migraine for psychiatrist, mae hong sorn, 54

8/7/2019 Migraine for Psychiatrist, Mae Hong Sorn, 54

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MigraineSurat Tanprawate, MD, MSc(Lond.), FRCP(T)

Division of Neurology

Chiang Mai University

Solving the problem

4.2.11Sunday, 6 February 2011


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Sunday, 6 February 2011


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Headache and

psychological conditions



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Headache and

psychological conditions1. Psychological conditions are highly co-

morbid of primary headache disorder

ex. migraine vs depression



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Headache and

psychological conditions1. Psychological conditions are highly co-

morbid of primary headache disorder

ex. migraine vs depression2. Headache can be caused by psychiatric

disorder

ICHD-II: Headache attributed topsychiatric disorder



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ICHD-II 2004Sunday, 6 February 2011


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Migraine

Epidemiology and problematicconcern

Clinical and pathophysiologicalground

Management strategies



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International Classicat ion of Headache Disorder-2004

International Classication of

Headache Disorder 2004

http://ihs-classication.org

Part 1 . The primary headaches

- Migraine , TTH, CH and otherTACs, and other primary headachedisorder

Part II . The secondary headaches

-Headache attributed to ....

Part III . Cranial neuralgias,central and primary facial pain andother headaches

http://ihs-classification.org/http://ihs-classification.org/http://ihs-classification.org/


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Steewart WF. Am J Epidemiol.1991;134:1111-1120

Incidence of migraine by age and sex Adjusted prevalence of migraine bygeographic area and meta-analysis of

studies using IHS criteria

Prevalence of Migraine



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Leading causes of years of life lived with adisability (YLDs)

Leonardi M . J Headache Pain (2003) 4:S12S17



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Clinicalmanifestation/

Diagnostic criteria



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Early migraine

description

Hippocrates (c.460-c.370 B.C.)

"He seemed to see somethingshining before him like a light ,

usually in part of the right eye ; atthe end of a moment, a violent pain

supervened in the right temple ,then in all the head and neck....

vomiting , when it becamepossible, was able to divert thepain and render it more moderate."

JMS Pearce . JNNP 1986;49:1097-1103Sunday, 6 February 2011


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"He seemed to see somethingshining before him like a light ,

usually in part of the right eye ; at the end of a moment, a violent pain

supervened in the right temple , then in all the head and neck....

vomiting , when it becamepossible, was able to divert thepain and render it more moderate."

Migraine with aura =

Classic migraine



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Only migraine without auraOnly migraine with auraBoth types

Launer LJ et al. Neurology 1999;53:537-42

Migraine without aura is more common(previously called common migraine)

Population-based study



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ICHD-II: Migraine

Migraine with/withoutaura

Migraine variant(migraine equivalent)

Migraine with prolonged auraMigraine aura without headacheHemiplegic migraine

Basilar-type migraineRetinal migraine

Childhood periodic syndromes thatare commonly precursors of migraine-Cyclic vomiting syndrome

-Abdominal migraine-Benign paroxysmal vertigo of childhoodSunday, 6 February 2011


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Migraine classication

ICHD-II 2004Sunday, 6 February 2011


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Description and Criteriahttp://ihs-classication.org

Description

Criteria

http://ihs-classification.org/http://ihs-classification.org/


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Triggerfactors

Genetic

Migraine attack

Environmentalfactors

Clinical Picture



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Typical aura

Typical aura consisting of visual and/orsensory and/or speech symptoms.Gradual development , duration nolonger than one hour , a mix of positive and negative features and complete

reversibility characterize the aura which isassociated with a headache.



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Migraine Aura

Michael B. R. et al. Brain 1996: 119, 355-361

n=163

99% 31%

6%

18%

Typical aura :-Visual-Sensory-Speech



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Visual aura

Typical visual aura is simple



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On a distinct form oftransient hemiopsia byDr. Hubert Airy in 1870.

Teichopsia (Greek for

townwall vision )



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Zig-zag lines (fortication)

Zig-zag lines in migraine aura

Visual Aura

Table of Fortication, from the 1728Olomouc (c.1757) bastion fortress intoday's Czech Republic



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Alice in WonderlandSyndrome (AWS)

Somesthetic metamorphopsia.Distortion of body and space

Did Lewis Carroll draw inspirationfrom migraine auras?

