Transcript Request for Expansion of Pain Management Services at Mount

How to Manage Recurrent Headache
Allan Gordon MD, FRCP(C)
Neurologist and Director
Wasser Pain Management Centre
John and Josie Watson Pain Education and Research Centre
www.mtsinai.on.ca/wasser
[email protected]
Objectives
• To discuss Chronic Headache Program at the Wasser Pain
Management Centre
• To discuss the Canadian Headache Society guideline for
headache prophylaxis
• To describe the management of chronic migraine
Disclosures
• Allergan
• Purdue Pharma
• Merck
• AstraZeneca
• Pfizer
• Eli Lilly
• Boehringer
• Mount Sinai Hospital Foundation
• CIHR
RECURRENT HEADACHE
|
Episodic Migraine
\< 14 days per month
|
Chronic Migraine
>/ 15 days per month
8 migraines
Stephanie
• 28 F lawyer
• Married no children (yet). On Yaz
• Onset of headaches at 14 (2 years after menarche)
• Now 1 per week except for week of menses when there may be 2
or 3 days in a row with a headache (6-7 per month). 8/10severity
• No aura except slight nausea
• Then pain usually right temple and forehead (70%), or left temple
(30%)
• Throbbing pain, severe, dark room
• Takes Advil, lies down, wakes up in 4 hours and feels better
• 50% of HA do not respond to this treatment and spends time off
• Physical Exam is normal
What is the diagnosis?
A
Migraine with aura
B
Tension type headache
C
Episodic Migraine without aura
D
Cervicogenic headache
E
Glioblastoma
F
Chronic migraine
Examples of oral acute therapy
• Acetaminophen
• ASA
• Ibuprofen
• Sumatriptan
• Rizatriptam
• Eletriptan
• Metclopromide
• Codeine and oxycodone (not usually recommended
Examples of prophylactic therapy used
• Topirimate
• Propranolol
• Lamotrigine
• Onabotulinum toxin A
• Valproic Acid
• “natural” medications
Canadian Guidelines
Migraine Prophylactic Guideline
Summary for Primary Care Physicians
Tamara Pringsheim, W. Jeptha Davenport, Gordon Mackie, Irene
Worthington, Michel Aubé, Suzanne N. Christie, Jonathan
Gladstone, Werner J. Becker1 on behalf of the Canadian Headache
Society Prophylactic Guidelines Development Group
Can J Neurol Sci. 2012; 39: Suppl. 2 - S41-S44
Objective
To assist the physician in choosing an appropriate
prophylactic medication for an individual with intermittent
migraine headaches (headache on ≤ 14 days a month).
Episodic migraine 17% of women /5% of men
Who should receive prophylaxis?
i. Migraine prophylactic therapy should be
considered in
patients whose migraine attacks have a
significant impact on
their lives despite appropriate use of acute
medications and
trigger management / lifestyle modification
strategies.
ii. Migraine prophylactic therapy should be considered
when the frequency of migraine attacks is such that
reliance on acute medications alone puts patients at
risk for medication overuse (rebound) headache.
Medication overuse is defined as use of opioids,
combination analgesics, or triptans on ten days a
month or more, or use of simple analgesics
(acetaminophen,ASA, NSAIDs) on 15 days a month or
more,
iii. Migraine prophylaxis should be considered for
patients with greater than three moderate or
severe headache days a month when acute
medications are not reliably effective,
and for patients with greater than eight
headache days a month even when acute
medications are optimally effective because of
the risk of medication overuse headache.
Botulinum toxin type A (Onabotulinum
toxin
Although there is good evidence for efficacy in chronic
migraine, onabotulinumtoxinA is not recommended for
prophylaxis of episodic migraine in patients with less than 15
headache days per month.
“We found high quality evidence that botulinum toxin type A is
no better than placebo for the prophylaxis of migraine in
such patients”.
Non pharmacologic treatments
• Biofeedback
• Acupuncture
• Hypnosis
• Injections
• CBT
• Mindfulness
• Psychotherapy
• Physical therapy
• Massage
• Chiropractic therapy
Dana
• 40 F Not working
• Every day a headache, more than 15 days a month
• Throbbing, nauseated photophobia, one or both sides
• Partial response to rizatriptan, zolmitriptan, ASA
acetaminophen, naproxen (taken almost every day)
• Failed gabapentin antiepileptics, beta blockers, tricyclics,
riboflavin, nerve blocks
• Widespread joint and muscle pain
• Irritable bowel
• Vulvar pain
Chronic Migraine (see Silberstein et al 2013)
Chronic Migraine is a distinct and severe neurological disorder
characterized by patients who have a history of migraine and
suffer from headaches on 15 days or more per month for at
least three months, with at least 8 headache days being
migraine and/or are treated and relieved by triptan/ergot
Report lower health related quality of life, use a greater
amount of direct and indirect medical/healthcare resources
and incur greater loss of productivity than patients suffering
from episodic migraine (<15 headache days per month)
Afflict 1.7% of global female population (.5% of men)
More overlap conditions
• Treatment of CM generally involves preventative
medications, take on a daily basis whether or not headache
is present and acute treatments, taken when attacks occur
to relieve pain and restore function
• Identifying and eliminating exacerbating factors including
the overuse of acute medications is the conventional
treatment
• Health Canada has approved BOTOX® (onabotulinumtoxinA)
manufactured by Allergan, Inc. as a prophylactic
(preventive) treatment for headaches in adult patients with
Chronic Migraine who suffer from headaches 15 days or more
per month, lasting four hours a day or longer.
• Compared with placebo-treated patients, topiramate 100
mg/day appears to contribute to reductions in migrainerelated limitations on daily activities and emotional distress
beginning as early as week 4 and continuing up to week 16
after treatment.
• Physician's Global Impression of Change results are very
similar with Subject's Global Impression of Change,
indicating concordance between the physician's and the
subject's assessment of improvement.
Onabotulinumtoxin A for treatment of
chronic migraine:
• PREEMPT 24 hour pooled subgroup analysis of patients who
had acute headache medication overuse at baseline
• Silberstein et al (2013) Journal of Neurological Sciences (in
press)
• The frequent intake of analgesics or other acute headache
medications may lead to the development of a secondary
headache disorder – MOH (medication overuse headache)
• Increasing headache frequency may lead to increased uptake
of acute headache medications
• In MOH withdrawal of drug therapy may improve headache
symptoms
• Most MOH patients in tertiary headache centres overuse
acute medications (73% Mathew 1996)
• Suggested to try terminating acute Rx does not always work
and hard to do
PREEMPT (Phase III Research Evaluating
Migraine Prophylaxis Therapy)
• Showed that onabotulinumtoxinA treatment is safe,
tolerable and effective as long-term (up to 56 weeks)
headache prophylaxis in adults with CM
• Silberstein 2013 showed that the number and severity of
headache days in the CM plus MO group but no decrease in
use of acute medications