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ECHO Ontario Chronic PainMigraine

Andrew J Smith, MDCM

Staff Physician, Neurology, Pain and Addiction Medicine

Centre for Addiction and Mental Health

Disclosures

• Presenter: Andrew Smith

• Conflicts of Interest: None

MigraineLearning Objectives

At the end of this session, participants will be able:

1. To have an overall approach to the assessment and management of headaches

2. To diagnose migraine

3. To outline an approach to treating migraines

4. Be familiar with headache guidelines

Migraine – Definition and Epidemiology

• A chronic neurological disorder characterized by attacks of moderate or severe headache and reversible neurological and systemic symptoms

• WHO: Migraine = 3rd most prevalent medical condition

• 1-year prevalence: 12% (18% women/ 6% men)

• Migraine affects ~ 10% of school aged children

• Most prevalent from 25 – 55 yrs old, then drops off

• But can occur earlier and later

• Infantile colic = earliest manifestation of migraine

• Disabling to inidividuals, families and societies ($20B/year in US; 113 M work-days)

Dodick DW et al. Lancet 2018; 391: 1315-30

Migraine - Undertreatment

• Only 41% of people with chronic migraines consult a clinician

• Only 25% of these receive accurate diagnosis

• Less than 50% of these are prescribed acute or preventive treatment

4% of people with chronic migraines receive appropriate treatment

Headache Diagnosis and ClassificationICHD -3 (2018)

A. Primary Headaches

B. Secondary Headaches – rule out red flags

C. Painful Cranial Neuropathies, Other Facial Pains and Other Headaches

Does the patient have a primary of secondary headache?

Good history and physical examination is usually sufficient to make Dx

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Migraine - Diagnostic Classification

1.1 Migraine without aura

1.2 Migraine with aura1.2.1 Migraine with typical aura

1.2.2 Migraine with brainstem aura

1.2.3 Hemiplegic migraine

1.2.4 Retinal migraine

1.3 Chronic migraine

Migraine - Diagnostic Classification

1.4 Complications of migraine1.4.1 Status migrainosus

1.4.2 Persistent aura without infarction

1.4.3 Migrainous infarction

1.4.4 Migraine aura-triggered seizure

1.5 Probable migraine

1.6 Episodic syndromes that may be associated with migraine1.6.1 Recurrent gastrointestinal disturbance

1.6.1.1 Cyclic vomiting syndrome

1.6.1.2 Abdominal migraine

1.6.2 Benign paroxysmal vertigo

1.6.3 Benign paroxysmal torticollis

Migraine without aura – ICHD 3A. At least 5 attacks fulfilling criteria B-DB. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated)C. Headache has 2 of the following characteristics:

1. unilateral location2. pulsating quality3. moderate or severe pain intensity4. aggravation by or causing avoidance of routine physical activity (eg, walking,

climbing stairs)D. During headache 1 of the following:

1. nausea and/or vomiting2. photophobia and phonophobia

E.Not better accounted for by another ICHD-3 diagnosis

Headache Red FlagsChance of finding a lesion?

US headache consortium meta-analysis of patient with migraine and normal exam:

•0.018% rate of significant pathology (for migraine)

•0.00% for TTH

AAN Quality Standard Subcommittee (2008)

1. Avoid testing if there will be no change in management

2. Avoid testing if chance of finding abnormality is not greater than in the general population

3. Use individual judgement for individual patients

4. Neuroimaging usually NOT WARRANTED with migraine and normal examination

AAN 2008. Cephalalgia 2005;25:30-35. Neurology 1994;44:1353-54

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Not a Tumor, But…What’s That?Incidentalomas on MRI Scans of Migraineurs

•Subcortical White Matter Lesions: 6-40%

•Developmental venous anomalies: 5-10%

•Cerebral aneurysms 1-5% (vs 2.4% found incidentally at autopsy)

•Cavernous malformations 0.1 – 0.5%

•Chiari 1 malformations 0.1 – 0.5%

Imaging Begets Imaging

Headache Diagnosis - History1. How many different headache types does the patient experience?

