Diagnosing and Managing Migraine Headache

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Diagnosing and Managing Migraine Headache Powered By Docstoc
					                                                                                                   not changed since 1989, based on evi-
                                                                                                   dence from three large studies: Amer-
                                                                                                   ican Migraine Study I, 1 American
                                                                                                   Migraine Study II, 2 and American
                                                    Diagnosing and Managing                        Migraine Prevention and Prevalence
                                                                                                   Study.3 Migraine in the United States is
                                                    Migraine Headache                              more prevalent in Caucasians than in
                                                                                                   African Americans, and the lowest
                                                    Loretta L. Mueller, DO                         prevalence in the United States is among
                                                                                                   Asian Americans.2 Migraine is gener-
                                                                                                   ally more common in people who are in
                                                                                                   lower socioeconomic groups.2
                                                                                                        Migraine typically begins affecting
                                                                                                   individuals when they are in their teens
                                                                                                   or twenties, with peak prevalence occur-
                                                                                                   ring at approximately age 40 years.2 First
                                                                                                   onset of migraine after age 50 years
Headache is one of the chief complaints among patients visiting primary care                       should raise suspicion of secondary
physicians. Diagnosis begins with exclusion of secondary causes for headache.                      headache causes. One quarter of adults
More than 90% of patients will have a primary-type headache, so diagnosis can                      with migraine will experience four or
often be completed without further testing. Although tension-type headaches are                    more severe attacks per month, each with
the most common kind of headache, patients with this type of headache rarely                       a mean duration of about 24 hours.2
seek treatment unless occurrence is daily. Migraine, which affects more than
30 million people in the United States, is the most common headache diagnosis                      Diagnosis of Migraine
for which patients seek treatment. Migraine is a chronic, often inherited condi-                   Migraine is a diagnosis strongly linked to
tion involving brain hypersensitivity and a lowered threshold for trigeminal-vas-                  a patient’s medical history. Typical char-
cular activation. Intermittent debilitating attacks are characterized by autonomic,                acteristics of migraine headache include
gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease                   unilateral throbbing pain associated with
in a patient’s quality of life, as measured by physical, mental, and social health-                moderate to severe disability, nausea, vom-
related instruments. Accurate assessment of a patient’s disability will guide
                                                                                                   iting, phonophobia, photophobia, and
physicians in prescribing appropriate modes of therapy. However, migraine
                                                                                                   increased pain with physical exertion.4
remains underdiagnosed, and patients with migraine remain undertreated.
                                                                                                   Migraine in children is generally shorter in
     A comprehensive treatment approach to migraine may include nonphar-
                                                                                                   duration than migraine in adults, with less
macologic measures, as well as abortive and prophylactic medications. Informing
                                                                                                   pronounced associated symptoms and
patients about realistic treatment expectations, possible delayed efficacy of med-
                                                                                                   possible presentation as cyclic vomiting,
ications, and avoidance of caffeine and overuse of medications is critical for suc-
                                                                                                   abdominal symptoms, or paroxysmal ver-
cessful outcomes. Management of migraine is a dynamic process, because
                                                                                                   tigo rather than head pain.4
headaches evolve over time and medication tachyphylaxis may occur, necessitating
                                                                                                         It is important to note that no iso-
changes in therapy. Pathologic findings in the neck constitute an accepted etiology
                                                                                                   lated characteristic is necessary to make
or precipitant for headache. Osteopathic manipulative treatment may reduce
                                                                                                   the diagnosis of migraine. The three most
pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-
                                                                                                   predictive characteristics for a migraine
autonomic regulatory mechanisms to reduce discomfort from headache.
                                                                                                   diagnosis are disability, nausea, and pho-
J Am Osteopath Assoc. 2007;107(suppl 6):ES10-ES16                                                  tophobia.5 An abbreviated set of diag-
                                                                                                   nostic criteria for migraine is available
                                                                                                   in a validated screening instrument called
Dr Mueller is an associate professor of family
medicine and director of the University Headache
Center at the University of Medicine and Den-
                                                    M      igraine is a common condition,
                                                           annually affecting 12% of the
                                                    United States population, including 18%
                                                                                                   ID Migraine.5
                                                                                                         Less than a third of patients with
                                                                                                   migraine have focal neurologic signs,
tistry of New Jersey-School of Osteopathic
Medicine in Stratford.                              of women, 6% of men, and 4% of chil-           termed auras, just before or during some
    Dr Mueller has been principal investigator in   dren.1-3 Lifetime prevalence of migraine       headaches.4 The diagnosis for these
clinical trials for Merck & Co, Inc; GlaxoSmith
Kline, Vernalis, Ortho-McNeil, and AstraZeneca.     in women in the United States exceeds          patients is migraine with aura (formerly
She is a national consultant for Merck & Co, Inc,   25%.1-3 The prevalence of migraine has         called “classic migraine”), in contrast to
and on speakers bureaus for Merck & Co, Inc, and
    Address correspondence to Loretta L.
