Prevent, Treat, Repeat: Getting Ahead of Migraines. Jennifer Bestard MD FRCPC Neurology

Transcription

1 Prevent, Treat, Repeat: Getting Ahead of Migraines Jennifer Bestard MD FRCPC Neurology

2 Faculty/Presenter Disclosure Presenter: Jennifer Bestard Relationships that may introduce potential bias and/or conflict of interest: Grants/Research Support: Jennifer Bestard has received grants from Allergan and Tribute to provide CME lectures on headache. Speakers Bureau/Honoraria: Jennifer Bestard has received a speaker fee and expense support from the Alberta College of Family Physicians; Jennifer Bestard has received honoraria from Allergan and Tribute to provide CME lectures on headache. Consulting Fees: N/A Other: N/A

3 Disclosure of Commercial Support This program is presented by the Alberta College of Family Physicians (ACFP) without any commercial or in-kind support. The ACFP provides a speaker fee and expense support for presenting at the Practical Evidence for Informed Practice. Potential for bias/conflict of interest due to commercial support: Jennifer Bestard has received grants and/or honoraria for presenting CME relating to a topic being discussed in this program and/or presentation.

4 Managing Sources of Potential Conflict and/or Bias Material/Learning Objectives and/or session descriptions were developed and reviewed by the Planning Committee composed of experts/family physicians/allied care professionals responsible for overseeing the program s needs assessment and subsequent content development to ensure accuracy and fair balance. Consideration was given by the Planning Committee to identify when speakers personal or professional interests may compete with or have actual, potential, or apparent influence over their presentations. Information and/or recommendations in the program are evidenceand/or guidelines-based, and the opinions of the independent speakers will be identified as such.

5 Presentation Outline Migraine backgrounder: Assessment, diagnosis and identification of migraine Treatment options for acute migraine Pharmacologic and non-pharmacologic When should prevention be started? 15 or more headache days per month

6 Steps to Diagnosing Headache Disorders Diagnostic Presentation & Classification of Chronic HA Courtesy of The American Headache Society

7 Case Vignette (Sara) Initial Consult 25-year-old female who presents to her primary care doctor with a four year history of headache Frequency Two attacks per month Prodrome Dysphoric mood Aura Zig-zag lines and a graying of vision in a visual field Pain Unilateral (R>L) throbbing severe pain lasting 24 hours untreated Symptoms Nausea, photophobia, unable to function Treatment Excedrin Migraine up to six per day Exam WNL (within normal limits) Diagnosis?

8 Primary or Secondary Headache? Step 1 Detailed History and Examination Red Flags? No Diagnose Primary Headache Disorder Yes Evaluate for Secondary Headache

9 Red Flags in Headache: SNOOP S N O O Systemic signs or symptoms Fever, weight loss, malignancy, HIV, meningismus, pregnancy Neurologic signs or symptoms Papilledema, hemiparesis, hemisensory loss, diplopia, dysarthria Onset Worst headache of life (thunderclap) Older New headache at age 50 P Progression of existing headache disorder Change in quality, frequency, or location 13. Dodick DW. Adv Stud Med 2003;3:S550-S555.

10 Sara has a Primary Headache Disorder Step 2 Categorize Primary Headache Disorder Sara has no headache alarms Four year history, lack of alarms and normal exam, additional work-up is not necessary

11 Categorize Into One of Three Groups Step 2 Primary Headaches Assess frequency and duration for each headache type Divide into headache syndromes Short Duration < 4hr duration Episodic (Long Duration) 4hr duration 15 days/month Chronic Daily Headache 4hr duration 15 days/month

12 Diagnose the Specific Disorder Within the Category Step 3 Differential Diagnosis Migraine vs. tension type headache Tension type headache is the most common primary headache Migraine is the leading headache disorder that causes patients to seek treatment

13 Diagnostic Criteria Migraine without Aura: A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hr 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 (e.g., walking, climbing stairs) D. During headache 1 of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not attributed to another disorder 22. International Headache Society,2 nd edition. Cephalalgia 2004;24 Suppl 1: Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy (New York, NY: Springer), 2011.

