Transcript Migraine Headache – Evaluation & Treatment

Migraine Headache – Update
on Diagnosis & Treatment
Herbert L. Muncie, Jr., M.D.
What is the diagnosis?

Sarah, a previously very healthy 14 year
old female complains of a severe
headache & nausea. It is the start of the
Thanksgiving holiday and all she wants to
do is lay on the sofa.

PMH
H. flu meningitis age 7 months
 Car motion sickness as a child

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Family history positive for migraines –
maternal grandmother & mother
Diagnosing Migraine Headache
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Any severe or recurrent headache most
likely is a form of migraine
Almost all patients will have family history
of migraines or at least “sick” headaches
Only 15% have preceded or
accompanied focal neurologic symptoms

Usually visual


Vision loss or distortion in one eye – ‘ocular
migraine’
“Classic migraine”
Sarah

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Spent most of Thanksgiving holiday
resting on the sofa
Diagnosed with onset of migraine
headaches
Recurrent Headaches
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Primary
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Migraine
Tension
Cluster
Other benign – cough, cold temperature,
post coital, exertion
Recurrent Headaches

Secondary (pain from complications)
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Intracranial tumor
Intracranial aneurysm
Intracranial A-V malformation
Temporal arteritis
Migraine with aura – Criteria*
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At least 2 attacks with 3 of the following:
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Fully reversible aura symptoms
At least 1 aura symptom develops gradually
during more than 4 minutes or 2 symptoms
occur in succession
Any aura symptom lasts less than 60
minutes
Headache follows the aura within 60 minutes
*International Headache Society - 2004
Migraine with aura
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Visual aura common
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Slowly evolving scintillating scotoma that
moves or passes through visual field
Duration of aura – 22 minutes
Should not be called ocular migraine if
bilateral eye involvement

Just call them migraine with aura
Migraine with aura –
vascular risk?

Migraine with aura is associated with 2
fold risk of ischemic stroke &
cardiovascular event
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Absolute risk is low (4 per 10000 women
years)
May be indication for aggressive treatment
of other risk factors
Unclear if more intense treatment &
prevention of migraines will alter the risk
Migraine without aura – Criteria*
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At least 5 attacks (bunch of them)
Lasting 4-72 hours untreated or unsuccessfully
treated (didn’t just go away quickly)
Must have one of these to be migraine:
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Nausea or vomiting
Photophobia
Phonophobia
*International Headache Society - 2004
Migraine without aura – Criteria*

Then usually have at least 2 of these:
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Unilateral pain
Throbbing/pulsating
Aggravation on movement
Moderate or severe intensity
And of course to be sure not something else:

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H & P does not suggest organic disorder
H & P suggests an organic disorder which is then
ruled out
An organic disorder is present but attacks do not
occur for the 1st time in close time to the disorder
*International Headache Society - 2004
Diagnosing the acute headache

The classification criteria are best suited for
a between-attack assessment of their typical
headache
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
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However, they are often used for the acute
attack
Once acute pain relieved, take time to make an
accurate diagnosis
Up to 1/3 of ED patients cannot be assigned
a diagnosis

Despite a through questionnaire-based
assessment
ER Clinical Decision Rule

“ID Migraine” – three features

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Sensitivity to light
Nausea or vomiting
Disabling intensity of headache
 0 - 1 positive - low probability
 If 2 positive higher probability of migraine
Criteria focus on typical attacks not the
current acute attack
Epidemiology - Migraine

Can start at any age, however,
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Peak incidence of onset is mid-adolescence
(age 13-16)
History of colic or motion sickness support Dx
Median frequency - 1.5/month
Greater increase in prevalence with aging
in women
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Females - 6.4% age 12 - 17; 17.3% age 18 - 29
Males - 4.0% age 12 - 17; 5.0% age 18 – 29
Usually more severe in women
Pathophysiology
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Migraine is a primary neural event
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Something lowers threshold for a cortical
spreading depression (CSD)
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Which causes regional hypoperfusion (aura)
Release of proinflammatory neurochemicals
Neural event results in vasodilation
Which leads to pain & more nerve activation
Migraine headache is not a primary
vascular event
Testing Indications*
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Laboratory tests not helpful or needed to
make the diagnosis
EEG not indicated as routine evaluation
Neuroimaging guidelines
Typical migraine with normal neurologic
exam
 Neuroimaging not warranted (SOR-B)
 Insufficient evidence regarding imaging in
presence of neurologic symptoms (SOR-C)
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*U.S. Headache Consortium (2000)
Neuroimaging - EBM
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For non-acute HA with unexplained abnormal
finding on neurologic examination – obtain
neuro image (SOR-B)
If atypical features or headache does not fulfill
definition of migraine – lower the threshold for
obtaining imaging (SOR-C)
CT vs. MRI?