Mueller, DO, University Headache Center, 42 E                      This continuing medical education publication is supported by
Laurel Rd, University Doctors Pavilion, Ste 1700,
                                                                          an educational grant from Purdue Pharma LP.
Stratford, NJ 08084-1354.
    E-mail: SOMPhysicians@umdnj.edu

ES10 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007                                  Mueller • Diagnosing and Managing Migraine Headache
migraine without aura (formerly called                                                             specific to migraine. For example, menses
“common migraine”).4 Auras are most                                                                is a trigger for 60% of female migraineurs
commonly visual and less commonly                     Diagnostic Criteria for                      and is also a trigger for tension-type
sensory or motor in nature. Migraines                 Migraine Without Aura                        headache.11 Stress or “let-down” after a
associated with motor auras are called                                                             stressful event, change in sleep or meal
hemiplegic migraines and may occur on a                A. At least five headache attacks           schedules, and such environmental fac-
hereditary basis within families and a                 fulfilling criteria B through D             tors as loud noise, odors, or flickering
sporadic basis among individuals.4 Trip-               B. Headache attacks lasting                 lights may also precipitate migraine
tans are contraindicated for patients with             4 to 72 hours (untreated or                 headache.11
hemiplegic migraine because of a lack                  unsuccessfully treated)                           Approximately a quarter of patients
of adequate testing of these medications                                                           with migraine recognize certain food as
in this small population.                              C. Headache has at least two of             migraine triggers.12 Such triggers include
                                                       the following characteristics:
      Migraine is often mistaken for sinus             Unilateral location                         monosodium glutamate (also known
or tension headache. Migraine is con-                  Pulsating quality                           as hydrolyzed yeast extract, natural fla-
fused with sinus headaches because the                 Moderate or severe pain                     voring, hydrolyzed vegetable protein),
autonomic symptoms of migraine                         intensity                                   often found in soups and Chinese food.12
include nasal stuffiness or discharge,                 Aggravation by, or causing                  Nitrites (a preservative found in lunch
                                                       avoidance of, routine physical
occurring in 87% of patients with                      activity (eg, walking or climbing           meats and hot dogs), tyramines (found in
migraine.6 In addition, the headache in                stairs)                                     wines and such aged foods as cheeses),
these patients may be located above the                                                            and phenylethylamine (found in choco-
sinuses.6 Migraine often is confused with              D. During headache, at least one            late, garlic, nuts, raw onions, and seeds)
tension headache because 75% of patients               of the following characteristics:           are other potential migraine triggers.12
                                                       Nausea and/or vomiting
with migraine have neck pain during or                 Photophobia and/or                          Alcohol of any kind, artificial sweeteners,
immediately before or after a migraine.7               phonophobia                                 citrus fruits, pickled products, and vine-
      The diagnosis of migraine is based                                                           gars are additional likely triggers.12 It
on criteria developed by the International             E. Headache cannot be                       should be noted that not all patients have
Headache Society in 1988 and revised                   attributed to another disorder              these food triggers, so a diet totally elim-
by the society in 2004—the International                                                           inating these items is not warranted in all
Classification of Headache Disorders II                                                            migraineurs.
(ICHD II).4 Similar to the Diagnostic and        Figure 1. The International Classification              Daily consumption of caffeine can
Statistical Manual of Mental Disorders           of Headache Disorders II (ICHD-II) criteria for   lead to caffeine withdrawal headaches
(DSM IV) used in psychiatric evalua-             migraine without aura. (Source: Headache          or rebound headaches interfering with
tions, the ICHD II requires that patients’       Classification Subcommittee of the Interna-       or negating the effects of migraine pre-
headaches must have certain character-           tional Headache Society. The international        ventive medications. Daily caffeine con-
istics for each kind of diagnosis (Figures       classification of headache disorders. Cepha-      sumption is much greater than many
                                                 lalgia. 2004;24(suppl 1):14-160.)
