Transcript New Advances in the Treatment of Migraines

Understanding Headaches
Grace Forde, M.D
Assistant Professor of Neurology
New York University
Director of Neurological Services
North Shore Pain Service
Migraine Epidemiology
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Migraine Prevalence
 Approximately 26 million patients with
migraine in the United States (> age 18)
 One in 4 households has at least 1
migraine sufferer
Lipton RB, et al. Neurology. 2007; 68(5):343-349.
National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.
Migraine Prevalence:
Age and Gender
Migraine prevalence peaks in the 25-55 age range
Lipton RB, et al. Neurology. 2007;68(5):343-349.
Migraine Economic Impact,
Productivity, and Quality of Life
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Economic Burden of Migraine in
US
 Lost productivity is the greatest contributor to migraine economic
burden
 Productivity losses cost US employers up to $13 billion annually
 Direct costs of migraine per patient range from ~$500-$7000/year
 Total medical costs in households with at least 1 member with
migraine are 70% higher than families without a member with migraine
Hu XH et al. Arch Int Med. 1999;159(8):813-818.
Hawkins K et al. J Occup Environ Med. 2007;49(4):368-374.
Edmeads J and Mackell JA. Headache. 2002;42(6):501-509.
Stewart WF et al. JAMA. 2003;290(18):2443-2454.
Osterhaus JT et al. Pharmacoeconomics. 1992;2(1):67-76.
Etemad LR, et al. JMCP. 2005;11(2):137–44.
Pesa J and Lage MJ. Headache. 2004;44(6):562–70.
Lafata JE, et al. J Gen Intern Med. 2004;19(10):1005–12.
Hawkins K, et al. Value Health. 2006;9:A85.
Stang PE, et al. Am J Manag Care. 2004;10(5):313–20.
Timing and Impact of Migraine
58% of Migraines Occurred During Typical Work Hours*
Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting,
June 26-29, 2008; Boston, MA.
*N=200
Full-Time Employees
Impact of Migraine: Productivity
Productivity Levels
74% of Patients With Migraine* Reported
Productivity Levels Below 80%
*N=157
Full-time employees
Landy SH, et al. Poster presented at: 50th Annual American Headache Society Meeting, June 26-29, 2008; Boston, MA.
Migraine Diagnosis
and Treatment
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International Headache Society
Criteria for Migraine
Migraine Is an Episodic Recurrent Headache
Lasting 4-72 Hours with:
Any 2 of these pain
qualities:
Any 1 of these
associated symptoms:
• unilateral pain
• throbbing pain
• pain worsened by
movement
• moderate or severe pain
• nausea
• vomiting
• photophobia and
phonophobia
+
Features such as osmophobia and posterior head and neck pain can also be present in a
headache that meets IHS criteria for migraine.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders.
2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.
Many Migraine Sufferers Remain
Undiagnosed
56%
Diagnosed Migraine
44%
Undiagnosed Migraine
Diamond S et al. Headache. 2007;47(3):355-363.
Patients with Recurrent Headache May
Meet Criteria for Migraine
87% of patients presenting to PCP with recurrent headache
met IHS criteria for migraine
Episodic Tension-type Headache (n=1)
0.4%
Probable Migraine
(n=31)
Other (n=3)
1%
11%
Migraine
(n=237)
87%
Tepper SJ et al. Headache. 2004;44(9):856-864.
Focusing on Migraine Diagnosis
 Opportunities for accurate diagnosis of
migraine patients still exist:
– 80% of “sinus headache” patients met IHS
criteria for migraine
– 85% of “tension/stress” headache patients
met IHS criteria for migraine
Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.
Kaniecki R et al. CMRO. 2006;22(8):1535-1544.
