prevent, treat, repeat: getting ahead of migraines · · 2017-10-17prevent, treat, repeat:...
TRANSCRIPT
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Prevent, Treat, Repeat:
Getting Ahead of
Migraines
Jennifer Bestard
MD
FRCPC Neurology
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Faculty/Presenter Disclosure
• Presenter: Jennifer Bestard
• Relationships that may introduce potential bias and/or conflict of
interest:
– Grants/Research Support: Jennifer Bestard has received grants
from Allergan and Tribute to provide CME lectures on headache.
– Speakers Bureau/Honoraria: Jennifer Bestard has received a
speaker fee and expense support from the Alberta College of
Family Physicians; Jennifer Bestard has received honoraria from
Allergan and Tribute to provide CME lectures on headache.
– Consulting Fees: N/A
– Other: N/A
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Disclosure of Commercial Support
This program is presented by the Alberta College of Family
Physicians (ACFP) without any commercial or in-kind support.
The ACFP provides a speaker fee and expense support for presenting at the
Practical Evidence for Informed Practice.
• Potential for bias/conflict of interest due to commercial
support:
– Jennifer Bestard has received grants and/or honoraria for presenting CME
relating to a topic being discussed in this program and/or presentation.
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Managing Sources of Potential Conflict and/or Bias
• Material/Learning Objectives and/or session descriptions were
developed and reviewed by the Planning Committee composed of
experts/family physicians/allied care professionals responsible for
overseeing the program’s needs assessment and subsequent
content development to ensure accuracy and fair balance.
• Consideration was given by the Planning Committee to identify
when speakers’ personal or professional interests may compete with
or have actual, potential, or apparent influence over their
presentations.
• Information and/or recommendations in the program are evidence-
and/or guidelines-based, and the opinions of the independent
speakers will be identified as such.
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Presentation Outline
• Migraine backgrounder: Assessment, diagnosis and identification of migraine
• Treatment options for acute migraine Pharmacologic and non-pharmacologic
• When should prevention be started? 15 or more headache days per month
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Steps to Diagnosing Headache Disorders
Courtesy of The American Headache Society
Diagnostic Presentation & Classification of Chronic HA
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Case Vignette (Sara)
Initial
Consult
• 25-year-old female who presents to her
primary care doctor with a four year
history of headache
Frequency • Two attacks per month
Prodrome • Dysphoric mood
Aura • Zig-zag lines and a graying of vision in
a visual field
Pain • Unilateral (R>L) throbbing severe pain
lasting 24 hours untreated
Symptoms • Nausea, photophobia, unable to
function
Treatment • Excedrin Migraine up to six per day
Exam • WNL (within normal limits)
Diagnosis • ?
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Primary or Secondary Headache?
Detailed History and Examination
No
Yes
Evaluate for Secondary Headache
Red Flags? Diagnose Primary
Headache Disorder
Step 1
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S Systemic signs or symptoms Fever, weight loss, malignancy, HIV, meningismus, pregnancy
N Neurologic signs or symptoms Papilledema, hemiparesis, hemi-sensory loss, diplopia, dysarthria
O Onset “Worst headache of life” (thunderclap)
O Older New headache at age ≥50
P Progression of existing headache disorder
Change in quality, frequency, or location
13. Dodick DW. Adv Stud Med 2003;3:S550-S555.
Red Flags in Headache: “SNOOP”
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Sara has a Primary Headache Disorder
• Sara has no headache alarms
• Four year history, lack of alarms and
normal exam, additional work-up is
not necessary
Categorize Primary Headache Disorder Step 2
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Divide into headache syndromes
Short Duration
< 4hr duration
Episodic
(Long Duration)
≥ 4hr duration
≤ 15 days/month
Chronic Daily
Headache
≥ 4hr duration
≥ 15 days/month
1 2 3
Categorize Into One of Three Groups
Primary Headaches
Assess frequency and duration for each
headache type
Step 2
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Diagnose the Specific Disorder
Within the Category
• Migraine vs. tension type headache
• Tension type headache is the most common primary headache
• Migraine is the leading headache disorder that causes patients to seek treatment
Differential Diagnosis Step 3
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Diagnostic Criteria
Migraine without Aura:
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hr
C. Headache has 2 of the following characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity (e.g., walking,
climbing stairs)
D. During headache 1 of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not attributed to another disorder
22. International Headache Society,2nd edition. Cephalalgia 2004;24 Suppl 1:1-160.
24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy (New York, NY: Springer), 2011.