2. Time questionsa. Why consulting now? b. How recent in onset? c. How frequent, and what temporal pattern (especially distinguishing between episodic and daily

or unremitting) …ie days per week or per monthd. Duration?

3. Character questionsa. Intensity of pain b. Nature and quality of pain c. Site and spread of pain d. Associated symptoms

For the patient presenting with headache for the first time or with a significant change in headache pattern, the headache history should include this information

Headache Diagnosis - History

4. Cause and Co-Morbidity questionsa. Predisposing and/or trigger factors b. Aggravating and/or relieving factors c. Family history of similar headache d. Co-existing? Insomnia, depression, anxiety, HTN, asthma, h/o heart disease or stroke

5. Response questionsa. What does the patient do during the headache? b. How much is activity (function) limited or prevented? c. What medication has been and is used, and in what manner

6. State of health between attacksa. Completely well, or residual or persisting symptoms? b. Concerns, anxieties, fears about recurrent attacks, and/or their cause

Headache: 8 Most Important Questions1. How many types of headaches?

2. How long does your headache last? seconds, minutes, days, hours (SUNCT—>Paroxysmal Hemicranial —> Cluster —> Migraine —> TTH —> MOH)

3. How frequent?

4. What is the intensity of the pain

5. What do you do during a headache attack

6. Where is the pain located?

7. Are there any associated sx

8. Do you take medications?

Headache Diagnostic Approach: HISTORYOnset

• Stable h/a of long duration ALMOST ALWAYS BENIGN

• Migraines often begin in childhood, adolescence or early adulthood

• Recent-onset = MORE WORRISOME

• Worst-ever, increasing severity; change for the worst in existing h/a all raise possibility of intracranial lesion

Headache Diagnostic Approach :HISTORYTime of Day and Precipitating Factors• Migraines can occur any time, but often in AM

• H/A of recent onset that disturbs sleep or is worse on awakening, may be cause by increased ICP

• TTH: present much of the day, often worsen as day goes on

• Obstructive sleep apnea h/a on awakening

• Medication overuse h/a h/a on awakening

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Headache Diagnostic Approach :HISTORYTime of Day and Precipitating Factors

• Migraine triggers• Bright light• Menstruation• Weather changes• Caffeine withdrawal• Fasting• Alcohol (esp beer and wine)• Sleeping more or less than usual• Stress and release from stress• Foods, food additives• Perfume• Smoke

Migraine – Clinical Overview

• Premonitory phase – begins hours to days before onset of pain• Psychological (depression, euphoria, irritability)• Arousal (drowsiness)• Somatic (yawning, constipation, diarrhea, food cravings, hunger, fluid

retention, increased urination)• Cranial parasympathetic (lacrimation)

• Aura

• Headache phase

• Postdromal phase• Occurs in about 80% of px – usally lasts less than 12h (but can last >24h in

~12%)• Most common sx: fatigue, impaired concentration, photophobia, irritability,

nasuea• Low threshold for recurrent, brief head pain with Valsalva or head

movement

Aura• Aura = focal, reversible cerebral symptoms assoc with a migraine attack• Occur in ~ 1/3 of patients with migraines

• Usu last 20-30 minutes (but can last an hour)…usu precede headache

• Visual sx most common (90%)• Positive: flickering lights, spots, lines• Negative: scotomas, visual field loss

• Other: Paresthesias (tingling, numbness)

• Expressive dysphasias are least common• Aura sx usually gradual onset and increase over minutes• Can experience mig aura without h/a• Pos sx, slow spread of symptoms and staggered onsets help differentiate migraine aura from

cardiovascular sx

Migraine – Headache Phase• Unilateral (60%), throbbing (50%), aggravated by

movement/activity (90%)

• Can change sides during and between attacks

• Mean time to peak: 1 hr

• Median duration: 24 hrs (range: 4-72h in adults; 2-48h in children)

• Can involve any part of the head, commonly posterior cervical and trap areas

• 75% of pts have neck pain along with migraine episode

• Sinus pain in 40% of migraineurs !!**!!