Alice in Wonderland. By Lewis Carroll



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Cortical SpreadingDepression (CSD)

CSD is a wave of neuronal andglial depolarization, followed by

long-lasting suppression ofneural activity



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Changes in cerebral blood ow in relation to theoccurrence of the aura and the headache in

migraine with aura

Olesen J et al. Ann Neurol. 1990;28:791798.Sunday, 6 February 2011


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Cortical spreading depressionthe cortical process

The spreading of a self-propagating wave of cellular depolarization in the cerebral cortex

The spreading of a wave of ischemia passingthrough an area of cortex

The spreading of a wave of vasoconstrictionfollowing vasodilation of contiguous corticalarterioles



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The Mechanismof Head Pain



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Neuroanatomical Processing of Vascular Head Pain

Goadsby P. J. Headache 2005; 45[Suppl 1]: S14-S24



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Mechanism of head painTrigeminovascular system



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Triggerfactors

Genetic

Migraine attack




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Migraine triggers

Diet

Hunger

Alcohol Additives Certain foods

Chronobiologic

Sleep (too much or toolittle)

Schedule change

Hormonalchange

Menstruation


Light glare Odors Altitude Weather change

Physicalexertion

Exercise

Sex

Stress and

anxiety

Headtrauma



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HypothesisTrigger factors

Periaqueductal gray matter (PAG), Cortical spreading depression [CSD]Nucleus raphe magnus (NRM)

Geoffrey A. Headache 2008.Sunday, 6 February 2011


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Triggerfactors

Genetic

Migraine attack


Clinical Picture



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Genetic factor and

migraine brain Migraine: hyperexcitability of brain network

Twin studies Familial hemiplegic migraine(FHM)

3 genes: CACNA1A , SCN1A , ATP1A2

disturb ion transportation

Russell M . Hum Genet 1995; 96: 72630

Wessman M . Lancet Neurol 2007; 6: 52132



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Functional roles of the proteins coded by known FHM genes within a glutamatergic synapse

Lancet Neurol 2007; 6: 52132



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Migrainemanagement



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IHS criteria

Assessments of

migraine impact

Attack frequencyAttack severity

Degree of disabilityNon-headache symptomsPatient participation:preference, prior response, co-existent conditions

Matchar DB. Neurology 2000; 54The US Headache Consortium Guideline


C h i


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Comprehensivetreatment plan

Education, reassurance and life stylemodication

Avoiding triggers to prevent attack Non-phamacologic treatment Treating the acute attack Long-term preventive therapy Physical and alternative medicine

Silberstein SD. Wolff s headache. 2008



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Education, reassuranceand life style modication

The simple fact that a headache patientdesires attention for his/herheadaches signals that advice regardinglifestyles should be offered.

Initially, it may be benecial to remind theheadache sufferer that his/her nervoussystem is highly sensitive , whichincludes changes in their environment androutines.



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Thus, regularity and predictablelifestyles are to be consideredbehavioral headache managementkeystones to success.

All patients are informed andcounseled about the A-H of behavioral life support for headache

Education, reassuranceand life style modication



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A = Apnea and Assessing psychophysiologic insomnia

B = Biofeedback and other behavioral relaxation

C = Caffeine : reduction of this and other substances; but mostimportantly caffeine

D = Diet : eating regularly as fresh and unprocessed an eating plan asfeasible

E = Exercise (cardiovascular) with increased non-exercise activity(walking)

F = Fluids : adequate hydration at all times

G = Groups : to enhance the benets of social connectedness

H = Habits of all of the above leading to Happiness with improvedwell-being

A-H for prevention by behavioral lifestyles

Taylor, FR.Techniques in Regional Anesthesia and Pain Management (2009) 13, 28-37



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Living asnatural life



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Medication

Ionic channels: Ca, Na Neurotransmitter system: Serotonergic system(5-HT),

Dopaminergic system(DA)