1 and 2). Headaches are categorized by                                                             people expect, with a typical cup (8 oz) of
primary or secondary headaches, with                                                               drip coffee containing about 135 mg of
four broad groups of primary headaches,                                                            caffeine.13 Patients should be advised
including migraine, tension, cluster, and        mary headache diagnosis. However, rec-            that caffeine is used in combination with
miscellaneous headaches, and 10 broad            ommendations by the US Headache                   many over-the-counter (OTC) pain med-
groups of secondary headaches                    Consortium8 state that neuroimaging is            ications because it enhances analgesia.14,15
(Figure 2).4                                     generally not necessary in adult patients         Caffeine has a half-life of up to 9.5 hours;
      Although necessary for medical             presenting with typical migraine, normal          and the body transforms it into more
research, the ICHD II criteria4 may be           findings on neurologic examination, and           than 25 metabolites.14
cumbersome for use by physicians in the          no recent change in headache character-                 Overuse of caffeine is a risk factor for
primary care setting. Nevertheless, the          istics.9 These recommendations are based          progression of occasional migraine to a
criteria do offer a process for organizing       on data indicating that only 0.18% of this        chronic daily pattern. Additional con-
a differential diagnosis; if patients have       patient group show a clinically signifi-          siderations for such a progression include
the symptoms listed in the criteria, physi-      cant intracranial pathologic lesion on            acute medication overuse, depression,
cians are more comfortable that the              neuroimaging.9                                    obesity, sleep disorders, and stressful life
patient truly has that primary headache                                                            events.16
diagnosis and is less likely to have a brain     Triggers of Migraine                                    Head trauma may cause or exacer-
tumor or other grave condition.                  Migraine is believed to be an inherited           bate headaches. Based on ICHD II cri-
      Any abnormalities in a patient’s           condition of cortical hyperexcitability.10        teria,4 new onset of headaches within
medical history or physical examination          Some patients with migraine are able to           7 days of head trauma is diagnosed as
suggesting secondary headache must be            identify headache triggers. Triggers may          posttraumatic headache, while continued
carefully evaluated before making a pri-         be inconsistent or additive and are not           headache after 3 months is termed

Mueller • Diagnosing and Managing Migraine Headache                                   JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES11
Figure 2. The International Classification of
Headache Disorders II (ICHD II) outline of pri-
mary headache disorders and secondary                  Outline of International Classification
headache disorders, developed by the Inter-            of Headache Disorders II
national Headache Society in 1988 and revised
by the society in 2004. (Source: Headache                   Primary Headache Disorders               Secondary Headache Disorders
Classification Subcommittee of the Interna-                 1. Migraine                              5. Headache attributed to head and
tional Headache Society. The international              —   Migraine without aura                    neck trauma
classification of headache disorders. Cepha-            —   Migraine with aura                       6. Headache attributed to cranial or
lalgia. 2004;24(suppl 1):14-160.)                       —   Childhood periodic syndromes that        cervical vascular disorders
                                                            are precursors of migraine               7. Headache attributed to
                                                        —   Retinal migraine                         nonvascular intracranial disorder
                                                        —   Complications of migraine                8. Headache atributed to substance
                                                        —   Probable migraine                        or its withdrawal
chronic posttraumatic headache. Even                        2. Tension-type headache                 9. Headache attributed to infection
mild head trauma without loss of con-                   —   Infrequent episodic tension-type         10. Headache attributed to
sciousness or objective findings can cause              —   Frequent episodic tension-type           disturbance of homeostasis
new onset or exacerbation of headaches,                 —   Chronic tension-type                     11. Headache or facial pain
necessitating long-term management.4                    —   Probable tension-type                    attributed to disorder of cranium,
                                                            3. Cluster headache and other            neck, eyes, ears, nose, sinuses, teeth,
      The proposed neurophysiologic                         trigeminal autonomic cephalgia           mouth, or other facial or cranial
basis for cervicogenic headache is nocio-               —   Cluster headache                         structures
ceptive input from trigeminal and cer-                  —   Paroxysmal hemicrania                    12. Headache attributed to
vical (C1-C3) afferent neurons converging               —   Short-lasting unilateral                 psychiatric disorders
on second-order neurons in the                              neuralgiform headache attacks with       13. Cranial neuralgias, central and
                                                            conjunctival injection and tearing       primary facial pain and other
trigeminocervical nucleus.17 In addition,               —   Probable trigeminal autonomic            headaches
several recent anatomic discoveries iden-                   cephalgia                                14. Other headache, cranial
tify direct neuronal connections between                    4. Other primary headaches               neuralgia, central or primary facial
extracranial structures and the dura                    —   Primary stabbing headache                pain
mater.18 Hack et al19 found a neuronal                  —   Primary cough headache
                                                        —   Primary exertional headache
connection between the rectus capitis                   —   Primary headache associated with
posterior minor muscle and dorsal spinal                    sexual activity
dura mater at the atlanto-occipital junc-               —   Hypnic headache
tion, which appears to restrict dural                   —   Primary thunderclap headache
movement toward the spinal cord.                        —   Hemicrania continua
                                                        —   New daily persistent headache
Abnormalities in the cervical spine, such
as muscular spasm, may transmit forces
to the pain-sensitive dura mater.