14 Sara has Classic Migraine Migraine with Aura Complex array of symptoms reflecting focal cortical or brainstem dysfunction Gradual evolution: 5-20 minutes (<60 minutes) May or may not be associated with headache Visual > sensory >, language, brainstem >motor*

15 Diagnosed Migraine: Tip of the Iceberg Males Females Diagnosed 29% 41% Undiagnosed 71% 59% 31. Lipton RB et al. Arch Intern Med 1992;152(6):

16 Migraine: Additional Features Predictable timing around menstruation or ovulation Stereotypical prodromal symptoms Characteristic triggers Abatement with sleep Positive family history Childhood precursors (motion sickness, episodic vomiting/vertigo) Osmophobia 36. Pryse-Phillips WEM et al. Can Med Assoc J 1997; 156(9):

17 Three-Item ID Migraine Screener * During the last three months, did you have any of the following with your headaches: Item You felt nauseated or sick to your stomach when you had a headache? Light bothered you (a lot more than when you don t have headaches?) Your headaches limited your ability to work, study or do what you need to do for at least one day? Yes / No Yes No Yes No Yes No * An affirmative response on 2 of 3 questions yields a sensitivity and specificity of 81% and 75%, respectively. 28. Lipton RB et al. Neurology 2003;61(3):

18 Migraine: A Common Episodic Headache Disorder Neurologic disorder Strong genetic component (up to 50%) Global prevalence: >10% Women: 15% 17% Men: 6% 9% Two major subtypes Without aura (~75%) With aura (~25%) Burden Among the world s 20 most disabling diseases (WHO) Affects 3 million women and 1 million men in Canada An Angus Reid poll suggests that the cost of migraine in the workplace is approximately $500 million annually 35. Pietrobon D. Neuroscientist. 2005;11(4): Stovner LJ et al. Cephalalgia. 2007;27(3): Linde M. Acta Neurol Scand. 2006;114(2): ICHD. Cephalalgia. 2004;24 Suppl 1: Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), Hu XH. et al Arch Intern Med. 1999;159(8):

19 Percent Prevalence of Migraine and Tension-type Headache in Various Settings Population Waiting Room Migraine Tension-Type Headache 28. Lipton RB et al. Neurology 2003;61(3):

20 Migraine is Often Misdiagnosed Tension-type Headaches 44% Sinus Headaches 43% Cluster Headaches 18% Inaccurate diagnosis received by migraine patients % MISDIAGNOSIS 27. Lipton RB et al. Headache 2001; 41(7):

21 Tension-Type Headache A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 30 min 7 days (untreated or unsuccessfully treated) C. Headache has 2 of the following characteristics: Bilateral location Pressure non pulsating quality Mild to moderate pain intensity Not aggravated by or causing avoidance of routine physical activity D. During headache 1 of the following: No nausea or vomiting Photophobia or phonophobia but not both E. Not attributed to another disorder Headache Classification Subcommittee of the International Headache Society, 2004

22 Why is Migraine Frequently Mistaken for Sinus Headache? Pain is often located over the sinuses Migraine is frequently triggered by weather changes Tearing and nasal congestion are common during attacks Sinus medication may help migraine

23 The Art and Science of Evaluating and Treating Migraine Planning and Management Strategies

24 Back to Sara What might be your preliminary treatment recommendation for her?

25 Formulate a Specific Treatment Plan Step 4 Specific Treatment Plan Non-pharmacologic approaches Trigger identification and management Identify triggers by history Headache diaries Education and enhance self-efficacy Sleep, exercise, diet and caffeine Biofeedback and cognitive behavioural treatment

26 Headache Journal

27 Medication Classes in Acute Migraine Treatment Health Canada-Approved Prescription Medications Triptans 24 naratriptan almotriptan frovatriptan sumatriptan rizatriptan eletriptan zolmitriptan Ergots 24 ergotamine tartrate dihydroergotamine NSAID 9 diclofenac potassium for oral solution (CAMBIA) No other prescription medications have met the criteria for Health Canada approval for treatment of acute migraine Other Medications Used in Migraine Treatment 24 NSAIDs Opioids Barbiturates 24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), CAMBIA Product Monograph. Tribute Pharmaceuticals Canada Ltd. March 9, 2012.

28 Principles of Acute Treatments 1. Stratified care 2. Early intervention 3. Use correct dose and formulation 4. Treat at least two or three attacks before judging acute medications 5. Use a maximum of 2-3 days / week 6. Use preventive therapy in selected patients 38. Silberstein SD. Neurology 2000; Sep 26;55(6): Lipton RB, et al. JAMA 2000;284(20):

29 Acute Management: Migraine Stratified Care Define the needs: clinical judgment Stepped care within attacks: according to immediate effect Low OTC analgesics Moderate Combination OTC Prescription NSAIDS Triptans High Triptans (Ergots) Opioids (rarely)

30 Follow-up Visits Review outcome measures (diaries, MIDAS, etc.) Assess efficacy, adverse effects, and satisfaction with current regimen If treatment is not working, find out why? Consider: Primary failure Effects take to long Poor consistency Recurrence Adverse events Interfering medications Expectations unrealistically high 39. Silberstein SD et al. Wolff s Headache And Other Head Pain, Seventh Edition (New York: Oxford University Press Inc), 2001.

