Managing Migraine: Primary Care for Primary Headaches

Transcription

1 Managing Migraine: Primary Care for Primary Headaches

2 Faculty Jeffrey Unger, MD, FAAFP, FACE Director, Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California; Director of Metabolic Studies, Catalina Research Institute, Montclair, California 2

3 Disclosures Jeff Unger, MD has no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated: Presentation will include non-approved indications for certain therapeutic interventions. Experimental therapies will also be discussed. The audience will be informed about unapproved drug interventions. 3

4 Learning Objectives 1. Utilize evidence-based strategies to diagnose patients presenting with headache. 2. Identify associated conditions (e.g. depression), and red flags for potentially life threatening causes of headache. 3. Use evidence-based recommendations to prescribe treatment for patients presenting with acute or emergent headache pain. 4. Develop collaborate management plans, emphasizing patient education on avoiding triggers that cause headache, and adherence to prescribed treatment strategies. 4

5 PRE-TEST QUESTIONS 5

6 Pre-test ARS Question 1 How confident are you in your ability to treat patients with migraine? 1.Not at all confident 2.Slightly confident 3.Moderately confident 4.Pretty much confident 5.Very confident 6

7 Pre-test ARS Question 2 How often do you consider a diagnosis of migraine in a patient presenting with a chief complaint of sinus headache? 1. Never 2. Rarely 3. Sometimes 4. Often 5. Always 7

8 Part 1 8

9 Headaches: Types and Features Prevalence: Any headache: 93% of men, 99% of women Migraine: 8% of men, 25% of women Primary headache Migraine, cluster, tension-type Idiopathic Defined clinically, no specific tests Rule out specific pathologic events Secondary headache Traumatic, vascular, infectious, metabolic, oncologic Underlying pathology Diagnostic tests useful Diagnosis based on defining pathology 9

10 Red Flags and Comfort Signs Red flags Comfort signs First or worst Abrupt onset Change in pattern New onset < 5 or > 50 years of age Cancer, HIV, pregnancy Neurological dysfunction Onset with seizure, syncope, exertion, sex or Valsalva Abnormal vital signs In children, get progressively worse Stable pattern for 6 months Long history of same headaches In children-recurring, INTERMITTENT Normal neurologic exam Occur with menstruation Family history of same Known consistent triggers Ravishankar K. Headache Nov;56(10):

11 Migraine Prevalence: Age and Gender Migraine prevalence peaks in the age range Adapted from Lipton RB, et al. Neurology. 2007;68(5):

12 Definition of Migraine Stable pattern of recurrent disabling headaches without evidence of underlying cause Migraineurs: Genetic sensitivity towards severe, disabling headaches Born with very sensitive nervous system The goal of migraine management is to help the migraineur learn to reduce their neurological sensitivity Migraine events disrupt normal neurologic brain function, which increases likelihood of additional events Unger J. Migraine prophylaxis. The Pain Practitioner. 17 (1)

13 Migraineurs Have a Genetically Predisposed Sensitive Neurological System Triggers Protective factors Stress Hormonal changes Skipping meals Specific food (cheap red wine, caffeine) Sleep disruptions Medications and medication overuse Weather Minor head trauma Standardized sleep patterns Regular meals Exercise Stress management Proactive treatment for menstrual migraine and prodromes Post menopause treatment Avoidance of triggers Reduction caffeine usage 13

14 Phases of a Migraine Attack Migraine Intensity Prodrome Migraine symptoms occurring hours/days prior to headache Symptoms : Food cravings Mood changes Yawning Fatigue Pre-HA Aura 20% Focal neurological symptoms preceding headache (<1 hour) Symptoms: Flashing lights or wavy lines Numbness Tingling in face Disturbed senses Mild Migraine when headache is mild Symptoms: Sensitivity to light Sensitivity to sound Nausea Pain in the back of the head and neck Loss of cognition Headache Moderate to Severe Migraine when headache is moderate to severe Symptoms: Same as mild but more intense Can develop allodynia within 2-4 hours Post- HA Postdrome Migraine symptoms occurring hours/days after headache resolution Symptoms: Tiredness Confusion Dizzy Lowered appetite Stiff or sore muscles Adapted from Cady RK. Headache. 2008;48(9): Time (4 hours 5 days) 14

15 Migraine: Aura 15

16 Neck Pain During Migraine Prevalence 75% of subjects Descriptions 69% - tightness 17% - stiffness 5% - throbbing 5% - other 82% had previously been given a diagnosis of tension- type headache 16 Kaniecki R. Neurology. 2002;58(Suppl 6):S15-S20.