• Photophobia: 94% / Phonophobia: 91% /Nausea 50% / Emesis 35% / Diarrhea 16%

• Cutaneous allodynia: 70% (may predict suboptimal triptan response and risk for progression to chronic migraine

Dodick DW et al. Lancet 2018; 391: 1315-30Silberstein SD. Headache 1995; 35: 387-96.

Clinical Diagnosis – Canadian HA Guidelines

Migraine without aura (migraine with aura if an aura is present) if they have at least two of:

1. Nausea during the attack

2. Light sensitivity during the attack

3. Some of the attacks interfere with their activities

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Clinical Diagnosis

• Chronic migraine if headaches meet migraine diagnostic criteria or are quickly aborted by migraine specific medications (triptans or ergots) on 8 days a month or more

• Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 days a month or more; or uses plain acetaminophen or NSAIDs on 15 days a month or more.

Patients with headache on 15 or more days per month for more than 3 months and with a normal neurological examination

Headache Diagnosis – Physical Examination

Patients presenting to a healthcare provider for the first time with headache, or with a headache that differs from their usual headache, should have a physical examination that includes the following:

1) A screening neurological examination2) A neck examination3) A blood pressure measurement4) A focused neurological examination, if indicated; and 5) An examination for temporomandibular disorders, if indicated

Screening Neurological Exam

1. General assessment of mental status

2. Cranial nerve examination: fundoscopy, examination of pupils for symmetry and reaction to light, eye movements, visual fields, facial movement for asymmetry or weakness

3. Assessment of all 4 limbs for unilateral weakness, reflex asymmetry, and evaluation of coordination in the upper limbs

4. Assessment of gait, including heel-toe walking (tandem gait)

Examination Pearls

• VS: BP; T r/o infection• Habitus: young, obese women Pseudotumour (IIH)• Thickened, irreg temporal aa with reduced pulse GCA• Scalp tender in mig and TTH• Short neck or low hairline basilar invagination or Chiari

malformation• Infant bulging fontanelles increased ICP • Occipital-Frontal Circumference IN KIDS• Examine cervical spine• r/o meningeal signs, nucchal rigidity

Migraine Pathophysiology

1. Triggers of an attack initiate a cortical depolarizing neuroelectric and metabolic event; termed cortical spreading depression Posterior to anterior 3 mm/sec

2. This activates mechanisms of pain (unknown exactly how)

3. Trigeminovascular system releases neuropeptides: CGRP Neurokinin A Substance P VIP

Activates trigeminal nociceptors

Vasodilatation

Migraine Pathophysiology

4. Headache occurs from activation of the gasserian ganglion

5. Central sensitization and cephalic allodynia secondary to activation of the trigeminal nucleus caudalis(also C1-C2 dorsal horns)

6. Extracephalic allodynia secondary to activation of central pain modulating centers and ipsilateralthalamus

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Pathophysiology of Migraine

Abnormal modulation of excitability rather than general hypo- or hyperexcitability could be the main factor underlying migraine attacks

Migraine Self-Management

• Encourage patients to participate actively in their treatment and to employ self-management principles:• Self-monitoring to identify factors influencing migraine

• Managing migraine triggers effectively

• Pacing activity to avoid triggering or exacerbating migraine

• Maintaining a lifestyle that does not worsen migraine

• Practising relaxation techniques

• Maintaining good sleep hygiene

• Developing stress management skills

• Using cognitive restructuring to avoid catastrophic or negative thinking

• Improving communication skills to talk effectively about pain with family and others

• Using acute and prophylactic medication appropriately

Comprehensive Migraine Management

• Pay attention to lifestyle and specific migraine triggers in order to reduce the frequency of attacks. Lifestyle factors to avoid include the following:• irregular or skipped meals• irregular or too little sleep• a stressful lifestyle• excessive caffeine consumption• lack of exercise• obesity

• Use acute pharmacologic therapy for individual attacks • Use prophylactic pharmacologic therapy, when indicated, to reduce attack

frequency • Use nonpharmacologic therapies • Evaluate and treat coexistent medical and psychiatric disorders

Types of Migraine Treatment

• Acute (Taken during an attack)• Treat attacks effectively, rapidly and consistently

• Minimize adverse events

• Restore the patient’s ability to function

• Preventive• Taken daily for months to years

• Reduces frequency, severity, and duration

• Used in addition to acute treatments

.