31 Sara Age 35 Working full-time as a social worker Married with 3 kids under age 6 Headache frequency has increased very gradually over the last 3 years Headaches are now occurring about 3-4 days per week Otherwise well, no change in headache characteristics, no new meds

32 Sara Age 35 What is the Diagnosis? How Would You Manage Sara s Headaches?

33 Chronic Migraine Chronic migraine: HA on 15 days/mt for >3 mts 8 days fulfilling criteria for migraine with or without aura, responding to migrainespecific medications, or recognized by patient as migraine Not better accounted for by another ICHD-3 beta diagnosis

34 Preventive Treatment: When? When patient has 15 headache days per month When 4 severe attacks per month poorly controlled with symptomatic medication When symptomatic medication needs to be used more than 2-3 days a week Special situations preclude the use of effective acute medications For how long? 3 month minimum trial If helpful, consider reduction and cessation after months

35 Goals of Chronic Migraine Therapy Reduce (1 or more of): Headache frequency Duration Severity Medication requirements Headache-related disability What to expect? 50% obtain a reduction of 50% in the frequency of attacks in the second or third month of use Monotherapy vs. Polytherapy? Monotherapy preferred but polytherapy may be necessary 16. Gladstone J and Dodick DW. Practical Neurology 2004;4:6-19.

36 Preventive Medications Antidepressants TCAs (i.e. amitriptyline, nortriptyline) Beta blockers Propranolol, Nadolol Anticonvulsants Topiramate Divalproex Gabapentin Calcium channel blockers Verapamil Flunarizine Interventional Botulinum toxin A (BOTOX)? Nerve blocks Miscellaneous Pizotifen (Sandomigran) Angiotensin II receptor antagonist? Natural Options Riboflavin, feverfew, magnesium

37 Overall Summary Clinical Pearls Migraines are the most common headache-type leading to medical attention (occurs in pediatric and adult population). Acute migraine management requires stratified care which may include OTC, NSAIDS and/or triptan and/or anti-emetic. Lifestyle strategies are critical for preventing migraine headaches and patients should be constantly reminded about them. When migraines are too frequent/disabling, consider prophylactic therapy (start low, go slow, and persist). Watch out for medication overuse headache and, when present, aggressively manage.

38 The Art and Science of Evaluating and Treating Migraine THANK YOU

39 ICHD-3 (beta) Definition Medication overuse (MOH)* 15 HA days/mt in a patient with a pre-existing HA disorder Regular overuse for >3 mts of 1 acute meds Not better accounted for by another ICHD-3b diagnosis *Also called transformed migraine, rebound headache CM: Current State of Classification & Diagnosis ICHD: International Classification of Headache Disorders. Headache Classification Committee. Cephalalgia 2013;33:

40 Classification of MOH ICDH-3 Beta Diagnostic Criteria: Fulfills criteria for MOH plus Overuse ( 15 days/mt for >3 months) of: Acetaminophen ASA Other NSAIDs Overuse ( 10 days/mt for >3 months) of: Ergotamines Triptans Opioids Combination analgesics Combinations of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids ICHD: International Classification of Headache Disorders; MOH: medication overuse headache; ASA: acetylsalicylic acid; NSAID: nonsteroidal anti-inflammatory drug Recognition and Diagnosis of MOH Headache Classification Committee. Cephalalgia 2013;33:

41 Screening For MOH BIMOH (Brief Intervention for MOH) Do you think your use of HA medication was out of control? Did the prospect of missing a dose make you anxious or worried? Did you worry about your use of your HA medication? Did you wish you could stop? How difficult would you find it to stop or go without your HA medication?* Cut-off scores for risk of MOH Recognition and Diagnosis of MOH 5 for women 4 for men Scoring 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always 0 = not difficult 1 = quite difficult 2 = very difficult 3 = impossible HA: headache; MOH: medication overuse headache Kristoffersen ES et al. J Neurol Neurosurg Psychiatry 2015;86:

42 Screening for MOH in Primary Care Quick 2-question screen for MOH 1 Do you take a treatment for attacks on 10 days/month? 2 Is this intake on a regular basis? Sensitivity 95.2%, specificity 80% Advantages: Simple Quick Low cost Recognition and Diagnosis of MOH Dousset V et al. J Headache Pain 2013;14:81.

