- 1.The Art and Science of Evaluating and Treating Migraine Ryan J Punambolam MD, FRCPC Neurology Abbotsford Regional Hospital ! ! Medicine Grand Rounds April 9, 2014.
2. Disclosure Advisory Board or Similar Committee None Clinical Trials or Studies None Honoraria or Other Fees Bayer, Sanofi-Aventis, Allergan, Tribute Phamaceuticals Research Grants No conflicts 3. Migraine Backgrounder The Art and Science of Evaluating and Treating Migraine 4. Case Vignette (Peter) Initial Consult 25-year-old obese (BMI=35) man who presents to his primary care doctor with a four year history of headache Frequency Two attacks per month Prodrome Dysphoric mood Aura Zig-zag lines and a graying of vision in a visual field Pain Unilateral (R>L) throbbing severe pain lasting 24 hours untreated Symptoms Nausea, photophobia, unable to function Treatment Excedrin Migraine up to six per day Exam WNL (within normal limits) Diagnosis ? 5. Primary or Secondary Headache? Detailed History and Examination No Yes Any unusualfeatures? Evaluate for Secondary Headache Red Flags? Diagnose Primary Headache Disorder Step 1 6. S Systemic signs or symptoms Fever, weight loss, malignancy, HIV, meningismus, pregnancy N Neurologic signs or symptoms Papilledema, hemiparesis, hemi- sensory loss, diplopia, dysarthria O Onset Worst headache of life (thunderclap) O Older New headache at age 50 P Progression of existing headache disorder Change in quality, frequency, or location 13. Dodick DW. Adv Stud Med 2003;3:S550-S555. Red Flags in Headache: SNOOP 7. Peter has a Primary Headache Disorder Peter has no headache alarms Four year history, lack of alarms and normal exam, additional work-up is not necessary Categorize Primary Headache Disorder Step 2 8. Divide into headache syndromes Short Duration < 4hr duration Recurrent (Long Duration) 4hr duration 15 days/month Chronic Daily Headache 4hr duration 15 days/month 1 2 3 Categorize Into One of Three Groups Primary Headaches Assess frequency and duration for each headache type Step 2 9. Diagnose the Specific Disorder Within the Category Differential Diagnosis Step 3 te example of inherited migraine on of missense mutations in the he gene for the P/Q type, voltage nel on chromosome 19 in families legic migraine.w1 Since then, other miplegic migraine have been found ations in the ATP1A2 gene, which unit of the Na+ /K+ pump,w2 and in for the neuronal voltage-gated age is of migraine as an ionopathy, n abnormal ion channels whose nd anatomical distribution in the clinical phenotype. If genetics can have headaches and what the bio- may be, then we can ask the the problem? or, framed in the rology, Where is the lesion? y of headachewhere is s promulgated by Gowers, sought cal answers to clinical questions. een successful, but the problems of e will need a physiological ome extent, human functional this. d 70s migraine was considered a on and is still often referred to cular headache. Wolff summarised the referral patterns of structures on 15 days a month for more than six months,3 the same area of the dorsolateral pons is activated,16 suggesting that infrequent and frequent migraine are ends of a shared spectrum. Use of blood oxygen level dependent (BOLD) contrast functional magnetic reso- nance imaging holds the promise of studying single patients and determining the site of abnormal activation.w7 Moreover, magnetic resonance angiogra- phy has shown that the blood flow changes seen in migraine14 and cluster headache10 are simply a result of ophthalmic division pain,17 18 not a cause of the syndrome. Table 1 Differentiating migraine from tension-type headache Characteristics Migraine Tension-type headache Pain features of acute attacks Throbbing Boring or squashing Unilateral Bilateral Worsening of pain with movement No effect of head movement Associated features Nausea or vomiting None Photophobia and phonophobia Triggering factors Altered sleep patterns (too little or too much) Psychological stress Skipping meals Overexertion Change in stress level (too much or relaxation) Excess afferent stimuli (such as bright lights) Weather change Chemical (delayed headache after alcohol or glyceryl trinitrate) Menstruation 27NUARY 2006 bmj.com 10. Peter has Migraine without Aura Migraine without Aura: " A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hr C. Headache has 2 of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs) D. During headache 1 of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not attributed to another disorder 22. International Headache Society,2nd edition. Cephalalgia 2004;24 Suppl 1:1-160. 24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy (New York, NY: Springer), 2011. 