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Migraine Headache Evaluation Treatment

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					Migraine Headache – Update
on Diagnosis & Treatment

      Herbert L. Muncie, Jr., M.D.
What is the diagnosis?
   Sarah, a previously very healthy 14 year
    old female complains of a severe
    headache & nausea. It is the start of the
    Thanksgiving holiday and all she wants to
    do is lay on the sofa.
       PMH
         H. flu meningitis age 7 months
         Car motion sickness as a child

       Family history positive for migraines –
        maternal grandmother & mother
    Diagnosing Migraine Headache
   Any severe or recurrent headache most
    likely is a form of migraine
   Almost all patients will have family history
    of migraines or at least “sick” headaches
   Only 15% have preceded or
    accompanied focal neurologic symptoms
       Usually visual
           Vision loss or distortion in one eye – „ocular
            migraine‟
       “Classic migraine”
Sarah

   Spent most of Thanksgiving holiday
    resting on the sofa
   Diagnosed with onset of migraine
    headaches
    Recurrent Headaches
   Primary
       Migraine
       Tension
       Cluster
       Other benign – cough, cold temperature,
        post coital, exertion
    Recurrent Headaches
   Secondary (pain from complications)
       Intracranial tumor
       Intracranial aneurysm
       Intracranial A-V malformation
       Temporal arteritis
 Migraine with aura – Criteria*

   At least 2 attacks with 3 of the following:
       Fully reversible aura symptoms
       At least 1 aura symptom develops gradually
        during more than 4 minutes or 2 symptoms
        occur in succession
       Any aura symptom lasts less than 60
        minutes
       Headache follows the aura within 60 minutes

*International Headache Society - 2004
Migraine with aura

   Visual aura common
       Slowly evolving scintillating scotoma that
        moves or passes through visual field
       Duration of aura – 22 minutes
       Should not be called ocular migraine if
        bilateral eye involvement
           Just call them migraine with aura
Migraine with aura –
vascular risk?

   Migraine with aura is associated with 2
    fold risk of ischemic stroke &
    cardiovascular event
       Absolute risk is low (4 per 10000 women
        years)
       May be indication for aggressive treatment
        of other risk factors
       Unclear if more intense treatment &
        prevention of migraines will alter the risk
 Migraine without aura – Criteria*
   At least 5 attacks (bunch of them)
   Lasting 4-72 hours untreated or unsuccessfully
    treated (didn‟t just go away quickly)
   Must have one of these to be migraine:
       Nausea or vomiting
       Photophobia
       Phonophobia



*International Headache Society - 2004
 Migraine without aura – Criteria*
   Then usually have at least 2 of these:
       Unilateral pain
       Throbbing/pulsating
       Aggravation on movement
       Moderate or severe intensity
   And of course to be sure not something else:
       H & P does not suggest organic disorder
       H & P suggests an organic disorder which is then
        ruled out
       An organic disorder is present but attacks do not
        occur for the 1st time in close time to the disorder
*International Headache Society - 2004
    Diagnosing the acute headache
   The classification criteria are best suited for
    a between-attack assessment of their typical
    headache
       However, they are often used for the acute
        attack
       Once acute pain relieved, take time to make an
        accurate diagnosis
   Up to 1/3 of ED patients cannot be assigned
    a diagnosis
       Despite a through questionnaire-based
        assessment
ER Clinical Decision Rule
   “ID Migraine” – three features
       Sensitivity to light
       Nausea or vomiting
       Disabling intensity of headache
          0 - 1 positive - low probability

