Transcript Attachment

DIAGNOSIS, PROPHYLAXIS AND
TREATMENT OF MIGRAINE IN
MEN, WOMEN AND CHILDREN
BASIL AL-SAIGH, FMR-2
JANUARY 2007
REGINA GENERAL HOSPITAL
BACKGROUND READING :

Diagnosis and Treatment of Migraine
ROGER CADY, MD; DAVID W. DODICK, MD From the Headache Care
Center, Primary Care Network, Springfield, Mo (R.C.); and Department of
Neurology, Mayo Clinic, Scottsdale, Ariz (D.W.D.).

Answers to Frequently Asked Questions About Migraine
IVAN GARZA, MD; JERRY W. SWANSON, MD From the Department of
Neurology, Mayo Clinic College of Medicine, Rochester, Minn.
Dr Garza’s headache fellowship was partially supported by
GlaxoSmithKline.

Prevention of Migraine in Women Throughout the Life Span
BEVERLY S. TOZER, MD; ELIZABETH A. BOATWRIGHT, MD;
PARU S. DAVID, MD; DEEPA P. VERMA, MD; JANIS E. BLAIR, MD;
ANITA P. MAYER, MD; JULIA A. FILES, MD From the Division of
Women’s Health Internal Medicine (B.S.T., E.A.B., P.S.D., D.P.V., J.A.F.),
Mayo Clinic College of Medicine, Scottsdale, Ariz.
Migraine in Men, Women and Children
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BACKGROUND READING :

Triptans. Are they all the same?
Lead author: William A. Kehoe, Pharm.D., MA, FCCP, BCPS
Prescriber's Letter U.S. 2002; 9(1):180105

Supplements for Migraine
Lead author: Gayle Nicholas Scott, Pharm.D., BCPS, ELS, Assistant Editor
Canadian Prescriber's Letter 2005; 12(4):210414

Drug Therapy for Children and Adolescents with Migraine Headaches
Lead author: Neeta Bahal O'Mara, Pharm.D., BCPS
Canadian Prescriber's Letter 2005; 12(3):210307

Canadian Family Physician
June 2005, pgs 838-843
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MIGRAINE IN PRIMARY CARE :

Overall prevalence – 1 migraineur / 4 households

Prevalence > asthma / diabetes combined

Most initially seek tx for HA in a primary care setting

Majority of patients who seek help for a HA have migraine

Median pain intensity 8/10

Median attack duration 24 hours
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MIGRAINE IN PRIMARY CARE Cont’d :

1/3 of migraineurs miss 1 day of work in a 3 month period

Most patients seek care from a primary care physician

3 : 1 Female : Male prevalence
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SPECTRUM OF HA :

Pt.’s with clinically relevant migraine experience spectrum of HA
presentations – Migraine / Migrainous / Tension-Type HA

All respond equally well to migraine-specific medications

Similar underlying biology?

HA expereinced by migraine sufferers differs more in degree vs
type
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CATEGORIES OF THE INTERNATIONAL HEADACHE
SOCIETY CLASSIFICATION SYSTEM :
1.Migraine
2.Tension-type headache
3.Cluster headache and chronic paroxysmal hemicrania
4.Miscellaneous headache not associated with structural lesions
5.Headache associated with head trauma
6.Headache associated with vascular disorders
7.Headache associated with nonvascular intracranial disorder
8.Headache associated with substance use or withdrawal
9.Headache associated with noncephalic infection
10.Headache associated with metabolic disorders
11.Headache or facial pain associated with disorders of the cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial
structure
12.Cranial neuralgias, nerve trunk pain, and deafferentation pain
13.Headache not classifiable
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SPECTRUM OF HA Cont’d :

“Thus, the academic headache community no longer supports the
concepts or use of the terms mixed headache disorder, tensionvascular headaches, vascular headaches, or muscle-contraction
headaches. These terms imply different headache types with a
different pathophysiological basis, and they are incompatible with
the current construct of migraine as a paroxysmal neurologic
disorder that is initiated within the central nervous system rather
than a disorder of cerebral blood vessels.”
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PRIMARY VS SECONDARY HA :

HA + Onset in adolescence or early adulthood – Primary HA

HA + Stable pattern of similar HA over 6 months or more –
Primary HA

HA + FHx of HA – Primary HA

HA + Association with mensturation – Primary HA

HA + Variable site of HA from attack to attack – Primary HA
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PRIMARY VS SECONDARY HA Cont’d :

HA + Sudden onset – Secondary HA

HA + Onset > age 40 – Secondary HA

HA + New type – Secondary HA

HA + New Level of Pain “Worst HA ever” – Secondary HA

HA + Exertion / Valsalva – Secondary HA

HA + Neurological changes – Secondary HA

HA + HIV/malignancy – Secondary HA

HA + Interrupts sleep – Secondary HA
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IMAGING :

