Evidence-Based Management of Migraine

1. Evidence-Based Management of Migraine Robert L. Ringler, Jr., MD FAAFP

2. Evidence New info? Maybe not….. What interventions have level A or level B evidence? A = Data supporting this statement derived from level 1 studies -> meet all of the evidence criteria for that study type B = Data supporting this statement derived from level 2 studies -> meet at least one of the evidence criteria for that study type ACP PIER (Physician’s Information and Education Resource), DynaMed

3. Study Types Clinical prediction guides Causation Diagnosis Differential diagnosis Prevention or Treatment Prognosis Quality improvement or Continuing education Economics of health care programs or interventions Systematic review articles

4. Screening 3 questions have validity for self-administered screening for migraine in primary care “Has a headache limited your activities for a day or more in the last three months?” “Are you nauseated or sick to your stomach when you have a headache?” “Does light bother you when you have a headache?”

5. Screening 3-item subset of disability, nausea & photophobia had: 81% sensitivity 75% specificity 93% positive predictive value 68% test-retest reliability for migraine based on semi-structured diagnostic interview (Neurology 2003 Aug 12;61(3):375), commentary in Evidence-Based Medicine 2004 Mar-Apr;9(2):56

6. Diagnosis Evaluate symptoms to distinguish migraine from tension-type or other types of headache in patients with normal neurologic exam [B - level 2 (mid-level) evidence] P ulsatile quality – described as pounding or throbbing O ne-day duration – episode lasts 4-72h if untreated U nilateral location N ausea or vomiting D isabling intensity – usual daily activities altered during episode Post-test probability 4 / 5 criteria – positive likelihood ratio 24 for definite / possible migraine 3 / 5 criteria – positive likelihood ratio 3.5 for definite / possible migraine 0-2 criteria has negative likelihood ratio 0.41

7. Laboratory tests Recognize that neuroimaging is not usually warranted for migraine patients with a normal neurologic exam [B - level 2 (mid-level) evidence] Apply lower threshold only for patients with atypical headache features or those who don’t meet strict definition of migraine Meta-analysis of studies of migraine pts with normal neuro exam found a rate of significant intracranial lesions of 0.18%

8. Hospitalization Consider hospitalization for pts with intractable migraine and “medication overuse” / “rebound” headache [B - level 2 (mid-level) evidence] Parenteral dihydroergotamine (DHE) Phenothiazines Corticosteroids Parenteral analgesics

9. Non-Drug Therapy: Diet Encourage patients to identify and avoid diet-related factors that may contribute to headaches [B - level 2 (mid-level) evidence] Caffeine withdrawal Nitrates and nitrites in preserved meats Phenylethylamines in aged cheeses, red wines, beer, champagne, chocolate, & MSG in Asian & other prepared foods Dairy products Fatty foods

10. Non-Drug Therapy: Behavioral Consider specific behavioral therapies for migraine patients, including relaxation training, biofeedback, or cognitive-behavioral therapy [AB - mix of level 1 (high-quality) and level 2 (mid-level) evidence] Preference for non-drug interventions Poor tolerance for specific Rx Medical contraindications for specific Rx Insufficient or no response to Rx Pregnancy, planned pregnancy, or nursing Hx of long-term, frequent, or excessive use of analgesic or acute Rx that can aggravate HA problems Significant stress or deficient stress-coping skills

11. Drug Therapy: Nonspecific Use nonspecific therapy with acetaminophen or NSAIDs for pts with mild-moderate attacks w/o severe N/V [A - level 1 (high-quality) evidence] Effective Less costly Less likely to cause adverse effects Naproxen 750mg initially, 500mg 1h later (or 660/440 if you use OTC) Aspirin 1,000 mg effective for acute migraine [A - level 1 (high-quality) evidence];

12. Drug Therapy: Specific Use Rx designed specifically for treating migraines in pts with severe attacks [A - level 1 (high-quality) evidence] Triptans – use first: more effective and cause less nausea Your oral triptan of choice Other delivery systems (sublingual, nasal, SQ) 3 HA without effect – switch dose or drug If not effective with first dose, don’t use second 70% rule Dihydroergotamine (DHE) Ergotamine All contraindicated in pts with CAD More effective than “stepped care”

13. Drug Therapy: Nausea Recognize that many migraine pts require specific Rx for N&V that is associated with their migraine attacks [AB - mix of level 1 (high-quality) and level 2 (mid-level) evidence] Metoclopramide (and some other antiemetics) + NSAIDs effective IV metoclopramide effective as monotherapy for HA and N/V Oral or rectal antiemetic with mild nausea – allows use of oral analgesics Non-oral route for antiemetics and migraine-specific drugs in pts with severe N or V

14. Drug Therapy: Rescue Provide a pt-administered rescue Rx and a plan for its use to migraine pts who have attacks that cause disability [AB - mix of level 1 (high-quality) and level 2 (mid-level) evidence] Opiate analgesics To be used if no relief within 1 hour Written plan: Not more than 2 doses per week or more than 50% of attacks

15. Drug Therapy: Prevention Consider preventive Rx in pts with frequent disabling HAs or poor relief from appropriately used acute treatments [A - level 1 (high-quality) evidence] Recurrent HAs that interfere with daily routine Contraindication to acute (abortive) therapy Failure or overuse of acute therapy Adverse effects from acute therapy A preference for preventive therapy Uncommon migraine (e.g. basilar migraine or hemiplegic migraine)

16. Drug Therapy: Prevention Choose among the following effective classes of agents, listed in order of strength of evidence for efficacy: Non-ISA ß-antagonists Propranolol (80-320 mg/day) Timolol (10-60 mg/day) Anticonvulsants Valproic acid (250 mg twice daily, maximum 800-1500 mg/day) Topiramate (100 mg/day) Antidepressants, calcium antagonists Amitriptyline (10-150 mg/day) Verapamil (80-240 mg/day)

17. Drug Therapy: Prevention Consider perimenstrual preventive treatment with a triptan for menstrual migraines Frovatriptan 2.5mg BID starting 2d before onset, continuing for 6d Valproate is the only antiepileptic drug approved by the FDA for migraine prevention Topiramate is also used Try a preventive Rx for at least two months before changing the agent Expected 33-50% reduction in migraine frequency; effectiveness is “bottom up”

18. Drug Therapy: Prevention SSRIs appear ineffective for migraine prophylaxis [B - level 2 (mid-level) evidence] Riboflavin has very limited evidence of efficacy [B - level 2 (mid-level) evidence] Riboflavin 400 mg/day for 3 months may reduce frequency of migraine attacks Recent evidence indicates ACE inhibitors may also be effective for prophylaxis

19. Patient Education Develop a plan for the self-management of acute attacks, including limits on dosing, rescue medication, and a plan for how and when to contact a healthcare provider [A - level 1 (high-quality) evidence] Identifies all treatment modalities used, including those used for coexisting conditions Includes a coordinated treatment plan that all parties acknowledge and accept (e.g. patient, primary care physicians, ED, neurologist, psychologist) Can be effectively communicated to the patient

20. Follow-up Consider prospectively monitoring symptoms with a HA diary to estimate effectiveness more objectively if the subjective assessment of initial Rx effectiveness is not clear [B - level 2 (mid-level) evidence] User-friendly Measure: attack frequency, severity, duration, disability, type of treatment, treatment response, and adverse effects of Rx http://www.achenet.org/resources/diary.php

21. Questions?