          If 2 positive higher probability of migraine

       Criteria focus on typical attacks not the
        current acute attack
    Epidemiology - Migraine
   Can start at any age, however,
       Peak incidence of onset is mid-adolescence
        (age 13-16)
       History of colic or motion sickness support Dx
   Median frequency - 1.5/month
   Greater increase in prevalence with aging
    in women
       Females - 6.4% age 12 - 17; 17.3% age 18 - 29
       Males - 4.0% age 12 - 17; 5.0% age 18 – 29
       Usually more severe in women
    Pathophysiology
   Migraine is a primary neural event
       Something lowers threshold for a cortical
        spreading depression (CSD)
           Which causes regional hypoperfusion (aura)
           Release of proinflammatory neurochemicals
       Neural event results in vasodilation
       Which leads to pain & more nerve activation
   Migraine headache is not a primary
    vascular event
Testing Indications*
   Laboratory tests not helpful or needed to
    make the diagnosis
   EEG not indicated as routine evaluation
   Neuroimaging guidelines
      Typical migraine with normal neurologic
       exam
         Neuroimaging not warranted (SOR-B)
      Insufficient evidence regarding imaging in
       presence of neurologic symptoms (SOR-C)

    *U.S. Headache Consortium (2000)
Neuroimaging - EBM
   For non-acute HA with unexplained abnormal
    finding on neurologic examination – obtain
    neuro image (SOR-B)
   If atypical features or headache does not fulfill
    definition of migraine – lower the threshold for
    obtaining imaging (SOR-C)
   CT vs. MRI?
       Insufficient data to recommend MRI compared to CT
        in evaluation of migraine or other nonacute
        headache (Grade C)
Red Flags!

   Strongly consider neuroimaging if
       New onset > age 50
       Thunderclap onset
       Focal and nonfocal symptoms
       Abnormal signs
       Headache with change in posture
       Valsalva headache
       HIV or cancer diagnosis
    Treatment
   Goals of treatment
       Reduce frequency, severity, & duration of
        headaches
       Improve quality of life (QOL)
       Avoid acute medication escalation
   Treatment Guidelines are based upon
    having a specific diagnosis
       Often difficult initially to make specific Dx
       Therefore, significant uncertainty about „best‟
        initial treatment
Treatment - Migraine
   The brain of patients with migraines does not
    tolerate peaks or troughs of life
   Patients should get:
       Regular sleep
          Go to bed and awaken same time every day
       Regular meals
          Eat same time every day
          Never skip meals – fasting associated with
           precipitating headache
       Regular exercise
       Avoid peaks of stress, troughs of relaxation
       Avoid unique dietary triggers
Migraine & Diet - EBM

   Frequency, duration & severity are NOT
    increased by dietary choices (SOR-A)
       Cheese, alcohol, chocolate, citrus are not
        universal triggers
   Low-fat diet reduced frequency of
    migraines (SOR-B)
         Migraine & Supplements - EBM
   Supplements reduced frequency & intensity
        Riboflavin – 400 mg qd
           Effect begins at 1 month, maximal @ 3 months
        Magnesium – 600 mg qd
           Diarrhea common - almost 20%
           360 mg qd during luteal phase reduced menstrual migraine
        Others
           Butterbur 100-150 mg/d
           CoQ10 300 mg/d
           Feverfew 18.75 mg/d

