Update on Diagnosis and Management of Migraines Joel J. Heidelbaugh, MD, FAAFP, FACG Clinical Professor Departments of Family Medicine and Urology University of Michigan
Learning Objectives To distinguish migraine headache from other headaches using Clinical findings Screening tools Evidence-based guidelines To assess the value of new medications and new delivery systems to enhance individualized treatment for patients with acute migraine headache To increase patient engagement within a collaborative care model that emphasizes Education Adherence Communication among the healthcare team members
Migraine Is Common Migraine Prevalence, % 30 25 20 15 10 5 0 0 20 30 40 50 60 70 80 100 Age, years Female Male US Prevalence (%) Female Male Sex 17 6 Race White Black 17 14 6 4 Highest prevalence Age 30-39 y 24 7 Lipton RB, et al. Headache. 2001;41:646-657; Lipton RB, et al. Neurology. 2007;68:343-349.
Migraine Is Debilitating Sexual life Love Finding friends Social position Leisure time Finances Family situation Pursuing studies Attendance at work Making career 7 8 28 3 6 22 2 8 3 10 24 8 14 37 4 6 8 8 20 4 23 38 3 8 16 12 27 18 47 Very negative influence Quite negative influence Some negative influence 0 20 40 60 80 Percentage of Pts with Migraine (N = 423) Linde M, Dahlöf C. Cephalalgia. 2004;24:455-465.
What Happens During a Migraine Attack? Clinical Phases of Migraine 1 hour ~4-72 hours Prodrome Fatigue Food craving Muscle pain Cognitive change Mood change Sensory disruption Aura (if present) Visual Scintillating scotoma Sensory Motor Headache Localization Throbbing Nausea Vomiting Photophobia Phonophobia Postdrome Fatigue Gastrointestinal upset Cognitive change Muscle pain Mood change Adapted from American Migraine Foundation. http://www.americanmigrainefoundation.org/assets/1/7/generalmigriane_final_web.p df. Accessed October 19, 2015.
Differential Diagnosis of Primary Headache Sinus headaches or infection often misdiagnosed when correct diagnosis is migraine In 90% of cases, clinician- or selfdiagnosed sinus headache is migraine American Headache Society. http://www.achenet.org/news/sinus_headache_or_migraine/. Accessed October 19, 2015.
Diagnosis: Importance of Headache History How does the headache begin? Precipitating event, illness, injury Frequency and patterns Any significant changes Location Quality and intensity Time to peak intensity Duration Warning symptoms and aura Associated symptoms and level of disability Triggers and aggravating or relieving factors Headache diary is helpful
Migraine vs Tension Headache: A Common Misdiagnosis Migraine 2 of the following 4 Unilateral (59% of migraines) Pulsating (85% of migraines) Moderate-severe intensity Aggravation by routine physical activity 1 of the following Nausea/vomiting (73% of migraines) Photophobia/phonophobia (~80% of migraines) Not attributable to another disorder Tension-type 2 of the following Bilateral Not pulsating Mild-moderate intensity Not aggravated by routine physical activity No nausea/vomiting One or neither: photophobia/phonophobia Not attributable to another disorder Headache Classification Committee of the International Headache Society. Cephalalgia. 2013;33:629-808; Lipton RB, et al. Headache. 2001;41:646-657.
Common Migraine Triggers Irregular meals, dehydration Irregular caffeine, chocolate, nuts, bananas, etc Irregular sleep (particularly excessive sleep) Weather, changes in weather Light, sunlight exposure Sensitivity to odors (osmophobia) Stress or let-down from stress Air travel, change in barometric pressure Menstrual period Hoffmann J, et al. Curr Pain Headache Rep. 2013;17:370-377.
Medications That Exacerbate Migraines Oral contraceptives Hormone replacement Selective serotonin reuptake inhibitors Steroids (tapering) Decongestants Short-acting sedatives Some bone density medications MacGregor EA. Curr Pain Headache Rep. 2009;13:399-403; Nierenburg Hdel C, et al. Headache. 2015;55:1052-1071; Allais G, et al. Neurol Sci. 2009;30(suppl 1):S15-S17.
Red Flags: SSNOOP S Systemic involvement (fever, myalgias, weight loss) Systemic disease (cancer, AIDS) N Neurologic symptoms or signs O Onset sudden (thunderclap headache) O Onset after age 40 years P Pattern of change: progressive headache/fewer headache-free periods; change in type of headache Be alert to signs/symptoms of secondary headache Dodick DW. Adv Stud Med. 2003;3:87-92.
Treatment of Acute Migraine: Triptans Selective 5-HT 1B/1D receptor agonists Pretreatment pain severity strongest predictor of pain relief Patients who do not respond to one triptan may respond to another Triptan Route Dose (mg) Sumatriptan Oral, a subcutaneous, nasal, iontophoretic patch Rizatriptan Oral, ODT 5, 10 Oral: 25, 50, 100; nasal: 5, 20; injection: 4, 6; patch: 6.5 Zolmitriptan Oral, ODT, nasal Oral, ODT: 2.5, 5; nasal: 5 Almotriptan Oral 6.25, 12.5 Eletriptan Oral 20, 40 Naratriptan Oral 1, 2.5 Frovatriptan Oral 2.5 a Combination with naproxen also approved in adult and pediatric patients. 5-HT = 5-hydroxytriptan; ODT = orally disintegrating tablet. Dahlöf CG. Cephalalgia. 2006;26:98-106.