Insufficient data to recommend MRI compared to CT
in evaluation of migraine or other nonacute
headache (Grade C)
Red Flags!
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Strongly consider neuroimaging if
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New onset > age 50
Thunderclap onset
Focal and nonfocal symptoms
Abnormal signs
Headache with change in posture
Valsalva headache
HIV or cancer diagnosis
Treatment
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Goals of treatment
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Reduce frequency, severity, & duration of
headaches
Improve quality of life (QOL)
Avoid acute medication escalation
Treatment Guidelines are based upon
having a specific diagnosis

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Often difficult initially to make specific Dx
Therefore, significant uncertainty about ‘best’
initial treatment
Treatment - Migraine

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The brain of patients with migraines does not
tolerate peaks or troughs of life
Patients should get:
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Regular sleep
 Go to bed and awaken same time every day
Regular meals
 Eat same time every day
 Never skip meals – fasting associated with
precipitating headache
Regular exercise
Avoid peaks of stress, troughs of relaxation
Avoid unique dietary triggers
Migraine & Diet - EBM
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Frequency, duration & severity are NOT
increased by dietary choices (SOR-A)
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Cheese, alcohol, chocolate, citrus are not
universal triggers
Low-fat diet reduced frequency of
migraines (SOR-B)
Migraine & Supplements - EBM

Supplements reduced frequency & intensity
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Riboflavin – 400 mg qd
 Effect begins at 1 month, maximal @ 3 months
Magnesium – 600 mg qd
 Diarrhea common - almost 20%
 360 mg qd during luteal phase reduced menstrual migraine
Others
 Butterbur 100-150 mg/d
 CoQ10 300 mg/d
 Feverfew 18.75 mg/d
National Guideline Clearing House
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SOR – A
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http://www.guideline.gov/summary/summary.aspx?doc_id=6231&nbr=004002&string=migraine
Question
22 yo female presents with throbbing
headache, nausea, photophobia for 5
hours. BP 116/76, P 86. Which of these
treatments would be appropriate for her?
a.
b.
c.
d.
e.
Ketorolac (Toradol®) 60 mg IM
Metoclopramide (Reglan®) 20 mg IV
Prochlorperazine (Compazine®) 10 mg IV
D.H.E. 45 1 mg IV
Sumatriptan (Imitrex®) 6 mg SQ
Treatment of Acute Pain
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NSAID (SOR-A)
Ketorolac (Toradol®) – 10 mg oral, 60 mg
IM, or 30 mg IV(SOR-C)
Combinations
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Isometheptene mucate, dichloralphenazone
and acetaminophen (Midrin®)
Butalbital has not been effective in controlled
trials (butalbital/acetaminophen/caffeine- 50/325/40
Fioricet®, butalbital/ASA/caffeine-50/325/40
Fiorinal®)
Treatment of Acute Pain

NSAIDs – more effective when:
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Taken early
With adequate initial dose
Combined with antiemetic
ASA 1000 mg
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Combined with metoclopramide IM
(Reglan®) reduces nausea/vomiting but not
better pain control
Treatment of Acute Pain

IV fluids may benefit patients, although
benefit is not well established
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Unlikely to be harmful especially in patients
with persistent GI symptoms
Parenteral therapy preferred due to gastric
stasis & delayed absorption of oral
medications
Treatment of Acute Pain
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Droperidol (Inapsine®) probably most
effective of dopamine agonists
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Pain relief at 2 hours approaching 100%
Ideal dose – 2.5 mg IV
FDA warning about QT prolongation
Treatment of Acute Pain
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Prochlorperazine (Compazine®) 10 mg IV
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Effective with diphenhydramine (Benadryl®)
– 25 mg IV [Friedman 2008]
Superior to SC sumatriptan in ED setting
[Kostic 2010]
Children 0.15 mg/kg IV over 15 minutes
(max 10 mg)
 If EPS develop give diphenhydramine
1mg/kg (max 50 mg)
Treatment of Acute Pain
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Metoclopramide* (Reglan®)
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IV – monotherapy 10 - 20 mg IV
IM – 10 mg adjunct to other therapies
(SOR-C)
* FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has
been linked to tardive dyskinesia.
Treatment of Acute Pain
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Ergot alkaloids
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Dihydroergotamine (D.H.E. 45®) – 1 mg
IM/IV/SC
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Since it may cause nausea, more effective with
metoclopramide (Reglan®) to reduce nausea
Nasal spray effective
Ergotamine/caffeine (1/100) (Cafergot®)
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Little evidence effective alone
High risk of overuse & rebound headache
Treatment of Acute Pain
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Complementary medicine
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Topical menthol 10% was more effective at
complete pain relief than placebo at 2 hours
(38.3% vs 12.1%) [Haghighi 2010]
 10% solution of menthol crystals in ethanol
 Forehead and the temporal area most
painful are washed with tap water
 After drying 1 ml is applied with sponge on
a surface area of 5 x 5 cm
 Can be reapplied in 30 min
Treatment of Acute Pain - EBM