   National Guideline Clearing House
        SOR – A
        http://www.guideline.gov/summary/summary.aspx?doc_id=6231&nbr=004002&string=migraine
     Question
22 yo female presents with throbbing
headache, nausea, photophobia for 5
hours. BP 116/76, P 86. Which of these
treatments would be appropriate for her?
a.   Ketorolac (Toradol®) 60 mg IM
b.   Metoclopramide (Reglan®) 20 mg IV
c.   Prochlorperazine (Compazine®) 10 mg IV
d.   D.H.E. 45 1 mg IV
e.   Sumatriptan (Imitrex®) 6 mg SQ
Treatment of Acute Pain
   NSAID (SOR-A)
   Ketorolac (Toradol®) – 10 mg oral, 60 mg
    IM, or 30 mg IV(SOR-C)
   Combinations
       Isometheptene mucate, dichloralphenazone
        and acetaminophen (Midrin®)
       Butalbital has not been effective in controlled
        trials (butalbital/acetaminophen/caffeine- 50/325/40
        Fioricet®, butalbital/ASA/caffeine-50/325/40
        Fiorinal®)
Treatment of Acute Pain
   NSAIDs – more effective when:
       Taken early
       With adequate initial dose
       Combined with antiemetic
   ASA 1000 mg
       Combined with metoclopramide IM
        (Reglan®) reduces nausea/vomiting but not
        better pain control
Treatment of Acute Pain
   IV fluids may benefit patients, although
    benefit is not well established
       Unlikely to be harmful especially in patients
        with persistent GI symptoms
       Parenteral therapy preferred due to gastric
        stasis & delayed absorption of oral
        medications
Treatment of Acute Pain
   Droperidol (Inapsine®) probably most
    effective of dopamine agonists
       Pain relief at 2 hours approaching 100%
       Ideal dose – 2.5 mg IV
       FDA warning about QT prolongation
Treatment of Acute Pain
   Prochlorperazine (Compazine®) 10 mg IV
       Effective with diphenhydramine (Benadryl®)
        – 25 mg IV [Friedman 2008]
       Superior to SC sumatriptan in ED setting
        [Kostic 2010]
       Children 0.15 mg/kg IV over 15 minutes
        (max 10 mg)
          If EPS develop give diphenhydramine
           1mg/kg (max 50 mg)
     Treatment of Acute Pain

       Metoclopramide* (Reglan®)
           IV – monotherapy 10 - 20 mg IV
           IM – 10 mg adjunct to other therapies
            (SOR-C)




* FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has
                              been linked to tardive dyskinesia.
    Treatment of Acute Pain
   Ergot alkaloids
       Dihydroergotamine (D.H.E. 45®) – 1 mg
        IM/IV/SC
           Since it may cause nausea, more effective with
            metoclopramide (Reglan®) to reduce nausea
           Nasal spray effective
       Ergotamine/caffeine (1/100) (Cafergot®)
           Little evidence effective alone
           High risk of overuse & rebound headache
    Treatment of Acute Pain
   Complementary medicine
       Topical menthol 10% was more effective at
        complete pain relief than placebo at 2 hours
        (38.3% vs 12.1%) [Haghighi 2010]
          10% solution of menthol crystals in ethanol

          Forehead and the temporal area most
           painful are washed with tap water
          After drying 1 ml is applied with sponge on
           a surface area of 5 x 5 cm
          Can be reapplied in 30 min
    Treatment of Acute Pain - EBM
   Patients with substantial disability will
    benefit from serotonin 5-HT1B/1D agonists
    („triptans‟)
       SOR – A
       Clinical Evidence
           http://www.clinicalevidence.com/ceweb/conditio
            ns/nud/1208/1208.jsp
Triptan Efficacy

   No one triptan is superior in all pain relief
    parameters
   Use one triptan for 2-3 attacks before
    abandoning that medication
   If one does not work try another one
How is pain relief measured?

1) Was pain better within 2 hours?
2) Did the pain go away at 2 hours?
3) Did the pain stay away for at least
   24 hours? (No immediate recurrence)
4) Did the patient consistently obtain pain
   relief from that medication?
Oral Triptan Efficacy

   Was pain better within 2 hours?
       55-65% of patients experience
        improvement at 2 hours
       Can be repeated in 1 – 2 hours if partial
        response
Oral Triptan Efficacy

   Did pain go away within 2 hours?
       25-35% of patients are pain free at 2 hours
Oral Triptan Efficacy

   Did pain stay away for 24 hours?
       Freedom from pain at 2 hours, no rescue
        medication, no recurrence of pain in 24
        hours
          20 - 25% of patients have sustained
           freedom from pain
Oral Triptan Efficacy