Treatment of Acute Migraine: Ergots, Diclofenac Ergots Also 5-HT 1B/1D receptor agonists More side effects than triptans but longer lasting Less frequently used Formulations DHE mesylate (tablet, injection, nasal spray; orally inhaled formulation in development) Ergotamine tartrate Ergotamine tartrate + caffeine Diclofenac potassium for oral solution (packets) NSAID
Nonspecific Treatments Antiemetics Combination NSAIDs Opiates (only for limited use in very severe migraine) Corticosteroid (intravenous) (rescue therapy) Butalbital/aspirin/caffeine: approved for tension headache; sometimes used for migraine, but not appropriate for this purpose
Acute Treatment Principles Treat at least 2 attacks with the same medication If medication is ineffective: Ensure that no other medications are interfering with response Treat early in the attack Maximize dose Change formulation/route of administration Change drug Add drug? combination therapy (eg, sumatriptan/naproxen)? prophylactic treatments
American Migraine Prevalence and Prevention Criteria for Use of Preventive Treatment for Episodic Migraine Epidemiologic studies suggest that approximately 38% of migraineurs benefit from preventive therapies, but only 11% currently receive them Headache- Related Impairment Headache Frequency, Days per Month 2 3 4-5 6-10 11-14 None Consider Offer Offer Some Consider Offer Offer Offer Severe/bedrest Consider Offer Offer Offer Offer Lipton RB, Silberstein SD. Headache. 2015;55(suppl 2):103-122; Silberstein SD, et al. Neurology. 2012;78:1337-1345; Lipton RB, et al. Neurology. 2007;68:343-349.
Lifestyle Modification: Consistency Is Key Don t skip meals Sleep Caffeine <200 mg/d Six 8-oz glasses of water per day Prophylactic medications Exercise
Behavioral Interventions and Collaborative Care NPs, PAs, Physicians Psychology/ Behavioral Specialists Physical Therapy/ Occu pational Therapy Techniques for All Patients Education x x x X Medical communication x x x x Adherence x x x x Relaxation x x x Stress x x Cognitive behavioral therapy x Techniques Based on Patient Presentation Biofeedback x x x Dialectic behavioral therapy Buse DC. http://www.painmedicinenews.com/viewarticle.aspx?d_id=95&a_id=28991. Accessed October 19, 2015. x x x
Prevention of Episodic Migraine: FDA-Approved Agents Start with the lowest dose and increase weekly to desired effect Sodium valproate, divalproex sodium Formulation Tablets, immediate-/ delayed-release capsules Starting Maintenance Dose (mg/d) 500 1000 Propranolol Tablets, oral solution 80 160-240 Timolol Tablets 10 30 Topiramate Tablets, sprinkle capsules 25 100 FDA = Food and Drug Administration. Reddy DH. Exp Rev Clin Pharmacol. 2013; 6:271-288.
Treatments Also Used for Prophylaxis NSAIDs Other β-blockers Tricyclic antidepressants (eg, amitriptyline) Gabapentin Angiotensin-converting enzyme inhibitors, calcium channel blockers Petasites (butterbur root) Magnesium Vitamin B2 (riboflavin) Coenzyme Q10 D Amico D, et al. Neuropsychiatr Dis Treat. 2008;4:1155-1167.
Principles of Preventive Pharmacotherapy Start at a low dose Give each treatment an adequate trial Preventive pharmacotherapy should be continued for at least several months Avoid interfering, overused, and contraindicated drugs Re-evaluate therapy Women of childbearing potential should understand risks Involve patients in their care to maximize adherence Consider comorbidities and choose medications to treat several coexisting disorders where possible Choose a drug based on efficacy, patient preferences, headache profile, adverse effects D Amico D, et al. Neuropsychiatr Dis Treat. 2008;4:1155-1167.
On the Horizon: Potential New Medications/Formulations for Migraine Sumatriptan in fast-acting, dry-powder intranasal form Orally inhaled DHE CGRP-blocking monoclonal antibodies Small-molecule CGRP receptor antagonists Neurally acting antimigraine agents that target 5-HT 1F receptors COL-144 Glutamate receptor antagonists
Summary Emphasize to patients the importance of keeping a headache diary to identify triggers and nature of headache and to assess treatment progress Differentiate between migraine and other primary headaches to ensure early and appropriate treatment Treat at least 2 migraines with same medication; consider alternatives if medication remains ineffective When starting preventive pharmacotherapy, start at low dose, consider comorbidities, and respect patient concerns and preferences Participate in a collaborative care model of migraine to improve communication, involve patients in decision making, and focus on prevention
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