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DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN

DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN. BASIL AL-SAIGH, FMR-2 JANUARY 2007 REGINA GENERAL HOSPITAL. BACKGROUND READING :. Diagnosis and Treatment of Migraine

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DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN

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  1. DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN BASIL AL-SAIGH, FMR-2 JANUARY 2007 REGINA GENERAL HOSPITAL

  2. BACKGROUND READING : • Diagnosis and Treatment of Migraine ROGER CADY, MD;DAVID W. DODICK, MDFrom the Headache Care Center, Primary Care Network, Springfield, Mo (R.C.); and Department of Neurology, Mayo Clinic, Scottsdale, Ariz (D.W.D.). • Answers to Frequently Asked Questions About Migraine IVAN GARZA, MD;JERRY W. SWANSON, MD From the Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minn. Dr Garza’s headache fellowship was partially supported by GlaxoSmithKline. • Prevention of Migraine in Women Throughout the Life Span BEVERLY S. TOZER, MD;ELIZABETH A. BOATWRIGHT, MD;PARU S. DAVID, MD;DEEPA P. VERMA, MD;JANIS E. BLAIR, MD;ANITA P. MAYER, MD;JULIA A. FILES, MD From the Division of Women’s Health Internal Medicine (B.S.T., E.A.B., P.S.D., D.P.V., J.A.F.), Mayo Clinic College of Medicine, Scottsdale, Ariz. Migraine in Men, Women and Children RGH, January 2007

  3. BACKGROUND READING : • Triptans. Are they all the same? Lead author: William A. Kehoe, Pharm.D., MA, FCCP, BCPS Prescriber's Letter U.S. 2002; 9(1):180105 • Supplements for Migraine Lead author: Gayle Nicholas Scott, Pharm.D., BCPS, ELS, Assistant Editor Canadian Prescriber's Letter 2005; 12(4):210414 • Drug Therapy for Children and Adolescents with Migraine Headaches Lead author: Neeta Bahal O'Mara, Pharm.D., BCPS Canadian Prescriber's Letter 2005; 12(3):210307 • Canadian Family Physician June 2005, pgs 838-843 Migraine in Men, Women and Children RGH, January 2007

  4. MIGRAINE IN PRIMARY CARE : • Overall prevalence – 1 migraineur / 4 households • Prevalence > asthma / diabetes combined • Most initially seek tx for HA in a primary care setting • Majority of patients who seek help for a HA have migraine • Median pain intensity 8/10 • Median attack duration 24 hours Migraine in Men, Women and Children RGH, January 2007

  5. MIGRAINE IN PRIMARY CARE Cont’d : • 1/3 of migraineurs miss 1 day of work in a 3 month period • Most patients seek care from a primary care physician • 3 : 1 Female : Male prevalence Migraine in Men, Women and Children RGH, January 2007

  6. SPECTRUM OF HA : • Pt.’s with clinically relevant migraine experience spectrum of HA presentations – Migraine / Migrainous / Tension-Type HA • All respond equally well to migraine-specific medications • Similar underlying biology? • HA expereinced by migraine sufferers differs more in degree vs type Migraine in Men, Women and Children RGH, January 2007

  7. CATEGORIES OF THE INTERNATIONAL HEADACHE SOCIETY CLASSIFICATION SYSTEM : 1.Migraine 2.Tension-type headache 3.Cluster headache and chronic paroxysmal hemicrania 4.Miscellaneous headache not associated with structural lesions 5.Headache associated with head trauma 6.Headache associated with vascular disorders 7.Headache associated with nonvascular intracranial disorder 8.Headache associated with substance use or withdrawal 9.Headache associated with noncephalic infection 10.Headache associated with metabolic disorders 11.Headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structure 12.Cranial neuralgias, nerve trunk pain, and deafferentation pain 13.Headache not classifiable Migraine in Men, Women and Children RGH, January 2007

  8. SPECTRUM OF HA Cont’d : • “Thus, the academic headache community no longer supports the concepts or use of the terms mixed headache disorder, tension-vascular headaches, vascular headaches, or muscle-contraction headaches. These terms imply different headache types with a different pathophysiological basis, and they are incompatible with the current construct of migraine as a paroxysmal neurologic disorder that is initiated within the central nervous system rather than a disorder of cerebral blood vessels.” Migraine in Men, Women and Children RGH, January 2007

  9. PRIMARY VS SECONDARY HA : • HA + Onset in adolescence or early adulthood – Primary HA • HA + Stable pattern of similar HA over 6 months or more – Primary HA • HA + FHx of HA – Primary HA • HA + Association with mensturation – Primary HA • HA + Variable site of HA from attack to attack – Primary HA Migraine in Men, Women and Children RGH, January 2007