   Intra-patient Consistency?
       The same patient experiences pain relief
        with the same medication
          Rizatriptan (Maxalt®) has highest intra-
           patient consistency of the oral
           medications
    Sumatriptan (Imitrex®) –
    Parenteral
   6 mg SC
       Pain decreased within 2 hours - 76%
       Pain gone within 2 hours - 48%
       Consistent pain relief for that patient - 90%
       In ER best candidates are those with
        previous response to this treatment
       Adverse events more frequent than with
        oral medication
           And more intense
     Sumatriptan (Imitrex®) –
     Parenteral
   Cutaneous allodynia - sensation of pain in
    response to normally non-toxic touch
    stimuli (e.g. brushing hair, taking shower,
    putting hair in ponytail)
       Presence of cutaneous allodynia associated
        with reduced response to SC sumatriptan
   Needle-free injection available (Sumavel®
    DosePro™)
       Causes as much pain as needle & more
        swelling, bruising & bleeding at site
     Question
22 yo female presents with throbbing
headache, nausea, photophobia for 5
hours. BP 116/76, P 86. Which of these
treatments would be appropriate for her?
a.   Ketorolac (Toradol®) 60 mg IM
b.   Metoclopramide (Reglan®) 20 mg IV
c.   Prochlorperazine (Compazine®) 10 mg IV
d.   D.H.E. 45 1 mg IV
e.   Sumatriptan (Imitrex®) 6 mg SQ
    Triptans – Side Effects
   Tingling
   Paresthesias
   Warmth head, neck, chest & limbs
   Nasal spray associated with taste
    disturbance
    Triptans – Cautions
   Contraindicated with CAD, uncontrolled
    hypertension or cerebrovascular
    disease, hemiplegic migraine
   Should not be taken within 24 hrs of
    another triptan or ergotamine-
    containing/ergot-type medication
   Taking them with an SSRI or SNRI can
    cause life-threatening serotonin
    syndrome
    Combining Medications
   Sumatriptan 85 mg & Naproxen 500 mg
    (Treximet®) more effective than either alone
    for acute pain relief
   Unknown effect of taking 2 separate pills (not
    tested)
   The combination may have some increased
    benefit in mild/moderate pain but no evidence
    of need for fixed dose combination (Medical
    Letter 2008)
Early Recurrence

   Up to 75% of patients will experience a
    recurrence of pain within 48 hours
       Naproxen (500 mg) or sumatriptan (100 mg)
        equally effective treating the recurrence
        [Friedman 2010]
       Naproxen prophylactically can prevent
        recurrence (NNT – 3)
       Triptans should not be used prophylacticly
     Preventing Early Recurrence

   Parenteral dexamethasone (10-25 mg IV)
       Produced 26% relative reduction in recurrence
        within 72 hours [Colman 2008]
       Modest benefit in the ED – prevented 1 in 10
        patients from experiencing moderate or severe
        recurrence [Singh 2008]
       Later trials failed to find benefit with oral
        dexamethasone or prednisone
    Acute Pain & Parenteral Opioids
   Should not be used as 1st line therapy
       International Headache Consortium
       Canadian Association of Emergency
        Physicians
       American Academy of Neurology
   Meperidine (Demerol®) less effective than
    DHE and there is an:
       Increased risk of sedation
       Toxic metabolite with repetitive use
    New Treatments Acute Pain
   Diclofenac oral solution (Cambia®) –
    dissolve contents in water
   Sumatriptan patch (Zelrix™) – similar
    levels to SC
    New Treatments Acute Pain
   DHE inhaled (Levadex®) – patients not
    responding to triptans or more than 6
    hours into headache?
   Calcitonin gene-related peptide (CGRP)
    antagonist (telcagepant) – as effective as
    zolmitriptan 5 mg oral
   Single-pulse transcranial magnetic
    stimulation (sTMS)
       More effective than placebo in pain-free at 2
        hours (39% vs 22%)
After the Migraine - Postdrome