Inammatory process



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Acute Medication

Medication

Non-specic vs specic medicationTreatment strategies

Step-care vs staged care vs stratiedcare

Lipton RB. Cephalalgia 1998; 18 (suppl 22):40-6Sunday, 6 February 2011


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Pharmacotherapy of

acute migraine attackNon-specic

Acetaminophen, NSAIDs butalbital

caffeine, opioids neuroleptic

Specic

Dihydroergotamine Ergotamine Triptan


Analgesics with evidence of efcacy


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Evers, S et al. European Journal of Neurology 2009, 16: 968981

Analgesics with evidence of efcacyEFNS migraine treatment guideline 2009



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Evers, S et al. European Journal of Neurology 2009, 16: 968981

Triptans



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Choice and route of

therapy severity and frequency of attack

associated symptoms

coexistent disorders previous treatment response

drugs efcacy potential for overuse

adverse events


Step-care


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Step care

Stratied care

Staged care

Migrainediagnosis

First-line Rx(simple analgesic)

Second-line Rx

(combinationtherapy)

Third-line Rx

(specicantimigraineous)

First series of attack Second series of attack Third series of attack

Migrainediagnosis

First treatment(simple analgesic)

Second-line Rx(combination

therapy)

Third-line Rx(combination

therapy)

0 h 2 h 4 h

Migrainediagnosis

Assessment of illness severity

Impact questionnaireHigh need

Moderateneed

Low needStratication

Treatment strategies


Step-care


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Step care

Stratied care

Staged care

Migrainediagnosis


Second-line Rx


Third-line Rx



Migrainediagnosis



therapy)


therapy)

0 h 2 h 4 h

Migrainediagnosis



Moderateneed



Step-care


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Step care

Stratied care

Staged care

Migrainediagnosis


Second-line Rx


Third-line Rx



Migrainediagnosis



therapy)


therapy)

0 h 2 h 4 h

Migrainediagnosis



Moderateneed



Step-care


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Step care

Stratied care

Staged care

Migrainediagnosis


Second-line Rx


Third-line Rx



Migrainediagnosis



therapy)


therapy)

0 h 2 h 4 h

Migrainediagnosis



Moderateneed




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Stratied care and

migraine assessmentFactors need to be considered

Frequency Severity

The present and level of disability

Associated non-headache symptoms

US Headache Consortium Guideline 2007Sunday, 6 February 2011


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Criteria for assessing migraine


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Criteria for assessing migrainepatient severity

Mild to moderate migraine Moderate to severemigraineHeadache are almost mild-to-moderate intensity

Non-headache associatedsymptoms, if present are notsevere in intensity

The impact of the headache on thepatients lifestyle is not signicant:MIDAS Gr. 1 or 2, HIT Gr. I or 2

Non-triptan

Headache that frequently developto moderate or severe in intensity

Signicant non-headache associatedsymptoms, which may be severe inintensity

The impact of the headache on thepatients lifestyle is signicant:MIDAS Gr. III or IV (moderate orsevere impact)

Triptan or DHECurr Med Res Opin 2002.


E l L


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Early vs Late

intervention

Early intervention preventsescalation and can increase theeffectiveness of the treatment.

Cady RK, Clin Therap 2000; 22: 103548.



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Successful treatment of migraine attack

Pain free after 2 hours

Improvement of headache from moderateor severe to mild or none after 2 hours

Consistent efcacy in two of three attacks

No Headache recurrence and no furtherdrug intake within 24 hours successfultreatment (so-called sustained pain relief orpain free)


Wh h d i


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When the drug is

ineffective at 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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Prevent medication overused

headache (MOH)

Simple analgesics:no more than 15 days/month

Combined analgesics:no more than 10 days/month



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Preventive Medication

Aim

Reduce attack frequency, severity, andduration

Improve responsiveness to acute headachetherapies

Improve function and reduce disability Reduce overall cost associated with migraine

treatment


Indication for pre enti e


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Indication for preventivetreatment in migraine

Recurring migraine that signicantly interferes withquality of life

Frequency of migraine attacks > 1/weeks Frequency of acute medication use>2/week Failure of, contraindication to, or trouble AE from acute

medication

Uncommon migraine: hemiplegic migraine, basilarmigraine, prolonged, disabling or frequent aura, ormigrainous cerebral infarction