Recent significant change

pattern, frequency, or severity

Progressive worsening
 in spite of appropriate treatment

Focal neurologic signs or symptoms

Onset of headache with exertion/cough

Onset of headache after age 40

Orbital bruit
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CRITERIA FOR DX OF MIGRAINE :

At least 5 attacks fulfilling criteria B-D

Headache attacks lasting 4-72 hours (untreated or unsuccessfully
treated)

Headache has at least 2 of the following characteristics:
 Unilateral location
 Pulsating quality
 Moderate or severe pain intensity
 Aggravation by or causing avoidance of routine physical
activity (eg, walking or climbing stairs)
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CRITERIA FOR DX OF MIGRAINE :

During headache at least 1 of the following
 Nausea and/or vomiting
 Photophobia and phonophobia

Not attributed to another disorder
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SCREENERS FOR DX OF MIGRAINE :

Aura is not present in 2/3 of patients

Identification of Migraine Screener :





Are you nauseated or sick to your stomach when you have a
headache?
Have your HA limited your activity for a day or more in the last
3 months?
Does light bother you when you have a HA?
If 2/3 positive : PPV 93 percent for migraine
If 3/3 positive : PPV 98 percent for migraine
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SCREENERS FOR DX OF MIGRAINE Cont’d :

INFOPOEM CMA Criteria for Dx Migraine HA

POUNDing





P – Pulsatile Quality
O – 4-72 hOurs duration
U – Unilateral location
N – Nausea and Vomiting
D – Disability and intensity
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COMMON MIGRAINE TRIGGERS :

Sleep (too much or too little) **

Schedule Change

Alcohol **

Caffeine **

Certain foods

Odors

Weather change

Head or neck pain

Trauma
Migraine in Men, Women and Children
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COMMON MIGRAINE TRIGGERS :

Fasting or skipping meals **

Hunger

Environmental factors

Altitude

Light glare or visual stimuli

Medications

Physical exertion
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COMMON MIGRAINE TRIGGERS :

Hormonal changes

Menopausal fluctuations

Menstruation **

Exercise

Sexual activity

Stress and anxiety **
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ACUTE MEDICATIONS FOR THE TX OF
MIGRAINE :

NON-SPECIFIC ANALGESICS







Acetaminophen
ASA
NSAID
Opiates
Combination Analgesics
(ASA/Acetaminophen/Caffeine/Codeine/Butalbital)
Antiemetics
SPECIFIC ANALGESICS


Dihydroergotamine (DHE)
Triptans
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APPROACHES TO TREATMENT :

STEP CARE



Initiate acute HA therapy with inexpensive low-end medications and
establishing failure before using more specific medications
Start with OTC products, then try NSAID’s, then combination
analgesics, and so forth
STRATIFIED CARE



Medications based on headache characteristics
High-end therapy for patents with severe HA, and so forth
If failure is established on low-end therapy, move up to higher-end
therapy
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APPROACHES TO TREATMENT :

STEP CARE WITHIN ATTACK CARE



Low end medications at beginning of migraine attack and then
advance to a stronger compound if not effective.
Beneficial in patients with slow to develop migraines, of mildmoderate severity
PATIENT-CENTERED STRATIFIED CARE

Educating migraineurs so that they determine treatment need based
on the individual HA characteristic
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ACUTE TX OF MIGRAINE HA :

Ambulatory :




High dose NSAID +/- antiemetic
DHE (Nausea)
Triptan (expensive, but effective)
In the ER :



Triptan?
IV proclorperazine 10 mg
IV DHE 1mg + metoclopramide 10 mg
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ACUTE MIGRAINE TX IN
CHILD/ADOLESCENTS :

Ibuprofen



Acetaminophen


Most studied medication
Safe and effective
Probably effective and well tolerated
Sumatriptan



Nasal spray effective
Inadequate data for SC or PO use
Other triptans have inadequate data to support their use
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TRIPTANS FOR ACUTE TX OF MIGRAINE :

ALMOtriptan – ELEtriptan – FROVAtriptan – NARAtriptan –
RIZAtriptan – SUMAtriptan – ZOLMItriptan

All are 5-HT 1B/D agonists




Induce vasoconstriction of cranial blood vessels
Help decrease release of neuropeptides responsible for vasodilation
and pain pathways involved in the Trigeminal Nerve
Vs Ergots : also bind to dopamine and adrenergic receptors – thus
worse side effect profile
Compared on basis of response 2 hour after medication
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TRIPTANS FOR ACUTE TX OF MIGRAINE
Cont’d :