Patients with substantial disability will
benefit from serotonin 5-HT1B/1D agonists
(‘triptans’)
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SOR – A
Clinical Evidence
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http://www.clinicalevidence.com/ceweb/conditio
ns/nud/1208/1208.jsp
Triptan Efficacy
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No one triptan is superior in all pain relief
parameters
Use one triptan for 2-3 attacks before
abandoning that medication
If one does not work try another one
How is pain relief measured?
1) Was pain better within 2 hours?
2) Did the pain go away at 2 hours?
3) Did the pain stay away for at least
24 hours? (No immediate recurrence)
4) Did the patient consistently obtain pain
relief from that medication?
Oral Triptan Efficacy
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Was pain better within 2 hours?
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55-65% of patients experience
improvement at 2 hours
Can be repeated in 1 – 2 hours if partial
response
Oral Triptan Efficacy
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Did pain go away within 2 hours?
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25-35% of patients are pain free at 2 hours
Oral Triptan Efficacy
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Did pain stay away for 24 hours?
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Freedom from pain at 2 hours, no rescue
medication, no recurrence of pain in 24
hours
 20 - 25% of patients have sustained
freedom from pain
Oral Triptan Efficacy
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Intra-patient Consistency?
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The same patient experiences pain relief
with the same medication
 Rizatriptan (Maxalt®) has highest intrapatient consistency of the oral
medications
Sumatriptan (Imitrex®) –
Parenteral
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6 mg SC
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Pain decreased within 2 hours - 76%
Pain gone within 2 hours - 48%
Consistent pain relief for that patient - 90%
In ER best candidates are those with
previous response to this treatment
Adverse events more frequent than with
oral medication
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And more intense
Sumatriptan (Imitrex®) –
Parenteral
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Cutaneous allodynia - sensation of pain in
response to normally non-toxic touch
stimuli (e.g. brushing hair, taking shower,
putting hair in ponytail)
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Presence of cutaneous allodynia associated
with reduced response to SC sumatriptan
Needle-free injection available (Sumavel®
DosePro™)
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Causes as much pain as needle & more
swelling, bruising & bleeding at site
Question
22 yo female presents with throbbing
headache, nausea, photophobia for 5
hours. BP 116/76, P 86. Which of these
treatments would be appropriate for her?
a.
b.
c.
d.
e.
Ketorolac (Toradol®) 60 mg IM
Metoclopramide (Reglan®) 20 mg IV
Prochlorperazine (Compazine®) 10 mg IV
D.H.E. 45 1 mg IV
Sumatriptan (Imitrex®) 6 mg SQ
Triptans – Side Effects
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Tingling
Paresthesias
Warmth head, neck, chest & limbs
Nasal spray associated with taste
disturbance
Triptans – Cautions
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Contraindicated with CAD, uncontrolled
hypertension or cerebrovascular
disease, hemiplegic migraine
Should not be taken within 24 hrs of
another triptan or ergotaminecontaining/ergot-type medication
Taking them with an SSRI or SNRI can
cause life-threatening serotonin
syndrome
Combining Medications
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Sumatriptan 85 mg & Naproxen 500 mg
(Treximet®) more effective than either alone
for acute pain relief
Unknown effect of taking 2 separate pills (not
tested)
The combination may have some increased
benefit in mild/moderate pain but no evidence
of need for fixed dose combination (Medical
Letter 2008)
Early Recurrence
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Up to 75% of patients will experience a
recurrence of pain within 48 hours
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Naproxen (500 mg) or sumatriptan (100 mg)
equally effective treating the recurrence
[Friedman 2010]
Naproxen prophylactically can prevent
recurrence (NNT – 3)
Triptans should not be used prophylacticly
Preventing Early Recurrence
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Parenteral dexamethasone (10-25 mg IV)
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Produced 26% relative reduction in recurrence
within 72 hours [Colman 2008]
Modest benefit in the ED – prevented 1 in 10
patients from experiencing moderate or severe
recurrence [Singh 2008]
Later trials failed to find benefit with oral
dexamethasone or prednisone
Acute Pain & Parenteral Opioids
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Should not be used as 1st line therapy
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International Headache Consortium
Canadian Association of Emergency
Physicians
American Academy of Neurology
Meperidine (Demerol®) less effective than
DHE and there is an:
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Increased risk of sedation
Toxic metabolite with repetitive use
New Treatments Acute Pain
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Diclofenac oral solution (Cambia®) –
dissolve contents in water
Sumatriptan patch (Zelrix™) – similar
levels to SC
New Treatments Acute Pain
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DHE inhaled (Levadex®) – patients not
responding to triptans or more than 6
hours into headache?
Calcitonin gene-related peptide (CGRP)
antagonist (telcagepant) – as effective as
zolmitriptan 5 mg oral
Single-pulse transcranial magnetic
stimulation (sTMS)
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More effective than placebo in pain-free at 2
hours (39% vs 22%)
After the Migraine - Postdrome
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Some patients may have:
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Mood changes
“Hangover”
Tired
Weak
Disoriented
“Not right”
Chronic Migraine (CM) or Medication
Overuse Headache (MOH)
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Chronic migraine previously called
‘transformed migraine’
Consider medication overuse if ≥ 2
days/week for > 3 months analgesic use
Over period of time (months to years)
can become almost daily headache
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Resembles mixture of tension & migraine
Occasionally called ‘tension-vascular’
Hint – if awaken with headache consider
medication overuse
CM Modifiable Risk Factors
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Risk factor associated with increased risk
of developing CM
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Stressful life events
Sleep disturbance (i.e. Snoring/sleep apnea)
Obesity
Baseline headache frequency
Medication overuse
CM & MOH
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Treatment
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Must stop acute medication to determine
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Headaches will go away in a few days if
medication overuse is etiology
No controlled trials of medication withdrawal
May get severe withdrawal headache