17 Part 2 17

18 Diagnosis of Migraine During the last 3 months, did you have the following with your headaches (Yes/No)? 1. You felt nauseated or sick to your stomach 2. Light bothered you (a lot more than when you don t have headaches) 3. Your headaches limited your ability to work, Yes answer = 1 point Score 2 out of 3 = migraine Sensitivity: 0.81 Specificity: 0.75 Quiz available at: Lipton RB, et al. Neurology. 2003;61:

19 Headache Workup Physical exam Laboratory tests Vital signs! CBC Look for any focal neurological findings Listen to the head! ESR T4, TSH, Thyroid Peroxidase Antibody Feel the scalp and neck muscles Unger Jeff, Cady Roger K, Farmer-Cady Kathleen. Migraine Headaches, Part 1: Presentation and Diagnosis. The Female Patient. May 2003: Vol

20 Listen to the Head! 20

21 Diagnostic Evaluation Headache Primary Headache NO Atypical Features Danger signs present? Investigations YES Secondary Headache Adapted from Silberstein et al. (eds.) Headache in Clinical Practice

22 Is This Migraine? 45 y/o man with nightly headaches x 2 weeks. Pain so severe he extracted his own teeth! 22

23 One Nerve Pathway: Multiple Symptoms of Migraine V1 V2 V3 (V3) 23

24 Diagnosis of Sinusitis: 2 Major or 1 Major + >2 Minor Symptoms Major symptoms Purulent nasal discharge Nasal congestion or obstruction Facial congestion or fullness Facial pain or pressure Loss of taste or smell Fever (acute sinusitis only) Minor symptoms Headache Ear pain, pressure or fullness Halitosis Dental pain Cough Fever (for subacute or chronic sinusitis) Fatigue Chow AW et al. IDSA clinical practice guidelines for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Disease. 2012: Patient_Care/PDF_Library/IDSA%20Clinical%20Practice%20Guideline%20for%20Acute%20Bacterial%20Rhinosinusitis%20in%20Children%20and %20Adults.pdf 24

25 Part 3 25

26 Strategies for Migraine Treatment Rescue Therapy When all else fails! Lipton RB, et al. Headache. 1998;38:87 96; Silberstein SD, et al. Cephalalgia. 1997;17:

27 Behavioral Approach to Migraine No meal skips Exercise Sleep hygiene Avoid triggers Stop smoking Stop analgesics >2 times weekly 2 cups java per day Relaxation exercises Have a written plan!! 27

28 Acute Migraine: Treatment Goals Headache free in 2 hours Back to full function in 2 hours Little to no side-effects from medication Headache does not come back for 24 hours Relief of associated symptoms Acute medication not needed > 2 times/week 28

29 Triptans Triptans are 5-HT 1B/D/F receptor agonists that attenuate migraine in many patients Inhibit release of CGRP within the trigeminal vascular system However, inhibition may be short lived; HAs can reoccur 30% of patients do not respond well to triptans, especially if drugs are used when the patient experiences peripheral and central sensitization Goadsby PJ, et al. Migraine-current understanding and treatment. New Engl J Med. 2002;346:

30 Triptans Sumatriptan Oral: 25, 50, 100 mg Nasal: 5, 20 mg Nasal powder: 11 mg Auto-injector: 4 or 6 mg Needle-free injector: 3 mg Zolmitriptan Oral: 2.5, 5 mg ODT: 2.5, 5 mg Nasal: 5 mg Naratriptan Oral: 1, 2.5 mg Rizatriptan Oral: 5, 10 mg ODT: 5, 10 mg Almotriptan Oral: 6.25, 12.5 mg Frovatriptan Oral: 2.5 mg Eletriptan Oral: 20, 40 mg Sumatriptan/Naproxen Oral: 85 mg/500 mg ODT, orally disintegrating tablet 30 Physicians' Desk Reference, th ed. Montvale, NJ: PDR Network, LLC; 2016; Silberstein SD. CNS Spectr (S1) 1-13