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Sara has “Classic Migraine”
Migraine with Aura
• Complex array of symptoms
reflecting focal cortical or brainstem
dysfunction
• Gradual evolution: 5-20 minutes
(<60 minutes)
• May or may not be associated with
headache
• Visual > sensory >, language,
brainstem >motor*
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Diagnosed Migraine:
“Tip of the Iceberg”
Diagnosed 29% 41%
31. Lipton RB et al. Arch Intern Med 1992;152(6):1273-1278.
Undiagnosed 71% 59%
Males Females
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Migraine: Additional Features
• Predictable timing around menstruation or ovulation
• Stereotypical prodromal symptoms
• Characteristic triggers
• Abatement with sleep
• Positive family history
• Childhood precursors (motion sickness,
episodic vomiting/vertigo)
• Osmophobia
36. Pryse-Phillips WEM et al. Can Med Assoc J 1997; 156(9):1273-87.
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Three-Item ID Migraine Screener *
During the last three months, did you have any of the following with your headaches:
28. Lipton RB et al. Neurology 2003;61(3):375–382.
* An affirmative response on 2 of 3 questions yields a sensitivity and specificity of 81% and 75%, respectively.
Item Yes / No
You felt nauseated or sick to your stomach when you had a headache?
Yes □ No □
Light bothered you (a lot more than when you don’t have headaches?)
Yes □ No □
Your headaches limited your ability to work, study or do what you need to do for at least one day?
Yes □ No □
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Migraine: A Common Episodic
Headache Disorder
Neurologic disorder• Strong genetic component (up to 50%)
Global prevalence: >10%• Women: 15%–17%
• Men: 6%–9%
Two major subtypes• Without aura (~75%)
• With aura (~25%)
Burden• Among the world’s 20 most disabling diseases (WHO)
• Affects 3 million women and 1 million men in Canada An Angus Reid poll suggests that the cost of migraine in the workplace is
approximately $500 million annually
35. Pietrobon D. Neuroscientist. 2005;11(4):373–386. 41. Stovner LJ et al. Cephalalgia. 2007;27(3):193–210. 26. Linde M. Acta Neurol Scand.
2006;114(2):71–83. 22. ICHD. Cephalalgia. 2004;24 Suppl 1:1-160. 24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic
Manual of Headache Therapy. (New York, NY: Springer), 2011. 20. Hu XH. et al Arch Intern Med. 1999;159(8):813–818.
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Prevalence of Migraine and
Tension-type Headache in Various Settings
12
75
40
16
0
10
20
30
40
50
60
70
80
Population Waiting Room
Migraine Tension-Type Headache
28. Lipton RB et al. Neurology 2003;61(3):375–382.
Perc
en
t
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Migraine is Often Misdiagnosed
27. Lipton RB et al. Headache 2001; 41(7):638-645.
† Inaccurate diagnosis received by migraine patients
Tension-type
Headaches
Sinus
Headaches
Cluster
Headaches
% MISDIAGNOSIS†
44%
43%
18%
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Tension-Type Headache
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 30 min – 7 days (untreated or unsuccessfully
treated)
C. Headache has 2 of the following characteristics:
• Bilateral location
• Pressure non pulsating quality
• Mild to moderate pain intensity
• Not aggravated by or causing avoidance of routine physical activity
D. During headache 1 of the following:
• No nausea or vomiting
• Photophobia or phonophobia but not both
E. Not attributed to another disorder
Headache Classification Subcommittee of the International Headache Society, 2004
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Why is Migraine Frequently Mistaken
for Sinus Headache?
• Pain is often located over the sinuses
• Migraine is frequently triggered by weather changes
• Tearing and nasal congestion are common during attacks
• Sinus medication may help migraine
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Planning and
Management Strategies
The Art and Science of Evaluating and Treating Migraine
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What might be your
preliminary treatment
recommendation for her?
Back to Sara…
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Formulate a Specific Treatment Plan
Non-pharmacologic approaches
• Trigger identification and management
Identify triggers by history
Headache diaries
• Education and enhance self-efficacy
• Sleep, exercise, diet and caffeine
• Biofeedback and cognitive behavioural treatment
Specific Treatment PlanStep 4
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Headache Journal
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Medication Classes
in Acute Migraine Treatment
Health Canada-Approved Prescription Medications
Triptans24 • naratriptan
• almotriptan
• frovatriptan
• sumatriptan
• rizatriptan
• eletriptan
• zolmitriptan
Ergots24 • ergotamine tartrate
• dihydroergotamine
NSAID9 • diclofenac potassium for oral solution (CAMBIA)
Other Medications Used in Migraine Treatment24
NSAIDs Opioids Barbiturates
24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), 2011.
