Faculty/Presenter Disclosure

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1 Headache Pathway Overview How can I help my migraine patient? Dr Elizabeth Leroux, MD, FRCPC Headache Program University of Calgary Banff 2018 Faculty/Presenter Disclosure Faculty/Presenter: Dr. Elizabeth Leroux Relationships with commercial interests: Grants/Research Support: Not Applicable Speakers Bureau/Honoraria: Allergan, Eli Lilly, Teva, Novartis, Amgen, Aralez Consulting Fees: Not applicable Other: This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses. 1

2 ACFP 63 rd ASA Disclosure of Commercial Support This program has received financial support in the form of sponsorship from: Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the 63rd ASA Program and on the Salon A/B slide scroll. Mitigating Potential Bias ACFP: The ACFP s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of Family Physicians of Canada s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities. ASA Planning Committee: Consideration was given by the 63 rd ASA Planning Committee to identify when Planning Committee members and speakers personal or professional interests may compete with or have actual, potential, or apparent influence over program content. Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program s needs assessment and subsequent content development to ensure accuracy and fair balance. The 63 rd ASA Planning Committee reviewed Sponsorship Agreements to identify any actual, potential or apparent influence over the program. Information/recommendations in the program are evidence and/or guidelines based, and opinions of the independent speakers will be identified as such. 2

3 Objectives Present the new Headache Pathway For each step of the pathway, present a clinical pearl and resources Leroux.neuro@gmail.com 10 steps of the Migraine Pathway 1 Detail the type of migraine 2 Identify and manage the co morbidities 3 Review the lifestyle and previous therapeutic trials 4 Explain the migraine diagnosis to patient and set up expectations 5 Train the patient to self monitor with a headache diary 6 Plan tailored behavioral interventions 7 Try adapted options for the migraine attack until success is reached 8 Try preventive treatments to reduce frequency of migraine headaches 9 Prevent, detect and withdraw medication overuse 10 Refer to neurology (CAT criteria) 3

4 Diagnosing Headache is tough Is it a secondary headache? Is it migraine? S N O O P P P P SNOOPPP Systemic Neurologic Onset Older Previous Postural Progressive Pregnancy ID MIGRAINE Migraine Disabling 2/3 = Sensory hypersensitivity (light sounds, smells) GI symptoms, nausea, vomiting Very probably migraine What type of migraine is it? Aura Triggers Frequency Severity Migraine phenotype Pattern Symptoms Overuse Disability 4

5 Who is this migraineur? Vascular Stroke, CAD, Raynaud s, POTS, hypertension, low BP OBGYN Dysmenorrhea, contraception, pregnancy, menopause Psychiatric Anxiety, depression, abuse, addiction, PTSD, ADHD, personality disorders Inflammatory Crohn s, arthritis, eczema Migraine & Body Other pain Fibromyalgia, pelvic pain, neck pain, post trauma Neurology Epilepsy, MS Respiratory Asthma, sleep apnea Vestibular Meniere s, BPPV The Migraine Story Childhood Genes (Abuse) Stressors Head trauma Overuse Medical dx Puberty Contraception Pregnancy Menopause Beginning Chronification Current state Treatment Trials, ED Visits, tests, consults Disability, guilt, powerlessness Migraine Identity 5

6 Explain the migraine diagnosis and set up expectations KEY MESSAGES Migraine is a real neurological disease It is common (15% of people, 3d most common disease) It can be disabling (2d most disabling disease of ALL) It varies from one person to the other NO miracle or cure No one size fits all treatment Chronic disease, with phases over life Management is a mix of behavioral, acute therapy and preventive treatments (three pronged) 6

7 Migraine Management: 3 tiered Lifestyle and behavioral Care for your brain Acute treatment Treating individual attacks as they come Preventive treatment Lower attack frequency Other resources and websites American Migraine Foundation Migraine.com Migraine Again My Daily Migraine The Migraine World Summit Migraine Warriors Calgary (Facebook, private) Move Against Migraine (Facebook US) But BEWARE...not everything is good on the web! If you see the word «cure», be careful 14 7

8 Train the patient to self monitor with a headache diary: SKILL #1 The goals of the headache diary are to: Establish the frequency of headaches of different severity Detect patterns and triggers Monitor the frequency of acute medication intake, prevent medication overuse Observe the efficacy of acute medications (attack control success rate) Determine the efficacy of prophylactic treatments (decrease in intensity and frequency of attacks). Some improvement may be subtle at the beginning. The Headache Diary: our favorite tool 8

