation

Diplomate of National Board of Medical Examiners

Curriculum Vitae - 6

Minneapolis Clinic of Neurology

(Largest Private in US)

AZMN Neurology

Curriculum Vitae - 8

1977 – Present: American Academy of Neurology

(AAN – the dominant professional Neurology

association in the world)

AAN was founded by the Chief of Neurology at the

University of Minnesota, Dr. A. B. Baker, who was

also was my Chief in training.

The idea for AAN came from Joseph Resch, MD, a

founder and past President of my clinic, The

Minneapolis Clinic of Neurology

It is VERY cold & dark in Minnesota in Winter

Headache Classification

Many Classifications

Generally Not Helpful Clinically

For most – dichotomy

Vascular – sounding

Non-vascular

© 2014 Frederick Strobl

Headache Classification: Non-vascular

Muscle-contraction

Stress

Cervical spine diseases

Tumor, ICH, Infection

© 2014 Frederick Strobl

Headache Classification: Vascular

Inflammatory

Lupus, GCA/TA, Vasculitis, Lyme

Migraine

Many forms

Grossly underdiagnosed

Prominent among Neurologists

© 2014 Frederick Strobl

Migraine - Pathophysiology

Primary brain disease

Spreading depolarization

Prominent Trigeminal/Brainstem Involvement

Role of Hypothalamus?

© 2014 Frederick Strobl

Migraine - Statistics

18% of Females >1 attack/year

6% of Males (likely underdiagnosed)

35 – 45 years old

Increased risk of seizures

© 2014 Frederick Strobl

Case Study

27 yo Neurology Resident walking in hall feels lightheaded. He notices

that his thinking is unclear. This all passes within a few minutes.

Over next few months the resident will have repeated identical episodes without any clearcut precipitants.

© 2014 Frederick Strobl

Case Study 1

As a resident, he had been asked to be a test subject normal for EEG at

three institutions.

All are read as normal.

MRI is normal.

© 2014 Frederick Strobl

Case Study 2

Routine bloods, including glucose during an attack, are normal.

Attacks become more common and longer.

He reports his cognition is slower during these attacks.

He can read but not comprehend.

© 2014 Frederick Strobl

Case Study 3

Almost never has headaches.

Occasionally sees visual scotomasand flashing lights.

Can’t read in car – nausea.

Since childhood he has had episodic attacks of severe abdominal pain, being rushed to ER for appy once.

© 2014 Frederick Strobl

Case Study 4

His four-year old daughter has similar

attacks of abdominal pain.

Suspecting migraines, he calls his mother who never reported them to

him because she didn’t want to trouble him, has identical symptoms plus severe HA’s as does her mother.

© 2014 Frederick Strobl

Case Study 5

Ibuprofen relieves his symptoms within 30’.

Daily aspirin 81 – 325 mg have markedly reduced frequency.

© 2014 Frederick Strobl

Acute Confusional Migraine (ACM)

Up to 8% of children w Migraine

Affects adults as well-under diagnosed

Alice-in-Wonderland syndrome (AIWS)

Micropsia, macropsia, or size distortion of other sensory modalities

© 2014 Frederick Strobl

Acute Confusional Migraine (ACM) 1

Amnesia

Inability to concentrate

Disorientation

Agitation

Exhaustion or Hyperalertness

Speech impairment

© 2014 Frederick Strobl

Migraine - Diagnosis

History

Family History

Exclude other etiologies

No direct test

MRI, MRA

EEG may be positive

© 2014 Frederick Strobl

Migraine - Treatment

Interventional

NSAIDs, Triptans (eg, Imitrex)

Preventive

Anti-epileptics, (eg, Depakote ER)

Calcium channel blockers

Beta blockers

Tricyclics

© 2014 Frederick Strobl

Questions & Answers