4/12/2018. ECHO Ontario Chronic Pain Migraine. Migraine Definition and Epidemiology. Migraine - Undertreatment. Migraine - Diagnostic Classification

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1 Andrew J Smith, MDCM ECHO Ontario Chronic Pain Migraine Staff Physician, Neurology, Pain and Addiction Medicine Centre for Addiction and Mental Health Migraine Learning Objectives At the end of this session, participants will be able: 1. To have an overall approach to the assessment and management of headaches 2. To diagnose migraine 3. To outline an approach to treating migraines 4. Be familiar with headache guidelines Migraine Definition and Epidemiology A chronic neurological disorder characterized by attacks of moderate or severe headache and reversible neurological and systemic symptoms WHO: Migraine = 3 rd most prevalent medical condition 1-year prevalence: 12% (18% women/ 6% men) Migraine affects ~ 10% of school aged children Most prevalent from yrs old, then drops off But can occur earlier and later Infantile colic = earliest manifestation of migraine Disabling to inidividuals, families and societies ($20B/year in US; 113 M work-days) Migraine - Undertreatment Only 41% of people with chronic migraines consult a clinician Only 25% of these receive accurate diagnosis Less than 50% of these are prescribed acute or preventive treatment 4% of people with chronic migraines receive appropriate treatment Dodick DW et al. Lancet 2018; 391: Headache Diagnosis and Classification ICHD -3 (2018) A. Primary Headaches B. Secondary Headaches rule out red flags C. Painful Cranial Neuropathies, Other Facial Pains and Other Headaches Does the patient have a primary of secondary headache? Good history and physical examination is usually sufficient to make Dx Migraine - Diagnostic Classification 1.1 Migraine without aura 1.2 Migraine with aura Migraine with typical aura Migraine with brainstem aura Hemiplegic migraine Retinal migraine 1.3 Chronic migraine 1

2 Migraine - Diagnostic Classification 1.4 Complications of migraine Status migrainosus Persistent aura without infarction Migrainous infarction Migraine aura-triggered seizure 1.5 Probable migraine 1.6 Episodic syndromes that may be associated with migraine Recurrent gastrointestinal disturbance Cyclic vomiting syndrome Abdominal migraine Benign paroxysmal vertigo Benign paroxysmal torticollis Migraine without aura ICHD 3 A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated) C. Headache has 2 of the following characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs) D. During headache 1 of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis Headache Red Flags Chance of finding a lesion? US headache consortium meta-analysis of patient with migraine and normal exam: 0.018% rate of significant pathology (for migraine) 0.00% for TTH AAN Quality Standard Subcommittee (2008) 1. Avoid testing if there will be no change in management 2. Avoid testing if chance of finding abnormality is not greater than in the general population 3. Use individual judgement for individual patients 4. Neuroimaging usually NOT WARRANTED with migraine and normal examination AAN Cephalalgia 2005;25: Neurology 1994;44: Not a Tumor, But What s That? Incidentalomas on MRI Scans of Migraineurs Subcortical White Matter Lesions: 6-40% Developmental venous anomalies: 5-10% Cerebral aneurysms 1-5% (vs 2.4% found incidentally at autopsy) Cavernous malformations % Chiari 1 malformations % Imaging Begets Imaging 2

3 Headache Diagnosis - History 1. How many different headache types does the patient experience? 2. Time questions a. Why consulting now? b. How recent in onset? c. How frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting) ie days per week or per month d. Duration? 3. Character questions a. Intensity of pain b. Nature and quality of pain c. Site and spread of pain d. Associated symptoms For the patient presenting with headache for the first time or with a significant change in headache pattern, the headache history should include this information Headache Diagnosis - History 4. Cause and Co-Morbidity questions a. Predisposing and/or trigger factors b. Aggravating and/or relieving factors c. Family history of similar headache d. Co-existing? Insomnia, depression, anxiety, HTN, asthma, h/o heart disease or stroke 5. Response questions a. What does the patient do during the headache? b. How much is activity (function) limited or prevented? c. What medication has been and is used, and in what manner 6. State of health between attacks a. Completely well, or residual or persisting symptoms? b. Concerns, anxieties, fears about recurrent attacks, and/or their cause Headache Diagnostic Approach :HISTORY Onset Stable h/a of long duration ALMOST ALWAYS BENIGN Migraines often begin in childhood, adolescence or early adulthood Recent-onset = MORE WORRISOME Worst-ever, increasing severity; change for the worst in existing h/a all raise possibility of intracranial lesion Headache Diagnostic Approach :HISTORY Onset Instantanous ICH (usu subarachnoid) Venous thrombosis Arterial dissection Pituitary apoplexy Spontaneous intracranial hypotension Benign angiopathy of the CNS Acute hypertensive crisis Idiopathic thunderclap h/a Older than 50 yo Intracranial lesion (e.g., subdural) GCA Headache Diagnostic Approach :HISTORY Time of Day and Precipitating Factors Migraines can occur any time, but often in AM H/A of recent onset that disturbs sleep or is worse on awakening, may be cause by increased ICP TTH: present much of the day, often worsen as day goes on Obstructive sleep apnea h/a on awakening Medication overuse h/a h/a on awakening Headache Diagnostic Approach :HISTORY Time of Day and Precipitating Factors Migraine triggers Bright light Menstruation Weather changes Caffeine withdrawal Fasting Alcohol (esp beer and wine) Sleeping more or less than usual Stress and release from stress Foods, food additives Perfume Smoke 3