Frovatriptan / Naratriptan less effective orally

Rest have 2-hour response rates b/w 57 – 77 percent

Great interindividual variation in patient preference and response
rate

Poor response to one does not mean ALL will be ineffective

Initial choice of triptan often driven by patient’s health plan
formulary
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TRIPTANS FOR ACUTE TX OF MIGRAINE
Cont’d :

If N and V early in attack, nasal spray (sumatriptan / zolmitriptan)
or SC injection (sumatriptan) preferred

Most S/E include facial flushing, tingling, chest discomfort
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TRIPTAN CONTRAINDICATIONS :
(Due to minor peripheral vasoconstrictive properties on coronary
vessels)

IHD

CVD

PVD

Uncontrolled HTN

Avoid if patient used Seratonin Agonist/Ergot in past 24 hours
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TRIPTAN FAILURE :

Troubleshooting a treatment failure with Triptans

May not be taking it early in attack, when they are most effective

Consider higher dose

Consider SC or Nasal Spray route if N and V

Consider anti-emetic

Consider adding NSAID

Flexible approach is necessary
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FREQUENCY OF USE OF ACUTE
MEDICATIONS :

Can cause Medication-Overuse HA

Highest risk – Opioids / butalbital-containing combination analgesics /
ASA-Acetominophen/Caffeine combinations


Moderate risk – Triptans


3 or fewer days / month
9 or fewer days / month
Low risk – NSAID

15 or fewer days / month
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PROPHYLACTIC MEDICATIONS IN THE TX OF
MIGRAINE :

Recurring migraine that interferes with activities of DL despite
acute tx

> 2 such HA / week

Failure / overuse / CI to acute tx

ADE of acute tx

Presence of Hemiplegic Migraine / Basilar Migraine / Migraine
with prolonged aura
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PROPHYLACTIC MEDICATIONS IN THE TX OF
MIGRAINE Cont’d :


Goal of prophylaxis

Reduce attack frequency, severity, duration

Improve response to acute medications

Improve function / reduce disability

Decrease cost of migraine management
Define an “Effective Agent” to the patient such that realistic goals are set

Patient should expect 50 percent reduction in frequency of attacks
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PROPHYLACTIC MEDICATIONS IN THE TX OF
MIGRAINE Cont’d :

Should be used one at a time

Efficacy of combination treatment is limited

Start low, go slow

Maximum clinical benefit can take as long as 3 months

HA diary helps document response to prophylactic tx
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PROPHYLACTIC MEDICATIONS IN THE TX OF
MIGRAINE Cont’d :

Can attempt to taper prophylactic medications in 6-12 months if
HA have been under good control

Patients may choose to continue tx for longer periods :
acceptable option
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PROPHYLACTIC MEDICATIONS IN THE TX OF
MIGRAINE Cont’d :








B Blockers – Propranolol
TCA – Amitryptaline
Non-DHP CCB – Verapamil
SSRI
Anticonvulsants – Valproic Acid
AED – Gabapentin, Topiramate
Choice can be driven by therapeutic opportunities
Patient preference is paramount
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ROLE OF COMBINED ACUTE AND
PROPHYLACTIC TREATMENT OF MIGRAINE :

Imperative !
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SUPPLEMENTS FOR MIGRAINE :

“But, if a patient tells you about a product that works
for him and it's not potentially toxic, it's probably best
not to refute his claim by explaining that the product
hasn't been clinically proven. An explanation of
evidence-based medicine to a patient who is not
getting relief from conventional treatment may be
perceived as arrogance. For some patients, migraine
remedies that are unproven, but not toxic nor
unreasonably expensive, may fall into the "worth a try"
category”
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SUPPLEMENTS FOR MIGRAINE Cont’d :

40 percent of patients with migraine respond to placebo

Study to compare effectiveness of fish oil for migraine, olive oil
(the placebo) was similar in efficacy to the first

American Academy of Neurology recognizes Feverfew, Riboflavin
and Mg as preventative tx of migraine

Some conventional tx of migraine also lack proof as the other
supplemental treatments

Many natural products fit the description of inexpensive, and
possibly effective with minimal risk of toxicity for prophylaxis
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SUPPLEMENTS FOR MIGRAINE Cont’d :

Feverfew [A]
 50 to 100 mg capsules daily

Riboflavin [A]
 Reduces frequency but not severity or duration
 400 mg per day
 Precursors of nucleotides needed for activity of enzymes in the ETC

Ginger
 Anecdotal reports suggest that ginger, ginko and valerian
might help
 No reliable research thus far
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SUPPLEMENTS FOR MIGRAINE Cont’d :

