Understanding Migraine From Diagnosis to Treatment

1. Understanding Migraine From Diagnosis to Treatment Sponsored Through an Educational Grant from Merck & Co., Inc.

2. Introduction • Welcome to a patient’s guide to understanding migraine • What is migraine? • How does migraine impact patients and families? • What causes migraine? • How is migraine diagnosed? • What are your treatment options?

3. What Is Migraine? • A neurological disorder characterized by hyperexcitability of the nervous system • You don’t get migraines, you have migraine • Your body is more sensitive to stimuli that can cause a headache attack • Defining characteristics • Recurrent headache attacks lasting 4-72 hours • One-sided, pulsating, moderate-to-severe pain • Presence of 2 of 3 key characteristics: inability to function, photophobia/phonophobia, nausea/vomiting International Headache Society classification criteria (Cephalalgia. 2004;24, suppl 1).

4. Before or during an attack Feeling of well-being or surge of energy Talkativeness or restlessness Increased appetite Drowsiness or depression Irritability or tension During an attack Nausea, vomiting, or diarrhea Sweating or cold hands Sensitivity to light or sounds Scalp tenderness or pressure pain Pale color Pulsing pain Some Common Symptoms of Migraine

5. Types of Migraine

6. Migraine With Aura: Example

7. How Many People Have Migraine? • 12% of adults (30 million patients in the US) • Most common between ages 15 and 55 • More common among women (17%) than men (6%) Centers for Disease Control and Prevention and American Migraine Prevalence and Prevention study results (Lipton RB et al. Neurology. 2007;68:343-349).

8. How Does Migraine Impact Patients and Families? Headache-Related Impairment During a Severe Attack American Migraine Prevalence and Prevention study results (Lipton RB et al. Neurology. 2007;68:343-349).

9. How Does Migraine Impact Patients and Families? Disability (MIDAS Score) MIDAS = Midgraine Disability Assessment. American Migraine Prevalence and Prevention study results (Lipton RB et al. Neurology. 2007;68:343-349).

10. How Does Migraine Impact Patients and Families? School, Work, and Social Impact in Previous 3 Months American Migraine Prevalence and Prevention study results (Lipton RB et al. Neurology. 2007;68:343-349).

11. What Causes Migraine? 3 Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness 4 Chemicals in the brain cause blood vessel dilation and inflammation ofthe surrounding tissue 5 The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain 2 Electrical impulses spread to other regions of the brain 1 Migraine originates deep within the brain

12. The Stages of a Migraine Attack Adapted from Cady, Headache Q.2001;12(suppl 1):3-8, with permission

13. Migraine and Women • Hormonal fluctuation plays an important role in migraine for many women • 60% of women with migraine experience “menstrual migraine” • Headaches are associated with changes in estrogen levels right before menses and most often occur up to 2 days before or during menses • Oral contraceptives may either exacerbate or alleviate the frequency, severity, and duration of headaches • Headaches are not anormal part of menstruation Dzoljic. MacGregor EA et al. Neurology. 2006;67:2154-2158. MacGregor EA, Hackshaw A. Neurology. 2004;63:351-353. NHF. Women & Migraine. www.headaches.org.

14. Menstrual Migraine • Menstrual migraine differs somewhat from other migraine • Pain may persist longer and be more severe • Headache attack is more likely to be accompanied by nausea or vomiting • Headache occurs more frequently • Menstrual migraine is more difficult to treat Granella F et al. Headache. 1993;33:385-389. Couturier EGM et al. Cephalalgia. 2003;23:302-308. MacGregor EA. J Fam Plan Reprod Health Care. 2007;33:36-47.

15. Migraine and Men • Recent online survey by NHF showed that migraine is the most common headache diagnosis in men (36%) • Yet, many men do not discuss migraine with their healthcare practitioners • Nearly 1/3 of men suffering from headache have not been diagnosed • Nearly 1/4 did not visit their doctor because they felt they should “tough it out” NHF. Migraine: Not Just a “Woman’s Disease.” www.headaches.org.

