acute migraine therapy, chiang rai 2012
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Beyond the frontier ofacute migraine
therapySurat Tanprawate, MD, MSc(London), FRCP(T)
Division of Neurology, Chiang Mai University
4.4.2012 Chiang Rai
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The Headache, George Cruikshank (1819)
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Why we got headache
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Why we got headache
(1)(2)
(3)
(1) primary
(2) secondary
(3) cranial neuralgiaWednesday, April 4, 2012
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Description and Criteria,Migraine, c/w aura
International Classification of
Headache Disorder-II, 2004
1. Primary headache:TTH, migraine, Cluster
2. Secondary headache:Headache attributed to...
3. Cranial neuralgia:e.g., trigeminal neuralgia...
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Leading causes of years of life livedwith a disability (YLDs)
Leonardi M. J Headache Pain (2003) 4:S12S17
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Genetic
Environmental
and factor
Cause Pathophysiology of
acute migrainePathophysiology of
episodic and chronic
migraine
- Genetic
: FHM, TREK
-Trigger factor
Pathophysiology- Aura
- vasodilatation
- neurogenic inflammation
- peripheral and central
sensitization
- Trigemino vascular system
Neurotransmitter
- Serotonergic system
- Dopaminergic system
Clinical: chronic and transform
migraine, allodynia, neck pain
Anatomical: PAG, centralsensitization
episodic
constant
episodic become chronic
acute on chronic
Evolution of MigraineWednesday, April 4, 2012
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Neuroanatomical
Processing of Vascular
Head Pain
CDS: Cortical Spreading DepressionPAG: Periaqueductal gray matterCSD: Cortical spreading depressionNRM: Nucleus raphe magnus
TG: Trigeminal GangliaTNC: Trigeminal Nucleus Caudalis
Geoffrey A. Headache2008
- substance P
- Neurokinin A
- CGRP
- serotonin
- glutamate
- prostaglandins
- inflammatory cytokines
Peripheral sensitization
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When headache
progress-what happen
Central sensitization
of Trigeminal nucleus
caudalis(TNC)
Periaqueductal grey
matter dysfunction
FEATUREs
- neck pain
- allodynia
- less features oftypical migraine
- less throbbing
- less N/V
- more tension
like headache
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How to treat migraine
effectively?
Dated 1583
Circa 300 AD
From papyrus, 2500 BCWednesday, April 4, 2012
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Comprehensive treatment plan
Education, reassurance and lifestyle modification
Avoiding triggers to prevent attack Non-phamacologic treatment
Treating the acute attack
Long-term preventive therapy Physical and alternative medicine
Silberstein SD. Wolffs headache. 2008
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Episodic
Migraine
Frequent
migraine attack
Life stylemodification Acute migrainetreatment
+ Prophylaxismedication
Treatment fail
Migraine with
co-morbidity
Inadequate
treatment
Migraine with
MOH
- Life stylemodification?- Right drug,
dose, duration?
- Psychiatriccondition- Sleep
condition
Suc
cessfultre
atment
True refractory
migraine
use acute
medication >
15days/months,
> 3 months
failed > 3
preventive
medication group
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Comprehensive treatment plan
Education, reassurance and lifestyle modification
Avoiding triggers to prevent attack Non-phamacologic treatment
Treating the acute attack
Long-term preventive therapy Physical and alternative medicine
Silberstein SD. Wolffs headache. 2008
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What do you prescribewhen they got headache?
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Pharmacotherapy of
acute migraine attack
Non-specific
Acetaminophen,
NSAIDs
caffeine
opioids
neuroleptic
Specific
Dihydroergotamine
Ergotamine
Triptan
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NSAIDs
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Evers, S et al. European Journalof Neurology 2009, 16: 968981
Non-specific
migraine
medication:
Analgesics withevidence of efficacyEFNS migraine
treatment guideline2009
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Options
Fixed combination ASA + Paracetamol+ caffeine more effective than single
substance
selective COX-2 inhibitors Valdecoxib 20-40 mg
Celecoxib 400 mg
Rofecoxib 25-50 mg
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Ergotamine
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Ergot
The word ergot is derived from argot,
old French for cock spur
The ergot of RyeCock spur
400 BC: ergotism was reported- vasospasm- gangrene
- abortion
Fungus Claviceps purpurea
1862: ergot use totreat migraine
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Specific
Medication These agents have a strong structural
similarity to neurotransmitters,
norepilephrine, dopamine(D2),serotonin(5-HT1A, 1B, 1C, 1D, 1F, 2A, 2C, 3, 4)
5-HT1B: constricts the pain-producingintracranial, extracranial blood vessel
in the meninges
5-HT1D: presynaptically inhibitstrigeminal peptide release andinterfere with central trigeminal
nucleus caudalis
DHE injection form
Ergotamine tartrate+ Caffeine
Ergot &
Dihydroergotamine
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Contraindication of ergot
use... coronary, cerebral and peripheral vascular disease
pregnancy
renal or hepatic failure
uncontrolled hypertension
sepsis
hypersensitivity reaction
hemiplegic and basilar type migraine
migraine with prolong aura
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Triptans
5-HT 1B/1D receptor agonists seven different formulations
options for route of delivery
oral tablets or melts
nasal spray
subcutaneous injection taken as soon as possible
* i.e. as soon as the patient knows that this is a migraine
* if there is aura, take at the start of the headache phase
Less side effect than
ergotamine
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Possible Sites of Action of Triptans in the
Trigeminovascular System
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Sumatriptan
Eletriptan
Zolmitriptan
Triptan available in
Thai market
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Evers, S et al. European Journal of Neurology 2009, 16: 968981
Triptans
(Imigran)
(Zomig)
(Relpax)
Sumatriptan 2.5
Zolmitriptan
Eletriptan3.31.0-2.0
Time to peak plasma(h)
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Opioids
IM 100 mg tramadol = IM 75 mgdiclofenac (80% response rate)
Pethidine; Morphine: highly addictive
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Parenteral acute treatment of migraine for
use in clinic or emergency department
Medication Dose Route
DHE Up to 1 mg sc, im, iv
Sumatriptan 4, 6 mg sc
Metoclopamide 10 mg iv
Chlorpromazine 25-50 mg iv
Ketorolac 30 mg iv im, iv
Dexamethasone 4-10 mg im, iv
Valproic acid 500-1000 mg iv
Magnesium 1 g iv
Tepper SJ, Spears RC. Neurol Clin 2009;417-427
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HOW TO
useDRUGS?