   Some patients may have:
       Mood changes
       “Hangover”
       Tired
       Weak
       Disoriented
       “Not right”
    Chronic Migraine (CM) or Medication
    Overuse Headache (MOH)
   Chronic migraine previously called
    „transformed migraine‟
   Consider medication overuse if ≥ 2
    days/week for > 3 months analgesic use
   Over period of time (months to years)
    can become almost daily headache
       Resembles mixture of tension & migraine
       Occasionally called „tension-vascular‟
       Hint – if awaken with headache consider
        medication overuse
CM Modifiable Risk Factors

   Risk factor associated with increased risk
    of developing CM
       Stressful life events
       Sleep disturbance (i.e. Snoring/sleep apnea)
       Obesity
       Baseline headache frequency
       Medication overuse
    CM & MOH
   Treatment
       Must stop acute medication to determine
           Headaches will go away in a few days if
            medication overuse is etiology
       No controlled trials of medication withdrawal
       May get severe withdrawal headache
           Severe withdrawal headache can be treated with
            short course of prednisone
           Randomized trial found no difference with steroid
            compared to placebo
Preventive Medication

   Candidates:
       Unresponsive to acute attack medication &
        disabling headache
       ≥ 2 attacks/month
       Increasing frequency of attacks
       Migraines with potential neurological
        sequelae
       Patient preference (just wants to use
        medication to prevent headaches)
     Audience Question
23 y. o. female with recurrent migraine
headaches. You advise starting
preventive therapy. Which medication
would be appropriate?

a)   Anticonvulsant medication
b)   Bipolar/anticonvulsant medication
c)   Beta-blocker medication
d)   Tricyclic medication
Prevention therapy - EBM
   First line treatment should be:
       Propranolol (Inderal®)
           20 – 240 mg/day
       Timolol
           10 – 30 mg/day
           Less evidence to support other beta-blockers
       Amitriptyline
           10 – 150 mg/day
Prevention therapy - EBM
   First line treatment should be:
       Divalproex sodium (Depakote®)
           125 – 500 mg BID
       Topiramate (Topamax®)
           50 - 100 mg BID
           May be as good as propranolol
           Anti-epileptic drugs had greater suicidal
            ideation vs. placebo (0.43% vs 0.22%)
         Prevention therapy

          Second line (SOR-B)
               Gabapentin - pregnancy category D
               Carbamazepine* - pregnancy category D




* FDA Alert 12/12/07 – Dangerous or even fatal skin reactions can be caused by
                       Carbamazepine therapy in patients with a particular HLA-B*1502 allele.
Prevention Therapies - EBM
   Relaxation training (SOR-A)
       Progressive muscular relaxation
       Breathing exercises
       Directed imagery
   Cognitive-behavioral (SOR-A)
       Combined with medication (SOR-B)
   Acupuncture appears to be effective (SOR-A)
       Sham acupuncture just as effective as real
        [Linde 2009]
   Thermal biofeedback with relaxation training
     Audience Question
23 y. o. female with recurrent migraine
headaches. You advise starting
preventive therapy. Which medication
would be appropriate?

a)   Anticonvulsant medication
b)   Bipolar/anticonvulsant medication
c)   Beta-blocker medication
d)   Tricyclic medication
 Menstrual Migraine – two classes

A. Pure menstrual migraine without aura
      Migraine without aura on days -2 to +3
       of cycle
      During at least 2 of 3 cycles
B. Menstrual related migraine without aura
      Migraine without aura as above and
      At other times of the month
Menstrual Migraine