9. CAMBIA Product Monograph. Tribute Pharmaceuticals Canada Ltd. March 9, 2012.
• No other prescription medications have met the criteria for Health Canada approval for
treatment of acute migraine
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Principles of Acute Treatments
1. Stratified care
2. Early intervention
3. Use correct dose and formulation
4. Treat at least two or three attacks before
judging acute medications
5. Use a maximum of 2-3 days / week
6. Use preventive therapy in selected patients
38. Silberstein SD. Neurology 2000; Sep 26;55(6):754-62.
32. Lipton RB, et al. JAMA 2000;284(20):2599-2605.
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Define the needs: clinical judgment
Stepped care within attacks: according to immediate effect
Acute Management: Migraine Stratified Care
Triptans
(Ergots)
Opioids (rarely)
Combination OTC
Prescription NSAIDS
Triptans
OTC analgesics
High
Low
Moderate
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Follow-up Visits
39. Silberstein SD et al. Wolff’s Headache And Other Head Pain, Seventh Edition (New York: Oxford University Press Inc), 2001 .
Review outcome measures (diaries, MIDAS, etc.)
Assess efficacy, adverse effects, and satisfaction with current regimen
If treatment is not working, find out why?
Consider:
• Primary failure
• Effects take to long
• Poor consistency
• Recurrence
• Adverse events
• Interfering medications
• Expectations unrealistically high
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Sara – Age 35
• Working full-time as a social worker
• Married with 3 kids under age 6
• Headache frequency has increased
very gradually over the last 3 years
• Headaches are now occurring
about 3-4 days per week
• Otherwise well, no change in
headache characteristics, no new
meds
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What is the Diagnosis?
How Would You Manage Sara’s Headaches?
Sara – Age 35
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Chronic Migraine
Chronic migraine:
• HA on ≥15 days/mt for >3 mts
• ≥8 days fulfilling criteria for
migraine with or without aura,
responding to migraine-
specific medications, or
recognized by patient as
migraine
• Not better accounted for by
another ICHD-3 beta diagnosis
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Preventive Treatment:
When?
• When patient has ≥15 headache days per month
• When ≥4 severe attacks per month poorly controlled with symptomatic
medication
• When symptomatic medication needs to be used more than 2-3 days a
week
• Special situations preclude the use of effective acute medications
For how long?
• 3 month minimum trial
• If helpful, consider reduction and cessation after 12-18 months
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Goals of Chronic Migraine Therapy
16. Gladstone J and Dodick DW. Practical Neurology 2004;4:6-19.
Reduce (1 or more of):• Headache frequency
• Duration
• Severity
• Medication requirements
• Headache-related disability
What to expect?• 50% obtain a reduction of ≥50% in the frequency of attacks in the
second or third month of use
Monotherapy vs. Polytherapy?• Monotherapy preferred but polytherapy may be necessary
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• Antidepressants
• TCAs (i.e. amitriptyline,
nortriptyline)
• Beta blockers
• Propranolol, Nadolol
• Anticonvulsants
• Topiramate
• Divalproex
• Gabapentin
• Calcium channel blockers
• Verapamil
• Flunarizine
• Interventional
• Botulinum toxin A (BOTOX)
• ? Nerve blocks
• Miscellaneous
• Pizotifen (Sandomigran)
• Angiotensin II receptor
antagonist ?
• “Natural” Options
• Riboflavin, feverfew, magnesium
Preventive Medications
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Overall Summary – Clinical Pearls
• Migraines are the most common headache-type leading to
medical attention (occurs in pediatric and adult population).
• Acute migraine management requires stratified care which
may include OTC, NSAIDS and/or triptan and/or anti-emetic.
• Lifestyle strategies are critical for preventing migraine
headaches and patients should be constantly reminded about
them.
• When migraines are too frequent/disabling, consider
prophylactic therapy (start low, go slow, and persist).
• Watch out for medication overuse headache and, when
present, aggressively manage.
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The Art and Science of
Evaluating and
Treating Migraine
THANK YOU
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ICHD-3 (beta) Definition
ICHD: International Classification of Headache Disorders.Headache Classification Committee. Cephalalgia 2013;33:629-808.
Medication overuse (MOH)*
≥15 HA days/mt in a patient with a pre-existing HA
disorder
Regular overuse for >3 mts of ≥1 acute meds
Not better accounted for by another ICHD-3b
diagnosis
*Also called transformed migraine, rebound headache
CM: Current State of Classification & Diagnosis
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Classification of MOH
Headache Classification Committee. Cephalalgia 2013;33:629-808.