      Theoretically, alleviating accessible       adequately treated with abortive or pro-       ability assessment is the Migraine Dis-
causes of pain through such modalities as         phylactic medications for migraine. A          ability Assessment (MIDAS) tool,21 which
osteopathic manipulative treatment                major obstacle in diagnosing headache in       can be used to assess the number of work
(OMT) should increase a patient’s                 a primary care setting is time constraint.     or school days lost during a 3-month
headache thresholds. However, because             An average office visit by a patient to a      period due to migraine. Studies show
of a lack of controlled studies on OMT            primary care physician lasts 9 minutes         that healthcare providers are more likely
and other modalities, biofeedback is the          and usually addresses multiple com-            to treat patients with effective, migraine-
only nonpharmacologic therapy for                 plaints.2 Scheduling additional visits         specific therapeutic modalities if they are
migraine that is considered to be “evi-           specifically to address the headache com-      aware of the patients’ migraine disabili-
dence-based” by the US Headache Con-              plaint and having patients keep diaries of     ties.22,23 The Disability in Strategies of
sortium.8                                         headache frequency, severity, and med-         Care (DISC) trial22 confirmed that patients
                                                  ications may help overcome obstacles to        with moderate to severe migraine-caused
Pharmacologic Management                          proper diagnosis and treatment.                disability are more likely to respond to
of Migraine                                             Patients are usually not adept at ini-   high-end modes of therapy. In the DISC
Abortive Medications                              tiating accurate descriptions of disability    trial, 75% of patients had a failed response
More than 90% of patients with migraine           experienced during migraine attacks, and       to high-dose aspirin (800-1000 mg/d) and
have disability with their attacks, and           physicians may not accurately assess           metoclopramide (10 mg/d) therapy,
half these patients require bed rest.20           migraine-related disability of their           requiring zolmitriptan (2.5 mg/d) as effec-
Despite this high level of disability, less       patients, many of whom may be healthy          tive high-end therapy.
than 60% of patients with migraine have           young individuals between headache                    The US Headache Consortium rec-
their headache diagnosed as such by a             attacks. In light of these problems, a clin-   ommends serotonin 5HT1B/D agonists
physician.20 Thus, many patients are not          ically useful, validated instrument for dis-   (ie, triptans) as first-line therapy in a strat-

ES12 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007                                Mueller • Diagnosing and Managing Migraine Headache
ified-care approach for patients with                                                               sition from one triptan to another to
migraine who experience moderate to                                                                 maintain efficacy.23 Assessment of effi-
severe disability (Figure 3).23 Seven trip-            Treatment Considerations                     cacy of triptans and other abortive med-
tans are available for migraine, all in tablet                                                      ications should be repeated at each
formulation.23 Two of these triptans (riza-           PROPHYLACTIC MEDICATION                       patient visit, with several questions asked
triptan, zolmitriptan) are available as oral             -Blockers                                  of patients and various target endpoints
wafers that may be taken without water;                 Good choice with hypertension,              addressed (Figure 4).