  10. PRIMARY VS SECONDARY HA Cont’d : • HA + Sudden onset – Secondary HA • HA + Onset > age 40 – Secondary HA • HA + New type – Secondary HA • HA + New Level of Pain “Worst HA ever” – Secondary HA • HA + Exertion / Valsalva – Secondary HA • HA + Neurological changes – Secondary HA • HA + HIV/malignancy – Secondary HA • HA + Interrupts sleep – Secondary HA Migraine in Men, Women and Children RGH, January 2007

  11. IMAGING : • Recent significant change • pattern, frequency, or severity • Progressive worsening • in spite of appropriate treatment • Focal neurologic signs or symptoms • Onset of headache with exertion/cough • Onset of headache after age 40 • Orbital bruit Migraine in Men, Women and Children RGH, January 2007

  12. CRITERIA FOR DX OF MIGRAINE : • At least 5 attacks fulfilling criteria B-D • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) • Headache has at least 2 of the following characteristics: • Unilateral location • Pulsating quality • Moderate or severe pain intensity • Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs) Migraine in Men, Women and Children RGH, January 2007

  13. CRITERIA FOR DX OF MIGRAINE : • During headache at least 1 of the following • Nausea and/or vomiting • Photophobia and phonophobia • Not attributed to another disorder Migraine in Men, Women and Children RGH, January 2007

  14. SCREENERS FOR DX OF MIGRAINE : • Aura is not present in 2/3 of patients • Identification of Migraine Screener : • Are you nauseated or sick to your stomach when you have a headache? • Have your HA limited your activity for a day or more in the last 3 months? • Does light bother you when you have a HA? • If 2/3 positive : PPV 93 percent for migraine • If 3/3 positive : PPV 98 percent for migraine Migraine in Men, Women and Children RGH, January 2007

  15. SCREENERS FOR DX OF MIGRAINE Cont’d : • INFOPOEM CMA Criteria for Dx Migraine HA • POUNDing • P – Pulsatile Quality • O – 4-72 hOurs duration • U – Unilateral location • N – Nausea and Vomiting • D – Disability and intensity Migraine in Men, Women and Children RGH, January 2007

  16. COMMON MIGRAINE TRIGGERS : • Sleep (too much or too little) ** • Schedule Change • Alcohol **   • Caffeine **  • Certain foods   • Odors   • Weather change • Head or neck pain   • Trauma  Migraine in Men, Women and Children RGH, January 2007

  17. COMMON MIGRAINE TRIGGERS : • Fasting or skipping meals **   • Hunger • Environmental factors   • Altitude   • Light glare or visual stimuli • Medications   • Physical exertion   Migraine in Men, Women and Children RGH, January 2007

  18. COMMON MIGRAINE TRIGGERS : • Hormonal changes   • Menopausal fluctuations   • Menstruation ** • Exercise   • Sexual activity • Stress and anxiety ** Migraine in Men, Women and Children RGH, January 2007

  19. ACUTE MEDICATIONS FOR THE TX OF MIGRAINE : • NON-SPECIFIC ANALGESICS • Acetaminophen • ASA • NSAID • Opiates • Combination Analgesics (ASA/Acetaminophen/Caffeine/Codeine/Butalbital) • Antiemetics • SPECIFIC ANALGESICS • Dihydroergotamine (DHE) • Triptans Migraine in Men, Women and Children RGH, January 2007

  20. APPROACHES TO TREATMENT : • STEP CARE • Initiate acute HA therapy with inexpensive low-end medications and establishing failure before using more specific medications • Start with OTC products, then try NSAID’s, then combination analgesics, and so forth • STRATIFIED CARE • Medications based on headache characteristics • High-end therapy for patents with severe HA, and so forth • If failure is established on low-end therapy, move up to higher-end therapy Migraine in Men, Women and Children RGH, January 2007

  21. APPROACHES TO TREATMENT : • STEP CARE WITHIN ATTACK CARE • Low end medications at beginning of migraine attack and then advance to a stronger compound if not effective. • Beneficial in patients with slow to develop migraines, of mild-moderate severity • PATIENT-CENTERED STRATIFIED CARE • Educating migraineurs so that they determine treatment need based on the individual HA characteristic Migraine in Men, Women and Children RGH, January 2007

  22. ACUTE TX OF MIGRAINE HA : • Ambulatory : • High dose NSAID +/- antiemetic • DHE (Nausea) • Triptan (expensive, but effective) • In the ER : • Triptan? • IV proclorperazine 10 mg • IV DHE 1mg + metoclopramide 10 mg Migraine in Men, Women and Children RGH, January 2007

  23. ACUTE MIGRAINE TX IN CHILD/ADOLESCENTS : • Ibuprofen • Most studied medication • Safe and effective • Acetaminophen • Probably effective and well tolerated • Sumatriptan • Nasal spray effective • Inadequate data for SC or PO use • Other triptans have inadequate data to support their use Migraine in Men, Women and Children RGH, January 2007