Pract Neurol 2007; 7: 383393



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Estimated 1-year incidence rate of:(a) chronic daily headache (180+ headaches/year) (b) increased headaches (105179)

in an episodic headache population by baseline headache frequency.Sunday, 6 February 2011

Concept


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Concept

Rightdrug

Rightperson

Right

dose

Preventive medication thatwas proven the efcacy

Consider patient proles,and co-morbidities

Titrate into the appropriated

dose

Right

duration

On the preventive therapylong enough



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Migraine Comorbid disease

Cardiovascular

Hyper- or hypotension, Raynauds disease, mitral valveprolapse, angina/myocardial infarction, strokePsychiatric

Depression, mania, panic disorder, anxiety disorderNeurologic

Epilepsy, positional vertigoGastrointestinal

Functional bowel disorderOther

Asthma, allergy

Wolff s headache and other head pain 2009Sunday, 6 February 2011

Group of medication used for migraine prevention based


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Group of medication used for migraine prevention basedon levels of evidence for efcacy (AAN)

5 GroupsGroup 1 : medications with proven high efcacy based on at leasttwo Class-I trials (should be used).Group 2 : medications probably effective based on one Class-I or

at least two Class-II trials (should be considered).Group 3 : medications possibly effective based on one Class-IItrial or at least two Class-III trials, or conicting studies (may beconsidered).Group 4 : medications cannot be recommended based on

inadequate or conicting data (Class-IV trials or no trials) (wecannot recommend these drugs one way or the other but some areclearly used frequentlyfor example, nortriptyline).Group 5 : medications probably ineffective (based on one Class-Ior at least two Class-II trials (should not be considered).



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The Quality StandardsSubcommittee of the AAN



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Recommendedmedication for

migraine preventionEFNS guideline

2009

Evers, S et al.European Journal of Neurology 2009, 16: 968981


Indications, contraindications, and adverse effects of conventional migraine preventive drugs


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Drugs Relative indicationsRelative

contraindication Adverse effect

Amytriptiline (TCA)

Propranolol (B-blocker)

Flunarizine (CCB)

Valproic acid (AED)

Topiramate (AED)

Other pain disorders,depression, anxiety,

insomnia

Hypertension, angina

Hypertension, vertigo

Epilepsy, mania, anxiety

Epilepsy, mania, anxiety

Mania, urinaryretention, heart blocks,

glaucoma

Asthma, depression,CHF, Raynauds disease

Obesity, depression, PD

Liver disease, bleedingdisorder

Renal calculosis, liverdisease

Drowsiness, drymouth, increase

appetite, weight gain

Fatique, lethargy,nausea, depression,

dizziness

Drowsiness, weightgain, depression, PD

Nausea dyspepsia,sedation, increase

appetite, weight gainParesthesia, weight

loss, alter taste,language disturbance

F. Galletti et al. Progress in Neurobiology 89 (2009) 176192



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Anti-epileptic drug

AEDs that act on multiple mechanism of actions are the best candidate (Topiramate,Valproic acid, Gabapentin)

Action: Glutamiatergic/ GABA, Ion channels



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Silberstein SD. Headache 2005; 45[Suppl 1]: S57-S65

Clinical trials-Topiramate



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Silberstein SD. Headache 2005; 45[Suppl 1]: S57-S65

Incident of most common adverse events

Adverse events in multicenter clinical trials (MIGR-001/-002/-003 and CAPSS-155) that occurred in at least10% of subjects, and at a greater incidence in the topiramate 100 mg per day and 200 mg per day groups



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Topiramate: RecommendedMigraine Prophylaxis dose and

titration

Brandes, J. L . Headache 2005;45[Suppl 1]:S66-S73



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Continue preventivemedication for 4-6 months


Comprehensive


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Comprehensivetreatment plan

Education, reassurance and life stylemodication

Avoiding triggers to prevent attack Non-phamacologic treatment Treating the acute attack Long-term preventive therapy Physical and alternative medicine

Silberstein SD. Wolff s headache. 2008Sunday, 6 February 2011


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Conclusion Migraine is common and high disable

disease

Migraine: various symptoms Pathophysiology links to symptoms Treatment plan: select right person,medication, dose, and duration



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