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Treating Migraines

Treating Migraines. Professor Yasser Metwally www.yassermetwally.com. Switzerland 13%. Denmark 10%. France 8% †. USA 12%. Japan 8%. Italy 16%. 1-year prevalence rates Population-based studies IHS criteria (or modified). Chile 7%.

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Treating Migraines

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  1. Treating Migraines Professor Yasser Metwally www.yassermetwally.com

  2. Switzerland 13% Denmark 10% France 8%† USA 12% Japan 8% Italy 16% • 1-year prevalence rates • Population-based studies • IHS criteria (or modified) Chile 7% Rasmussen and Olesen (1994); Rasmussen (1995);Lipton et al (1994); Lavados and Tenhamm (1997); Sakai and Igarashi (1997) †Prevalence measured over a few years World prevalence of migraine

  3. Females Males Prevalence of migraine by sex and age Migraine prevalence (%) 30 25 20 15 10 5 0 20 30 40 50 60 70 80 100 Age (years) The American Migraine Study (n=2479 migraine sufferers) Lipton and Stewart (1993)

  4. Diagnosis of migraine • Diagnosis depends on patient history • No specific tests or clinical markers for migraine • Positive diagnosis if attack history fulfils IHS criteria for migraine • Other pointers include: • family history of migraine • age of onset <45 • presence of aura • menstrual association • Organic disease must be excluded Cady (1999); Warshaw et al (1998)

  5. Migraine Criteria • 5 attacks lasting 4–72 h • 2 of the following 4 • Unilateral • Pulsating • Moderate or severe intensity • Aggravation by routine physical activity • 1 of the following • Nausea and/or vomiting • Photophobia and phonophobia • Not attributable to another disorder

  6. evere ni ateral hrobbing Ctivity worsens ausea Lite and sound ensitivity SULTANS: two from column A, one from column B N S U S L T A

  7. Migraine without aura (MO) What is migraine? Migraine with aura (MA) At least five attacks fulfilling these criteria: Headache lasting 4–72 h (2–48 h in children) • At least two attacks fulfilling these criteria: • At least three of the following: • one or more fully reversibleaura symptoms • gradually developing orsequential aura symptoms • no one aura symptom lastslonger than 1 h • headache shortly follows or accompanies aura • With at least two of: • unilateral location • pulsating quality • moderate/severe intensity • aggravated by activity • Accompanied by at least one of: • nausea • vomiting • photophobia and/or phonophobia No evidence of organic disease No evidence of organic disease Headache Classification Committee of IHS (1988)

  8. Normal Headache Normal Vomiting Vomiting nausea Anorexia Deep sleep Limited yawning Craving Appetite Appetite food tolerance Sleepy Photophobia yawning Tired Awake/sleep Tired Phonophobia Awake/sleep Photophobia Light tolerance Phonophobia Light tolerance Feeling high or low Osmophobia Heightened Osmophobia Noise perception Noise Smell Smell retention Diuresis Fluid Fluid balance Fluid balance I II Normal Prodromes Aura III IV Headache Resolution V Postdromes Normal Blau (1992) Clinical features of migraine

  9. No single criterion necessary nor sufficient for diagnosis Russell MB, et al. Cephalalgia. 1996. Pryse-Phillips WEM, et al. Can Med Assoc J. 1997. IMPORTANT DIAGNOSTIC CONSIDERATIONS 15% of patients have a neurological aura IHS criteria do not require GI symptoms Vomiting occurs in < 1/3 of patients 41% of migraine patients report bilateral pain 50% of the time, pain is non-pulsating Recurring moderate to severe headache is migraine until proven otherwise

  10. Postdrome • Occurs in 90% patients • Symptoms can persist for several days • lethargy • exhaustion • impaired concentration • irritability • sluggishness • diminished appetite • euphoria Premonitory, aura and postdromal symptoms • Prodrome • Occurs in 60% of attacks • Alterations in • mood • alertness • appetite • Originate in hypothalamus and frontal lobes Aura • Occur in MA (20% patients) • Visual symptoms • blurring, rippling • spots or flashes • fortification spectra • scotoma • Sensory symptoms • numbness/tingling • Motor symptoms • hemiparesis Silberstein and Lipton (1994); Lance (1993); Blau (1992)