43 Established CM With MOH: Treatment Strategies Wean overused medication(s) Encourage use of non-pharmacological approaches Switch to effective preventive treatment and place limits on acute meds Education MOH: medication overuse headache; CM: chronic migraine Management Strategies Tepper. Neurology Continuum 2012 ;18:

44 Bibliography References: 1. Acute treatment of migraine attacks: efficacy and safety of a nonsteroidal anti-inflammatory drug, diclofenac-potassium, in comparison to oral sumatriptan and placebo. The Diclofenac-K/Sumatriptan Migraine Study Group. Cephalalgia 1999;19(4): Aurora SK, Kori SH, Barrodale P, et al. Gastric stasis in migraine: more than just a paroxysmal abnormality during a migraine attack. Gastric stasis in migraine: more than just a paroxysmal abnormality during a migraine attack. Headache 2006;46(1): Aurora SK, Kori SH, Barrodale P, et al. Gastric stasis occurs in spontaneous, visually induced, and interictal migraine. Headache 2007;47(10): Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8): Boyle R, Behan PO, Sutton JA. A correlation between severity of migraine and delayed gastric emptying measured by an epigastric impedance method. Br J Clin Pharmacol 1990;30(3): Brandes JL, Kudrow D, Stark SR, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA 2007;297(13): Burstein R, Collins B, Bajwa Z, et al. Triptan therapy can abort migraine attacks if given before the establishment or in the absence of cutaneous allodynia and central sensitization: clinical and preclinical evidence. Headache 2002, 42: Burstein R, Yarnitsky D, Goor-Aryeh I, et al. An association between migraine and cutaneous allodynia. Ann Neurol 2000;47(5): Pr CAMBIA. Product Monograph. Tribute Pharmaceuticals Canada Ltd. March 9, Dahlöf C. Integrating the triptans into clinical practice. Curr Opin Neurol 2002;15:

45 Bibliography 11. Data on file, Nautilus Neurosciences. 12. Diener, HC, Montagna, P, Gács G, et al. Efficacy and Tolerability of Diclofenac Potassium Sachets in Migraine: A Randomized, Double-Blind,Cross-Over Study in Comparison with Diclofenac Potassium Tablets and Placebo. Cephalalgia 2006;26(5): Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:S550-S Dodick DW, Capobianco DJ. Treatment and management of cluster headache. Curr Pain Headache Rep 2001;Feb;5(1):83-91Gladstone J and Dodick DW. Practical Neurology 2004;4: Ferrari MD, Roon KI, Lipton RB et al. Oral triptans (serotonin 5-HT(1B/1D) agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 2001;358(9294): Gladstone J and Dodick DW. Practical Neurology 2004;4: Graben RD, Maichle W. Pharmaceutical Formulation & Quality. Product Spotlight Dynamic Buffering Technology. September 2006: Goadsby PJ. Re: Donnan GA, Davis SM 'Neurology: reflections on the past millennium as we enter the next. Journal of Clinical Neuroscience 2000;7:1-2. J Clin Neurosci 2000 Jul 7(4): Haberer LJ, Walls, Lener, et al. Distinct pharmacokinetic profile and safety of a fixed-dose tablet of sumatriptan and naproxen sodium for the acute treatment of migraine. Headache 2010;50(3): Hu XH, Markson LE, Lipton RB, et al. Burden of migraine in the United States: disability and economic costs.arch Intern Med 1999;159(8): Idkaidek N and Arafat T. Effect of microgravity on the pharmacokinetics of Ibuprofen in humans.j Clin Pharmacol 2011;51(12):

46 Bibliography 22. International Headache Society, 2 nd edition. Cephalalgia 2004;24 Suppl 1: Kahn K. Cambia (diclofenac potassium for oral solution) in the management of acute migraine. US Neurology. 2011;7(2): Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), Krymchantowski AV, Filho PF, Bigal ME, et al. Rizatriptan vs. rizatriptan plus trimebutine for the acute treatment of migraine: a double-blind, randomized, cross-over, placebo-controlled study.cephalalgia 2006;26(7): Linde M. Migraine: a review and future directions for treatment. Acta Neurol Scand 2006;114(2): Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001;41(7): Lipton RB, Dodick D, Sadovsky R, et al. A self-administered screener for migraine in primary care: The ID Migraine validation study. Neurology 2003;61(3): Lipton RB, Grosberg B, Singer RP, et al. Efficacy and tolerability of a new powdered formulation of diclofenac potassium for oral solution for the acute treatment of migraine: Results from the International Migraine Pain Assessment Clinical Trial (IMPACT), Cephalalgia 2010;30(11): Lipton RB, Stewart WF. Headache 1999;39 (Suppl 2):S20-S Lipton RB, Stewart WF, Celentano DD, et al. Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis. Arch Intern Med 1992;152(6): Lipton RB, Stewart WF, Stone AM, et al. Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized trial. JAMA 2000;284(20):