Mg [A]
 Helpful especially in those with low levels
 GI S/E

Butterbur [A]
 Reduces frequency, duration and intensity of attacks
 Potential cause of allergy in pt’s allergic to ragweed/related
plants

Caffeine/ASA or Acetaminophen [A]

Melatonin not yet recommended b/c it is too early
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SUPPLEMENTS FOR MIGRAINE Cont’d :

L-Arginine



Has been used in combination with Ibuprofen
Contribution of Arginine unclear as Ibuprofen alone relives migraine
CoQ10 [A]
 Favorable
 Impaired O2 metabolism and low energy states implicated in
pathogenesis of Migraine
 Improves mitochondrial oxidative phosphorylation
 Watch for patients on Warfarin as might reduce anticoagulant
effect
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BOTULINUM TOXIN FOR PROPHYLAXIS OF
MIGRAINE :

RCT thus far have yielded mixed results

“Many HA specialists believe that it is effective in a subset of
patients”

Currently it is routinely part of a HA specialist’s armamentarium
for migraine prevention

Injected pericranially, and tx repeated Q3 months if beneficial

Ptosis, frontal m. weakness, and local injection site pain are mild
and temporary
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

MC in women than men, by a ratio of 3 : 1

MC than DM, OA or asthma

MC occurs in reproductive years

Menstruation, pregnancy, OCP use, menopause, HRT influence
incidence of migraine and subsequent management
Migraine in Men, Women and Children
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

CHILDHOOD

In 4-7 y/o, boys get migraine > girls

By puberty, girls get migraine > boys by 3 : 1

Shorter in duration (1-48 vs. 4-72), peak to intensity more
quickly (w/in 1 hour), bilateral rather than unilateral

More common to see migraine variants – hemiplegic migraine,
basilar migraine, cyclic vomiting

Stress is a more common trigger in children
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

CHILDHOOD

More on weekdays than on weekends

Ibuprofen is proffered over Tylenol or triptans due to lack of
evidence

1/3 require prophylactic tx

Topiramate preferred for obese patients for weight reducing
side effects
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RGH, January 2007
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

MENSTURAL MIGRAINE

60 percent have migraines associated with menstrual cycles

Migraine without aura MC than with aura

? Related to decline in Estrogen in late luteal phase of cycle

Miniproprophylaxis with NSAID’s, ergots and triptans
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

USE OF OCP

Unpredictably induce, alter or alleviate migraines

If OCP’s exacerbate symptoms, lower OCP to an EE of less
than 20 mgm

Persistent HA despite above might necessitate OCP’s in these
patients
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

USE OF OCP

Both migraine and OCP’s increase stroke risk

Migraineurs with aura or other RF for stroke should be
assessed individually for appropriate OCP use

OCP’s should not be used in migraineurs who smoke
Migraine in Men, Women and Children
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

PREGNANCY

50-80 percent of 1st trimester pregnancies in ladies with
migraine cause a decrease in migraine frequencies

Secondary causes should be considered in pregnant patients
who experience migraine for the first time during a pregnancy

Avoid preventative medications b/c of potential for
teratogenecity
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

PREGNANCY

Topiramate or propranolol are a last measure

Definitely avoid valproic acid or ergot derivative-medications
Migraine in Men, Women and Children
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

MENOPAUSAL TRANSITION

Fluctuations in hormone levels can exacerbate migraines

Continuous use low-dose OCP can provide necessary
contraception and migraine control

Migraine improves after menopause as hormone levels
stabilize
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

MENOPAUSAL TRANSITION

Migraines worsen in 2/3 of females with surgically induced
menopause

Preventative medications in this context should focus on
therapeutic opportunities

New onset HA after age 45 should be investigated more
thoroughly for secondary causes
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

ELDERLY WOMEN

Migraine beginning after age 65 very uncommon

> 1/3 of all HA in elderly women has a secondary cause

Avoid triptans in patients with PVD, CVD, ACS or uncontrolled
HTN

B blockers good for prevention in patients with CAD or HTN
Migraine in Men, Women and Children
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PREVENTION OF MIGRAINE IN WOMEN
THROUGHOUT THE LIFE SPAN :

ELDERLY WOMEN

Avoid TCA in patients with urinary retention or arrhythmias

Aura w/out HA – easily confused with TIA

Positive (scotoma) vs. Negative symptoms (loss of vision)

Gradual buildup vs. abrupt

Sequential in modality vs. simultaneous appearance

20-30 mins vs < 15 mins

Flurry of mid-life attacks vs. not as common
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DIAGNOSIS, PROPHYLAXIS AND
TREATMENT OF MIGRAINE IN
MEN, WOMEN AND CHILDREN
BASIL AL-SAIGH, FMR-2
JANUARY 2007
REGINA GENERAL HOSPITAL