  11. Complex array of symptoms reflecting focal cortical or brainstem dysfunction International Headache Society. Cephalalgia. 1988;8;(suppl 7):1-96. MIGRAINE WITH AURA(FORMERLY “CLASSIC” MIGRAINE) Gradual evolution: 5–20 minutes (<60 minutes) May or may not be associated with headache Visual > sensory > motor, language, brainstem

  12. MIGRAINE AURA“Cheiro-oral”

  13. Fortification Spectrum

  14. Detailed History and Examination NO • Primary Headache? • Preliminary Diagnosis YES Secondary Headache Atypical Features Diagnostic Testing DIAGNOSIS AND TESTING

  15. Alice in Wonderland

  16. Migraine is a referred pain syndrome (V1, C1-C3) Raskin NH. Headache. 2nd ed. 1988; Barbanti P, et.al. Cephalalgia. 2001; Kaniecki R. Cephalalgia. 2001. REASONS FOR MISDIAGNOSIS OF MIGRAINE AS TTH OR SINUS Sinus Up to 50% of migraine patients report their headaches are influenced by weather 45% of migraine patients report attack related ‘sinus’ symptoms including lacrimation, rhinorrhea, nasal congestion Tension-Type Headache 75% of migraine patients report posterior neck pain/tightness/stiffness during attacks Stress/anxiety frequent migraine trigger Migraine is bilateral in up to 40% of patients

  17. Clinical feature Migraine Cluster headache Tension headache Family history Yes Sex More females Onset Variable Location Usually unilateral in adults Character/severity Pulsatile Throbbing Frequency/ 2–72 h/attack duration 1 attack/year to >8 per month Associated Visual aura symptoms Phonophobia Photophobia Pallor Nausea/vomiting No More males During sleep Behind/around one eye Excruciating/ sharp Steady 15–90 min/attack 1–8 attacks/day for 3–16 weeks 1–2 bouts/year Sweating Facial flushing Nasal congestion PtosisLacrimation Conjunctival injection Pupillary changes Yes More females Under stress Bilateral in band around head DullPersistent Tightening/pressing 30 min to 7 days 3–4 attacks/weekto 1–2 attacks/year Mild photophobia Mild phonophobiaAnorexia Differential diagnosis of primary headaches Dubose et al (1995); Goadsby (1999); Marks and Rapoport (1997)

  18. WORRISOME HEADACHE RED FLAGS“SNOOP” Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, systemic cancer) Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness) Onset: sudden, abrupt, or split-second Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis) Previous headache history: first headache or different (change in attack frequency, severity, or clinical features)

  19. Headache ‘red flags’ • First or worst headache • Significant change from previous headache pattern • no longer fulfils IHS criteria • New onset headache in middle age or later • New or progressive headache that lasts for days • Precipitation of headache by coughing/sneezing/bending down • Systemic symptoms such as myalgia, fever, malaise, weight loss, scalp tenderness, jaw claudication • Focal symptoms, seizures, confusion, impaired conciousness, physical examination abnormalities Pryse-Phillips et al (1997)

  20. EVALUATION STRATEGIES “Investigate the Atypical and the Red Flags”

  21. Idiopathic thunderclap headache (TCH) SAH Venous sinus thrombosis Sexual headache Pituitary apoplexy Exertional headache Arterial dissection Cough headache Meningoencephalitis Acute hydrocephalus Acute hypertension Spontaneous intracranial hypotension deBruijn, SF, et al. Lancet. 1996; Lancet. 1998. SUDDEN ONSET HEADACHE Primary Secondary

  22. The first unusually severe headache Evans RE, Rozen TD, Adelman JU. In: Wolff’s Headache And Other Head Pain. 2001. LUMBAR PUNCTURE Thunderclap headache with negative CT head Subacute progressive headache Headache associated with fever, confusion, meningism, or seizures High or low CSF pressure suspected (even if papilledema is absent)

  23. SENSITIVITY OF CT SCAN IN SUBARACHNOID HEMORRHAGE (SAH) van Gijn J, van Dongen KJ. Neuroradiology. 1982. Kassell NF et al. J Neurosurg. 1990.