Migraine Acute Treatment Strategies

1.Review past treatments – successes, failures (what does that mean?)

2.NB: Attack frequency: INCREASED RISK OF MEDICATION OVERUSE HA

3.Consider entire spectrum of migraine syndrome (eg. Nausea, emesis, disability)

4.TREAT ALL ASPECTS: Pain and Associated Sx

5.Specifically ask about DISABILITY

6.Consider comorbidies

7.Understand what “It doesn’t work” means – assessing unmet treatment needs (M-TOQ)

Acute Treatment Principles

• Treat attacks rapidly and consistently

• First physician recommendation may not be effective. Educate patient of the need to follow-up and that there are other options

• Tailor treatment to the patient and the sx (Stratified approach)

• Non-specific meds for mild-moderate sx – NSAIDS, etc

• Specific meds for more severe attacks, or those that don’t respond – triptans

• Eg. If nausea/vomiting / gastroparesis avoid oral route, consider antiemetics

• Oral disintegrating tabs good for px with mild nausea in whom water would exacerbate

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Acute Treatment Principles• Back-up/rescue if initial treatment fails

• Two or more acute meds can be combined if necessary

• Sumatriptan + naproxen

• Antiemetic + NSAID +/- triptan

• Minimize adverse events and cost

• Limit to 3 days per week or less

• NO BUTALBITAL/OPIOIDS lead to medication overuse

Acute Treatment - Triptans

• Reasonable first choice for patients with moderate to severe disability from migraines

• Limit use to 2-3 days per week

• Patients who fail one triptan often respond to another

• Do not use one triptan within 24 hours of another

Acute Treatment - Triptans

Mechanism of action

• 5HT-1B/1D agonists

• Inhibit release of CGRP & substance P

• Inhibit activation of the trigeminal nerve

• Inhibit vasodilation in the meninges

Precautions

• Ischemic heart dz or stroke

• High risk for CAD

• Pregnancy

• Hemiplegic or basilar migraine

• Ergots

• Use w/ SSRIs?

Johnston et al Drugs 2010Loder NEJM 2010

Acute Treatment - Triptans

Fast onset/short duration

• Sumatriptan

• Rizatriptan

• Zomitriptan

• Almotriptan

• Eletriptan

• Treximet (Suma + Naproxen)

Slow onset/long duration

• Naratriptan

• Frovatriptan

NSAIDs Antiemetics

• Prevent and treat nausea

• Improve GI motility

• Enhance absorption of other anti-migraine medications

• Limited RCT to support their use in migraine

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Status Migranosus: ER Options

• Sumatriptan 4-6 sc

• Antiemetics + DHE iv

• Neuroleptics

• Ketorolac 30-60mg im helpful for cutaneous allodynia if not complicated by opioid use

• MgSO4 1-2g iv limited evidence but better for Mig with aura

• VPA 300-500mg iv

• Corticosteroids

Migraine: Why Treatment Fails

• Wrong diagnosis

• Wrong medication or subtherapeutic dose

• Premature discontinuation

• Raising dose too quickly

• Failure to recognize full spectrum of symptoms of exacerbating factors

• Eg…GI symptoms tablets less effective (zolmatriptan nasal; sumatriptan injectible)

• Failure to recognize comorbidites (NB MOOD DISORDERS)

• MOU (nb caffeine)

• Unrecognized triggers

Migraine Acute Treatment: Unmet NeedsDomain Yes or No Questions Response

Functional response Are you able to quickly return to your normal activities after taking your migraine medication?

Consistency and Onset Can you count on your migrainemedication to relieve your pain within 2 hours for most attacks?

Recurrence Does one dose of your migraine medication usually relieve your headache and keep it away for at least 24 hours?

Side Effects Is your migraine medication well tolerated?

Global Are you comfortable enough to be able to plan your daily activities?

