Chronic Migraine in Primary Care. December 11 th, 2017 Werner J. Becker University of Calgary

Transcription

1 Chronic Migraine in Primary Care December 11 th, 2017 Werner J. Becker University of Calgary

2 Disclosures Faculty: Werner J. Becker Relationships with commercial interests: Grants/Research Support: Clinical Trials Support, Allergan and Amgen Speakers Bureau/Honoraria: Allergan, Amgen, Serono. Consulting Fees: Allergan, Amgen Other: None

3 What is Migraine? Migraine is an inherited, disabling neurological condition that leads to attacks of head pain, sensitivity to the environment, and other neurological symptoms. Migraine is a genetic condition, but many factors over a person s lifetime affect how frequent and severe migraine can be.

4 Overall, the one year point prevalence of migraine is 12 % in the adult general population 4

5 Prevalence of Chronic Migraine in the United States Chronic migraine accounts for 8 % of all migraine cases, 1 % of the general population Schwedt TJ BMJ 2014; 348: g1416

6 Diagnosis and Management of Chronic Migraine is Complex Chronic migraine must be differentiated from secondary headaches causing frequent or daily headache There is often no single simple solution to the pain and disability faced by patients Many patients will need: 1. Lifestyle and trigger advice 2. Behavioural management (e.g. stress management skills, relaxation skills etc.) 3. Acute pharmacological treatment 4. Prophylactic pharmacological treatment 5. Management of acute medication overuse

7 Diagnosis

8 8 Headache Case A 30 year old female has a history of unilateral headaches starting at age 20 that throbbed, lasted 36 hours untreated, and had significant associated nausea. For two years she has had headache on about 23 days a month. These are often bilateral and of moderate severity. On about 12 days a month she has more severe unilateral throbbing headache. She is taking sumatriptan on at least 12 days a month, and acetaminophen with codeine on 8 additional days a month.

9 9 Case 2. Her headache disorder is most correctly classified as: a. b. c. d. e. Medication overuse headache Chronic migraine Chronic tension-type headache Both chronic migraine and medication overuse headache Mixed headache with both migraine and tension-type headache

10 Diagnostic Criteria

11 11 Criteria for Chronic Migraine A. Headache (tension-type and / or migraine) on 15 days per month for at least 3 months. B. Has had at least 5 attacks of migraine with or without aura. C. On 8days per month for 3 months has fulfilled criteria for migraine, or was believed to be migraine and treated successfully with a triptan or ergot. D. Not better accounted for by another diagnosis. ICHD-3 Cephalalgia 2013; 33(9):

12 12 Migraine Without Aura At least 5 attacks with: 4-72 hour duration 2 of: unilateral location pulsating pain moderate or severe intensity aggravation by or causing avoidance of physical activity during attack 1 of: nausea and/or vomiting photo and phonophobia No other cause apparent ICHD-3Cephalalgia 2013; 33(9):

13 How is Chronic Migraine defined in ICHD-3 beta? Changes from ICHD-2 Chronic Migraine diagnosis excludes chronic tension-type headache diagnosis 8 migraine days a month may be with or without aura Patients who meet criteria for both Chronic Migraine and medication-overuse headache should be diagnosed with both Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2013;33:

14 Diagnostic Algorithm for Chronic Migraine Becker WJ, Headache 2017 Oct;57(9):

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16 Diagnostic Algorithm for Chronic Migraine (Continued) Becker WJ, Headache 2017 Oct;57(9):

17 Management of Chronic Migraine Becker WJ, Headache 2017 Oct;57(9):

18 Becker WJ, Headache 2017 Oct;57(9):

19 Becker WJ, Headache 2017 Oct;57(9):

20 The Headache Diary Record days with headache and headache intensity Record acute medication use, and the response to these medications Record prophylactic medication use Keep a record of occurrence of potential triggers Record menstrual cycle

21 Management of Medication Overuse Headache Becker WJ, Headache 2017 Oct;57(9):

22 Case 1: 58 year old male Migraine since 12 years of age Chronic daily headache for at least ten years prior to being seen, associated with daily use of acetaminophen and ibuprofen On amitriptyline 25 mg daily What is the single most important management strategy at this point?

