Transcript New treatments for migraine

Migraine
Prophylaxis in
Patients with
Patent Foramen
Ovale:
PFO Closure vs.
Traditional Preventative
Measures
By: Samantha Howell
Submitted to: Dr. Gurwell
Migraines
• 28 million Americans each year
• Characterized by: pulsing or throbbing pain,
unilateral pain commonly, interferes with daily
activities, worsened by physical activity
• Has to be accompanied by one of the following:
N/V, photophobia, or phonophobia
• 2 types: Migraine with aura (20%)
Migraine without aura (80%)
• Aura-a sensory disturbance (visual typical)
Pathophysiology
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Poorly understood
Excitation wave theory
Cerebral ischemia
Lungs may play a role
-if bypassed allow microemboli
and substances like serotonin
and ADP to get to the brain via
circulation
-one possibility is PFO or ASD
Neurovascular
cause
Patent Foramen Ovale
• Failure of foramen
ovale to close at birth
• Right-to-left shunt of
blood
• PFO may be present
in 40-60% of migraine
with aura sufferers
• Closing this defect
may be a future
treatment for migraine
Traditional Migraine Prophylaxis
• Avoidance of Triggers
• Stress Management
• Pharmacological Prophylactic Treatments
used if MHA occurs more than 2x a month,
not controlled with acute tx, or the patient
takes abortive tx more than 2x a week
•Anti-epileptics (Topiramate,
Gabapentin)
•Beta blockers (Atenolol)
•Magnesium
•Botox
•NSAIDS (Ibuprofen)
•Calcium channel
blockers (Verapamil)
•Antidepressants
•ACEi (Lisinopril)
•Other
Vitamins/Minerals
Clinical Question
• In patients with migraine with aura who
have a known patent foramen ovale
(PFO), is there a quality-of-life benefit to
PFO closure surgery or would migraine
symptoms be equally controlled with
pharmacological prophylactic treatment?
• Methods: Three PubMed Database
searches were performed to attempt to
answer this question
Wilmshurst, 2000
• Retrospective study looking at effects of PFO
closure on migraine headaches (n=21)
• Surgery was performed to treat decompression
illness
• Treated with aspirin for 6 mos. post-op
• Patients were interviewed about migraine after
the surgery (had to recall symptoms before and
after procedure)-IHS guidelines used to
determine if patients had migraines
• 9-32 month follow-up
Giardini, 2006
• Prospective study looking at long-term efficacy
of PFO closure on migraine in stroke patients
(n=13)
• Surgery was performed due to previous stroke
• Treated with aspirin for 12 months following the
surgery
• Patients were interviewed about migraine and
the condition severity was assessed using
MIDAS questionnaire
• 4.9 ± 1.4 years follow-up
Results
Table 1-Effect of PFO closure on migraine headaches
Study
Wilmshurst
(2000)
Giardini
(2006)
Headache
Type
Migraine (of
any type)
Migraine with
Aura
Migraine
Without Aura
Migraine (of
any type)
Migraine with
Aura
Migraine
Without Aura
Cured
Improved
8/21 (38%)
Cured or
Improved
18/21 (86%)
No Change or
Worsened
3/21 (14%)
10/21 (48%)
7/16 (44%)
8/16 (50%)
15/16 (94%)
1/16 (6%)
3/5 (60%)
0/5 (0%)
3/5 (60%)
2/5 (40%)
11/13 (85%)
1/13 (8%)
12/13 (92%)
1/13 (8%)
NA
NA
NA
NA
NA
NA
NA
NA
Silberstein, 2004
• Randomized, double-blind, placebo-controlled trial
(n=284)
• 26 week treatment period using 50, 100, or 200 mg/d of
Topiramate and matching amounts of placebo
• Patients kept diaries recording periods with migraine
headache
• Success of the drug was based on change from baseline
• Percentage of patients with decreased frequency and
severity in each group:
100 mg/d Topiramate = 54%
200 mg/d Top. = 52.3%
50 mg/d Top. = 35.9%
Placebo = 22.6%
Schrader, 2001
• Randomized, placebo controlled, crossover study (n=60)
• 30 pts. took 10 mg Lisinopril once daily for 1 wk and then
two 10 mg tablets once daily for 11 wks followed by 2 wk
washout period-then one placebo pill daily for one wk
and then two placebo pills once daily for 11 wks.
• Another 30 pts. took the placebo pills during the first 12
wks and lisinopril during the next 12 wks
• Patients also recorded symptoms in a diary
• Results:
-For days with migraine, a reduction by at least 50% was
seen in 30% of participants
-32% of participants saw at least a 50% reduction in
headache severity compared to placebo period
For Comparison
Table 2-Reduction of migraine activity by PFO closure vs.
Traditional Migraine Prophylaxis
Source
Prophylactic
Daily Dosage
% Reduction in Migraine
Activity
Buchanan 2006
Gabapentin (anti-epileptic)
1.8-2.4 g
36%
Botox
25 International Units
45%
Vitamin B2-Riboflavin
400 mg
56%
Coenzyme 10
300 mg microparticles
48%
Silberstein 2004
Topiramate (anti-epileptic)
100 mg/d
54%
Silberstein 2002
Propanolol (beta-blocker)
120-240 mg
44%
Magnesium
600 mg
41.6%
Aspirin (NSAID)
650 mg
20-30%
Schrader 2001
Lisinopril (ACE Inhibitor)
20 mg
30%
Wilmshurst 2000
PFO Closure
N/A
86%
Giardini 2006
PFO Closure
N/A
92%
Study Strengths and Limitations
Strengths (PFO)
• MIDAS
• IHS
• Follow-up 5 yrs
Limitations (PFO)
•Sample size
•Retrospective (Wilmshurst,
2000)
•Participant Recall error
Strengths (Meds)
• Randomized, placebocontrolled
• Large number of subjects
• Quantitative measures
Limitations (All)
•All data gathered was
somewhat subjective
(participant diaries, etc.)
Conclusions
• PFO closure looks promising-higher percentage of
patients in the PFO closure trials had reduced frequency
and severity of migraines
• PFO closure is invasive and there is not enough
research
• Additionally, not everyone who has migraines has the
heart wall defect
• The surgical procedure should only be recommended at
this time for individuals with multiple conditions related to
PFO
• Our patients with PFO and migraines should simply be
placed on traditional prophylactic meds or use acute
treatment until more research is done
References
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