New Study Finds Americans Need 6 Hours Of Sleep At Work

1. New Study Finds Americans Need 6 Hours Of Sleep At Work

2. “…And then a throb hits you on the left side of the head so hard that your head bobs to the right…There's no way that came from inside your head, you think. That's no metaphysical crisis. God just punched you in the face.” --Andrew Levy, A Brain Wider Than the Sky: A Migraine Diary

3. Migraine Prevention LT Sara Pope, MD 7 February 2013

4. Objectives • Briefly reviewed treatment of migraines • Explored the importance of prophylaxis • Assessed when to start prophylaxis • Discussed treatment types

5. Migraines: In Brief • Common, complex and recurrent • >30 million people have 1+ migraines/year • 13% prevalence, 75% female • 80% have a 1st degree relative with a history • Environmental, behavioral triggers

6. Migraines: Sensitive CNS? • Intracranial vasoconstriction + rebound dilation • Neurogenic process w/2°changes in cerebral perfusion • Classic: +AURA, gradual, unilateral, pulsating, +sensory • Common: NO AURA, episodic vs. chronic

7. True Migraine? • Head pain + nausea + sensory sx • >4 h, <72h • Starts young, rare >50 yo • Common in reproductive years • Predictable triggers • Red flags

8. Why Prophylaxis? • Reduce frequency, severity and duration • Improve responsiveness to acute tx • Improve function, reduce disability, +QOL • Reduce costs • Only 13% on preventive therapy

9. When to Start? • Recurrent, interfere w/ADL’s despite tx • >4 attacks/month • Contraindications or failure/overuse of acute tx • Adverse events to acute tx • Hemiplegic, basilar, prolonged aura, infarction • Menstrual: mini-prophylaxis

10. How? • Several medications • Varied mechanisms of action • No ‘gold standard’, pt specific • Success: reduction in migraine frequency by 50% in first 3 months

11. What does the evidence say?

12. Small Groups • Three Groups • Three Medication Categories • Three Teaching Points • Three Cases

13. Anti-Hypertensives

14. Anti-Hypertensives • Propanolol, metoprolol,timolol: Effective • Verapamil, nimodipine: Insufficient • Lisinopril, candesarta: Possibly effective • Telmisartan: Possibly not effective

15. Anti-Convulsants

16. Anti-Convulsants • Topiramate: Effective, as good as BB, VA, TCA • Divalproex, valproate: Effective • Gabapentin: Insufficient • Lamotrigine, oxcarbazepine: Ineffective

17. Anti-Depressants&Others

18. Anti-Depressants • Fluoxetine: Limited, conflicting data • Venlafaxine: Probably Effective • Amitriptyline: Probably Effective, as good as topiramate, maybe Venlafaxine

19. Others… • Triptans • Botox • Butterbur • Co-enzyme q10 • Feverfew • Magnesium • Methylsergide • Riboflavin • Acupuncture • Relaxation, biofeedback • CBT • Hypnosis • TENs • Hyperbaric oxygen

20. Principles of Prophylaxis • Start low, go slow • Adequate trial in duration, dosage • Avoid overuse: analgesics, opioids, triptans • Caution: women of child bearing age • Address expectations, preferences, side effects, commitment • Slowly taper w/improvement, recommend 6-9 months

21. Objectives • Briefly reviewed treatment of migraines • Explored the importance of prophylaxis • Assessed when to start prophylaxis • Discussed treatment types

22. Questions?