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Severe withdrawal headache can be treated with
short course of prednisone
Randomized trial found no difference with steroid
compared to placebo
Preventive Medication
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Candidates:
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Unresponsive to acute attack medication &
disabling headache
≥ 2 attacks/month
Increasing frequency of attacks
Migraines with potential neurological
sequelae
Patient preference (just wants to use
medication to prevent headaches)
Audience Question
23 y. o. female with recurrent migraine
headaches. You advise starting
preventive therapy. Which medication
would be appropriate?
a)
b)
c)
d)
Anticonvulsant medication
Bipolar/anticonvulsant medication
Beta-blocker medication
Tricyclic medication
Prevention therapy - EBM

First line treatment should be:

Propranolol (Inderal®)


Timolol
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20 – 240 mg/day
10 – 30 mg/day
Less evidence to support other beta-blockers
Amitriptyline
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10 – 150 mg/day
Prevention therapy - EBM

First line treatment should be:

Divalproex sodium (Depakote®)
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
125 – 500 mg BID
Topiramate (Topamax®)
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
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50 - 100 mg BID
May be as good as propranolol
Anti-epileptic drugs had greater suicidal
ideation vs. placebo (0.43% vs 0.22%)
Prevention therapy

Second line (SOR-B)
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Gabapentin - pregnancy category D
Carbamazepine* - pregnancy category D
* FDA Alert 12/12/07 – Dangerous or even fatal skin reactions can be caused by
Carbamazepine therapy in patients with a particular HLA-B*1502 allele.
Prevention Therapies - EBM
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Relaxation training (SOR-A)
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Cognitive-behavioral (SOR-A)
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Combined with medication (SOR-B)
Acupuncture appears to be effective (SOR-A)
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Progressive muscular relaxation
Breathing exercises
Directed imagery
Sham acupuncture just as effective as real
[Linde 2009]
Thermal biofeedback with relaxation training
Audience Question
23 y. o. female with recurrent migraine
headaches. You advise starting
preventive therapy. Which medication
would be appropriate?
a)
b)
c)
d)
Anticonvulsant medication
Bipolar/anticonvulsant medication
Beta-blocker medication
Tricyclic medication
Menstrual Migraine – two classes
A. Pure menstrual migraine without aura