31 Triptan Dosing Strategies Treat early after migraine onset Use highest dose formulation Expect to be pain free and associated symptom free within 2 hours If headache worsening after 2 hours, repeat dose x1 If headache worsens after initial dosing, reduce dose of triptan by 50% and add NSAID Can use ondansetron 4-8 mg for nausea In presence of nausea consider SQ injection or nasal spray If no response to triptan use rescue therapy Keep a migraine diary to record frequency, intensity and duration of migraine 31

32 Non-Triptans To Consider Dihydroergotamine 4 mg/ml nasal spray Administer 1 spray each nostril at onset of migraine Repeat dosing in 15 minutes Potassium diclofenac 50 mg powder Taken at onset of migraine Rapid onset of relief and low rate of recurrence Joshi, S and Rappaport A. Ther Adv Neurol Disord Apr; 10(4):

33 Formulation Considerations Orals Use at onset of migraine Block release of CGRP from trigeminal afferents Injections Fast acting Relief in minutes Autoinjector for some triptans Nasal spray Consider use in children Proper technique is important If no response to triptans, can try ergotamine Non-triptans Rapid onset of pain relief Low rate of recurrence Expensive Consider ondansetron 8 mg SL if patient has severe nausea Silberstein SD. CNS Spectr (S1)

34 Migraine Rescue Strategies Olanzapine 10 mg PO Quetiapine 100 mg PO Magnesium sulfate 1 g IV push* Occipital nerve block* Sphenopaletine ganglion block* Use a sphenocath *Office procedure by a family physician Krusz JC. Aggressive Interventional Treatment of Intractable Headaches In The Clinic Setting. In: Unger, J (ed). Clinics in Family Practice. Elsevier (Philadelphia) Sept

35 Part 4 35

36 When to Consider Preventive Therapy Migraine significantly interferes with patient s daily routine, despite acute treatment Attack frequency >1/week Acute medication ineffective, contraindicated, over-used, or not tolerated Patient preference Presence of uncommon migraine conditions 36

37 American Academy Neurology American Headache Society Preventive Recommendations Level A Level B Divalproex sodium Amitriptyline Sodium valproate Venlafaxine Topiramate Atenolol Metoprolol Nadolol Propranolol Naratriptan* Timolol Zolmitriptan* Frovatriptan* *= menstrual migraine American Academy of Neurology. Pharmacologic treatment for episodic migraine prevention in adults. Available at: 37

38 Other Preventive Options Herbals Onabotulinum toxin A Butterbur 75 mg BID 1 B2 (Riboflavin) 400 mg a day* Mg mg a day* Feverfew 3 dried leaves daily* Coenzyme Q mg a day Indications: Adults with chronic migraine (>15 headache days/month lasting >4 hours each) *= Effective for pediatric migraine Matchar DB, et al. AAN. US Headache Consortium. 2000:1-58. Level A evidence. Levin M. Headache 2012;52;S2: Markley H. Headache 2012;52:S2:

39 Menstrual Migraine Prevention Frovatriptan 2.5 mg BID x 6 days starting 2 days before onset of period Frovatriptan 10 mg at onset of period Frovatriptan 2.5 mg QD x 6 days beginning 2 days before onset of period Tepper, SJ. Treatment of menstrual migraine: evidence-based review. Manag Care Jul;16(7 Suppl 7):10-4; discussion Cady, RK, et al. Two center randomized pilot study of migraine prophylaxis comparing paradigms using pre-emptive frovatriptan or daily topiramate: research and clinical implications. Headache. 2012; 52 (5)

40 IV Magnesium 1 g IV push Side effect: severe hot flash lasting <1 minute Eliminates migraine and migraine-associated symptoms within 2-3 minutes Works best for HA <24 hour duration. For HA >24 hour duration use valproate sodium 500 mg IV push over 3-5 minutes 40

41 Chronic Migraine Disease Impact Incomplete Recovery Incapacity Comorbidities: Anxiety Depression Sleep disturbances Severity Frequency Headache Brain is highly reactive. Pt cannot recover. Migraines do not stop. CGRP levels elevated Normal 41 Lipton RB, et al. Managing migraine: A healthcare professional s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:27.

