eople feel unwell for few hours before the start of migraine
Classification of Headaches help in development of Medications-Peter Goadsby
KARACHI: The first scientific session of the 6th National Headache Conference held on December 17th during the Neurology Update 2023 was devoted to Headache in which guest speakers from different countries shared their knowledge and experience through video link. The session was moderated by Dr. Wajid Jawaid.
Dr. Saad Khalid Niaz Sindh Health Minister chairing the inaugural session of 23rd Int. Neurology Update and 6th National Headache Conference held at Karachi from March 15th to 18th 2023. Also sitting on a dais from (L to R) are Dr. Abdul Malik, Prof. Akhtar Sherin, Prof. Adnan Khan President PNS, Dr. Naila Shahbaz (Chairperson of the conference) and Dr. Bashir Ahmed Soomro.
Dr. Abdul Malik in his introductory remarks gave an overview of headache disorders in Pakistan. Dr. Peter Goadsby discussed the classification of Headache and why it is useful. He described in detail Migraine and Tension Type Headaches, Cluster Headache, Cranial Autonomic symptoms. Medication overuse, he opined, can also lead to Headaches. He then talked about new daily persistent headaches. He also mentioned the classification of headache disorders, primary and Secondary Class-I and Class-II. This, he opined, is helpful in development of new medications.
Dr. Fayaz Ahmad from UK talked about “Understanding Migraine in 2024”. He also talked about what new changes has occurred in the understanding of migraine? Headache, he opined, does not get the attention it deserves. Billions of people are suffering from migraine from headache and it is much more common in women. It is the second leading cause of disability. Tension Type headaches is pulsating, throbbing and one should avoid physical activity during this headache. It usually lasts for four hours only then it is known as migraine.
Dr. Khurram Haq Nawaz, alongwith Dr. Muslim Lakhiar, Dr. Shaista Khawaja, Dr. Sarmad Ishtiaq, chairing one of the scientific sessions during Neurology Update conference which was moderated by Dr. Muhammad Irfan.
It usually starts after the age of fifty years. Aura become more common while headache is reduced. Its symptoms are similar to mini stroke. Those who suffer are usually of young age, has family history of migraine and complain of visual blurring. People get aura and it spreads like depression which progresses with the passage of time. Speaking about coherence of physiology Dr. Fayaz said that people feel unwell for few hours before the start of migraine. They feel carving for chocolate and cheese during migraine but it does not cause migraine. He also discussed different phases of migraine, pre monitoring imaging with H2O, PET monitoring of premonitoring phase, acute migraine attack, hypothalamic activation of migraine. Almost 42% of people Dr. Fayaz stated, have family history of migraine. These people have low threshold.
Speaking about what triggers migraine Dr. Fayaz Ahmed said that people have low threshold, some may have gastric susceptibility. He also listed a few chemicals which are culprits and cause migraine. He then referred to the therapeutic targets. During the next ten to twenty years, we will witness numerous development In Technology and some of these people will be treated with different gadgets. Some of these gadgets are already available while many others are being developed.
Dr. Sumera Rafat Umer (Moderator), Dr. Nadeem Ahmed Memon,
Dr. Shaheen Ahmed Mughal, Dr. Junaid Shaikh chairing scientific session
No. 1 on first day of the Neurology Update organized by Pakistan
Neurology Society at Karachi recently.
Some of these gadgets are approved by FDA in USA and NICE in UK. He then referred to Guna Core device which is used for cluster headache. Weary like CEFALY is available through Amazon. Arm Band is yet another device which is FDA approved which prevents migraine attacks. KOS is also available which was originally developed for Sinusitis. He also discussed differential diagnosis. Tension Type Headache, he said, are easy to diagnose but cluster headache is much difficult to diagnose. Migraine, he further stated, was not just headache but it was much more than that. New Gadgets are being developed to manage migraine. These gadgets are mostly available in USA but not in Europe though in private people are using it.