4 Migraine Clinical Overview Premonitory phase begins hours to days before onset of pain Psychological (depression, euphoria, irritability) Arousal (drowsiness) Somatic (yawning, constipation, diarrhea, food cravings, hunger, fluid retention, increased urination) Cranial parasympathetic (lacrimation) Aura Headache phase Postdromal phase Occurs in about 80% of px usally lasts less than 12h (but can last >24h in ~12%) Most common sx: fatigue, impaired concentration, photophobia, irritability, nasuea Low threshold for recurrent, brief head pain with Valsalva or head movement Aura Aura = focal, reversible cerebral symptoms assoc with a migraine attack Occur in ~ 1/3 of patients with migraines Usu last minutes (but can last an hour) usu precede headache Visual sx most common (90%) Positive: flickering lights, spots, lines Negative: scotomas, visual field loss Other: Paresthesias (tingling, numbness) Expressive dysphasias are least common Aura sx usually gradual onset and increase over minutes Can experience mig aura without h/a Pos sx, slow spread of symptoms and staggered onsets help differentiate migraine aura from cardiovascular sx Migraine Headache Phase Dodick DW et al. Lancet 2018; 391: Silberstein SD. Headache 1995; 35: Unilateral (60%), throbbing (50%), aggravated by movement/activity (90%) Can change sides during and between attacks Mean time to peak: 1 hr Median duration: 24 hrs (range: 4-72h in adults; 2-48h in children) Can involve any part of the head, commonly posterior cervical and trap areas 75% of pts have neck pain along with migraine episode Sinus pain in 40% of migraineurs!!**!! Photophobia: 94% / Phonophobia: 91% /Nausea 50% / Emesis 35% / Diarrhea 16% Cutaneous allodynia: 70% (may predict suboptimal triptan response and risk for progression to chronic migraine Clinical Diagnosis Canadian HA Guidelines Migraine without aura (migraine with aura if an aura is present) if they have at least two of: 1. Nausea during the attack 2. Light sensitivity during the attack 3. Some of the attacks interfere with their activities Clinical Diagnosis Chronic migraine if headaches meet migraine diagnostic criteria or are quickly aborted by migraine specific medications (triptans or ergots) on 8 days a month or more Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 days a month or more; or uses plain acetaminophen or NSAIDs on 15 days a month or more. Patients with headache on 15 or more days per month for more than 3 months and with a normal neurological examination 4

5 Headache Diagnosis Physical Examination Screening Neurological Exam Patients presenting to a healthcare provider for the first time with headache, or with a headache that differs from their usual headache, should have a physical examination that includes the following: 1) A screening neurological examination 2) A neck examination 3) A blood pressure measurement 4) A focused neurological examination, if indicated; and 5) An examination for temporomandibular disorders, if indicated 1. General assessment of mental status 2. Cranial nerve examination: fundoscopy, examination of pupils for symmetry and reaction to light, eye movements, visual fields, facial movement for asymmetry or weakness 3. Assessment of all 4 limbs for unilateral weakness, reflex asymmetry, and evaluation of coordination in the upper limbs 4. Assessment of gait, including heel-toe walking (tandem gait) Examination Pearls VS: BP; T r/o infection Habitus: young, obese women Pseudotumour (IIH) Thickened, irreg temporal aa with reduced pulse GCA Scalp tender in mig and TTH Short neck or low hairline basilar invagination or Chiari malformation Infant bulging fontanelles increased ICP OCP IN KIDS Examine cervical spine r/o meningeal signs, nucchal rigidity Migraine Pathophysiology 1. Triggers of an attack initiate a cortical depolarizing neuroelectric and metabolic event; termed cortical spreading depression Posterior to anterior 3 mm/sec 2. This activates mechanisms of pain (unknown exactly how) 3. Trigeminovascular system releases neuropeptides: CGRP Neurokinin A Substance P VIP Vasodilatation Activates trigeminal nociceptors Migraine Pathophysiology 4. Headache occurs from activation of the gasserian ganglion 5. Central sensitization and cephalic allodynia secondary to activation of the trigeminal nucleus caudalis (also C1-C2 dorsal horns) 6. Extracephalic allodynia secondary to activation of central pain modulating centers and ipsilateral thalamus Pathophysiology of Migraine Abnormal modulation of excitability rather than general hypo- or hyperexcitability could be the main factor underlying migraine attacks 5

