Migraine Management Slide Kit File Date: 10/30/01 · Migraine Management Slide Kit File Date: 10/30/01 1 1 Improving Care for Migraine Patients Alan R. Towne, MD VCU School of Medicine

Migraine Management Slide KitFile Date: 10/30/01

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Improving Care for Migraine Patients

Alan R. Towne, MDVCU School of Medicine

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Diagnosis

Evaluating the Patient with Headache

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Headache Classification and Diagnosis

Primary Headaches– migraine– tension-type– cluster headache

Secondary Headaches– tumor– meningitis– giant cell arteritis

Adapted from Headache Classification Committee of the IHS. Cephalalgia. 1988

Primary Headache

90%

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Diagnostic Evaluation

InvestigationsInvestigations

Secondary Secondary HeadacheHeadache

NO YES

AtypicalFeatures

Primary Primary HeadacheHeadache

HeadacheHeadache

Warning signs Warning signs present?present?

Adapted from Silberstein SD, et al. (eds.) Headache in Clinical Practice. 1998

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Headache red flags -“SNOOP”Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, systemic cancer)Neurologic symptoms or abnormal signs (confusion, impaired alertness or consciousness)Onset: sudden, abrupt, or split-secondOlder: new onset and progressive headache, especially in middle-age > 50 (arteritis)Previous headache history: first headache or different (change in attack frequency, severity or clinical features)Postural 6

Neuroimaging in Headache Patients

Recurrent migraine: neither CT nor MRI is warranted except – recent change in headache pattern– new onset seizures– focal neurologic signs or symptoms

Nonmigraine headache: Role of CT or MRI is unclearRole of CT versus MRI in headache patients is unclear, but some secondary headache causes may not be evident on CT

Adapted from Practice Parameter. Neurology. 1994Adapted from Silberstein SD. Neurology. 2000


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Lumbar Puncture

Thunderclap headacheSubacute progressive headache Headache associated with fever, meningismus, confusion, or seizureHigh or low intracranial pressure

Note: Cranial imaging should be normal prior to LP

Adapted from Silberstein SD, et al. (eds.) Headache in Clinical Practice. 1998 8

Chronic Migraine and TTHPsychiatric Comorbidity

Depression 25% – 80%– improves with effective headache

treatmentGeneralized anxiety – 70%Minnesota Multi-Phase Personality Inventory – abnormal in 60% (predictor of intractability)

Adapted from Verri AP, et al. Cephalalgia. 1998Adapted from Mitsikostas DD & Thomas AM. Cephalalgia. 1999

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SummaryPrimary headache syndromes are diagnosed by defining the clinical features of an individual’s attacks and applying them to established definitionsThe majority of headaches seen in primary care will be one of the primary headache disordersIf care is taken to identify warning signs and symptoms, the chances of missing a secondary headache is greatly diminished

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Headache Types:Primary Headaches

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Dichotomous vs. Continuum Theory

Dichotomous theory = Each headache has a distinct, unrelated etiologyContinuum theory = Each headache shares common pathophysiological components of varying intensities

ETTH Migranous Migraine12

Common Clinical Presentations of Migraine

Sinus

Tension

Migraine


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Characteristic Migraine Features

Frequent temporal association with menstrual cycleCharacteristic triggersParadoxical relationship to sleep –frequently occur during sleep or upon awakening but also abated by sleepFamily history of migraineReversible attack-related cognitive impairmentDizziness, vertigo

Adapted from Pryse-Phillips WEM et al. Can Med Assoc Journal. 1997 14

PostdromePostdromeProdromeProdrome Headache

The Migraine Attack

Associated Features

Aura

TimeTime

Intensity of Symptoms or Phases

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Migraine Characteristics:Prodrome

60%60% of people with migraine experience premonitory phenomena

25%25% feel elated, irritable, depressed, hungry,

thirsty, or drowsy

Adapted from Silberstein SD. Semin Neurol. 1995 16

Premonitory SymptomsExcitatory– irritability– elation– physical hyperactivity– yawning– food craving– photophobia/

phonophobia– increased bowel

and/or bladder activity

Adapted from Waelkens J. Cephalalgia. 1985

Inhibitory– mental/physical

slowing– poor concentration– word finding difficulty– weakness/fatigue– chill, anorexia,

constipation, abdominal bloating

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The Migraine Attack: AuraComplex of focal neurologic symptoms made up of positive or negative phenomenaVisual– scotoma– fortification spectra– scintillations

Motor– hemiparesis

Sensory– numbness– dysasthesias

Complicated– basilar– ophthalmoplegic

ProdromeProdrome

Associated Associated FeaturesFeatures

TimeTime

HeadacheHeadache PostdromePostdromeAuraAura

Adapted from Lashley KS. Arch Neurol Psych. 1941 18

Migraine With Aura

≥ 2 Attacks Meeting ≥ 3 of the Following:– one or more fully reversible aura symptoms

(cortical or brainstem dysfunction)– one or more aura symptoms that develop

gradually over > 4 minutes or ≥ 2 symptoms that occur in succession

– no single aura symptom lasting longer than 60 minutes

– headache follows aura within 60 minutes or may begin simultaneously with aura

Adapted from Headache Classification Committee of the IHS. Cephalalgia. 1988


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The Migraine Attack:Headache

