On behalf of program chair @headacheMD and my fellow @migraine_ce faculty @EhrlichNP @NinaRiggins @rashmihalker, thanks for joining us! Previous programs, available for CE/#CME credit, are at https://t.co/3Rt15X6pUA.
— @migraine_ce (@migraine_ce) November 15, 2021
3) So we’ve been learning a lot about #migraine and we know it’s #NotJustAHeadache. But there are a lot of other headache disorders out there. Sometimes we don’t realize they are related to migraine and sometimes they are not migraine at all.
— @migraine_ce (@migraine_ce) November 15, 2021
5) I want you to try to figure out the diagnosis before it is revealed in the subsequent tweets. That’s right! We’re doing this case-based learning style!
— @migraine_ce (@migraine_ce) November 15, 2021
7) However, her wife noted that her symptoms seemed more severe than just typical postpartum symptoms and urged her to bring it up to her PCP. Her PCP then ordered an MRI that had the report of a normal with no evidence of any lesions.
— @migraine_ce (@migraine_ce) November 15, 2021
9) In fact, patient is symptomatically at her best after having a nap for at least 20 minutes. She also complains of a moderate headache in the back of her head that is throbbing and soreness in her neck that worsens throughout the day, lasting up to 6 hours at a time.
— @migraine_ce (@migraine_ce) November 15, 2021
11) Julia does meet the ICHD-3 diagnostic criteria for migraine, with a moderate severity, throbbing headache lasting 6 hours and with associated nausea. However, this does not completely explain the story. Let’s take a look at that MRI ourselves.
— @migraine_ce (@migraine_ce) November 15, 2021
13) On exam, Julia is noted to be very tall and skinny. Her neurological exam is normal but you notice that when she stretches her arms out, she hyperextends at the elbows, knees and fingers. She says she’s always been flexible and “double jointed.” pic.twitter.com/T057CY08uo
— @migraine_ce (@migraine_ce) November 15, 2021
15) Julia notes that she does not have any symptoms when she first wakes up in the morning but within a few minutes of getting out of bed, they begin and they persist and worsen throughout the day. When she lies down, they resolve completely within 20 minutes.
— @migraine_ce (@migraine_ce) November 15, 2021
17) Given her migraine and cognitive symptoms as well as the imaging findings, you diagnose Julia with migraine secondary to intracranial hypotension, aka a #CSFleak, likely from the epidural she received after giving birth.
— @migraine_ce (@migraine_ce) November 15, 2021
19) … could be a reason why her meninges did not completely close after the epidural procedure.
The ICHD-3 Diagnostic Criteria for Headache attributed to low cerebrospinal fluid pressure
a. Any headache fulfilling criterion C
b. Either or both of the following:— @migraine_ce (@migraine_ce) November 15, 2021
21) Causes of intracranial hypotension vary. Common causes include meningeal diverticula, connective tissue d/o's, spondylitic dural tears, trivial trauma, CSF shunt over drainage, traumatic CSF leaks, post-surgical procedures or -dural puncture, & spontaneous/idiopathic.
— @migraine_ce (@migraine_ce) November 15, 2021
23) … that make it different, particularly the positional component. https://t.co/BGMq9qp7VF The symptoms are due to CSF leakage causing sinking of the brain (aka Brain Sag). This leads to traction or distortion of the supporting pain-sensitive structures, particularly the …
— @migraine_ce (@migraine_ce) November 15, 2021
25) People with intracranial hypotension find their symptoms worsen after being upright, and might improve or disappear after rest in supine position. However, over time, this orthostatic nature may be less obvious making the diagnosis even harder if found later.
— @migraine_ce (@migraine_ce) November 15, 2021
27) … in Julia’s MRI. But note that 20% of brain MRIs can be normal, so headache due to intracranial hypotension is still a clinical diagnosis. You can also consider CT myelography if you want to look for the leak location, especially if the patient is refractory to treatment.
— @migraine_ce (@migraine_ce) November 15, 2021
29) … such as abdominal binders to increase intraabdominal pressure and therefore CSF pressure. When conservative treatment doesn’t work, experts suggest a blind epidural blood patch. This leads to immediate volume replacement with long term goal of sealing the leak.