Phases of a Migraine Attack
Treatment Phase
Pre-HA
Premonitory/
Prodrome
Headache
Aura
Postdrome
Moderate
to Severe
Migraine Intensity
Mild
Migraine
symptoms
occurring
hours/days prior
to headache
Post-HA
Focal
neurological
symptoms
preceding
headache
(<1 hour)
Symptoms:
• Flashing lights
Symptoms :
or wavy lines
• Food cravings • Numbness
• Mood changes • Tingling in face
• Yawning
• Disturbed
• Fatigue
senses
Migraine when
headache is mild
Symptoms:
• Sensitivity to light
• Sensitivity to sound
• Nausea
• Pain in the back of
the head and neck
Migraine when
headache is moderate
to severe
Symptoms:
• Same as mild but
more intense
Migraine
symptoms
occurring
hours/days
after headache
resolution
Symptoms:
• Tiredness
• Confusion
• Lowered appetite
• Stiff or sore
muscles
Time
Adapted from Cady RK. Headache. 2008;48(9):1415-1416.
Headache Classification Subcommittee of the International Headache
Society. Cephalalgia. 2004;24(suppl 1):117-118.
Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone.
1999;1(6):21-32.
National Institutes of Health. National Institute of Neurological
Disorders and Stroke.
http://www.ninds.nih.gov/disorders/headache/detail_headache.htm.
Accessed December 7, 2009.
Possible Triggers of a Migraine
Attack
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Food and food additives
Bright lights/glare
Smells/odors
Dieting/hunger
Loud noises/sounds
Changes in altitude/
air travel
Wober C et al. J Headache Pain. 2006;7(4):188-195.
Friedman DI and De Ver Dye T. Headache. 2009;49(6):941-952.
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Stress
Weather changes
Caffeine
Alcoholic beverages
Changes in sleep habits
Hormonal fluctuations/
menstrual cycle
Medication Options Available
for
Migraine
Acute Medications


May work quickly to relieve
migraine pain and other symptoms
Usually taken during a migraine
attack
– Triptans
– NSAIDs
– Opioids
– Analgesics (Rx and OTC)
– Ergotamine/DHE
– Antiemetics
– Neuroleptics
– Corticosteroids
Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.
Silberstein SD. Neurol Clin. 2009;27(2):429-443.
Preventative Medications
 May prevent or reduce the number
of migraine attacks
 Typically taken on a daily basis
– Antiepileptics
– Antidepressants
– Beta blockers
– Calcium channel blockers
Differences in Patients with
Migraine
 Migraine patient’s brain is in a state of hyperexcitability
– Reduced threshold for stimuli
– Everyday things can trigger a migraine attack
 Migraine patient’s gut is slowed
– Gastric stasis is common and can delay tablet
absorption
– Conventional tablets rely on surface erosion and gastric
motility for dissolution in the stomach, which must occur
before being absorbed
Hargreaves RJ and Shepheard SL. Can J Neurol Sci. 1999;26(suppl 3):S12-S19.
Aurora S et al. Headache. 2006;46(1):57-63.
The Triptans
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Sumatriptan
Zolmatriptan
Naratriptan
Rizatriptan
Almotriptan
Frovatriptan
Eletriptan
Sumatriptan and Naproxen sodium
Triptan Prescribing Information:
Contraindications and Precautions for ALL
Triptans
 Ischemic cardiac disease
 Cerebrovascular disease
 Uncontrolled hypertension
 Hypersensitivity
 Use within 24 hours of other 5-HTs/ergots
 Hemiplegic/basilar migraine
 History of risk factors for CAD
 SSRI precaution
Case Scenario 2
 29-year-old single woman,
sales clerk; history of 8-9
migraines / month lasting
for 12-14 hours, frequent
recurrence
 HA associated with nausea
and sensitivity to light and
sound
 Currently taking an oral
triptan tablet
 Says that current treatment
takes too long to act and does
not fully relieve headache pain
 Looking for a way to
prevent attacks
Preventive Medication Groups
 Anticonvulsants
– valproate*
– topiramate*
 Antidepressants
– TCAs
– SSRIs
 β-adrenergic blockers
– propranolol*
– timolol*
SSRI = selective serotonin reuptake inhibitor
TCA = tricyclic antidepressant
 Calcium channel
antagonists
 Serotonin antagonists
 Others
–
–
–
–
–
–
Botulinum toxin A*
coenzyme Q10
NSAIDs
Petasites
Riboflavin
Magnesium
*Approved by FDA for this use.
Silberstein SD. Lancet. 2004;363:381-391.