Lipton et al. Cephalalgia 29: 751-9, 2009

2 or more unmet needs: CHANGE MEDICATION

Indications for a Preventive Agent• Migraine-related disability > 3d/month

• Migraines last over 48 hours

• Migraines cause profound disability or prolonged aura (hemiplegic migraine, migraine with brainstem aura)

• Acute treatments are contraindicated, ineffective, or overused

• > 10 days per month: Triptans, Ergotamines, Opioids, Combination

• > 15 days per month: acetaminophen, NSAIDs

• Patient preference

Goal: Reduce migraine attack frequency and HA related disabilityEFFECTIVE TREATMENT = REDUCE ATTACK FREQUENCY BY 50% or MOREUse MIDAS or HIT-6 – Standard measurements of HA disability

Pharmacological Prophylaxis for Migraine

• Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage

• Realistic expectations of prophylaxis:-Headache attacks will likely not be abolished completely-A reduction in headache frequency of 50% = success-~4-8 wk for substantial benefit to occur

• If the prophylactic drug provides substantial benefit in the first 2 mo of therapy, this benefit might increase further over several additional months of therapy

• Evaluate the effectiveness of therapy using patient diaries that record headache frequency, drug use, and disability levels

Pharmacological Prophylaxis for Migraine

• For most prophylactic drugs, start low and go slow (eg topiramate 15mg q 2-4 weeks

• Increase the dose until the drug proves effective, until dose- limiting side effects occur, or until a target dose is reached

• Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6-8 wk after dose titration is completed

• Because migraine attack tendency fluctuates over time, consider gradual discontinuation of the drug for many patients after 6 to 12 mo of successful prophylactic therapy, but preventive medications can be continued for much longer in patients who have experienced substantial migraine-related disability

Scottish Intercollegiate Guidelines Network. Diagnosis and management of head-ache in adults. A national clinical guideline. Publication no. 107. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2008. Available from: www.sign.ac.uk/ guidelines/fulltext/107/index.html.

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Risk Factors for Chronification:Some Modifiable

• Female

• Depression / Anxiety

• Excessive caffeine use

• Sleep disorders

• Obesity

• Other pain conditions

• Baseline headache frequency

• Traumatic Brain Injury

(especially mTBI)

• Medication overuse

• Low Education

• Low Socioecononic Status

• Stressful life events

Approach to Chronic Migraine

• Acute • Discontinue overused medication abruptly

• Taper opioids/butalbital; consider clonidine, phenobarbital

• Transitional• Daily use for 2-4 week to manage and attenuate severity of w/d

• Use other non-overused meds e.g. NSAIDs, DHE, Corticosteroids

• Consider nerve blocks

• Prevention

Botulinum Toxin for Chronic Migraine

• Efficacy• Botulinum Toxin superior to placebo in 2 large, double blind, randomized,

controlled trials• Botulinum Toxin similar to topiramate and amitriptyline in small, shorter

duration studies• Botulinum toxin = placebo for episodic migraine

• Side effects = muscle weakness, injection site pain, and “spread of toxin effect”

• Mechanism of Action; Blocks release of Substance P and CGRPInhibits peripheral signals to CNS and blocks central sensitization

N: 1130 px with chronic migraineRadomized to Quarterly, Monthly, PlaceboMean HA Days/Month: 13.2 / 12.8 / 13.3

SIGNIFICANT REDUCTION in HA Days:Q: -4.3 daysM: -4.6 daysP: -2.5 days

Side effects: Pain at injection site

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Monoclonal Ab – vs CGRP receptorN: 955 px with episodic migraineRCT: 70mg s/c vs 140mg s/c vs placebo monthly x 6 months

Migraine days per month at baseline: 8.370mg: 3.2 d/month (P<0.001)140mg: 3.7d/month (P<0.001)Placebo: 1.8 d/month

Migraines in 5 Minutes• Rule out red flags and indicators of secondary

headaches --> quick history

• Does the headache interfere with activity; associated with light sensitivity; associated with nausea?: 2/3 MIGRAINE

• What tends to trigger these headaches?

• What do you take to treat them? How many days per month

• Self-management

• Screening neuro exam

• NO IMAGING unless red flag or abnormal neuro exam