  24. In patients with recurrent migraine, neither CT nor MRI is warranted except in cases where: • Recent substantial change in headache pattern • History of seizures • Focal neurologic symptoms or signs Report of Quality Standards Subcommittee of AAN. Neurology. 1994. DIAGNOSIS TESTINGCT AND MRI Role of CT or MRI in patients with nonmigraine headache is unclear Consensus expert opinion • MRI is more sensitive

  25. EEG is not useful • In the routine evaluation of patients with headache to exclude structural cause Report of Quality Standards Subcommittee of AAN. Neurology. 1995. DIAGNOSTIC TESTING ELECTROENCEPHALOGRAPHY EEG may be useful in those patients with • Alteration or loss of consciousness • Residual focal neurologic defects or encephalopathy • Atypical migrainous aura

  26. Aneurysm (>5 mm) Acute SAH AV malformation CNS vasculitis Arterial dissection Arterial dissection Venous thrombosis (MR venography) Leclerc X et al. Neuroradiology. 1999. MR AND CONVENTIONAL ANGIOGRAPHY MR Angiography Angiography

  27. Cerebrovascular Arterial dissection (MRA) Cerebral venous sinus thrombosis (MRV) CNS vasculitis Tumors Posterior fossa Pituitary Leptomeninges Bousser MG et al; Wall M et al; Mokri B; and Newman C, Solomon S. In: Wolff’s Headache And Other Head Pain. 2001. Tien RD et al. AJR Am J Roentgenol. 1993. MRA = magnetic resonance angiography. MRV = magnetic resonance venography. INDICATIONS FOR GADOLINIUM ENHANCED MRI High and low intracranial pressure syndromes Herpes encephalitis

  28. CEREBRAL VENOUS SINUS THROMBOSIS Bousser MG et al. In: Wolff’s Headache And Other Head Pain. 2001.

  29. Sleepers Awake!! Treatment

  30. Acute treatment To stop pain and prevent progression Silberstein SD. Cephalalgia. 1997. STRATEGIES FOR MIGRAINE TREATMENT Preventive Treatment Decrease in migraine frequency warranted Preemptive treatment Migraine trigger time-limited and predictable

  31. ACUTE MIGRAINE TREATMENT Objectives Evaluate the general principles of treatment Review the clinical evidence for acute treatment alternatives Present an approach for selecting and sequencing acute therapies Discuss problems that arise in the acute management of migraine

  32. PRINCIPLES OF MIGRAINE MANAGEMENT Establish a therapeutic partnership Patient education and behavioral management • Nature and mechanism of the disorder • Strategies for identifying and avoiding triggers • Behavioral strategies • Regular sleep, exercise, meals • Stress management, biofeedback • Cognitive behavioral therapy Pharmacologic management • Acute treatment • Preventative strategies

  33. Effective: GRADE A • Relaxation training • Thermal biofeedback with relaxation training • EMG biofeedback • Cognitive behavioral therapy Goslin RE et al. Behavioral and Physical Treatments for Migraine Headache. 1999. NONPHARMACOLOGIC TREATMENTS Insufficient evidence to recommend: GRADE C • Acupuncture • TENS • Cervical manipulation • Occlusal adjustment • Hyperbaric oxygen • Hypnosis The benefits of behavioral therapy (eg, biofeedback, relaxation) are in addition to preventive drug therapy (eg, propranolol, amitriptyline):GRADE B

  34. Goals of Treatment • Establish diagnosis • Educate patient • Discuss findings • Establish reasonable expectations • Involve patient in decisions • Encourage Pt to avoid triggers • Choose the best treatment (tailoring) • Create treatment plan