47 Bibliography 33. Lychkova AE. Serotoninergic nervous system in intact heart and abdominal organs. Bull Exp Biol Med 2004;138(2): Matchar DB, Young WB, Rosenberg, JH, et al. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks Pietrobon D. Migraine: new molecular mechanisms. Neuroscientist 2005;11(4): Pryse-Phillips WEM, Dodick DW, Edmeads, JG et al. Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Headache Society. Can Med Assoc J 1997; 156(9): Rapoport AM. Acute Treatment of Migraine: established and Emerging Therapies. Headache 2012;52;S2: Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; Sep 26;55(6): Silberstein SD, Lipton RB, Dalessio DJ, Wolff s Headache And Other Head Pain, Seventh Edition (New York: Oxford University Press Inc), Silberstein SD and Ruoff G. Combination therapy in acute migraine treatment: the rationale behind the current treatment options. Postgrad Med April;Spec No: Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007;27(3): Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), Tfelt-Hansen P. Headache 2007;47(6): Tfelt-Hansen P, DeVries P, Saxena PR. Triptans in migraine: a comparative review of pharmacology, pharmacokinetics and efficacy. Drugs. 2000; 60(6): The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 (Suppl)1:9 160.

48 Bibliography 46. Thomsen LL, Dixon R, Lassen LH, et al. 311C90 (Zolmitriptan), a novel centrally and peripheral acting oral 5-hydroxytryptamine- 1D agonist: a comparison of its absorption during a migraine attack and in a migraine-free period. Cephalalgia 1996;16(4): Tokola RA and Neuvonen PJ. Effect of migraine attacks on paracetamol absorption. Br J Clin Pharmacol 1984;18(6): Volans GN. The effect of metoclopramide on the absorption of effervescent aspirin in migraine. Br J Clin Pharmacol 1975;2(1):57-63.

49 The Art and Science of Evaluating and Treating Migraine Additional Slides

50 Assessing Treatment Success Severity of disability (MIDAS or HIT-6) Duration, intensity, and frequency of attacks Use of medical resources: Second dose Rescue medication Emergent care / clinic visits Incidence of adverse events Level of patient satisfaction 37. Silberstein SD. Neurology 2000; Sep 26;55(6): Lipton RB, et al. JAMA 2000;284(20):

51 Recurrence Return of episodic headache during the same attack following acute treatment Prevention: Treat early, add NSAID Use long-duration triptan or DHE Treatment: Repeat initial acute headache drug which is almost always effective 43. Tfelt-Hansen P et al, Drugs. 2000; 60(6): Dodick DW, Capobianco DJ Curr Pain Headache Rep 2001; Feb;5(1):83-91.

52 Rebound Recurring headache induced by repetitive and chronic overuse of acute headache medication Prevention: Limit frequency and dose of medications Treatment: Withdrawal and washout of overused medication; consider using preventives 14. Dodick DW, Capobianco DJ Curr Pain Headache Rep 2001; Feb;5(1):83-91.

53 Mechanism of Cutaneous Allodynia Activation of the trigeminovascular system (TGVS) release of substance P, calcitonin gene-related peptide (CGRP), and neurokinins by V (trigeminal) ganglion neurogenic inflammation in dura vasodilatation of meningeal vessels, plasma extravasation, and mast cell degranulation Neurogenic inflammation may activate/sensitize meningeal V nociceptors Central sensitization occurs when there is sustained firing of sensitized meningeal nociceptors activation/sensitization of 2 nd order central trigeminovascular (TV) neurons reduced pain threshold and cutaneous allodynia

54 Non-pharmacological Therapies Behavioural Treatments Include: Stress management / relaxation training Regular diet and sleep Trigger identification and avoidance Avoidance of excessive over-the-counter medications Cognitive / behavioural management therapy etc. Physical Treatments Include: Natural remedies / complementary medicines Acupuncture Transcutaneous electrical nerve stimulation Occlusal adjustment Cervical manipulation 22. ICHD. Cephalalgia. 2004;24 Suppl 1:1-160