9 The technique Headache free day Mild Moderate Severe Intensity Pain free! Mild Moderate Severe Accompanying symptoms None May be absent Acute treatment None Maybe not needed Impact on function Present Usually works Prominent May fail None Can work Work slowed Work impossible Baseline: determine location (including neck), aggravating factors, circadian pattern, presence of sensory hypersensitivity, level of tolerability Headache diary: an example T Headache * * Aura V V Period X X X X Number of days for each HA severity Tot Lifestyle E E E E E E E E Tx IBU X X X X X X Tx: ALMO X X X Tx: Zomig X X X Effect acute tx S F S P P F P S S Total number of days with any acute medication intake 9 STABLE Prev Nadolol 80 mg Magnesium 300 mg NEW #1 TPX Notes This person has frequent episodic migraine (12 days per month). There is no medication overuse. One day was associated with missed work. Some attacks are with visual aura. She is exercising, but cannot exercise during bad migraine stretches. The attack during the period is worse and difficult to control. Using only Ibuprofen does not seem to control number 2s. Zomig seems to work better. She does not have clear overuse but she is using close to 10 days per month of acute treatments. This person is already taking 2 preventives, nadolol and magnesium. She is now trying topiramate (TPX). It is still too early to determine if there has been a benefit. If the next 2 months show a frequency of 6 days/month, then TPX would seem effective. 9

10 The brain is bathed in its bodily environment 9 skills for migraine management Sleep Quality Exercise Posture Routine Nutrition and hydration CBT Good medication use HEADACHE SELF MANAGEMENT Pacing Lifestyle Balance Self- Monitoring (Diaries) Relaxation Stress Management Trigger Management 10

11 Plan tailored behavioral interventions Easy Advanced Sleep Basic tips on sleep hygene CBT, sleep clinic Online module Nutrition Regular meals, increase protein, reduce processed and high sugar, limit alcohol Nutrition consult Ketogenic diet FODMAP, gluten free, lactose free Hydration Drink 1 2 l of water per day Avoid before bedtime Caffeine Limit to < 2oo mg/day Stop for 2 months Exercise Regular and moderate Crossfit and HIIT not very good Kinesiology or physio consult Athletes Relaxation Breathing techniques, podcasts, CBT, ACT, full mindfulness training apps Pacing Books, simple advice Occupational Therapy eval Do you need help to educate your patients? If you think that it would be helpful for your patients to have access to educational sessions on migraine... Please me at leroux.neuro@gmail.com with the title «Help needed for migraine» 11

12 Acute treatment: notes on triptans Patients vary in their response (efficacy and side effects) Try many before diagnosing «triptan nonresponder» Monotherapy with SSRI is NOT a contraindication Sulfa allergy is NOT a contra indication Raynaud is NOT a contra indication 12

13 The treat early principle Many people delay treatment «it s not a migraine» Financial «save the triptan dose» Fear of side effects Treating early = more success Be careful IF frequency is over 10/month Use a diary to monitor as needed Refer to our Migraine Canada You Tube videos Try adapted options for the migraine attack until success is reached If monotherapy fails, then combination is warranted. Many patients have 2 types of attacks and may need to tailor their treatment. Attacks difficult to control include: Fast rising attacks Attacks starting during sleep or upon awakening Attack with prominent nausea or vomiting Attacks occurring during the menstrual period If attacks are difficult to control, consider the following approaches: Combinations (NSAID + triptan taken early together) Use of adjunct therapy (anti emetics) Use of parenterals (nasal sprays, suppositories, injectors) Start prophylaxis (may increase efficacy of acute treatments) 13

14 My favorite options for tough attacks Cambia (diclofenac powder 50 mg) Injectable ketorolac 30 mg (should be IM but SC works) Indomethacine suppositories Zomig nasal spray 5 mg Injectable sumatriptan 6 mg Watch our teaching videos! 14

15 Try preventive treatments to reduce frequency of migraine headaches Consider if > 6 days/month Choose according to comorbidity profile Use a headache diary 50% chance of success Side effects are a problem Increase dose (1 month), keep and observe (2 months) If successful, keep for 1 year, then reassess Prevent, detect and withdraw medication overuse DO NOT PRESCRIBE NARCOTICS Use a headache diary Some patients chronify for other reasons Stratify the subtype of patient Type 1 = easy: recent overuse, no psych, no narcotics Type 2 = difficult: long history, previous attempt, narcotics, psych problems, addiction Start a preventive Improvement will be partial in most 10 30% will not stop or not improve 15

16 Indications for onabotulinum Type A Chronic migraine (and post traumatic) Failed 2 3 preventives 2 3 cycles to observe response Success rate isstill 50% Excellent tolerability Injector Network Refer to neurology (CAT criteria) Enough information on the headache type Cluster headache will be expedited No urgent secondary headache is seen at CHAMP Detail migraine type and previous trial Failed at least 2 triptans Failed at least 2 preventives Be clear if post traumatic Mention narcotic use 16

17 CGRP and migraine Why should we block it? will it cure migraine? Results of the CGRP antibody trials Once per month injection, probably at home Mechanism of action is specific to migraine AS effective as existing preventives Some people respond very well 75% less migraine in 30% of patients Much better tolerated, almost no side effects Effect is seen faster (as early as 1 week!) Safety: so far no alarming vascular signal Cost is likely to be high (access challenge) 17

18 Conclusions We want to help you to manage migraine Questions? 18