  35. MIGRAINE TRIGGERS Diet Physical exertion Hormonal changes Head trauma Stress and anxiety Sleep deprivation or excess Environmental factors

  36. ACUTE MIGRAINE MEDICATIONS Nonspecific • NSAIDs • Combination analgesics • Opioids • Neuroleptics/antiemetics • Corticosteroids Specific • Ergotamine/DHE • Triptans

  37. GROUP 1a:Substantial empirical evidence and pronounced clinical benefit in migraine Migraine-Specific Medications • Triptans • DHE • SC, IM, IN, IV (plus antiemetic) Silberstein SD. Neurology. 2000. ACUTE THERAPIES FOR MIGRAINE Nonspecific Prescription Medications • Butorphanol IN • Ibuprofen/Naproxen sodium • Prochlorperazine IV

  38. GROUP 1b:Substantial empirical evidence of clinical benefit in restricted populations Silberstein SD. Neurology. 2000. ACUTE THERAPIES FOR MIGRAINE Over-the-Counter Analgesics • Aspirin • Acetaminophen, aspirin, plus caffeine GROUP 2: Moderate empirical evidence and clinical benefit • OpioidsOthers

  39. Match treatment intensity to attack severity (stratified care) • Ask about migraine disability and impact Silberstein SD. Neurology. 2000. CONSIDERATIONS IN INITIAL ACUTE THERAPY As disability increases, nonspecific treatments less likely to work In the most severely afflicted 25% of migraine sufferers, an NSAID-metoclopramide combination is successful in only 25% of patients Try to get the treatment “right” the first time

  40. Trigeminovascular model of migraine Cranium Dura mater Afferent Peptide releasing neurones Trigeminal ganglion Dura mater Blood vessels Efferent Trigeminal nerve Afferent Efferent CGRP/SPrelease Efferent Dilatation Adapted from Goadsby and Olesen (1996)

  41. Trigeminal nerve INHIBITION 5-HT1D 5-HT1F triptan CGRP NK SP CONSTRICTION 5-HT1B CGRP calcitonin gene related peptide NK neurokinin A SP substance P Blood vessel Adapted from Goadsby (1997) Mechanisms for treatment

  42. Selective 5-HT1B/1D/1F agonists Silberstein SD. Neurology. 2000. TRIPTANS As a class, relative to nonspecific therapies, triptans provide • Rapid onset of action • High efficacy • Favorable side effect profile Adverse events and contraindications

  43. Are there differences between the triptans? If one triptan fails, will another triptan work? Sumatriptan • Tablet (25, 50, 100 mg) • Injection (6 mg) • Nasal spray (5, 20 mg*) Question and Answer • Eletriptan • Tablet (20, 40 mg) * Pediatric efficacy shown Ferrari MD et al. Lancet. 2001. TRIPTANS:TREATMENT CHOICES • Almotriptan • Tablet (6.25, 12.5 mg) • Frovatriptan • Tablet (2.5 mg) Zolmitriptan • Tablet (2.5, 5 mg) • Nasal spray (5 mg) Naratriptan • Tablet (1, 2.5 mg) Rizatriptan • Tablet (5, 10 mg)

  44. ROUTES OF ADMINISTRATION Oral therapies: most medications Nasal sprays: sumatriptan, DHE, butorphanol, zolmitriptan Injectable (SL, IM, IV) sumatriptan, DHE, injectable NSAIDs, opioids, neuroleptics Suppositories: antiemetics, ergots, opioids

  45. Increasing Speed Oral Parenteral Tablet IN IM/SC IV PR SL FORMULATION: ONSET

  46. Sumatriptan • Sumatriptan (Glaxo Wellcome) • 5-HT1B/1D agonist Major advance – good efficacy with subcutaneous formulation Slow onset (2–4 h p.o.); LogD -1.5 Short t1/2 (2 h) Ferrari et al (1995)

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