Strategies in Migraine Care

Transcription

1 Strategies in Migraine Care Julie L. Roth, MD Rhode Island Hospital Assistant Professor, Neurology The Warren Alpert Medical School of Brown University March 28, 2015 Financial Disclosures None. Objectives Review migraine clinical features, as well as links to other comorbid conditions Outline principals of treatment, both pharmacological and non-pharmacological, as well as abortive and prophylactic. Briefly discuss several women s health issues related to migraine All, in 20 minutes or less. 1

2 Migraine facts Extremely prevalent, for a neurological disorder Affects about 6-7% men and 16% of women Probably underdiagnosed And often misdiagnosed Sinusitis and sinus disease, allergies, dental, eye, hormones In neurology: stroke, seizures, neuropathy Features Often but not always Pain is throbbing Unilateral Gradual onset Lasting hours to all day Sensitivities to surroundings Light, sound Smells, motion Nausea Worse with exertion, bending over, head movement Relieved by lying in a dark room Aura can occur in 10-20% migraines Visual more common than sensory Motor, language, spatial misperceptions Vertigo, coordination and gait abnormalities, complex symptoms Migraine: a Neurovascular Disorder 2

3 Migraine Comorbidities are Numerous Comorbid with: Depression, bipolar, anxiety, panic d/o, suicidality Epilepsy Chronic pain conditions (fibromyalgia) Vasovagal syncope Gluten intolerance/celiac disease Restless leg syndrome Asthma Obesity Stroke Cardiovascular disease Seen in genetic conditions (mitochondria, ion channel disorders, CADASIL) 3

4 Acute Treatment: Before selecting a drug, be aware of time to peak Time to peak Principles of treatment: ACUTE NSAIDS (like ibuprofen) and other analgesics, triptans (serotonin receptor agonists), ergotamines are first line Cocktail, acetaminophen and opiate meds NOT first line; rebound Fast time to peak (<60min) demands a fast-acting triptan Sumatriptan, zolmitriptan, rizatriptan Migraine that builds slowly, lasts > 24 hrs, or returns after med wears off: longer acting Naratriptan, frovatriptan Can also be used for predictable migraines (perimenstrual) Triptans can be mixed with NSAIDs, antiemetics, acetaminophen Theoretical risk with antidepressants 5HT syndrome For those who cannot use triptans, ergots Vascular disease, heart disease, stroke, allergy or adverse reactions Avoid rebound headache (<3 headache days/week) -FREQUENCY (>1 HA day/wk) -COMORBIDITIES -INDIVIDUAL RISK to pt -COST 4

5 Principles of treatment: PREVENTION First line: AEDs: Topiramate (A), Valproic acid* (A) Antidepressants: Amitriptyline (B), Venlafaxine (A) Blood pressure meds: Propranolol (A), metoprolol (A) Second line: AEDs: Gabapentin (U), carbamazepine (C) Antidepressants: Duloxetine (U), Nortriptyline (U), Imipramine (U), Desipramine (U) Blood pressure meds: nadolol (B), atenolol (B), verapamil (U), lisinopril (C), candesartan (C) NSAIDs: ASA/daily (U though used in Europe) Drugs in development: antibodies to CGRP, others -PATIENT DOES NOT WANT TO GO ON Preventative DAILY therapy Rx -PATIENT FAILED Rx -ADJUNCTIVE TO Rx Behavioral Treatment of the sensory (pain, sensitivities) and affective (mood changes, anxiety) aspects of headache Level A evidence for migraine prevention: cognitive behavioral therapy [CBT], relaxation training, biofeedback, and stress management. Obesity comorbid with migraine weight loss study (RCT) WHAM, we are recruiting!! 5

6 Behavioral Identify triggers Meals, sleep habits, stress, caffeine, other substances, hormones. Less likely to have specific food triggers Avoid changes in routine Headache diary smartphone app Helps patient more than doctor to identify patterns Supplements Also in the AAN guidelines supplements can help prevent migraine Butterbur (petasites) (A)* Riboflavin (B) Magnesium (B) Feverfew (B) Level C evidence: Co-Q10, estrogen Cyproheptadine **BUTTERBUR case reports of liver failure, pulled from the market in Europe U.S. next? : -Triptans -NSAIDs.adjunctive treatments (antiemetics, cocktail meds when used responsibly) : -Beta blockers (and ca++ channel bl.) -Anticonvulsants -Antidepressants (SNRIs, TCAs) -Botulinum toxin (chemodenervation) -Other injections : -Lying in a dark room -Ice -Avoid stimuli. Biofeedback, behavioral techniques : -Behavioral techniques -Supplements.other complementary treatments -Electrical or other stimulation 6

7 Other Ways to Prevent and Treat Migraines Botulinum toxin (chemodenervation)» Other injections in development Electrical and magnetic stimulation devices» VNS, Vestibular stimulator in development Cefaly SpringTMS Women s Health and Migraines Hormones ACOG recommendation: women who have migraine w/aura are at greater risk for stroke if they use estrogen- OCPs Age, smoking, candid discussion Childbearing Most migraines improve in pregnancy Some link with hypertensive disorders of pregnancy/pec Split between meds safe in pregnancy and effective for migraine, especially with daily ppx 7