Transcript Migraine (16-08-11)

Migraine
What is migraine?
www.cks.library.nhs.uk/migraine
MeReC Bulletin 2002; 13: 5-8
• Primary episodic headache disorder
• Characterised by various combinations of:
– Neurological
– Gastrointestinal
– Autonomic changes
• Diagnosis is based on headache characteristics and associated
symptoms
Migraine classification
International Classification of Headache Disorders 2nd Ed (1st
revision) (ICHD-IIR1)
• Migraine without aura (common migraine)
• Migraine with aura (classic migraine)
• Childhood periodic syndromes that are commonly precursors of migraine
(eg cyclical vomiting, abdominal migraine)
• Retinal migraine
• Complications of migraine eg chronic migraine
• Probable migraine – fills all but one of the criteria for a definitive diagnosis
How common is it?
Goadsby PJ, et al. N Engl J Med 2002; 346: 257-70
MeReC Bulletin 2002; 13: 5-8
• 1 year prevalence is 11%
– 6% men
– 15-18% women
• Median attack frequency
– 1.5 per month
– 10% have weekly attacks
• Median attack duration
– 24 hours
– In 20% attacks can last 2-3 days
• In a 2000 patient practice
– 5 new cases per year
– 40 consultations per year
Implications
Clinical Evidence. Migraine headache
Goadsby PJ, et al. N Engl J Med 2002; 346: 257-70
MSGP4. Office for National Statistics
• Acute migraine is self-limiting
• It only rarely results in permanent neurological complications
• Most patients do not see a doctor
• However:
• Chronic recurrent migraine may cause disability through pain and may
affect daily functioning and quality of life
• Severe episodes can last 3 days during which the person is unable to carry
out normal daily activities
• 1 in 3 believe the condition controls their life
• Migraine is underdiagnosed and undertreated
The WHO judged that a day with severe migraine is
as disabling as a day with quadriplegia
History – the key to diagnosis
www.cks.library.nhs.uk/migraine
• Migraine is diagnosed by history
– Examination normal after an attack
– There are no diagnostic tests
– Ixs not required and often reveal no abnormalities
• There may be a family history
• Attack can be divided into 4 phases:
– Premonitory
– Aura
– Headache
– Headache resolution
Headache history
www.cks.library.nhs.uk/migraine
•
Headache usually:
– Frontotemporal
– Unilateral
– Of gradual onset, peaking after 2-12 hours, then gradually subsiding
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Attacks often begin in the morning, possibly waking the person but may begin at
any time
•
The frequency of attacks is extremely variable:
– Some have several attacks a week
– Others may go for years between attacks
•
Other features include:
– Anorexia, blurred vision, impaired consciousness, nasal stuffiness, hunger,
pallor, sweating, heat or cold sensations
Predisposing factors
www.cks.library.nhs.uk/migraine
• Different from trigger factors
• Their treatment may reduce migraine frequency
• They include:
– Depression and anxiety
– Head or neck trauma
– Hormonal changes – menstruation and menopause
– Stress (and relaxation after periods of stress)
Trigger factors
www.cks.library.nhs.uk/migraine
• Most attacks have no obvious trigger
• They include:
– Bright lights
– Foods (certain alcoholic drinks, cheese, citrus fruits, chocolate)
– Extremes of weather (v. hot or cold, strong winds)
– Long distance travel
– Loud noise
– Missing meals
– Strenuous unaccustomed exercise
– Too much or too little sleep
Aura
www.cks.library.nhs.uk/migraine
• Complex of focal neurological symptoms that precedes, accompanies, or
rarely, follows an attack
• Develops over 5-20 mins and usually lasts < 60 minutes
• Headache usually develops within 60 mins of the end of the aura
• Visual aura is the most common type with fortification spectra, scotoma,
simple flashes, specks and shimmerings
• Paraesthesia is the second most common type
– Usually numbness in the hand, which migrates up the arm, then
involves the face,lips and tongue
• Speech disturbances are the third most common type
– Usually dysphasia
• Most people who have migraine with aura also have episodes of migraine
without aura
What else could it be?