two (sumatriptan, zolmitriptan) are avail-              angina, anxiety                                   Alternative abortive medications to
able as nasal sprays; and one (suma-                    Caution with asthma, depression,            triptans include ergots and their syn-
triptan) is available in a subcutaneous                 bradycardia,hypotension, type 1             thetic derivative, dihydroergotamine;
formulation.23 Headache relief with trip-               diabetes mellitus, Raynaud                  butalbital-containing analgesics or other
                                                        disease, congestive heart failure,
tans is not pathognomonic to migraine;                  prolonged aura, athlete
                                                                                                    analgesic combinations; isometheptene
migraine, tension-type, and secondary                                                               mucate combination; nonsteroidal anti-
headaches may all respond to these                      Tricyclic Antidepressants                   inflammatory drugs (NSAIDs); and opi-
drugs.24 Conversely, not all migraines                  Good choice with insomnia,                  oids.23 Administration of butalbital-con-
respond to triptans.24                                  depression, fibromyalgia                    taining products is controversial because
      Triptans have the same contraindi-                Caution with heart block, bipolar           there are no placebo-controlled trials sup-
cations in patients with known or sus-                  disorder, epilepsy, urinary                 porting their efficacy for migraine. In
pected ischemic cardiac, cerebrovascular,               retention, hypotension,                     addition, the potential exists for butal-
peripheral vascular, or uncontrolled                                                                bital overuse resulting in rebound
hypertensive disease.25 However, the                                                                headaches, and some patients may use
                                                        Antiepileptic Drugs
Triptan Cardiovascular Safety Expert                    Good choice with epilepsy,                  butalbital-containing products to treat
Panel concluded that chest symptoms                     bipolar disorder, anxiety, obesity          underlying comorbid anxiety.23 Opioid
occurring with triptan use are generally                (topiramate)                                therapy is also controversial, with sev-
not serious or ischemic; the incidence of               Caution with liver disease,                 eral studies reporting activation of prono-
serious cardiovascular events with triptan              bleeding disorder, obesity                  ciceptive mechanisms with long-term
use appears to be extremely low; and the                (valproate), nephrolithiasis                use of opioids.27,28
cardiovascular risk-benefit profile of trip-            (topiramate)                                      “Rescue” treatment options when
tans favors their use in the absence of                                                             first-line agents fail in an outpatient or
                                                        Calcium Channel Blockers
contraindications.25 One type of triptan                Good choice with hypertension,
                                                                                                    emergency department setting include
should not be combined with another                     angina, prolonged aura                      the following: dihydroergotamine, dival-
type or with a vasoconstrictor within                                                               proex sodium,29 droperidol,30 intranasal
                                                        Caution with heart block,
24 hours of administration. Rizatriptan,                hypotension, constipation                   lidocaine,31 ketorolac, magnesium sul-
sumatriptan, and zomitriptan should not                                                             fate,32 opioids, parenteral sumatriptan,
be used within 2 weeks of administration                                                            prochlorperazine, propofol, 33 and
of a monoamine oxidase (MAO) inhibitor;          Figure 3. Prophylactic medication consider-        steroids. All of these medications except
rizatriptan should be dosed at 5 mg per          ations for patients with migraine, as recom-       sumatriptan and dihydroergotamine are
dose for patients using propranolol              mended by the United States Headache Con-          used off-label for migraine.
hydrochloride; and eletriptan should not         sortium. (Source: Silberstein SD. Practice               Abortive polytherapy is an option
be used within 3 days of the use of strong       parameter: evidence-based guidelines for           when single agents do not provide ade-
cytochrome P4503A inhibitors, such as            migraine headache (an evidence-based               quate relief for patients with migraine.