Dr. Sharoon discussed practical approach to pediatric headache disorders. This, he said, was a major cause of being absent from school. He then shared a few case history of pediatric migraine. Some of these children had non headache symptoms during attack of migraine. These attacks can be modest to severe and occur during school time. All these children need normal GIT assessment. He also discussed benign positional vertigo.
Abdominal migraine can be modest or severe. Different age groups have different phases. Those who complain of cyclic vomiting syndrome also needs normal GIT assessment. They complain of nausea and vomiting. It starts from six years of age and then lasts for the rest of the life. Some of these children also indulge in sleep walk and sleep talking. They have a non-REM sleep phase. He then referred to retinal migraine and also discussed acute psychosis. These people complain that so many people are watching them all the time and there is a monster under the bed, he added.
Dr. Aziz Sonawala, Dr. Fayaz Ahmed, Dr. Naila Shahbaz, Dr. Ismail Khatri
and Dr. Abdul Malik speaking at the 6th National Headache Conference
organized during the 23rd International Neurology Update held at
Karachi from March 15th to 18th 2023.
Peter Goadsby’s next presentation was on CGRP and headache disorders. He discussed the migraine therapeutic evaluation of the last century. Some of these patients will have prior treatment for prevention. He discussed at length the CGRP pathways Monocolonical Antibodies in Migraine and shared some real word considerations as to what happens when treatment is stopped in those who respond to these drugs.
In his other presentation Dr. Fayaz spoke on Secondary Headaches and shared some useful tips how not to miss them during diagnosis. Secondary headaches, he opined, makes us all worried. There are certain Red Flags, scan and make diagnosis. There could be some tumor infection. Primary headache accounts for 98% of cases while secondary headache is just 2% but it also leads to mortality. The prevalence of migraine in primary healthcare set up is about 3% while in a neurology clinic it accounts for just 1%. People over fifty years of age and pregnancy are some of the red flags. Sudden onset of headache is mostly secondary, abnormal neurological examination may be related to less secondary cause. Some people may have abnormal scans with headache but some may have normal scans but also suffer from headache. Some people are also victims of modern imaging.
If during imaging you find aneurysm, you need to report it for insurance and mortgage of property. One might come across some of these incidental abnormalities. SAH accounts for 85% while aneurysmal can be just 15%. Speaking about Thunderclap headache, he said that SAH and many other conditions are associated with this. HRCT of head has 100% sensitivity if done within six hours while CSF examination has 100% sensitivity until two weeks. In case of recurrent Thunderclap headache, do CT angio and MRI as there could be some aneurysm. He also referred to the NICE guidelines on Headache which is a useful document. He concluded his presentation by stating that secondary headache is rare but very serious. Red Flags remain strategy of suspicion, scanning for reassurance is not recommended and remember Do No Harm.
During the discussion it was pointed out that scan is not a replacement for good history and comprehensive physical examination. Thunderclap headache needs to be investigated. Migraine should not be a dustbin diagnosis. We must see can we cure it or just switch if off and must also know when to stop medications for headache. It is important to stop prophylactics to allow drugs to work.
Dr. Memoona Siddiqi in her concluding remarks emphasized the importance of advocacy and creating awareness. We also need to ensure the availability of drugs but above all listening to the patient was extremely important. In the next session Dr. Sabrina Khan discussed Quality of Life in CM with CGRP/Botox Therapy in comparison with oral preventives. Dr. Fayaz Ahmed spoke about Menstrual Migraine- its diagnosis and management. He discussed at length the hormonal aspects of migraine. This, he said, was more common in women and account for about 22%. Women can suffer form it during pregnancy and breast feeding and during Menopause as well. One has to strike a risk analysis. This migraine is more common in fertile age group. One has to be careful in 20s as it starts in this age group. Estrogen withdrawal can also cause menstrual migraine without aura. Estrogen can trigger aura. It starts two days before and lasts till three days after menstrual bleeding. In some female it is very severe and less responsive and they also suffer from it at other times. If one starts estrogen a week before menstrual cycle it can be managed.