11. Three-Item ID Migraine Screener * During the last three months, did you have any of the following with your headaches: " 28. Lipton RB et al. Neurology 2003;61(3):375382. * An affirmative response on 2 of 3 questions yields a sensitivity and specificity of 81% and 75%, respectively. Item Yes / No "" You felt nauseated or sick to your stomach when you had a headache? Yes No Light bothered you (a lot more than when you dont have headaches?) Yes No Your headaches limited your ability to work, study or do what you need to do for at least one day? Yes No 12. Migraine: A Common Episodic Headache Disorder Neurologic disorder Strong genetic component (up to 50%) " Global prevalence in women: >10% Women: 15%17% Men: 6%9% " Two major subtypes Without aura (~75%) With aura (~25%) " Burden Among the worlds 20 most disabling diseases (WHO) Affects 3 million women and 1 million men in Canada An Angus Reid poll suggests that the cost of migraine in the workplace is approximately $500 million annually "35. Pietrobon D. Neuroscientist. 2005;11(4):373386. 41. Stovner LJ et al. Cephalalgia. 2007;27(3):193210. 26. Linde M. Acta Neurol Scand. 2006;114(2): 7183. 22. ICHD. Cephalalgia. 2004;24 Suppl 1:1-160. 24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), 2011. 20. Hu XH. et al Arch Intern Med. 1999;159(8):813818. 13. Pain Pathways in the Head 18. Goadsby PJ. et al. J Clin Neurosci 2000 Jul; 7(4):377. 14. Peter also has Classic Migraine Migraine with Aura" " " 15. Prevalence of Migraine and Tension-type Headache in Various Settings 0 20 40 60 80 Population Waiting Room 16 40 75 12 Migraine Tension-Type Headache "28. Lipton RB et al. Neurology 2003;61(3):375382. Percent 16. Migraine is Often Misdiagnosed 27. Lipton RB et al. Headache 2001; 41(7):638-645. Inaccurate diagnosis received by migraine patients Tension-type Headaches Sinus Headaches Cluster Headaches % MISDIAGNOSIS 44% 43% 18% 17. Why is Migraine Frequently Mistaken for Sinus Headache? Pain is often located over the sinuses Migraine is frequently triggered by weather changes Tearing and nasal congestion are common during attacks Sinus medication may help migraine 18. Planning and Management Strategies The Art and Science of Evaluating and Treating Migraine Step 4 19. What might be your preliminary treatment recommendation for Peter? Back to Peter 20. Formulate a Specific Treatment Plan Non-pharmacologic approaches Trigger identification and management Identify triggers by history Headache diaries Education and enhance self-efficacy Biofeedback and cognitive behavioural treatment Specific Treatment Plan Step 4 21. Principles of Acute Treatments Stratified care " Early intervention " Use correct dose and formulation " Treat at least two or three attacks before judging acute medications " Use a maximum of 2-3 days / week " Use preventive therapy in selected patients 38. Silberstein SD. Neurology 2000; Sep 26;55(6):754-62. 32. Lipton RB, et al. JAMA 2000;284(20):2599-2605. 22. Goals of Migraine Treatment Terminate the attack without increasing the risk for subsequent attacks Address the potential peripheral and central mechanisms of migraine pathogenesis Initiate treatment early to reduce risk of central sensitization Reduce the risks of long-lasting latent central sensitization and progression to chronic migraine Consider the clinical aspects Rapid onset of analgesic effect with low rate of recurrence Minimal interaction with other migraine treatments Significant efficacy across multiple end points Address patient" considerations Well-tolerated adverse event (AE) profile Improved function Convenient and flexible administration 34. Matchar DB, et al. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks. http://www.aan.com/professionals/practice/pdfs/ gl0087.pdf 6. Brandes JL, et al. JAMA. 2007;297(13):1443-1454. 4. Bigal ME, et al. Headache. 2008;48(8):1157-1168. 40. Silberstein SD and Ruoff G. Postgrad Med. 2006 April;Spec No:20-6. 9. CAMBIA Product Monograph. Tribute Pharmaceuticals Canada Ltd. March 9, 2012. 12. Diener HC, et al. Cephalalgia. 2006;26(5):537-547. 29. Lipton RB, et al. Cephalalgia. 2010;30(11):1336-1345. 23. Acute Pharmacotherapy: What Do Patients Want? Patients Rating Attribute as Important or Very Important (%) 78 80 83 85 87 87 86 83 79 30. Lipton RB, Stewart WF. Headache 1999;39(Suppl 2):S20-S26. No Side Effects Rapid Relief No Recurrence Complete Relief Treatment Attributes Patients Choosing Route of Administration as 1st Choice (%) 0 20 40 60 80 2.6 73 15 8.3 Nasal Spray Rapidly Dissolving Tablet Tablet or Capsule SC Injection Route of Administration 24. Medication Classes in Migraine Treatment 24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), 2011. 9. CAMBIA Product Monograph. Tribute Pharm