Moderate to severe unilateral, throbbing pain aggravated by normal physical activityAssociated symptoms: nausea, vomiting, photophobia, phonophobia, osmophobiaResolution with sleep

Adapted from Headache Classification Committee of the IHS. Cephalalgia. 1988Adapted from Pryse-Phillips WEM, et al. Can Med Assoc J. 1997 20

Tension Headache

Most common type of headacheMay be episodic or chronic Least distinct of the headache disorders

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Tension Headache:Clinical Features

Dull, achy, bilateral, nonpulsating painSensation of pressing or tighteningRoutine physical activity does not aggravate painNo vomiting and no more than one of– nausea– photophobia– phonophobia

Usually no prodrome or auraModerate or severe pain is less commonMusculoskeletal component

Adapted from Headache Classification Committee of the IHS. Cephalalgia. 1988Adapted from Hatch JP, et al. Pain. 1992

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Chronic Daily Headache: (CDH)Primary headache disorders:– transformed migraine – chronic tension-type headache– new daily, persistent headache– hemicrania continua

Association with medication overuse in someSecondary headachesMixed headache features

Adapted from Mathew NT, Stubits E, Nigam MR. Headache. 1982Adapted from Silberstein SD, Lipton RB, Sliwinski M.. Neurology. 1996Adapted from Solomon S, Lipton RB, Newman LC. Cephalalgia. 1992

Adapted from Vanast WJ. Headache. 1986

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New Daily Persistent Headache (NDPH)

Average frequency > 15 days / month for > 1 monthAverage duration > 4 hours (frequently constant but may fluctuate with medication)No history of migraine or TTH that increases in frequency and decreases in severity with onset of NDPHAcute onset (developing < 3 days) of constant headacheConstant in location

Adapted from Silberstein SD, et al. Neurology. 1996 24

Hemicrania ContinuaHeadache present > 1 monthStrictly unilateralPain has all 3 of the following:– continuous but fluctuating– moderate severity, at least some of the time– lack of precipitating mechanism

One of:– absolute response to indomethacin– autonomic symptom or sign with severe pain

exacerbationMay have idiopathic stabbing headaches

Adapted from Goadsby PJ & Lipton RB. Brain. 1997


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Cluster Headache

Relatively uncommonMore prevalent in men than in womenPredominantly afflicts men in their 20s and 30sGenetic predispositionTend to be smokers

Adapted from Ekbom K, Ahlborg B, Schele R. Headache. 1978Adapted from Russell MB. Cephalalgia. 1997

Adapted from Swanson JW, et al. Neurology. 1994 26

Cluster Headache:Circadian and Annual Periodicity

January

JulyAugust

December

MayFebruary

October

AprilMarch

November

June

September

Adapted from Kudrow L. Cephalalgia. 1987Adapted from Trucco M. Waldenlind E. Cephalalgia. 1993

Adapted from Waldenlind E. Cluster Headache and Related Conditions. 1999

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Cluster Headache:Pain

SevereUnilateralOrbital, suborbital, or temporal painLasts 15 to 180 minutes (untreated)

Adapted from Lance JW and Goadsby PJ (eds). Mechanisms and Management of Headache. 1998 28

Cluster Headache:Autonomic Features

ConjunctivalinjectionLacrimationCongestionRhinorrhea

SwellingMiosisPtosisEyelid edema

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Impact: Prevalence of Migraine Globally

Adapted from Lipton RB, et al. Headache. 1994

France 5-12%

Denmark 10%

Germany 11%

Italy 12%

Taiwan 9.1%

UK 7%

USA 9-12%30

Impact: Migraine Prevalence by Age and Gender

Migraine Prevalence %

Age (years)

0 20 30 40 50 60 70 80 1000

5

10

15

20

25

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Adapted from Lipton RB, Stewart WF. Neurology. 1993

MalesMales

FemalesFemales


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31Lipton RB et al. Headache. 1998.

Where Do Migraine Sufferers Seek Medical Care?

Other17%

Primary Care/Internist

67%

Headache Specialty Care

16%

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Migraine Treatments:Acute Treatment

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General Principles of Management

Establish a diagnosisEducate patients about their condition and its treatmentEstablish realistic expectationsEncourage patients to participate in their own management– discuss treatment / medication preferences

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000 34

General Principles of Management (cont.)

Individualize management (stratified care)Treatment choice depends on– attack frequency and severity– presence and degree of disability– associated symptoms– prior response to medications– comorbid and coexistent conditions

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

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Step Care Across Attacks:What Happens to Some Patients…

The migraine patient may “step through” 4 to 6 therapies before

finding one that is effective.

Step 1Step 1

Step 5Step 5Step 4Step 4

Step 3Step 3Step 2Step 2

aspirin

acetaminophen combination

butalbitalcombination

triptan

Office Visit 1

Office Visit 2

isometheptenecombination

Office Visit 3

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Recommendations for Acute Migraine Management

Use Migraine-specific Agents (eg, triptans, ergots, DHE)– as first-line treatment in patients with

moderate or severe headache (stratified care)

– issue: how do we define moderate or severe headache?