www.cks.library.nhs.uk/headache, ICHD-IIR1
• Tension type headache (TTH)
– Most common type of headache
– Usually mild to moderate severity
– More commonly seen in women and those with sedentary lifestyles, is often
stress related
• Cluster headache (CH)
– 3-4x more common in men
– Pain is excruciating, lasts 15-180 minutes, and may occur from once every
other day to 8x daily
– Attacks occur in clusters lasting for weeks or months, separated by remission
periods lasting months or years
• Secondary headache
– Attributed to underlying organic pathology et trauma, vascular disorder,
cancer, psychiatric disorder, medication overuse
Migraine
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Headache lasting 4-72h
At least 2 of the following:
– Unilateral location
– Pulsating character
– Moderate to severe
– Exacerbated by activity
And at least one of the following:
– Nausea and/or vomiting
– Photophobia and phonophobia
Without aura: at least 5 attacks
With aura: at least 2 attacks
Tension type headache
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Headache lasting 30 mins to 7 days
At least 2 of the following:
– Bilateral location
– Non-pulsatile character
– Mild to moderate
– Not aggrevated by activity
And neither of the following:
– Nausea and/or vomiting
– Photophobia and phonophobia
(but may have one or the other)
Medication overuse headache (MOH)
www.cks.library.nhs.uk/migraine
• Most common cause of intractable headache
• Affects up to 1 in 50 people
– 5x more common in women
• Results from the chronic overuse of medication used to treat headache
– Aspirin, paracetamol (esp combined with codeine), NSAIDs, triptans,
opioids, ergotamine
• Does not develop when the same analgesia is used for other chronic
conditions
• Consider in people with a pre-existing primary headache who says their
headaches have worsened, and frequency of headache, and medication
use, has, increased
• A detailed medication history is necessary
The POUNDing mnemonic
Detsky ME, et al. JAMA 2006; 296: 1274-83
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Pulsating headache
Duration 4-72 hOurs without medication
Unilateral headache
Nausea or vomiting
Disabling intensity (disrupts daily activities)
Rule out serious pathology – red flags
NPS News 2005; 38
Goadsby PJ, BMJ 2006; 332: 25-9
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Confusion
Drowsiness
Vomiting
Neurological signs that persist between headaches
Fever
New headache in patient >50 years of age
Sudden onset
Headache that wakes patient
Head injury
Severe and debilitating pain
Marked change in character or timing
Neck stiffness
Pain associated with local tenderness eg temporal artery
Complications
www.cks.library.nhs.uk/migraine
• Status migrainosus – debilitating migraine lasting over 72 hours
• Migrainous infarction – a cerebral infarction occuring during the course of
a typical attack of migraine with aura
• It is associated with an increased risk of:
– Ischaemic (not haemorrhagic) stroke
– Cardiovascular disease (CVD) in women with migraine with aura
– Depression, anxiety, panic disorder, bipolar disorder
Migraine management – overview
www.cks.library.nhs.uk/migraine
• Identify any trigger factors, and avoid them if possible
• Treat in a stepwise manner until symptoms are controlled
– 1st line Rx is oral analgesia +/- anti-emetics
– If 1st line Rxs are ineffective treat with a triptan
– Consider using combination therapy (triptan + analgesia + antiemetic)
if triptan alone is ineffective
• Consider using prophylactic treatment if attacks are frequent and
troublesome
Simple analgesics
www.cks.library.nhs.uk/migraine
• Aspirin 600-900mg, NSAIDs, paracetamol +/- anti-emetics
• Start treatment early in the attack
• Gastric stasis during migraine reduces drug absorption
– Soluble forms may be preferable as more quickly absorbed
– Anti-emetics increase rate of absorption of analgesic
• Codeine and other opioid drugs, or combinations containing these should
be avoided
– Little additional benefit
– Risk of medication overuse headache
– Adverse effects eg reduced gastric motility
Prokinetic agents
www.cks.library.nhs.uk/migraine
• As well as being anti-emetic they increase gastric emptying and increase
the rate of absorption of oral analgesics
• More evidence supports metoclopramide usage but domperidone has
fewer adverse effects
• Effective alone and synergistic in combination with analgesics and triptans
• A rectal anti-emetic (+/- analgesic) may be useful if a person is vomiting
and oral therapy is not being absorbed
– Diclofenac 100mg plus domperidone 30mg suppositories
Triptans
www.cks.library.nhs.uk/migraine
http://emc.medicines.org.uk/
• Do not take too early in an attack unlike standard analgesia
– The first dose should be taken when the pain is beginning to develop
(ie is mild) but not before this stage (eg during the aura stage)
• Find the best one for an individual patient by trial and error