ICHD: International Classification of Headache Disorders; MOH: medication overuse headache; ASA: acetylsalicylic acid; NSAID: nonsteroidal anti-inflammatory drug
Overuse (≥15 days/mt for >3 months) of:
Overuse (≥10 days/mt for >3 months) of:
Acetaminophen Ergotamines
ASA Triptans
Other NSAIDs Opioids
Combination analgesics
Combinations of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids
ICDH-3 Beta Diagnostic Criteria: Fulfills criteria for MOH plus…
Recognition and Diagnosis of MOH
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Screening For MOH
Kristoffersen ES et al. J Neurol Neurosurg Psychiatry 2015;86:505-12.
HA: headache; MOH: medication overuse headacheRecognition and Diagnosis of MOH
BIMOH (Brief Intervention for MOH) Scoring
Do you think your use of HA medication was out of control? 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always
Did the prospect of missing a dose make you anxious or worried? 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always
Did you worry about your use of your HA medication? 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always
Did you wish you could stop? 0 = never/almost never 1 = sometimes 2 = often 3 = always/nearly always
How difficult would you find it to stop or go without your HA medication?*
0 = not difficult 1 = quite difficult 2 = very difficult 3 = impossible
Cut-off scores for risk of MOH≥5 for women
≥4 for men
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Screening for MOH in Primary Care
Dousset V et al. J Headache Pain 2013;14:81.
Recognition and Diagnosis of MOH
• Sensitivity 95.2%, specificity 80%
• Advantages:
– Simple
– Quick
– Low cost
Quick 2-question screen for MOH
1 Do you take a treatment for attacks on ≥10 days/month?
2 Is this intake on a regular basis?
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Established CM With MOH: Treatment Strategies
Tepper. Neurology Continuum 2012 ;18:807-22.
Wean overused medication(s)
Encourage use of non-pharmacological
approaches
Switch to effective preventive treatment
and place limits on acute meds
Education
MOH: medication overuse headache; CM: chronic migraine
Management Strategies
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Bibliography
References:
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2. Aurora SK, Kori SH, Barrodale P, et al. Gastric stasis in migraine: more than just a paroxysmal abnormality during a migraine attack. Gastric stasis in migraine: more than just a paroxysmal abnormality during a migraine attack. Headache 2006;46(1):57-63.
3. Aurora SK, Kori SH, Barrodale P, et al . Gastric stasis occurs in spontaneous, visually induced, and interictal migraine. Headache2007;47(10):1443-1446.
4. Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-1168.
5. Boyle R, Behan PO, Sutton JA. A correlation between severity of migraine and delayed gastric emptying measured by an epigastric impedance method. Br J Clin Pharmacol 1990;30(3):405-409.
6. Brandes JL, Kudrow D, Stark SR, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA2007;297(13):1443-1454.
7. Burstein R, Collins B, Bajwa Z, et al. Triptan therapy can abort migraine attacks if given before the establishment or in the absence of cutaneous allodynia and central sensitization: clinical and preclinical evidence. Headache 2002, 42:390–391.
8. Burstein R, Yarnitsky D, Goor-Aryeh I, et al. An association between migraine and cutaneous allodynia. Ann Neurol2000;47(5):614-624.
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10. Dahlöf C. Integrating the triptans into clinical practice. Curr Opin Neurol 2002;15:317-322.
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Bibliography
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13. Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:S550-S555.
14. Dodick DW, Capobianco DJ. Treatment and management of cluster headache. Curr Pain Headache Rep 2001;Feb;5(1):83-91Gladstone J and Dodick DW. Practical Neurology 2004;4:6-19.
15. Ferrari MD, Roon KI, Lipton RB et al. Oral triptans (serotonin 5-HT(1B/1D) agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 2001;358(9294):1668-75.
16. Gladstone J and Dodick DW. Practical Neurology 2004;4:6-19.
17. Graben RD, Maichle W. Pharmaceutical Formulation & Quality. Product Spotlight Dynamic Buffering Technology. September 2006:58-59.
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19. Haberer LJ, Walls, Lener, et al. Distinct pharmacokinetic profile and safety of a fixed-dose tablet of sumatriptan and naproxen sodium for the acute treatment of migraine. Headache 2010;50(3):357-373.
20. Hu XH, Markson LE, Lipton RB, et al. Burden of migraine in the United States: disability and economic costs.Arch Intern Med1999;159(8):813–818.
21. Idkaidek N and Arafat T. Effect of microgravity on the pharmacokinetics of Ibuprofen in humans.J Clin Pharmacol2011;51(12):1685-1689.