– in those who respond poorly to nsaids and combination medications



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Recommendations for Acute Migraine Management

Select a nonoral route of administration for migraine associated with severe nausea or vomitingConsider a self-administered rescue medication for severe migraine that fails to respond to other treatmentsGuard against medication-overuse headache

Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000 38

Acute Medications With EstablishedStatistical and Clinical Benefit (Class A Evidence)

Triptans (Class A)DHE (Class A)Acetaminophen/aspirin + caffeine (Class A; studied in nondisabling attacks)Aspirin/ ibuprofen/naproxen sodium (Class A)Butorphanol Intranasal (Class A)Class-A Evidence = Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielding a consistent pattern of findings.


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Triptans: Treatment ChoicesSumatriptan (Imitrex)– tablet (25, 50, 100 mg)– nasal spray (20 mg)– subcut. injection (6 mg)

Zolmitriptan (Zomig)– tablet (2.5, 5 mg)– orally dissolving tablet– nasal spray (pending)

Naratriptan (Amerge)– tablet (1, 2.5 mg)

Almotriptan (Axert)– tablet (6.25, 12 mg)

Rizatriptan (Maxalt)– tablet (5, 10 mg)– orally dissolving tablet

Frovatriptan (Frova)– tablet (2.5 mg)

Eletriptan (Relpax)– tablet (20, 40 mg)

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Other Acute therapies

Antiemetics (chlorpromazine, metoclopramide, prochlorperazine)Opiates IM, IVIsomethepteneCorticosteroids IVO2VPA IV

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Migraine Treatments:

Preventive Treatment

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Preventive or Preemptive Treatment

Episodic– for known trigger such as exercise

or sexual activity– pretreat just prior to exposure or activity

Subacute (short term)– for time-limited exposure such as

menstruation– medicate before and during exposure

Chronic– for ongoing susceptibility– medicate on regular basis


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Preventive or Preemptive Treatment (cont.)

Most current recommendations focus on number of attacks that occur each monthMust also consider – patient’s response to acute medication– patient’s needs or preferences– attack characteristics

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Consider Preventive Medication For:Recurring migraine that is disabling to the patient despite acute treatmentFrequent attacks (>2/week) thereby increasing the risk of acute medication overuseProblems with acute medications (ineffective, contraindicated, troublesome AEs, or overused) Patient preference Presence of uncommon migraine conditions

– Hemiplegic Migraine– Migraine with Prolonged Aura– Basilar Migraine– Migrainous Infarction

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Preventive Medication Groups

Anticonvulsants– Valproate– Gabapentin– Topiramate

Antidepressants– TCAs– SSRIs– MAOIs

ß-adrenergic blockers – Propranolol

Calcium channel antagonists – Verapamil

Serotonin antagonists– Methysergide

Others – NSAIDs– Riboflavin– Magnesium

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Preventive Drug TreatmentAvoid interfering, overused, and contraindicated drugsIn case of failure, consider overused medications: analgesics, opioids, triptans, or ergotInterfering medications: sex hormones– oral contraceptives– hormone replacement therapy

Contraindicated vasodilating drugs– Nifedipine or nitroglycerine

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Drug TreatmentAssess Coexisting ConditionsSelect drug to treat both disordersDo not treat migraine with drug contraindicated for other conditionDo not use drug for other condition that exacerbates migraine Beware of drug interactionsSpecial care needed for women of child-bearing potential

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Medication Overuse and Rebound80% patients with CDHPrimary headache type– migraine 65%– TTH 27%– other (cluster) 8%

Female > male (3.5:1)Dosage and time to rebound unknownGeneral considerations:– simple analgesics: > 5 days / week– triptans / combination analgesics: > 3 days / week– opioids / ergotamine: > 2 days / week

Adapted from Soloman S, et. al. Headache 1992Adapted from Diener C & Dahlof K. The Headaches 2000

Adapted from Mathew NT. Neurol Clin 1990


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Nonpharmacologic Therapies

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Candidates for Nonpharmacologic Therapy

Patient’s preferencePoor tolerance to drug therapyContraindications to drug therapyInsufficient response to medication alonePregnancyAcute medication overuseHigh stress


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Relaxation Techniques

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Nonpharmacologic Therapies Tested in Clinical Trials

Behavioral TreatmentsRelaxation training*– hypnotherapy– thermal biofeedback

training*– electromyographic

biofeedback therapy*– cognitive / behavioral

management therapy*

Physical Treatments– acupuncture– transcutaneous

electrical nerve stimulation (tens)

– occlusal adjustment– cervical manipulation

*Proven effective in clinical trials


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Principles of Management When Using Nonpharmacologic Therapies

Involve patient in management planManage patient expectations on when and how much improvement Coordinate treatment plan with other health care providers and the patient


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Migraine Management Slide Kit File Date: 10/30/01 · Migraine Management Slide Kit File Date: 10/30/01 1 1 Improving Care for Migraine Patients Alan R. Towne, MD VCU School of Medicine