6 Comprehensive Migraine Management Pay attention to lifestyle and specific migraine triggers in order to reduce the frequency of attacks. Lifestyle factors to avoid include the following: irregular or skipped meals irregular or too little sleep a stressful lifestyle excessive caffeine consumption lack of exercise obesity Use acute pharmacologic therapy for individual attacks Use prophylactic pharmacologic therapy, when indicated, to reduce attack frequency Use nonpharmacologic therapies Evaluate and treat coexistent medical and psychiatric disorders Encourage patients to participate actively in their treatment and to employ self-management principles: Migraine Self-Management Self-monitoring to identify factors influencing migraine Managing migraine triggers effectively Pacing activity to avoid triggering or exacerbating migraine Maintaining a lifestyle that does not worsen migraine Practising relaxation techniques Maintaining good sleep hygiene Developing stress management skills Using cognitive restructuring to avoid catastrophic or negative thinking Improving communication skills to talk effectively about pain with family and others Using acute and prophylactic medication appropriately Types of Migraine Treatment Acute (Taken during an attack) Treat attacks effectively, rapidly and consistently Minimize adverse events Restore the patient s ability to function Preventive Taken daily for months to years Reduces frequency, severity, and duration Used in addition to acute treatments Migraine Acute Treatment Strategies 1. Review past treatments successes, failures (what does that mean?) 2. NB: Attack frequency: INCREASED RISK OF MEDICATION OVERUSE HA 3. Consider entire spectrum of migraine syndrome (eg. Nausea, emesis, disability) 4. TREAT ALL ASPECTS: Pain and Associated Sx 5. Specifically ask about DISABILITY 6. Consider comorbidies 7. Understand what It doesn t work means assessing unmet treatment needs (M-TOQ). Acute Treatment Principles Treat attacks rapidly and consistently Acute Treatment Principles Back-up/rescue if initial treatment fails First physician recommendation may not be effective. Educate patient of the need to follow-up and that there are other options Tailor treatment to the patient and the sx (Stratified approach) Non-specific meds for mild-moderate sx NSAIDS, etc Specific meds for more severe attacks, or those that don t respond triptans, DHE Eg. If nausea/vomiting / gastroparesis avoid oral route, consider antiemetics Oral disintegrating tabs good for px with mild nausea in whom water would exacerbate Non-specific meds for mild-moderate sx NSAIDS, etc Two or more acute meds can be combined if necessary Sumatriptan + naproxen Antiemetic + NSAID +/- triptan Minimize adverse events and cost Limit to 3 days per week or less NO BUTALBITAL/OPIOIDS lead to medication overuse 6

7 Acute Treatment: Non-Pharm TOO! Planting the SEEDS of Recovery Acute Treatment - Triptans Sleep Exercise Eating (caffeine, hydration, meals, etc) Diary Stress Also: CBT, mindfulness TMS Supraorbital n stimulator (Cefaly) Non-invasive vagal n stimulator (nvns) Reasonable first choice for patients with moderate to severe disability from migraines Limit use to 2-3 days per week Patients who fail one triptan often respond to another Do not use one triptan within 24 hours of another Acute Treatment - Triptans Acute Treatment - Triptans Mechanism of action 5HT-1B/1D agonists Inhibit release of CGRP & substance P Inhibit activation of the trigeminal nerve Inhibit vasodilation in the meninges Johnston et al Drugs 2010 Loder NEJM 2010 Precautions Ischemic heart dz or stroke High risk for CAD Pregnancy Hemiplegic or basilar migraine Ergots Use w/ SSRIs? Fast onset/short duration Sumatriptan Rizatriptan Zomitriptan Almotriptan Eletriptan Treximet (Suma + Naproxen) Slow onset/long duration Naratriptan Frovatriptan NSAIDs Antiemetics Prevent and treat nausea Improve GI motility Enhance absorption of other anti-migraine medications Limited RCT to support their use in migraine 7