clarithromycin.                                  review): report of the Quality Standards Sub-      An NSAID and/or a gastrokinetic drug
      Labels on all triptans carry a cau-        committee of the American Academy of Neu-          (eg, metoclopramide) may be used in
tionary statement noting that these drugs        rology [published erratum appears in Neu-          addition to a triptan.34
                                                 rology. 2000;56:142]. Neurology. 2000;55:
may cause the “serotonin syndrome”                                                                        Researchers have found that cuta-
when used in combination with other                                                                 neous allodynia (a condition in which
serotonergic drugs such as serotonin                                                                such nonnoxious stimuli as mechanical
reuptake inhibitors (SSRIs, including the                                                           pressure and thermal changes cause skin
antidepressant fluoxetine hydrochlo-             mented efficacy for migraine with and              pain) develops in nearly 80% of patients
ride).26 Symptoms of serotonin syndrome          without aura (including menstrual                  with migraine.35 Studies indicate that
may include autonomic hyperactivity              migraine), naratriptan and frovatriptan            cutaneous allodynia is a marker for cen-
such as tremor, diarrhea, hypertension           generally have slower onset of action as           tral sensitization and abortive medica-
and tachycardia. Neuromuscular abnor-            demonstrated by 2 hours’ pain relief data.         tions are less likely to produce complete
malities or mental status changes such                 Interpatient variability also exists         pain relief after this phenomenon
as rigidity, hyperreflexia, hyperthermia,        for triptan efficacy, with different patients      develops.35
anxiety, or akathisia are additional symp-       responding differently to particular trip-               Providing abortive treatment during
toms. Although all triptans have docu-           tans, and some patients requiring tran-            the early mild phase of migraine results

Mueller • Diagnosing and Managing Migraine Headache                                    JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES13
                                                                                               botulinum toxin A for migraine or chronic
                     Assessment of Abortive Medication Efficacy
                                                                                               daily headache prophylaxis, with most
  Factor to Assess                                     Target Endpoint                         studies not achieving primary endpoint
      Rapidity of relief                      Meaningful onset within 1 h
                                                                                                     For patients with infrequent
      Partial vs total pain relief            Total relief within 2 h                          migraines and those who are reluctant
      Relief of associated symptoms           No nausea, vomiting, photophobia,                or unable to use prescription prophy-
                                                                                               lactic medications, alternative agents may
      Return to normal function               2 h without sedation                             be considered. Dietary supplements that
      Headache recurrence                     Total relief with 1 dose of abortive             may be effective for migraine preven-
                                                                                               tion, based on results of placebo-con-
      Consistency of response                 Relief for every headache                        trolled trials, include butterbur root (Pet-
      Adverse effects                         None or minimal                                  asites hybridus), coenzyme Q10, feverfew,
      Preference/convenience                                                                   magnesium, melatonin, and riboflavin
      of formulation                          Ease of use, taste, convenience                  (vitamin B2).37,38 Many combination prod-
      Cost                                    Weigh cost against efficacy and function         ucts are available, such as MigreLief
                                                                                               (feverfew, magnesium, riboflavin) and
Figure 4. Factors to assess and target endpoints for assessment of efficacy of abortive med-   Migravent (butterbur root, feverfew,
ications in treatment of patients with migraine.                                               magnesium, riboflavin; Vita Sciences,
                                                                                               Airmont, NY).
                                                                                                     The following anecdotal case pre-
                                                                                               sentation describes a typical patient
in higher pain-free rates among                   times, such as during menses, exercise,      whose case illustrates the diagnosis and
patients.35 However, for patients with            or sexual activity.23                        management of migraine.
frequent headaches who consistently                    Physicians should keep in mind that
require treatment more than 2 days per            prophylactic medications are not a cure      Case Presentation
week, prophylactic medication may be              for headache, and abortive therapy will      Cheryl is a 44-year-old woman with peri-
needed to reduce headache frequency.              remain necessary for breakthrough            menopausal symptoms of hot flashes inter-
The potential for headache rebound                attacks. In addition, patient education      rupting sleep. She is seen by her physician
exists with frequent use of most abortive         about medication use is important for        because of an exacerbation of headaches that
medications, including butalbital-com-            compliance.                                  are unilateral, hemicranial, throbbing, and
bination products, caffeine-containing                 No prophylactic medication was          associated with nausea and photophobia. At
products, and triptans.23                         originally developed to treat patients       times she must lie in a dark quiet room to
                                                  with migraine, and only four medica-         try to help ease her headache pain. She denies
Prophylactic Medications                          tions have US Food and Drug Adminis-         having associated neurologic symptoms such
Generally, prophylactic medications               tration (FDA) indication for migraine:       as vision loss, but she says that she often
(Figure 3) are taken daily to reduce              divalproex sodium, propranolol, timolol      yawns for several hours before headaches,
headache frequency, decrease headache             maleate, and topiramate. Major classes       and she has some nasal congestion and neck
intensity, and/or allow for improved              of prophylactic medications for migraine     ache during the pain phase.