   Strongly associated with estrogen
       Steep drop in estrogen just prior to menses
        may trigger headache
       Peak incidence is 1st day and preceding day
        of cycle
   Other clinical features
       Greater severity of pain
       Increased risk of nausea & vomiting
       Less responsive to acute treatment
    Menstrual Migraine
   Acute therapy the same as other
    migraines
   Short-term prevention
       NSAID on days -7 to +6 helped
           Naproxen sodium (Anaprox®) & mefenamic acid
            (Ponstel®) orally have been studied
       Triptans starting day -2 for 5-6 days helped
           Frovatriptan (Frova®), naratriptan (Amerge®) &
            sumatriptan (Imitrex®) orally have been studied
    Prognosis of Migraines
   Study with 10 year follow-up of 11-14 year olds
    at onset of migraines
       40% no longer had headache
       20% had episodic tension headache
       20% had migraine type that was different from the
        original diagnosed headache
   Frequency & intensity usually decreases after
    menopause
   Two fold increased risk of CVA [Spector 2010]
       May influence how aggressive to be with other
        therapies to reduce risk of CVA
    Tension Type Headache
    (TTH) - Criteria
   First
       No vomiting – if vomiting probably a
        migraine
       Not worsened by routine physical activity
       But can have one of these clinical
        features
           Photophobia
           Phonophobia
TTH - Criteria
   If no vomiting & only 1 other symptom -
    then need 2 of the following:
       Pressing, tightening or non-pulsatile pain
       Mild to moderate intensity of pain
       Bilateral
       No aggravation with movement
   Diagnosis best made with use of
    headache diary for 4 weeks
TTH

   Underlying cause uncertain
   Muscle tenderness & psychological
    tension associated with aggravating them
       But are not clearly the cause
   Susceptibility influenced by genetic
    factors
TTH

   Gender ration female:male 5:4
   Age of onset – 25-30 years old
   Peak prevalence – 30-39 years old
   Prevalence increases with higher
    educational level
    TTH – Treatment
   OTC analgesic medications
   NSAID (prescription)
   May be augmented with:
       Promethazine (Phenergan®)
       Diphenhydramine (Benadryl®)
       Metoclopramide (Reglan®)
   Efficacy tends to decrease with
    increasing frequency of headaches
    Cluster Headaches - Criteria
   Severe unilateral, bilateral, supraorbital or
    temporal pain lasting 15-180 minutes
    (untreated) and one of following on same side
       Lacrimation
       Rhinorrhea
       Forehead or facial swelling
       Ptosis
       Miosis
       Eyelid edema
    Cluster Headaches - Criteria
   Sense of restlessness (93% patients) or
    agitation
       Prefer to be erect & move about
   5 attacks with frequency of 1-8 on any
    given day from no other cause
       75% of attacks last < 60 minutes
Cluster Headaches

   Male : female – 2.1 : 1
   Peak onset in 40‟s
   60% right sided
   Probably most severe pain known to
    humans
       Female patients describe attacks as worse
        than childbirth
    Cluster Headache Treatment
   Acute
       Sumatriptan
           6 mg SC – relief in 15 min
       Intranasal spray sumatriptan or zolmitriptan
        – relief in 30 min
       Triptans limits on daily usage
           Limit to 2 SC or 3 nasal sprays per day to
            prevent tachyphylaxis or rebound
       High flow O2 effective & safe [Cohen 2009]
           O2 – 7 - 15 L/min with loose fitting
            nonrebreathing facial mask for 15 min
    Cluster Headache Treatment
   Acute
       DHE 0.5 - 1 mg IM or IV useful as abortive
        agent
       Octreotide (Sandostatin®) 100 mcg SC can
        abort an attack
          NNT 5 for complete relief in 30 min
       Prednisone 50-80 mg – short course
Cluster Headache Treatment
   Prophylactic
       Verapamil 240-960 mg/day
    Daily Headache
   When chronic daily headache is strictly
    unilateral, same side, consider diagnosis
    to be:
       Hemicrania continua
           Ipsilateral side one or more autonomic symptoms
            (ptosis, lacrimation, etc.)
       Defined by absolute response to
        indomethacin (25 – 300 mg daily, must be
        continued indefinitely)
           If intolerant of indomethacin conside COX2
            inhibitor
     Key Points

   Diagnosis of migraine headache is clinical
       Almost always positive family history
   Triptans are preferred treatment for
    frequent migraines
   Discuss preventive therapy with all patients
   Provide treatment plan for breakthrough
    pain
What Questions do you have?

				
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posted:11/27/2011
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