— @migraine_ce (@migraine_ce) November 15, 2021
31) …epidural placement of a mixed blood and fibrin sealant, a targeted patch (if you know the site of the leak) with fibrin glue, & surgical closure. Here's the latest from experts on diagnosis & mgt of intracranial hypotension which was the source for the above information.
— @migraine_ce (@migraine_ce) November 15, 2021
33) So did you learn a thing? See you tomorrow where we talk about the next case! @melissarayhill @RebeccaCBurch @stephanieJnahas @eloder @obegassededhaem @HeadacheJournal @jkiarashiMD @ahsheadache @AMastersMD @DrMeganDonnelly @AEPaceMD @ffiorito27 @daviddodick
— @migraine_ce (@migraine_ce) November 15, 2021
35) Case 2: Antoine is a 32 year old man with history of tobacco use disorder & hypertension who presents to your clinic with headaches that have been going on for three years. Prior to that, he would have an occasional headache when he was stressed, tired or caffeine deprived.
— @migraine_ce (@migraine_ce) November 16, 2021
37) … & his BP has since been under control. He is in the process of trying to quit smoking as well & is down to one or two cigarettes a week. However, the #headache, while ⬇️in severity from the onset 3y ago, has been constant since. His PCP had gotten an MRI brain which …
— @migraine_ce (@migraine_ce) November 16, 2021
39) He typically has a baseline low level pain in the front center of his head and increases in severity to moderate about three times a week, during which he stays in bed and rests until it improves. He has light and sound sensitivity when he has the higher severity attacks …
— @migraine_ce (@migraine_ce) November 16, 2021
41) … to find out what is going on because he knows this isn't normal. His PCP rec'd he see you for migraine. What is the diagnosis?
a. Chronic intractable migraine w/status migrainosus
b. Hypertensive headache
c. Chronic Tension Type Headache
d. New Daily Persistent Headache— @migraine_ce (@migraine_ce) November 16, 2021
43) There are two typical subtypes of NDPH, one that resolves spontaneously and one that is recurrent and refractory. Antoine fits the description of the latter and therefore will need aggressive treatment. https://t.co/jhHl9GCVsV
Here’s a little bit more about #NDPH …— @migraine_ce (@migraine_ce) November 16, 2021
45) About half of patients can name a precipitating factor such as an infection or flu-like illness being the most common. There have been a significant population who recognize surgical interventions like intubation as a trigger.
— @migraine_ce (@migraine_ce) November 16, 2021
47) … during persistent systemic or CNS inflammation (which is why it tends to occur after an infection). It might also be due to chronic central nervous system inflammation, cytokine production and persistent glial activation that arise in response to precipitating events.
— @migraine_ce (@migraine_ce) November 16, 2021
49) Most headache specialists treat NDPH based upon the prominent headache phenotype, whether migrainous or tension type. There is some evidence for using antiepileptics like topiramate or gabapentin or using Botox. There is less evidence for . . .
— @migraine_ce (@migraine_ce) November 16, 2021
51) Given that he has light and sound sensitivity, I would treat Antoine with migraine preventive and rescue therapy. He is started on a combination of preventive and rescue therapy and is able to get his baseline pain lowered and his number and severity of exacerbations ⬇️d.
— @migraine_ce (@migraine_ce) November 16, 2021
53) … I am often quicker to add on multi-modal combination therapies and explain that we may not be able to get a patient headache free but we will do everything to decrease the severity of symptoms.
— @migraine_ce (@migraine_ce) November 16, 2021
55) Come back tomorrow for the third & final case and your link to CE/#CME credit! @MigraineDisordr @amfmigraine @MiaMinenMD @paulrizzolimd @HumaSheikhMD @GrahamHeadache @AngelikiVgontza @AHDAorg @headachedoc @williambyoung59 @migraineaus @headacheMD @NinaRiggins @EhrlichNP
— @migraine_ce (@migraine_ce) November 16, 2021
57) … and we’re going to move onto the 3d and final case. #NeuroTwitter #HeadacheMedicine. Case 3: Anaya is a 23yo healthy ♀️ who comes in w/3 mo dizziness. She describes "feeling drunk”; when she is still with eyes closed, she feels like she is swaying back & forth.