Migraine without aura on days -2 to +3
of cycle
During at least 2 of 3 cycles
B. Menstrual related migraine without aura

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Migraine without aura as above and
At other times of the month
Menstrual Migraine

Strongly associated with estrogen

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
Steep drop in estrogen just prior to menses
may trigger headache
Peak incidence is 1st day and preceding day
of cycle
Other clinical features



Greater severity of pain
Increased risk of nausea & vomiting
Less responsive to acute treatment
Menstrual Migraine


Acute therapy the same as other
migraines
Short-term prevention

NSAID on days -7 to +6 helped
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
Naproxen sodium (Anaprox®) & mefenamic acid
(Ponstel®) orally have been studied
Triptans starting day -2 for 5-6 days helped

Frovatriptan (Frova®), naratriptan (Amerge®) &
sumatriptan (Imitrex®) orally have been studied
Prognosis of Migraines
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Study with 10 year follow-up of 11-14 year olds
at onset of migraines
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40% no longer had headache
20% had episodic tension headache
20% had migraine type that was different from the
original diagnosed headache
Frequency & intensity usually decreases after
menopause
Two fold increased risk of CVA [Spector 2010]

May influence how aggressive to be with other
therapies to reduce risk of CVA
Tension Type Headache
(TTH) - Criteria
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First
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No vomiting – if vomiting probably a
migraine
Not worsened by routine physical activity
But can have one of these clinical
features


Photophobia
Phonophobia
TTH - Criteria
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If no vomiting & only 1 other symptom then need 2 of the following:
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Pressing, tightening or non-pulsatile pain
Mild to moderate intensity of pain
Bilateral
No aggravation with movement
Diagnosis best made with use of
headache diary for 4 weeks
TTH


Underlying cause uncertain
Muscle tenderness & psychological
tension associated with aggravating them


But are not clearly the cause
Susceptibility influenced by genetic
factors
TTH
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
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Gender ration female:male 5:4
Age of onset – 25-30 years old
Peak prevalence – 30-39 years old
Prevalence increases with higher
educational level
TTH – Treatment



OTC analgesic medications
NSAID (prescription)
May be augmented with:




Promethazine (Phenergan®)
Diphenhydramine (Benadryl®)
Metoclopramide (Reglan®)
Efficacy tends to decrease with
increasing frequency of headaches
Cluster Headaches - Criteria

Severe unilateral, bilateral, supraorbital or
temporal pain lasting 15-180 minutes
(untreated) and one of following on same side


Lacrimation
Rhinorrhea

Forehead or facial swelling
Ptosis
Miosis

Eyelid edema

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Cluster Headaches - Criteria

Sense of restlessness (93% patients) or
agitation


Prefer to be erect & move about
5 attacks with frequency of 1-8 on any
given day from no other cause

75% of attacks last < 60 minutes
Cluster Headaches




Male : female – 2.1 : 1
Peak onset in 40’s
60% right sided
Probably most severe pain known to
humans

Female patients describe attacks as worse
than childbirth
Cluster Headache Treatment

Acute

Sumatriptan



Intranasal spray sumatriptan or zolmitriptan
– relief in 30 min
Triptans limits on daily usage


6 mg SC – relief in 15 min
Limit to 2 SC or 3 nasal sprays per day to
prevent tachyphylaxis or rebound
High flow O2 effective & safe [Cohen 2009]

O2 – 7 - 15 L/min with loose fitting
nonrebreathing facial mask for 15 min
Cluster Headache Treatment

Acute



DHE 0.5 - 1 mg IM or IV useful as abortive
agent
Octreotide (Sandostatin®) 100 mcg SC can
abort an attack
 NNT 5 for complete relief in 30 min
Prednisone 50-80 mg – short course
Cluster Headache Treatment

Prophylactic

Verapamil 240-960 mg/day
Daily Headache

When chronic daily headache is strictly
unilateral, same side, consider diagnosis
to be:

Hemicrania continua


Ipsilateral side one or more autonomic symptoms
(ptosis, lacrimation, etc.)
Defined by absolute response to
indomethacin (25 – 300 mg daily, must be
continued indefinitely)

If intolerant of indomethacin conside COX2
inhibitor
Key Points

Diagnosis of migraine headache is clinical

Almost always positive family history

Triptans are preferred treatment for
frequent migraines

Discuss preventive therapy with all patients

Provide treatment plan for breakthrough
pain
What Questions do you have?