Nonpharmacologic Therapies
Tested in Clinical Trials
Behavioral Treatments
Relaxation training*
Hypnotherapy
Thermal biofeedback
training*
Electromyographic
biofeedback therapy*
Cognitive / behavioral
management therapy*
*Proven effective in clinical trials
Physical Treatments
Acupuncture
Transcutaneous
electrical nerve
stimulation (TENS)
Occlusal adjustment
Cervical manipulation
Adapted from US Headache Consortium Headache Guidelines. www.aan.neurology.org. 2000
Case Scenario #3
Migraine Is Often Overlooked
Sinus headache is the most common
misdiagnosis
 Sinus pain caused by
inflammation induced
allergens or by infection
occurs when exudate in
inflamed, blocked sinuses
exerts pressure that
stimulates local trigeminal
nerve fibers
 Chronic sinusitis is not
validated as a cause of
headache unless it
relapses into an acute
Headache:
A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS*
 Major factors
 Minor factors
– Purulence in nasal cavity on
exam
– Headache
– Facial pain/pressure/congestion**
– Halitosis
– Nasal obstruction/blockage/
discharge
– Fatigue
– Fever (in acute only)
– Hyposmia/anosmia
– Fever (chronic)
– Dental pain
– Cough
– Ear
pain/pressure/fullness
** Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the
absence of another major nasal symptom or sign.
Sinus Features May Hide the Presence of
Migraine
Headache Symptoms at Screen Among IHS Diagnosed Migraineurs
Moderate/Severe Pain
96%
Pulsatile
87%
Sinus Pressure
84%
Worsened by Activity
84%
Sinus Pain
82%
Nausea
70%
Nasal Congestion
65%
n=2257
Phonophobia/Photophobia
57%
Rhinorrhea
42%
Watery Eyes
38%
IHS Migraine Symptom Criteria
Aura
28%
Itchy Nose
Sinus Like Features
27%
Vomiting
23%
0
20
40
60
80
% of Subjects
Schreiber et al. Poster Presented at: American Headache Society Meeting; June 21-23, 2002: Seattle, WA.
Data on file, GlaxoSmithKline.
100
Why do so many
Americans think they
have Sinus
Headache?
In his 1988 review, “Sinus Headache: A Neurologist’s Viewpoint,” Couch writes:
In my experience and in that of others, “sinus headache,” as reported
by patients, is a popular conception that is often erroneous. Patients
reason that, since the sinuses are close to the eyes (as depicted in
advertisements in popular magazines), headaches located in the
frontal, supraorbital, or infraorbital region are sinus headaches…
[These] headaches frequently are associated with some gastrointestinal
symptomatology, photophobia, and phonophobia, and may have some
visual or neurologic symptoms. In short, these “sinus headaches” are
usually migraine headaches, most often of the common migraine type.
Couch, J. Seminars in Neurology. 1988;8(4):298-302.
Migraine Is Often Overlooked
(cont’d)
 Tension headache is another common
misdiagnosis
 Symptoms include
– Dull steady ache
– Physical activity does not worsen pain
– Nausea, photo/phonophobia
are not usually present
– Vomiting never present
have likely tried OTCs and failed
Cady –
et al.Patients
Headache Free. 1993;36-38.
Migraine Pain Can Be Felt in Peripheral
Locations Such as the Neck
 In Kaniecki’s study of 144 patients with
migraine
– 75% reported neck
pain
with their migraine
– 43% described neck
pain as bilateral and
57% as unilateral
75%
reported neck pain
with their migraine
– 69% described the
neck
pain as “tightness” and
17% as stiffness”
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.
Activation of the TNC May Result in
Referred Pain that Could be Perceived
Anywhere along the Trigeminocervical
Network
Case Scenario 5
 26-year-old man, computer programmer,
married with 2 children
 Has severe, stabbing
pain behind his right eye
 Headaches are
accompanied by
lacrimation and nasal
congestion
 Pain lasts 30 to
45 minutes; attacks
occur daily for several
weeks, then stop for
months at a time
Treatment of Hypnic Headach
 Lithium
Carbonate (200600mg)
 Indomethacin
 Verapamil
(160my QHS)
 Methysergide
 Caffeine (60mg)
 Lamotrigene
TRIGEMINAL NEURALGIA