abortive management of migraine.                  include antiepileptics, -blockers, cal-            Cheryl’s headaches started at age
However, more subtle improvements                 cium-channel blockers, and tricyclic         14 years, typically occurring only during her
in quality of life may warrant continu-           antidepressants (Figure 3).23 The exact      menses and persisting for 1 day. She now
ation of prophylactic therapy, even if a          physiologic mechanisms of these varied       complains of a gradual increase in headache
high level of headache reduction is not           drugs are not known, but the mecha-          frequency and duration during the previous
achieved. Serial MIDAS tests can mon-             nisms are believed to involve suppression    2 years, with her typical “bad” headaches
itor improvements for such measures               of central hyperexcitability and/or          (ie, migraine without aura) occurring both
as lost work or school days and loss of           enhancement of antinociceptive path-         during menses (lasting 4 days) and outside of
productivity related to home chores or            ways.10                                      menses (two attacks lasting 1 day each).
social functions.21 More than one pro-                 Comorbidities (eg, angina, depres-      Sumatriptan succinate tablets (100 mg/d) no
phylactic medication may be used in               sion, epilepsy) generally will influence     longer provide her with adequate relief.
combination when only a partial                   prescribing considerations for prophy-             On further questioning, Cheryl admits to
response is achieved with one drug and            lactic medications (Figure 3). The           milder headaches occurring on a daily basis for
when that drug’s dosage cannot be                 US Headache Consortium has published         at least the entire previous year. She says she
increased because of maximal dose or              evidence-based guidelines for selecting      manages those headaches daily with six OTC
drug intolerance. Prophylactic modes              a prophylactic medication for patients       combination analgesics containing caffeine,
of therapy may be used intermittently             with migraine.23 There are conflicting       accounting for 390 mg of caffeine
for headaches occurring at predictable            reports regarding the efficacy of            (65 mg/tablet) per day. She had not initially

ES14 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007                              Mueller • Diagnosing and Managing Migraine Headache
noted this analgesic use on her medication          headaches and may be additive with                 Cheryl was encouraged to not take any OTC
list because she believed she could control these   other stimuli.                                     medications for her daily milder headaches,
milder headaches on her own. She also admits              The patient should be especially             but she was given an NSAID as needed for up
to drinking two cups of coffee daily (20 oz         careful to avoid migraine triggers during          to 2 days per week. A daily regimen of low-
each), accounting for approximately 675 mg          her most vulnerable time for headaches             dose amitriptyline (10 mg/d for 1 wk; then
of additional caffeine (135 mg/8 oz)13 per day.     (ie, during menses). Regular exercise may          20 mg/d) at bedtime was started for headache
       Cheryl reports that all previous preven-     have beneficial effects on headaches.              prevention; this medication also helped Cheryl
tive treatments had failed, including dival-        Relaxation activities, including biofeed-          sleep. She was provided with detailed written
proex sodium (1000 mg/d for 3 wk), topira-          back training, listening to relaxation             instructions on her treatment and a diary to
mate (25 mg/d for 2 mo), and verapamil              tapes, and performing yoga, may also               keep track of her headache frequency, severity,
(240 mg/d for 1 mo). She notes that she could       be beneficial. Furthermore, OMT for par-           and medications.
not tolerate propranolol hydrochloride              avertebral cervical spasm associated with
(60 mg/d) because it made her too tired.            headaches may be beneficial—though                      Have the Patient Follow Up—
                                                    some patients have cutaneous allodynia             Headaches change with time, and sec-
Management of Cheryl’s Headaches                    during acute migraine and may prefer               ondary headaches may develop in
    Make the Proper Diagnosis—Take                  not to be touched at such times.                   patients who have had life-long
a detailed headache history of the patient,                                                            headaches. In addition, abortive and pro-
including all prescription and OTC med-                 Educate the Patient About Pharma-              phylactic medications need to be contin-
ications used and the frequency of their            cologic Management—Use of all anal-                ually assessed and adjusted to achieve
use.                                                gesics and caffeine was terminated. Cheryl         maximal benefit. Physicians should
      Cheryl’s headache diagnosis is migraine       was warned that she would probably have            review headache diaries, any medication
without aura, in addition to probable medi-         more intense headaches while withdrawing           adverse effects, and any changes in med-
cation overuse headache. She has a long his-        from these substances and that any prescribed      ical condition that may warrant changes
tory of typical migraines. However, the char-       abortive medications may not work as effec-        in therapy. Generally, prophylactic med-
acter of her headaches has changed. They have       tively as a caffeine product for the next few      ications are continued for approximately
become more frequent and more difficult to          weeks.                                             6 months if a beneficial response is
manage, requiring additional medications.                 Removal of offending agents alone may        achieved, then attempts are made to
These changes may indicate the need for fur-        markedly improve headaches, but most               wean the patient away from the medi-
ther testing, such as brain MRI, though there       patients still require prophylactic therapy.       cations.