Estrogen supplements patch is also available. Some female report that its severity is delayed but they do suffer from migraine. Some women use NSAIDS two days before and till three days after the menstrual cycle. Some also use vaginal coil. Migraine is more sever in first trimester but it improves in second and third semester. One of my patients said that she would like to avoid pregnancy just to get rid of this migraine, he remarked. Paracetamol is the safest drug at all times during pregnancy. NSAIDs are also used and there is little data about TCAs. Beta Blockers are used in a very low dose. However, there is a general saying that nothing is safe during pregnancy and one has to be extremely careful. He then referred to the use of Botox in pregnancy. We put one hundred two patients on Botox of which seventy-six continued.
Group photo shows some of the participants who attended the 23rd International Neurology Update and 6th National Headache Conference held at Karachi from December 15th to December 17th 2023. The conference was jointly organized by Pakistan Society of Neurology and Pakistan Headache Society.
There was one miscarriage during the first trimester but there were no fetal malformations. Now we have used it in about one thousand pregnancies but still it is not so safe. We give choice to the patients to use Botox or not, he remarked. Two third of patients does improve during menopause. HRT is a viable option. Migraine varies throughout different phases. NSAIDs are only used up to second trimester but paracetamol is safe. Steroids has no role, he remarked.
Panel Discussion
This was followed by a panel discussion in which the panelists included Dr. Peter Goadsby, Dr. Fayaz Ahmed, Dr. Aziz Sonawala and Prof. Muhammad Wasy. Dr. Abdul Malik moderated this session. During the panel discussion it was pointed out that CGRPs are the most cost effective treatment. Dr. Wasay referred to the burden of headache disorders and said migraine is most common complaint and cause more disability. It is very common in Pakistan as well. Tension Type headache is also very common. We do not know the true prevalence as we have mostly hospital based data.
There is lot of suffering in young women who also work at home. They seldom get medical treatment. We need to create awareness among masses and in the medical profession. Some patients get NSAIDs injection during acute migraine. Lot of education is needed for prophylactic treatment. In view of the lot of sufferings and disability due to pain, doctors need to be trained for intervention in acute phase. CGRP drugs are most expensive and they are not available in Pakistan. Dr. Aziz Sonawala remarked that we must make use of the available facilities. Guidelines have been prepared by AKUH in collaboration with Pakistan Headache Society. We are making a list of all potential NSAIDS as well as preventive medications and it will be finalized soon.
Speaking about the Asian perspective, it was stated that migraine is under diagnosed. Some patients even tend to commit suicide. Many people and the politicians are not aware of it. Headaches should be recognized as an important disorder. Dr. Fayaz Ahmed remarked that Botox is being used in Pakistan. It should be as cost effective as CGRPs. If Botox is available, CGRPs should also be made available. It was pointed out that in UK CGRP costs between five to seven hundred US dollars while in Pakistan Botox costs about three thousand two hundred rupees which is quite cost effective. Dr. Pete was asked can Internaitonal Society of Headache help the developing countries to make these drugs available and how they can help us in Pakistan.? Dr. Peter said that it was available in countries like Philippines and Brazil. Marketing people needs to be persuaded to make it available in Pakistan.
Dr. Bashir pointed out that life style modification can also help these patients to a great extent. Some of these patients have other overlap symptoms. CGRP looks promising and in the next few years it will be more common. It may surprise us in the next few years. Dr. Wasay suggested formation of a migraine advocacy group to bring it into limelight. Disability due to migraine is most common. Society should recognize it because migraine is the most common cause of neurological disorders. New drugs are very costly. Dr. Fayaz remarked that medical economics does play an important role, you need to find out the real burden, collect data and then tell the policy makes how it affects the economy. Dr. Peter remarked its cost to the community, loss of productivity and how it affects the community needs to be highlighted.