• Sumatriptan is the most established triptan with the greatest associated
clinical experience
• Contraindications include uncontrolled hypertension, CHD or
cerebrovascular disease (or at risk of these)
Comparison of oral triptans to sumatriptan
100mg
Ferrari MD, et al. Lancet 2001; 358: 1668-75
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Differences between the triptans was small but may be clinically relevant to the individual
patient
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There was a high degree of variability in individual response to specific triptans
– If a particular triptan is not effective in an individual another can be tried which may be
effective
– If a triptan is poorly tolerated it can be switched
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If the initial dose of triptan proves ineffective a further dose is unlikely to be effective and
should not be taken (except zolmitriptan)
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If the triptan successfully relieves pain, but there is a relapse, the dose can be repeated
within 2-4 hours, in accordance with product licenses
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Treatment should be individualised for each person
Adverse effects
www.cks.library.nhs.uk/migraine
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There is no evidence that any particular triptan is safer than another
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Triptan sensations include:
– Warm-hot sensation
– Tightness
– Tingling
– Flushing
– Feelings of heaviness or pressure in face and limbs and occasionally the chest
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There are theoretical concerns that triptans may increase the likelihood of MI but
extensive experience shows this is very rare
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Discontinue if there are intense chest pains or sensations as this could indicate
vasoconstriction or anaphylaxis
Prophylactic drug treatment
www.cks.library.nhs.uk/migraine
• Consider in patients with:
– ≥ 2 attacks per week
– Increasing headache frequency
– Significant disability despite acute treatments
– Cannot take suitable treatment
• Propranolol or amitriptyline are suitable first choices:
– Good evidence to support use for the prevention of migraine
– Metoprolol, timolol and atenolol are alternative beta-blockers
• Sodium valproate or topiramate are suitable 2nd line:
– Good evidence of efficacy
– Clinical utility of topitamate limited and specialist input needed
Non-drug interventions
www.cks.library.nhs.uk/migraine
• Lie down in a darkened quiet room
• Good physical fitness can lower the incidence and exercise should be
encouraged
• Relaxation techniques, stress reduction and coping strategies are 1st line
treatments when stress and anxiety exist
Case study
• Jane is 38 years old with a history of migraine without aura.
The migraines started in her late teens. She takes aspirin and
domperidone for the attacks which have become more
frequent in the last few months since starting work on the
check-in desk of a major airport. She has had to take several
days off in the last few weeks and has been taking OTC
ibuprofen regularly
What would you ask?
• Have the characteristics of the headache pain changed?
• Has the frequency of the headaches changed?
• Are there any new associated symptoms?
• Has she noticed any new trigger factors?
• Does she take the aspirin and ibuprofen together?
• Is she fully recovered between attacks?
• She says her headaches are similar in nature to usual but are
happening almost every day. She has no new associated
symptoms. She wonders is the stress of her new job isn’t
helping.
• She takes aspirin and domperidone on the days when the
headaches start but uses the ibuprofen on subsequent days is
symptoms are still present. She has needed ibuprofen on
almost every day during the last month
What do you think it could be?
• Medication overuse headache
What advice would you offer?
• Stop taking OTC ibuprofen. Headaches will initially worsen but
improvement will be seen in weeks or months
• If the cause was ibuprofen she could try amitriptyline.
• If stress is associated advise relacation therapies eg self-help books, tapes,
yoga
• If the patient is using medication more than 2 days per week on a regular
basis this requires further Ix. Ask more about the frequency and timing of
medication taking in relation to symptoms. The initial diagnosis should be
reviewed
At what point would you consider prescribing
a triptan?
• Migraine should be managed in a stepwise manner until symptoms are
controlled
• 1st line is oral analgesia +/- anti-emetics which she has already tried
• If not tolerating oral medication consider parenteral or rectal medication
• If 1st line is not effective consider a triptan
• Prophylactic treatment can be considered if attacks are frequent and
troublesome