Alberta Pain Conference 2020 – More on Migraines

Notes taken while attending. Please contact me to advise on errors. Thank you

Dr. Werner Becker: Migraine needs a complex and comprehensive treatment trial.

He organized CHAMP headache program.

He emphasized that avoiding Codeine is important. Tryptans have replaced Ergotamine. Eletriptan and Rizatriptan are good examples, and injectable Sumatriptan, nasal Zolmitriptan.

The future is here – south of Canada’s border. The Gepantsa and Lasmiditan that doesn’t cause vasoconstriction, although it causes sleepiness and dizziness, and may cause driving impairment. Of note, the benefit is still to be discovered. In some studies it helps about 20% compared to 10% helped with placebo.

Dr. Lara Cooke spoke about when is a headache not just a headache. She gave us fabulous Pearls.

Migraine is a primary headache because it is not caused by something else, like a tumor. Usually it’s longer than 4 hours. It is usually one one side, pulses or throbs, usually is moderately to severely painful, it can be made worse by activity. It often comes with nausea or vomiting or light sensitivity or sound. Only 20-30% of people will have auras.

Look for red flags – then may need imaging. Examples of secondary headaches include caffeine withdrawal and a post-concussion headache. Thunderclap and new daily headaches need to be investigated.

Cluster headaches are so bad they are called suicide headaches. An awful pain. I have seen these patients in my office, thank goodness not for a while. Injectable Sumatriptan can work. I have used high dose oxygen – luckily our ER is close by and costs the patient zilch. zero. nada. Got love Canada. Can’t help bragging.

SUNCT – short acting unilateral neuralgiform headache with conjunctival injection and tearing. Certain anticonvulsant medications can work. They can be associated with pituitary lesions.

Look for red flags for another cause – like headaches getting worse over time. Short lasting headaches can be from a tumor in the posterior fossa.

SNOOP4: Systemic symptoms, signs, disease, Neurologic symptoms or signs – like vision or auditory symptoms, Onset sudden, like a thunderclap, Older onset, Papilledema, Positional symptoms from changes to intracranial pressure- worse lying or standing, Precipitated by Valsalva. and if Progressive. Ask – what do you do if you have this headache.

I would also like to remind professionals to think about temporal arteritis. A simple CRP in a suspicious case can save a person’s vision.

Dr. Michael Knash focused on the clinical side of headaches and migraines. 3 Billion people have some kind of headache disorder. He reminded us that headache in pregnancy could be associated with a clot.

He reinforced acute and preventative measures for chronic migraine and how socioeconomic factors can influence migraine management. He did mention the very real risk of death associated with use of opioids over 200mg equivalent Morphine.

Canada is still waiting for approval of many drugs. I don’t mind the wait. I appreciate the need for caution. Erenumab is now available (CGRP Mabs). Also mentioned the use of Botulintoxin and Topiramate.

Such a great way to spend a Saturday.

Thank you all


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