Migraine

1. Migraine Primary Care Conference July 29, 2010 Samuel Ash, MD Resident, Internal Medicine University of Washington samash@uw.edu

2. Outline • Cases • Epidemiology • Costs • Pathophysiology • Diagnosis • Treatment • Abortive • Preventative • Special considerations • Summary

3. Cases • Case Number 1: 32 year old woman with no other significant medical history who states that she has frequent severe headaches and has previously been diagnosed with migraine.

4. Cases • Case Number 2: 43 year old woman with self-reported history of: • Migraine without aura • Seizure disorder • Depression • Anxiety • PMDD • Chart history of: • Axis II, cluster B disorder • Benzodiazepine and opiate dependence/abuse

5. 1 year prevalence: overall: 11.7% women: 17.1% men: 5.6% additional 4.5% have "probable migraine“ Lifetime prevalence: Women: 25% Men: 8% Epidemiology Image from yourhealth.net.au

6. Epidemiology

7. Chronic migraine: 1-year period prevalence 1-2% Migraine among neurologists 50% prevalence Migraine among headache specialists 75% prevalence Epidemiology

8. Famous migraineurs (suspected or known) Lewis Carroll Elvis Presley Joan of Arc Elizabeth Taylor Julius Caesar Napoleon Bonaparte Thomas Jefferson Ulysses Grant Frederich Nietzsche Sigmund Freud Claude Monet Alexander Graham Bell Terrell Davis Epidemiology http://www.aiws.info/

9. Cost to Society • Direct Costs: • Total cost of annual medical care: • Family with migraineur: $7007 per year • Family without migraineur: $4435 per year • National Burden: $11 billion • $4.6 billion was in prescription drugs • $5.2 billion in outpatient costs • $0.5 billion in ER • $0.7 billion in inpatient costs

10. Cost to Society • Indirect Costs: • Estimated to be approximately $13.3 billion • Due to missed work days and impaired work performance • Does not include: • unemployment or underemployment • burden experienced between attacks • lost home-worker time due for chores • lost time because of caring for family members with migraine.

11. Pathophysiology ?

12. Genetics • Familial hemiplegic migraine • Three different abnormal genes • Mutations relate to ion channel function and neuronal hyperexcitability

13. Genetics

14. Pathophysiology • Syndromic approach with migraine as “final common pathway” • Maladaptive activation of trigeminal cervical pain apparatus • Early warning system to protect the brain and cervical cord from injury

15. Aura cortical spreading depression initially decreased and then increased blood flow may be related to initiation of migraine Pathophysiology Image courtesy of http://migraine.co.nz/

16. Pathophysiology • Micro-emboli • Increased prevalence of PFO in patients with migraine with aura • Uncontrolled of PFO closure trials promising • Controlled studies thus far not as promising

17. Types of Migraine • Migraine without aura (common migraine) • Migraine with aura (classic migraine) • Typical aura with migraine headache • Typical aura with non-migraine headache • Typical aura without headache • Familial hemiplegic migraine • Sporadic hemiplegic migraine • Basilar-type migraine

18. Diagnosis • International Classification of Headache Disorders (ICHD) • Very detailed set of criteria available at: http://www.ihs-classification.org/en

19. Diagnosis • Alternative (ie shorter) history: • POUND • Pulsatile quality of headache • One day duration (usually 4-72 hours) • Unilateral location • Nausea or vomiting • Disabling intensity • 3/5 criteria = likely migraine • 4/5 criteria = very likely to be migraine

20. Diagnosis • Prodrome vs. Aura • Prodrome • Euphoria, depression, fatigue, hypomania, food cravings, dizziness, cognitive slowing, or asthenia • Occurs in 60-70% of migraine patients • Aura • Visual changes, loss of vision, hallucinations, numbness, tingling, weakness, or confusion • Occurs in 15-20% of migraine patients

21. Diagnosis • Consider headache diary to better determine triggers, etc. http://www.relieve-migraine-headache.com/diary-headache-migraine.html

22. Developmental History • Childhood periodic syndromes that are commonly precursors of migraine • Cyclical vomiting • Abdominal migraine • Benign paroxysmal vertigo of childhood

23. Alarm Features

24. Alarm FeaturesBased on History • Changes in headache pattern/freq/intensity • Daily headache • Blurred vision • Dizziness/syncope/discoordination/focal neuro deficits • Sudden/explosive onset • Pain worse with coughing • Change in personality • Headache that wakes you up from sleep • Onset after 50 years of age

25. Alarm FeaturesBased on Physical • Vitals: fever or hypertension (diastolic >120) • Mental status change • Meningeal signs • Diminished pulse or tenderness of temporal artery • Focal neurologic deficits: including visual acuity • Papilledema • Intraocular pressure • Necrotic or tender scalp lesions • Other signs of infection