16. How Is Migraine Diagnosed? • Complete medical history, including headache history • Physical exam • Potential additional evaluations • MRI (magnetic resonance imaging) • CT (computed tomography) scan • Other • Possible referral to a specialist • Neurologist • Other specialist

17. Communicate Symptoms to Your Healthcare Provider • Describe the headache • Where is the pain? How long does it last? How often do you have a headache? • How do you feel before, during, and after? • Is there an aura? • Do you have other symptoms? • Nausea, vomiting or diarrhea • Sensitivity to light or sound • Other symptoms

18. Keep a Headache Diary • Record • Frequency, severity, and duration of headache • Treatments you used and how well they worked • Possible triggers (environmental, diet, stress, sleep, changes in daily routine) • Keep the diary for at least 1 month • Look for patterns and share the results with your healthcare provider • Download a diary at: www.headaches.org

19. Other Information to ShareWith Your Provider • Are you taking any medications? • Include prescription, over-the-counter, and nutritional supplements • Do others in your family have headaches? • Is your headache affected by menses? • Describe your habits • Sleep, smoking, caffeine and alcohol intake, and exercise

20. What Are Your Treatment Options? • Lifestyle modification • Nonpharmacologic and complementary therapies • Acute medications • Preventive medications • Combinations of treatments

21. Lifestyle Modification for Migraine • Eat healthfully and regularly; do not skip meals • Get enough sleep, but do not oversleep • Keep a regular sleep schedule • Keep well hydrated • Exercise regularly • Rest during a migraine, and do not overexert afterward • Reduce your stress • Identify your triggers and avoid when possible

22. Nonpharmacologic and Complementary Therapies • Relaxation training • Hypnotherapy • Biofeedback training • Cognitive/behavioral management • Acupuncture • Nutritional supplements (B2 and others) • Physical therapy and/or massage

23. Acute Medications for Migraine • Triptans • Almotriptan (Axert) • Rizatriptan (Maxalt) • Eletriptan (Relpax) • Sumatriptan (Imitrex) • Frovatriptan (Frova) • Zolmitriptan (Zomig) • Naratriptan (Amerge) • Ergotamine derivatives (eg, DHE) • Over-the-counter pain killers (acetaminophen, ibuprofen, naproxen, and combinations of aspirin/acetaminophen/caffeine) • Prescription pain killers (used infrequently)

24. When Should You Take Your Acute Migraine Medicine? • Triptans need to be taken as soon as you recognize an attack • Many patients wait too long • There is no need to suffer during an attack • Triptans work best in the first couple of hours of an attack • Dihydroergotamine works at any time during an attack • Do not overuse acute medications • Talk to your healthcare provider if you take an acute medication more than 2 times per week

25. Factors That May Influence Choice of Treatment • Symptoms • Oral medications will not work if you vomit • Patient preference • Injections work fast, but are harder to use • Nasal spray is convenient, but there are fewer choices available • Maxalt and Zomig do not require water • How fast the medication works and how long it keeps working • Other medications you are taking

26. Preventive Medicationsfor Migraine • Preventive medications are taken every day to reduce the frequency and severity of headache attacks • Approved therapies include • Beta blockers (propranolol, timolol maleate) • Anticonvulsants (divalproex sodium, topiramate) • Serotonin antagonist (methysergide maleate) • Other (antidepressants, other serotonin antagonists, NSAIDs)

27. Combination Treatment • Some patients benefit from a combination of acute and preventive therapies • Even when taking a preventive medication, keep an acute medication on hand to treat breakthrough attacks • Menstrual migraine may be treated with short term prevention (also known as mini-prophylaxis), or preventive treatment before and during menses, with acute medication for breakthrough attacks

28. Some Medications May Cause Migraine to Become Chronic • May cause chronic headaches • Opiates • Combination OTC analgesics (including sinus medications and combinations that contain caffeine) • Caffeine • Barbiturate-containing medications • Ergotamine tartrate, isometheptene • Triptans • Others • Not clearly associated with chronic headaches: acetaminophen, aspirin, DHE, others

29. Summary • Migraine is a common, chronic condition of the nervous system • Migraine can cause substantial impairment, affecting both patients and their families • Migraine is treatable • Lifestyle modification • Nonpharmacologic therapies • Acute and preventive medications • Learn how to manage your migraine

30. The National Headache Foundation • For more information about headache causes and treatments, visit the National Headache Foundation (NHF) Web sitewww.headaches.org • A online database of NHF physician members is available on the NHF Web site