are certain known reasons for escalation of         Treatment with prophylactic medications was              Prophylactic medications may be
Cheryl’s headaches.                                 initiated immediately, and Cheryl was made         stopped with continued observed bene-
      She is overusing caffeine and analgesics,     aware that medication doses are started low        fits, or headaches may worsen. If
substances that may cause, worsen, or main-         and gradually increased, depending on              headaches worsen, the lowest dose that
tain her daily headache pattern. She is also        observed efficacy and adverse effects. It may      adequately controls headache should be
perimenopausal, with hormonal fluctuations          take 3 months for prophylactic medications to      maintained.
and sleep disturbance. Thus, it may be rea-         achieve complete benefit at the full therapeutic         Cheryl had severe headaches during the
sonable to withdraw the overused agents with        doses. In the past, this patient did not achieve   first week she was off caffeine and the
close follow-up before conducting further           effective doses of prophylactic medications or     acetaminophen-ASA-caffeine formulation.
testing.                                            did not use these medications long enough. In      She then noticed a lessening of headache inten-
                                                    addition, she had been overusing caffeine and      sity, with some headache-free days by the
     Educate the Patient About Non-                 abortive medications during prophylactic           third week of therapy. At her next visit,
pharmacologic Management—Cheryl                     medication trials, rendering the medications       1 month later, amitriptyline was increased
should understand that her diagnosis is             ineffective.                                       to 40 mg/d. Two months after her second
migraine, that there are no objective markers                                                          visit, Cheryl had only one migraine with
for this disorder, and that it is usually inher-        Initiate Treatment—Cheryl was edu-             menses per month. The use of her triptan
ited, chronic, and biochemical in nature.           cated; weaned off caffeine and an OTC pro-         during these episodes provided complete pain
       There is no single definitive cause          prietary acetaminophen-acetylsalicylic acid        relief within 2 hours. Recurrence of headache
of migraine or definitive treatment for             (ASA)-caffeine formulation; started on an          24 hours later was again relieved with her
patients with migraine. However, the                alternative triptan for first-line acute treat-    triptan. After 2 months, Cheryl rarely had
disorder can be successfully managed.               ment; and given a second-line abortive med-        mild tension-type headaches and did not
It is important for the patient to stay reg-        ication (a phenothiazine) for nausea and/or        require abortive treatment for such headaches.
imented in her daily schedule, including            rescue pain when the triptan did not provide
meals and sleep. Fluid intake should be             complete relief.                                   Comment
maintained, because dehydration is a                      Rescue therapy is often sedating,            Migraine is the most common type of
trigger for migraine. Any identified food           but the goal of rescue therapy is allevia-         headache seen in primary care. Yet,
triggers for migraine should be avoided,            tion of pain and associated symptoms               migraine is often not properly diagnosed,
though food may not consistently trigger            rather than restoring full function.               and patients with migraine are often

Mueller • Diagnosing and Managing Migraine Headache                                      JAOA • Supplement 6 • Vol 107 • No 11 • November 2007 • ES15
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9. Practice parameter: the utility of neuroimaging      2000;40:783-791.                                          Editor’s Note
in the evaluation of headache in patients with                                                                    Physicians are advised to check the full
normal neurologic examinations (summary state-          25. Dodick D, Lipton RB, Martin V, Papademetriou          prescribing information for all the medications
ment). Report of the Quality Standards Subcom-          V, Rosamond W, MaassenVanDenBrink A, et al.;              discussed in this article and keep current
mittee of the American Academy of Neurology.            Triptan Cardiovascular Safety Expert Panel. Con-          with all FDA advisories and warnings.
Neurology. 1994;44:1353-1354.                           sensus statement: cardiovascular safety profile of

ES16 • JAOA • Supplement 6 • Vol 107 • No 11 • November 2007                                               Mueller • Diagnosing and Managing Migraine Headache

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