26. Labs • ESR • Indicated for new onset headache if age>50 • Screens for temporal arteritis and other vasculitides • Obtain even if symptoms consistent with migraine • Headache is predominant feature in 65-80% of patients with temporal arteritis

27. Neuro-Imaging

28. Neuro-Imaging • Consider if: • Atypical migraine features • Substantial change in headache pattern • Signs or symptoms of neurologic abnormalities

29. EEG • Consider only if associated symptoms suggest a seizure disorder. • No useful headache subtype groups are defined by EEG • EEG is not able to identify patients with structural cause of headaches

30. Treatment • “My migraine only gets better with that ‘d’ drug. You know, d…d…dilaudid…” • “My dilaudid only works IV and only if I get at least 8mg at once.” • “I have to get benadryl with it or I get itchy – I need 50mg… It has to be IV.” • “I’m sooo nauseated too. I’m allergic to all the anti-nausea medications except IV phenergan.” - Patient from my last night in the UWMC ED

31. Treatment • Brust’s Rule: if we have a lot of treatments for a disease… none must work very well… Images from migraine support blogs

32. Treatment: Non-Pharmacologic

33. Treatment: Non-Pharmacologic • Diet • Some benefit to elimination diets • 20% of patients report dietary triggers • Common triggers: • Caffeine withdrawal • Packaged meats • MSG • Dairy • Fatty foods • Aged cheese • Red wine • Beer • Champagne • Chocolate

34. Alcohol “If you must drink, no more than two normal size drinks” “Suggested drinks: Riesling Seagram’s VO Cutty Sark Vodka” - As per Diamond S and Dalessio DJ. The practicing physician’s approach to headache. New York: Williams and Wilkings. 1982. Treatment: Non-Pharmacologic

35. Treatment: Non-Pharmacologic • Behavioral • Shown to be effective • 30-50% reduction of migraine frequency • Modalities • Relaxation training • Thermal biofeedback with relaxation training • Electromyogram biofeedback • Cognitive behavioral therapy • No data to guide selection of modality…

36. Treatment: Abortive • Tenets: • Educate migraine sufferers • Use migraine specific agents in severe disease • Non-oral route for patients with significant nausea and vomiting • Be aware of medication overuse and rebound

37. When to treat? EARLY Within 2 hours Treatment during prodrome or aura is even more effective Treatment: Abortive Image courtesy of denverpost.com

38. Treatment: Mild to Moderate • NSAIDS • Ibuprofen • Naproxen • Diclofenac • Tolfenamic acid • Indomethacin suppository • Aspirin • Tylenol • Combinations

39. Treatment: Severe • If severe symptoms present then don’t bother with OTC preparations • Improved outcomes with migraine specific therapy • Consider route of administration • Consider contraindications/PMH

40. First line More effective Less nausea Contraindications CAD Cost Routes Oral Intranasal Subcutaneous Treatment: Triptans Image courtesy of headaches.about.com

41. Treatment: Triptans • Mechanism of Action • Selective serotonin agonist • 5HT1B/1D • Pharmacokinetics/dynamics • Both long and short acting available • Long acting more effective during aura but take longer to act • Short acting have more side effects

42. Treatment: Triptans • Options • Sumatriptan (subq/nasal/oral) • Almotriptan (oral) • Eletriptan (oral) • Frovatriptan (oral) • Naratriptan (oral) • Rizatriptan (oral/ODT) • Zolmitriptan (oral)

43. Treatment: Triptans • Which one to choose… • No class effect • Recurrent headache may indicate need for repeat dose, not new triptan • Pharmacokinetics/dynamics • Side effect profile

44. Treatment: Triptans • Which one to choose… • Specific concerns • Teratogenicity • Menstrual migraine • Subq • not effective during prodrome/aura • More contraindications

45. Treatment: Dihydroergotamine • Mechanism of Action • Non-selective serotonin agonist • Routes • Nasal • Subq • IM • IV • Contraindications • Pregnancy (category X) • Cannot be used with a triptan • IV contraindicated in CAD

46. Treatment: Adjuncts • Anti-emetics • Metoclopromide both as adjunct and mono-therapy • Ondansetron IV/oral/ODT • Caffeine • Rebound • Steroids • Dexamethasone • Prednisone

47. Treatment: Rescue • Opiates • Should be used only a few times per year • Up to ½ of patients with recurrent headache do not adhere to drug treatment regimen

48. Treatment: Prevention

49. Definitely consider: Disabling headaches > 2x per month Poor relief from abortive therapy Uncommon migraine Basilar Hemiplegic Might consider: Contraindication to acute therapy Failure of acute therapy Preference for preventative therapy Treatment: Prevention

50. Treatment: Prevention • Rules to live by: • Headache diary • Patience • No right agent • Consider: • Side effects • Other benefits