23 Provide information of necessary limits to avoid risk of medication overuse headache: -Use of triptans and combination analgesics on < 10 days a month -Use of acetaminophen or NSAIDs on < 15 days a month or more.

24 Medication Overuse Headache: Headache days per month: Brief advice intervention versus usual care Intervention: Information and advice to stop medication overuse by primary care physician Double-blind Randomized Controlled Trial Mean duration of Medication overuse: 8 years Baseline: dotted lines; 3 month follow up: solid lines

25 Medication Overuse Headache Medication days: Brief advice intervention vs usual care Intervention: Information And advice to stop medication Overuse by primary care physician Double-blind Randomized Controlled Trial Mean duration of Medication overuse: 8 years Baseline: dotted lines; 3 month follow up: solid lines

26 Management of Medication Overuse Headache (Continued)

27 Systematic Review of Medication Overuse Headache: Conclusions Adding preventive medications to early discontinuation of overused medications leads to a better outcome than early discontinuation alone. Preventive medications alone may have some utility in medication overuse headache Chiang C-C, et al Cephalalgia 2016; 36(4):

28 Standard of Care Standard of Care for patients with chronic migraine and medication overuse headache: 1. Stop overused medication, but combine with: - Preventive medications and / or biobehavioural therapy Chiang C-C, et al Cephalalgia 2016; 36(4):

29 Treatment of medication overuse headache Patient education Stop medication overuse Start prophylactic Treat severe attacks Patient follow-up 29

30 Management of Chronic Migraine (Continued) Becker WJ, Headache 2017 Oct;57(9):

31 Prescribing a Migraine Preventive Medication Educate the patient that the medication must be taken daily Ensure the patient has realistic expectations of benefit: 1. Headache attacks will not be abolished completely 2. A reduction of headache frequency of 50% is considered worthwhile 3. In chronic migraine, even lesser reductions in frequency, or reductions in intensity may make prophylaxis worth while. 4. It may take 4 to 8 weeks for significant benefit to occur, and this may increase with time Increase the dose until the medication is effective, dose limiting side effects occur, or a target dose is reached Becker WJ, Headache 2017 Oct;57(9):

32 Schwedt TJ BMJ 2014; 348: g1416 *Other drugs With evidence fo Efficacy in Episodic migraine Are also used clinically

33 Motto: Start Low and go Slow Becker WJ, Headache 2017 Oct;57(9):

34 Management of Chronic Migraine (Continued) Becker WJ, Headache 2017 Oct;57(9):

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37 Use of OnabotulinumtoxinA in Chronic Migraine Becker WJ, Headache 2017 Oct;57(9):

38 OnabotulinumtoxinA mode of action OnabotulinumtoxinA blocks release of glutamate and peptides from nociceptive nerve endings. Sensory neurons not only take up local onabot, but moves it via fast axonal transport to their central terminals. Onabot may regulate cell surface expression of a number of receptors and ion channels (TRPV1, AMPA, etc). Some (many) nociceptive nerve fibers have branches both on the meninges and in the extracranial structures. Ramachandran R et al B J Pharmacol 2014; 171:

39 Roles of Primary Care Provider In Chronic Migraine Becker WJ, Headache 2017 Oct;57(9):

40 Referral of the Chronic Migraine Patient By the Primary Care Provider And Role After Referral Becker WJ, Headache 2017 Oct;57(9):

41 Factors associated with reversion of Chronic migraine to episodic migraine 1. Lower baseline headache frequency (15 19 vs days per month) 2. Adherence to prophylactic drugs 3. Withdrawal of overused acute drugs 4. Physical exercise 5. Correction of sleep disturbances (Calhoun AH Headache Sep;47(8): )

42 The Diagnosis and Management of Chronic Migraine in Primary Care The primary care physician is critical in identifying patients with chronic migraine and initiating therapy. Initiation of therapy should include both pharmacological and nonpharmacological approaches. In Canada, the availability of medical resources and the high prevalence of chronic migraine dictates that the role of the primary care physician must be significant in order to help patients with chronic migraine