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Bibliography
22. International Headache Society, 2nd edition. Cephalalgia 2004;24 Suppl 1:1-160.
23. Kahn K. Cambia® (diclofenac potassium for oral solution) in the management of acute migraine. US Neurology. 2011;7(2):139-143.
24. Kriegler JS. In: Tepper SJ and Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. (New York, NY: Springer), 2011.
25. Krymchantowski AV, Filho PF, Bigal ME, et al. Rizatriptan vs. rizatriptan plus trimebutine for the acute treatment of migraine: a double-blind, randomized, cross-over, placebo-controlled study.Cephalalgia 2006;26(7):871-874.
26. Linde M. Migraine: a review and future directions for treatment. Acta Neurol Scand 2006;114(2):71–83.
27. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001;41(7):638-645.
28. Lipton RB, Dodick D, Sadovsky R, et al. A self-administered screener for migraine in primary care: The ID Migraine validation study. Neurology 2003;61(3):375–382.
29. Lipton RB, Grosberg B, Singer RP, et al. Efficacy and tolerability of a new powdered formulation of diclofenac potassium for oral solution for the acute treatment of migraine: Results from the International Migraine Pain Assessment Clinical Trial (IMPACT), Cephalalgia 2010;30(11):1336-45.
30. Lipton RB, Stewart WF. Headache 1999;39 (Suppl 2):S20-S26.
31. Lipton RB, Stewart WF, Celentano DD, et al. Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis. Arch Intern Med 1992;152(6):1273-1278.
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33. Lychkova AE. Serotoninergic nervous system in intact heart and abdominal organs. Bull Exp Biol Med 2004;138(2):127-130.
34. Matchar DB, Young WB, Rosenberg, JH, et al. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks. http://www.aan.com/professionals/practice/pdfs/gl0087.pdf.
35. Pietrobon D. Migraine: new molecular mechanisms. Neuroscientist 2005;11(4):373–386.
36. Pryse-Phillips WEM, Dodick DW, Edmeads, JG et al. Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Headache Society. Can Med Assoc J 1997; 156(9):1273-87.
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The Art and Science of Evaluating and Treating Migraine
Additional Slides
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Assessing Treatment Success
• Severity of disability (MIDAS or HIT-6)
• Duration, intensity, and frequency of attacks
• Use of medical resources:
Second dose
Rescue medication
Emergent care / clinic visits
• Incidence of adverse events
• Level of patient satisfaction
37. Silberstein SD. Neurology 2000; Sep 26;55(6):754-62.
32. Lipton RB, et al. JAMA 2000;284(20):2599-2605.
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Recurrence
Return of episodic headache during the same attack
following acute treatment
• Prevention: Treat early, add NSAID
Use long-duration triptan or DHE
• Treatment: Repeat initial acute headache drug which is almost
always effective
43. Tfelt-Hansen P et al, Drugs. 2000; 60(6):1259-87
14. Dodick DW, Capobianco DJ Curr Pain Headache Rep 2001; Feb;5(1):83-91.
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Rebound
Recurring headache induced by repetitive and
chronic overuse of acute headache medication
• Prevention: Limit frequency and dose of medications
• Treatment: Withdrawal and washout of overused medication;
consider using preventives
14. Dodick DW, Capobianco DJ Curr Pain Headache Rep 2001; Feb;5(1):83-91.
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Mechanism of Cutaneous Allodynia
• Activation of the trigeminovascular system (TGVS) → release of
substance P, calcitonin gene-related peptide (CGRP), and
neurokinins by V (trigeminal) ganglion → neurogenic inflammation
in dura → vasodilatation of meningeal vessels, plasma
extravasation, and mast cell degranulation
• Neurogenic inflammation may activate/sensitize meningeal V
nociceptors
• Central sensitization occurs when there is sustained firing of
sensitized meningeal nociceptors → activation/sensitization of 2nd
order central trigeminovascular (TV) neurons → reduced pain
threshold and cutaneous allodynia
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Non-pharmacological Therapies
Behavioural Treatments Include:
• Stress management / relaxation
training
• Regular diet and sleep
• Trigger identification and
avoidance
• Avoidance of excessive
over-the-counter medications
• Cognitive / behavioural
management therapy etc.
Physical Treatments Include:
• Natural remedies /
complementary medicines
• Acupuncture
• Transcutaneous electrical
nerve stimulation
• Occlusal adjustment
• Cervical manipulation
22. ICHD. Cephalalgia. 2004;24 Suppl 1:1-160