42 Free Iron Deposition in PAG in Chronic Daily Headache Control Chronic Daily Headache Welch, et al. Periaqueductal Gray Matter Dysfunction in Migraine: Cause or the Burden of Illness? Headache. 41(7) P With Permission 42

43 CGRP and Migraine CGRP released during physiologic or emotional stress Sensitizes trigeminal afferents, recruiting other nerves As more nerves sensitized, thalamus activated and central sensitization develops Levels are increased during migraine Infusions can trigger migraine CGRP inhibitors block migraine progression and reduce frequency, intensity and duration CRRP inhibition allows brain to recover more fully from a migraine event A brain that has not fully recovered from a migraine event is more reactive another migraine will follow Frequent migraine, result in more frequent events Juhasz G, et al. NO-induced migraine attack: strong increase in plasma calcitonin gene- related peptide (CGRP) concentration and negative correlation with platelet serotonin release. Pain. 2003;106:

44 CGRP Inhibitors (Not FDA Approved) ALD403 AMG 334 LY TEV Dosing Single 1 g dose IV, lasts up to 6 months SC 70 and 140 mg monthly SC 70 mg/month SC 900 mg once monthly or 675 load mg monthly Notes Inhibits CGRP and removes CGRP from receptors Some patients achieved complete remission ~60% reduction in episodic migraine vs. PBO 60% reduction in episodic migraine 75% reduction in headaches in 32% treated vs 16% PBO 1)Glamberadino MA, et al. Challenging chronic migraine: targeting the CGRP receptor. Lancet Neurol (6): )Ramon C, et al. Calcitonin gene-related peptide monoclonal antibodies for migraine prevention: comparisons across randomized controlled studies. Curr Opion Neurol. 2017; 30 (3):

45 Cycle Breakers For Chronic Migraine Stop offending agent(s) Frovatriptan 2.5 mg at 4pm daily x 8 days Dexamethasone PO x 3 days: 12 mg 8 mg 4 mg IV magnesium sulfate 1 g stat, then 1 g weekly x 3 doses total Occipital nerve block Sphenopalatine ganglion block Olanzapine 20 mg or quetiapine 100 mg x 7 days Dihydroergotamine Rodrigo D, et al. Pain Physician. Jan-Feb 2017;20(1):E151-E159; Mojica J, et al. Curr Pain Headache Rep. Jun 2017;21(6):27; Morren JA, et al. Expert Opin Pharmacother. Dec 2010;11(18): ; Trucco M, et al. J Headache Pain. Sep 2005;6(4): ; Jimenez XF, et al. Clin J Pain. Oct ; Lionetto L, et al. Expert Opin Emerg Drugs. Sep 2012;17(3):

46 Summary 46

47 Summary Migraineurs are born with an inherently weak pain protective mechanism Migraine headaches are recurrent and disabling Migraine may be accurately diagnosed in patients who experience nausea, photophobia and/or disability during their headaches Migraine interventions include lifestyle changes, preventative therapies, abortive drugs, and rescue therapies Avoid prescribing opioids to migraineurs as they may induce neuroinflammation Sinus headache? Treat for migraine 47

48 Practice Recommendations Imaging studies are not needed in patients with intermittent disabling headaches (ie. Migraine). (SOR A) Patients presenting with the complaint of sinusitis should be considered as having a migraine unless symptoms are associated with fever, discolored nasal secretions, halitosis and loss of smell. (SOR A) Avoid the use of chronic opioids in patients with headache disorders. (SOR A) 48

49 POST-TEST QUESTIONS 49

50 Post-test ARS Question 1 After completing this activity, how confident are you in your ability to treat patients with migraine? 1.Not at all confident 2.Slightly confident 3.Moderately confident 4.Pretty much confident 5.Very confident 50

51 Pre-test ARS Question 2 After completing this activity, how often do you intend to consider a diagnosis of migraine in a patient presenting with a chief complaint of sinus headache? 1. Never 2. Rarely 3. Sometimes 4. Often 5. Always 51

52 Thank You For Joining Us! To receive your credits for today s activity: You will also receive an after the program and again in the next few days with a link to the CME activity evaluation form to complete. We look forward to seeing you again at our next program. Check out our website at naceonline.com for all of our educational offerings. 52