NEW TRENDS IN HEADACHE AND MIGRAINE TREATMENT

1. NEW TRENDS IN HEADACHE AND MIGRAINE TREATMENT Kathie Teta, RN, CPNP PANDA Neurology Atlanta, Georgia

2. OBJECTIVES • 1. Define concepts of a migraine headache and migraine variants from other headache types in the pediatric/adolescent population • 2. Discuss pathophysiology of migraine headaches • 3. Discuss indications for diagnostic testing for migraines • 4. Identify appropriate treatment strategies for acute migraine management

3. OBJECTIVES • 5. List types of preventive versus abortive treatments for headaches and migraines • 6. Discuss when referrals to pediatric neurology are needed for further evaluation and management

4. “So you think YOU’VEgot a Headache?!”

5. Migraine without aura • Moderate to severe pain: • Unilateral/bilateral • Throbbing/squeezing • 2 of 3 cardinal features: • Photophobia • Inability to function • Nausea/vomiting • Exertional worsening • Sound sensitivity • Duration of 4 to 72 hours

6. Migraine with aura • Similar to migraines without aura • 20 – 30 % migraneurs have aura (99% of these have visual auras) • Warning symptoms may include: • Visual disturbances • Numbness in arm or leg • Difficulty speaking • Warning symptoms last 5 – 6 minutes and typically are followed by headache pain

8. Chronic migraine • Headaches occurring on or > 15 days per month • Current or prior diagnosis of migraine • Lasting on average > 4 hours per day

9. Risk factors for chronic migraine • Obesity • Lowered social economic status • Stressful events • Snoring • Overuse of caffeine • Depression • Anxiety

10. Medication overuse headache • Use of over-the-counter medications more than 1 – 2 times per week • Overuse of abortive prescription medications

11. Migraine Variants • Abdominal migraines • Diffuse abdominal pain, sometimes associated with headache • Can last 1 – 72 hours • Benign paroxysmal vertigo • Usually occurs in toddlers and young children • Appear off balance, may refuse to walk • Can last minutes to hours • Cyclic vomiting • Occurs in school-age children • Forceful, frequent vomiting lasting 1 hour to 5 days

12. Incidence of migraine • 4 -5% of young children • 5 – 6% in preadolescents • Increases in adolescence • 18% women, 6% men as adults

13. Migraine Prevalence (%) Lipton RB, Stewart WF. Neurology. 1993. AGE- AND GENDER-SPECIFIC PREVALENCE OF MIGRAINE

14. PATHOPHYSIOLOGY OF MIGRAINE

15. The Migraine Process: Activation of Nerves and Blood Vessels

16. One Nerve Pathway, Multiple Symptoms, Multiple Manifestations of Migraine

17. Genetic basis • Strong family history of migraines

18. Avoid Triggers • Foods: • MSG, peanuts, chocolate, caffeine, cheese, nitrites • Chronobiology: sleep disturbance • Environmental: weather changes • Stress: school, family changes, moving • Physical: sports activities, heat • Letdown: weekends, vacation, end of projects

19. Differential diagnoses • Sinus infection • Nasal congestion • Nasal drainage • Pain over frontal or maxillary sinuses

20. Cranial Parasympathetic Activation May Explain“Sinus-Like” Symptoms in Migraine

21. Tension headache • Dull, aching, nonthrobbing • Not associated with vomiting • Pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas

22. Differential diagnoses • Brain lesion • Subarachnoid hemorrhage • Meningoencephalitis • Acute hydrocephalus • Chiari I malformation • Pseudotumor Cerebri

23. Chiari I malformation

25. Diagnostic testing • Imaging studies • CT vs MRI • If new onset severe headache • Hard to treat or progressive headaches • AM headaches/AM vomiting • Focal features on examination • Poor family history • Blood tests • R/O causes for fatigue, possible infection, thyroid abnormalities • Lumbar puncture • If concerns with papilledema

26. Treatment for migraines • Lifestyle modifications • Diet • Increase water • Decrease caffeine • Decrease nitrates • Sleep • Dealing with stress • Decrease use of over-the-counter medications • Phamacologic therapy

28. Goals of Acute treatment • Functional response (ability to return to normal activities) • Consistent and quick onset • Prevent headache recurrence • Well tolerated

29. Mechanisms of action of acute anti-migraine drugs • Cranial vasoconstriction • Peripheral neuronal inhibition • Modulates activity in neuroreceptors at multiple sites along trigeminal pathway

30. Acute Treatment Options for Migraines • Nonspecific: (for mild/moderate pain) • NSAIDs • Combination analgesics • Opioids • Neuroleptics/antiemetics • corticosteroids • Specific (for severe pain) • Triptans • Ergotamine (DHE)

31. Routes of Administration • Oral therapies: most medications • Nasal sprays: sumatriptan, zolmitriptan, DHE • Injectable: (SQ, IM, IV) sumatriptan, DHE, injectable NSAIDs, opioids, neuroleptics • Suppositories: antiemetics, ergots, opioids

32. Triptan use • Imitrex (sumatriptan) and Maxalt (rizatriptan) – usually tier 1 on insurance formularies • Use at early onset migraine • May repeat 1X in 2 hours if needed • Maximum 2 doses in 24 hours • Should be used no more than 2 times per week

33. GOALS OF PREVENTIVE TREATMENT • Decrease attack frequency (by 50%) duration and intensity • Improve responsiveness to acute treatment • Improve function and decrease disability

34. GUIDELINE: WHEN TO USE PREVENTIVE MEDICATIONS • Migraine significantly interferes with patient’s daily routine, despite acute Rx • Acute medications contraindicated, ineffective, intolerable AEs or overused • Frequent headache (>1 - 2 attacks per week) • Uncommon migraine conditions • Patient preference

35. Preventive Medication Groups • Calcium channel antagonists • Verapamil • Others • NSAIDs • Riboflavin • Magnesium • Petadolex • Feverfew • Anticonvulsants • Valproate • Gabapentin • Topiramate • Zonegran • Neurontin • Antidepressants • TCAs • SSRIs • MAOIs • ß-adrenergic blockers • Propranolol

36. Tailor Therapy Appropriately to Comorbid Conditions Adapted from Silberstein S. Headache in Clinical Practice. 2002:93. 56

37. Preventive Treatment Options • First line preventive treatment • Corticosteroids – for daily headaches that have been occurring for several weeks • Topamax (topiramate) - consider weight/eating habits • Amitriptyline – consider mood, sleep difficulties • Cyproheptadine – consider for young children • Calcium channel blockers/beta blockers – consider if mildly hypertensive

38. Nonpharmacologic Therapies Tested in Clinical Trials • Behavioral Treatments • Relaxation training* • Hypnotherapy • Thermal biofeedback training* • Electromyographic biofeedback therapy* • Cognitive/behavioral management therapy* Physical Treatments Acupuncture Transcutaneous electrical nerve stimulation (TENS) Occlusal adjustment Cervical manipulation *Proven effective in clinical trials Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000

39. New Trends in Migraine Management • Botox injections • Nerve blocks • Trigger point injections • Nerve stimulator trials • Transcutaneous sumatriptan (battery powered) • Livodex – inhaled DHE

40. Referral to Pediatric Neurology • Refer children and adolescents with headaches if: • Poor response to acute treatment • Uncertainty of diagnosis • Unusual features • Co-morbidities • Need for preventive treatment • Concerns or alarming findings on examination