— @migraine_ce (@migraine_ce) November 17, 2021
59) In between these attacks, which occur once every other week, she has a constant feeling of unsteadiness “like I’m on a boat.” She is able to power through the unsteadiness but the unpredictability of the severe attacks have her nervous. pic.twitter.com/BWlb3lv8I3
— @migraine_ce (@migraine_ce) November 17, 2021
61) However, she came to you because it was not getting better. What are your thoughts so far? Answer in the comments down below before continuing on!
— @migraine_ce (@migraine_ce) November 17, 2021
63) Those have been less freq as she aged & she never has headaches like that anymore. She does notice that she gets a mod headache after the dizzy attacks that lasts throughout rest of day & she has to take it easy & would prefer to be in a dark & quiet room until they resolve.
— @migraine_ce (@migraine_ce) November 17, 2021
65) Anaya meets the diagnostic criteria of migraine but there has been a change in her pattern & she now has nonheadache sx that are more disabling. She is now having vertigo symptoms both assoc'd and unassoc'd with the headaches. Thus she has a diagnosis of #VestibularMigraine.
— @migraine_ce (@migraine_ce) November 17, 2021
a. At least five episodes fulfilling criteria C and D
b. A current or past history of migraine with or without aura
c. Vestibular symptoms of moderate or severe intensity lasting between 5 minutes and 72 hours
d. At least half the episodes are associated with at least one of …— @migraine_ce (@migraine_ce) November 17, 2021
67) Here is what is defined as vestibular symptoms: a) spontaneous vertigo (internal: sensation of self-motion, external: sensation that visual surroundings are spinning or flowing) b)positional vertigo, occurring after a change of head position, c) visually induced vertigo …
— @migraine_ce (@migraine_ce) November 17, 2021
69) Lifetime prevalence of VM has been estimated to 1% of the population, but about 10-20% of patients presenting to headache clinics end up with a diagnosis of VM so it’s an important diagnosis to consider. It’s a commonly underdiagnosed cause of vertigo.
— @migraine_ce (@migraine_ce) November 17, 2021
71) … a family history of vertigo in 66% of patients diagnosed with VM. https://t.co/XUsRTsFKAH
— @migraine_ce (@migraine_ce) November 17, 2021
73) There are diagnostic tests that can support the diagnosis which is still largely clinical. These include high frequency headshake test, video-oculography (VOG) position testing, videonystagmography (VNG) calorics, Electrocochleography (ECoG), MRI.
— @migraine_ce (@migraine_ce) November 17, 2021
75) Current treatments are based on treatment of underlying migraine. In addition, symptomatically you can treat acute vertigo episodes with antiemetic drugs or benzodiazepines. For a preventive, in addition, lamotrigine & acetazolamide may be effective in management of vertigo.
— @migraine_ce (@migraine_ce) November 17, 2021
https://t.co/5IeT2iKb1y https://t.co/w6VxWBQr0S
— @migraine_ce (@migraine_ce) November 17, 2021
78) And of course, I have a TikTok on vestibular migraine as well: https://t.co/u07x2BhguP
— @migraine_ce (@migraine_ce) November 17, 2021
80) And that’s a whirlwind tour of three #HeadacheDisorders that are often either misdiagnosed as migraine or actually due to migraine and misdiagnosed as something else. Did you learn a thing? If so, don’t forget to go to https://t.co/tzVa7kAqHm and claim your CE/#CME credit!
— @migraine_ce (@migraine_ce) November 17, 2021
81) I am @CSWhiteMD and thanks for joining! Please follow us for more accredited #Tweetorials from #migraine experts! @Neurotweeps @headacheMD @rashmihalker @HindiyehNada @RKrel @RRaoMD @NithiAnandMD @okheadachedr @EHF_Official @Neurology_JC @SocBlackNeuro @diamondheadache @NHF
— @migraine_ce (@migraine_ce) November 17, 2021