8 Status Migranosus: ER Options Sumatriptan 4-6 sc Antiemetics + DHE iv Neuroleptics Ketorolac 30-60mg im helpful for cutaneous allodynia if not complicated by opioid use MgSO4 1-2g iv limited evidence but better for Mig with aura VPA mg iv Corticosteroids Migraine: Why Treatment Fails Wrong diagnosis Wrong medication or subtherapeutic dose Premature discontinuation Raising dose too quickly Failure to recognize full spectrum of symptoms of exacerbating factors Eg GI symptoms tablets less effective (zolmatriptan nasal; sumatriptan injectible) Failure to recognize comorbidites (NB MOOD DISORDERS) MOU (nb caffeine) Unrecognized triggers Migraine Acute Treatment: Unmet Needs Domain Yes or No Questions Response Functional response Are you able to quickly return to your normal activities after taking your migraine medication? Consistency and Onset Can you count on your migraine medication to relieve your pain within 2 hours for most attacks? Recurrence Does one dose of your migraine medication usually relieve your headache and keep it away for at least 24 hours? Side Effects Is your migraine medication well tolerated? Global Are you comfortable enough to be able to plan your daily activities? 2 or more unmet needs: CHANGE MEDICATION Lipton et al. Cephalalgia 29: 751-9, 2009 Indications for a Preventive Agent Migraine-related disability > 3d/month Migraines last over 48 hours Migraines cause profound disability or prolonged aura (hemiplegic migraine, migraine with brainstem aura) Acute treatments are contraindicated, ineffective, or overused > 10 days per month: Triptans, Ergotamines, Opioids, Combination > 15 days per month: acetaminophen, NSAIDs Patient preference Goal: Reduce migraine attack frequency and HA related disability EFFECTIVE TREATMENT = REDUCE ATTACK FREQUENCY BY 50% or MORE Use MIDAS or HIT-6 Standard measurements of HA disability Pharmacological Prophylaxis for Migraine Pharmacological Prophylaxis for Migraine Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage Realistic expectations of prophylaxis: -Headache attacks will likely not be abolished completely -A reduction in headache frequency of 50% = success -~4-8 wk for substantial benefit to occur If the prophylactic drug provides substantial benefit in the first 2 mo of therapy, this benefit might increase further over several additional months of therapy Evaluate the effectiveness of therapy using patient diaries that record headache frequency, drug use, and disability levels For most prophylactic drugs, start low and go slow (eg topiramate 15mg q 2-4 weeks Increase the dose until the drug proves effective, until dose- limiting side effects occur, or until a target dose is reached Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6-8 wk after dose titration is completed Because migraine attack tendency fluctuates over time, consider gradual discontinuation of the drug for many patients after 6 to 12 mo of successful prophylactic therapy, but preventive medications can be continued for much longer in patients who have experienced substantial migraine-related disability Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. A national clinical guideline. Publication no Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; Available from: guidelines/fulltext/107/index.html. 8

9 Risk Factors for Chronification: Some Modifiable Female Depression / Anxiety Excessive caffeine use Sleep disorders Obesity Other pain conditions Baseline headache frequency Traumatic Brain Injury (especially mtbi) Medication overuse Low Education Low Socioecononic Stressful life events Approach to Chronic Migraine Botulinum Toxin Acute Discontinue overused medication abruptly Taper opioids/butalbital; consider clonidine, phenobarbital Transitional Daily use for 2-4 week to manage and attenuate severity of w/d Use other non-overused meds eg NSAIDs, DHE, Corticosteroids Consider nerve blocks Prevention Efficacy Botulinum Toxin superior to placebo in 2 large, double blind, randomized, controlled trials Botulinum Toxin similar to topiramate and amitriptyline in small, shorter duration studies Botulinum toxin = placebo for episodic migraine Side effects = muscle weakness, injection site pain, and spread of toxin effect Mechanism of Action; Blocks release of Substance P and CGRP Inhibits peripheral signals to CNS and blocks central sensitization Migraines in 5 Minutes Rule out red flags and indicators of secondary headaches --> quick history Does the headache interfere with activity; associated with light sensitivity; interfere with activities: 2/3 MIGRAINE What tends to trigger these headaches? What do you take to treat them? How many days per month Self-management Screening neuro exam NO IMAGING unless red flag or abnormal neuro exam 9