-content...
whats drug
whats route
early vs late treatment
how to evaluate
what need to be concernWednesday, April 4, 2012
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Choice and route of
therapy
severity and frequency of attack
associated symptoms coexistent disorders
previous treatment response
drugs efficacy
potential for overuse
adverse events
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Strategies in acute
migraine attack
Step care
Strategic care
treatment is escalated after first-line medication fail
initial treatment is based on measurement of the
severity of illness or other factors
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Second series of attack
Step-care
Stratified care
Migrainediagnosis
First-line Rx
(simple analgesic)
Second-line Rx
(combination
therapy)
Third-line Rx
(specific anti-
migraineous)
First series of attack Third series of attack
Migrainediagnosis
Assessment of
illness severity
Impact questionnaire High need
Moderate
need
Low need
Stratification
Step vs Stratified care
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The Disability in Strategies of Care(DISC study)
RCT trail: step vs strategic care
Participant: 835 adults
Result: Strategic care provides significantlybetter outcomes than step care strategies
within or across attacks as measured by
headache response and disability time(52.7% vs 40.6% vs 36.4%, p< 0.001)
Lipton RB, Stewart WF et al. JAMA 2000;284:2599-2605
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Stratified care and
migraine assessmentFactors need to be considered
Frequency Severity
The present and level of disability
Associated non-headache symptoms
US Headache Consortium Guideline 2007
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MIDAS and HIT-6
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Scale used in Chiang MaiHeadache Clinic
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C it i f i i i
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Criteria for assessing migraine
patient severity
Mild to moderate migraine Moderate to severe migraine
Headache are almost mild-to-
moderate intensity
Non-headache associatedsymptoms, if present are not severe
in intensity
The impact of the headache on the
patients lifestyle is not significant:MIDAS Gr. 1 or 2, HIT Gr. I or 2
Non-triptan
Headache that frequently develop
to moderate or severe in intensity
Significant non-headacheassociated symptoms, which may
be severe in intensity
The impact of the headache on the
patients lifestyle is significant:MIDAS Gr. III or IV (moderate or
severe impact)
Triptan or DHE
Curr Med Res Opin2002.Wednesday, April 4, 2012
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Early intervention preventsescalation and can increase
the effectiveness of the
treatment
Cady RK, Clin Therap 2000; 22: 103548.
Ferrari MD,Eur Neurol 2005;53(Suppl 1):17-21
Should we advise patients to treat
migraine attacks early ?
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Pain free after 2 hours
Improvement of headache from moderate or
severe to mild or none after 2 hours
Consistent efficacy in two of three attacks
No Headache recurrence and no further drug
intake within 24 hours successful treatment
(so-called sustained pain relief or pain free)
Successful treatment of
migraine attack
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When the drug is
ineffectiveat least two attacks should be treated
inadequate response
change the dose
change the route
add adjuvant therapy
change medication
SD Silberstein Lancet 2004; 363: 38191
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Occipital nerve
block technique
Location
Occipital protuberance-
Mastoid process
23-gauge needle
Bupivacaine orLidocaine 2-4 cc
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What need to be
concerned ?Medication Overuse Headache
(MOH)
Migraine co-morbidities
Long term medication side effect
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Diagnosis: Medication Overuse Headache
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Diagnosis: Medication Overuse Headache
Paemeleleire K et al. Acta neurol. belg., 2006, 106, 43-51
Sun-Edelstein C et al. Cephalalgia, 2008, 29, 445452Classification using ICHD-IIR
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A man with chronic A CM woman with addict
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A man with chronic
migraine got addict to
medication, diazepam,
xanax, diazepam
A CM woman with addict
to tramadol, cafergot, and
pethidine iv
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E ti
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Ergotism: Limb ischemia
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A 42 Thai woman
with ergotamine
overuse (15 tab/day)
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..
Ravichankra, India
.
.
.
..
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