  24. TRIPTANS FOR ACUTE TX OF MIGRAINE : • ALMOtriptan – ELEtriptan – FROVAtriptan – NARAtriptan – RIZAtriptan – SUMAtriptan – ZOLMItriptan • All are 5-HT 1B/D agonists • Induce vasoconstriction of cranial blood vessels • Help decrease release of neuropeptides responsible for vasodilation and pain pathways involved in the Trigeminal Nerve • Vs Ergots : also bind to dopamine and adrenergic receptors – thus worse side effect profile • Compared on basis of response 2 hour after medication Migraine in Men, Women and Children RGH, January 2007

  25. TRIPTANS FOR ACUTE TX OF MIGRAINE Cont’d : • Frovatriptan / Naratriptan less effective orally • Rest have 2-hour response rates b/w 57 – 77 percent • Great interindividual variation in patient preference and response rate • Poor response to one does not mean ALL will be ineffective • Initial choice of triptan often driven by patient’s health plan formulary Migraine in Men, Women and Children RGH, January 2007

  26. TRIPTANS FOR ACUTE TX OF MIGRAINE Cont’d : • If N and V early in attack, nasal spray (sumatriptan / zolmitriptan) or SC injection (sumatriptan) preferred • Most S/E include facial flushing, tingling, chest discomfort Migraine in Men, Women and Children RGH, January 2007

  27. TRIPTAN CONTRAINDICATIONS : (Due to minor peripheral vasoconstrictive properties on coronary vessels) • IHD • CVD • PVD • Uncontrolled HTN • Avoid if patient used Seratonin Agonist/Ergot in past 24 hours Migraine in Men, Women and Children RGH, January 2007

  28. TRIPTAN FAILURE : • Troubleshooting a treatment failure with Triptans • May not be taking it early in attack, when they are most effective • Consider higher dose • Consider SC or Nasal Spray route if N and V • Consider anti-emetic • Consider adding NSAID • Flexible approach is necessary Migraine in Men, Women and Children RGH, January 2007

  29. FREQUENCY OF USE OF ACUTE MEDICATIONS : • Can cause Medication-Overuse HA • Highest risk – Opioids / butalbital-containing combination analgesics / ASA-Acetominophen/Caffeine combinations • 3 or fewer days / month • Moderate risk – Triptans • 9 or fewer days / month • Low risk – NSAID • 15 or fewer days / month Migraine in Men, Women and Children RGH, January 2007

  30. PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE : • Recurring migraine that interferes with activities of DL despite acute tx • > 2 such HA / week • Failure / overuse / CI to acute tx • ADE of acute tx • Presence of Hemiplegic Migraine / Basilar Migraine / Migraine with prolonged aura Migraine in Men, Women and Children RGH, January 2007

  31. PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d : • Goal of prophylaxis • Reduce attack frequency, severity, duration • Improve response to acute medications • Improve function / reduce disability • Decrease cost of migraine management • Define an “Effective Agent” to the patient such that realistic goals are set • Patient should expect 50 percent reduction in frequency of attacks Migraine in Men, Women and Children RGH, January 2007

  32. PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d : • Should be used one at a time • Efficacy of combination treatment is limited • Start low, go slow • Maximum clinical benefit can take as long as 3 months • HA diary helps document response to prophylactic tx Migraine in Men, Women and Children RGH, January 2007

  33. PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d : • Can attempt to taper prophylactic medications in 6-12 months if HA have been under good control • Patients may choose to continue tx for longer periods : acceptable option Migraine in Men, Women and Children RGH, January 2007

  34. PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d : • B Blockers – Propranolol • TCA – Amitryptaline • Non-DHP CCB – Verapamil • SSRI • Anticonvulsants – Valproic Acid • AED – Gabapentin, Topiramate • Choice can be driven by therapeutic opportunities • Patient preference is paramount Migraine in Men, Women and Children RGH, January 2007

  35. ROLE OF COMBINED ACUTE AND PROPHYLACTIC TREATMENT OF MIGRAINE : • Imperative ! Migraine in Men, Women and Children RGH, January 2007

  36. SUPPLEMENTS FOR MIGRAINE : • “But, if a patient tells you about a product that works for him and it's not potentially toxic, it's probably best not to refute his claim by explaining that the product hasn't been clinically proven. An explanation of evidence-based medicine to a patient who is not getting relief from conventional treatment may be perceived as arrogance. For some patients, migraine remedies that are unproven, but not toxic nor unreasonably expensive, may fall into the "worth a try" category” Migraine in Men, Women and Children RGH, January 2007

  37. SUPPLEMENTS FOR MIGRAINE Cont’d : • 40 percent of patients with migraine respond to placebo • Study to compare effectiveness of fish oil for migraine, olive oil (the placebo) was similar in efficacy to the first • American Academy of Neurology recognizes Feverfew, Riboflavin and Mg as preventative tx of migraine • Some conventional tx of migraine also lack proof as the other supplemental treatments • Many natural products fit the description of inexpensive, and possibly effective with minimal risk of toxicity for prophylaxis Migraine in Men, Women and Children RGH, January 2007

  38. SUPPLEMENTS FOR MIGRAINE Cont’d : • Feverfew [A] • 50 to 100 mg capsules daily • Riboflavin [A] • Reduces frequency but not severity or duration • 400 mg per day • Precursors of nucleotides needed for activity of enzymes in the ETC • Ginger • Anecdotal reports suggest that ginger, ginko and valerian might help • No reliable research thus far Migraine in Men, Women and Children RGH, January 2007

  39. SUPPLEMENTS FOR MIGRAINE Cont’d : • Mg [A] • Helpful especially in those with low levels • GI S/E • Butterbur [A] • Reduces frequency, duration and intensity of attacks • Potential cause of allergy in pt’s allergic to ragweed/related plants • Caffeine/ASA or Acetaminophen [A] • Melatonin not yet recommended b/c it is too early Migraine in Men, Women and Children RGH, January 2007

  40. SUPPLEMENTS FOR MIGRAINE Cont’d : • L-Arginine • Has been used in combination with Ibuprofen • Contribution of Arginine unclear as Ibuprofen alone relives migraine • CoQ10 [A] • Favorable • Impaired O2 metabolism and low energy states implicated in pathogenesis of Migraine • Improves mitochondrial oxidative phosphorylation • Watch for patients on Warfarin as might reduce anticoagulant effect Migraine in Men, Women and Children RGH, January 2007

  41. BOTULINUM TOXIN FOR PROPHYLAXIS OF MIGRAINE : • RCT thus far have yielded mixed results • “Many HA specialists believe that it is effective in a subset of patients” • Currently it is routinely part of a HA specialist’s armamentarium for migraine prevention • Injected pericranially, and tx repeated Q3 months if beneficial • Ptosis, frontal m. weakness, and local injection site pain are mild and temporary Migraine in Men, Women and Children RGH, January 2007

  42. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • MC in women than men, by a ratio of 3 : 1 • MC than DM, OA or asthma • MC occurs in reproductive years • Menstruation, pregnancy, OCP use, menopause, HRT influence incidence of migraine and subsequent management Migraine in Men, Women and Children RGH, January 2007

  43. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • CHILDHOOD • In 4-7 y/o, boys get migraine > girls • By puberty, girls get migraine > boys by 3 : 1 • Shorter in duration (1-48 vs. 4-72), peak to intensity more quickly (w/in 1 hour), bilateral rather than unilateral • More common to see migraine variants – hemiplegic migraine, basilar migraine, cyclic vomiting • Stress is a more common trigger in children Migraine in Men, Women and Children RGH, January 2007

  44. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • CHILDHOOD • More on weekdays than on weekends • Ibuprofen is proffered over Tylenol or triptans due to lack of evidence • 1/3 require prophylactic tx • Topiramate preferred for obese patients for weight reducing side effects Migraine in Men, Women and Children RGH, January 2007

  45. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • MENSTURAL MIGRAINE • 60 percent have migraines associated with menstrual cycles • Migraine without aura MC than with aura • ? Related to decline in Estrogen in late luteal phase of cycle • Miniproprophylaxis with NSAID’s, ergots and triptans Migraine in Men, Women and Children RGH, January 2007

  46. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • USE OF OCP • Unpredictably induce, alter or alleviate migraines • If OCP’s exacerbate symptoms, lower OCP to an EE of less than 20 mgm • Persistent HA despite above might necessitate OCP’s in these patients Migraine in Men, Women and Children RGH, January 2007

  47. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • USE OF OCP • Both migraine and OCP’s increase stroke risk • Migraineurs with aura or other RF for stroke should be assessed individually for appropriate OCP use • OCP’s should not be used in migraineurs who smoke Migraine in Men, Women and Children RGH, January 2007

  48. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • PREGNANCY • 50-80 percent of 1st trimester pregnancies in ladies with migraine cause a decrease in migraine frequencies • Secondary causes should be considered in pregnant patients who experience migraine for the first time during a pregnancy • Avoid preventative medications b/c of potential for teratogenecity Migraine in Men, Women and Children RGH, January 2007

  49. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • PREGNANCY • Topiramate or propranolol are a last measure • Definitely avoid valproic acid or ergot derivative-medications Migraine in Men, Women and Children RGH, January 2007

  50. PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN : • MENOPAUSAL TRANSITION • Fluctuations in hormone levels can exacerbate migraines • Continuous use low-dose OCP can provide necessary contraception and migraine control • Migraine improves after menopause as hormone levels stabilize Migraine in Men, Women and Children RGH, January 2007

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