“Say Something About Migraine”(Freelove 2012)

Anne Walling MB, ChB

“Say Something About Migraine” It Hurts!! “Under-diagnosed” in

primary care “Under-treated” in

primary care especially Low use of prophylaxis

Objectives participants will be able to

Describe diagnostic criteria and tools Discuss new recommendations for

preventive therapy Select and manage preventive therapy in

migraine patients

Under-diagnosis? FPs very good at

positive diagnosis (95% accurate) Alleged to mis-

diagnose 25% of migraine mainly as tension or sinus

Definition (International Headache Society)

1. Recurrent headache lasting 4-72 hours2. Nausea/vomiting and/or photo-phonophobia 3. At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion

4. No alternative explanation for symptoms

Several subtypes based on symptoms

Office Diagnostic Tools:When you have a headache do you have…….

PIN Photophobia, Incapacity, Nausea(PPV 2 symptoms 93%, 3=98%) or

POUNDPulsating, One day, Unilateral, Nausea,

Pounding(PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

On treating acute attacks: Stratified Therapy based

on severity/disability Mild – analgesics & symptomatic

therapyModerate – consider triptans or

ergots Treat early in attack Monitor for transformed

migraineNew US Headache Consortium

guidelines due this year

Preventive Therapy: indicationsSignificant disability

(impact on quality of life)

Medication overuse or contraindication

High risk of serious migraine complication (rare)

Estimate 39% “need” 3-13% use

Basically a PATIENT decision

Preventive Therapy for Migraine Potential 50% reduction in attacks May reduce attack severity

Multiple agents & mechanisms (esp anti-hypertensives, -depressants,-convulsants,

NSAIDs, herbs)- Can’t predict response by migraine/patient type- Quality problems in studies

New guidelines (AAN 2012)

Patient Mrs. Smith24 yr old teacher. Married G0P0 No significant PMH, FH, SH, RoSc/o recurrent headaches used to be every 4-6 weeks for 2-3 hours , now nearly every 10-14 days and lasting longer (entire day or longer)•Temple/eye area mostly right side, sometimes left•Nausea, some vomiting, can’t stand smell of food•Noise & light make worse•Feels exhausted & can’t concentrate during episode•Feels headache coming on but no clear warning signs•Takes tylenol & goes to bed. Recently taking excedrin <6/dayStress over time off work, student loans/mortgage, husband’s job, decisions about starting a family – feeling miserable several days/weekPhysical - normal except vitals 130/90, 70, 210lbs, 63”

Exercise:

Does she have migraine? What is your evidence? How confident can you be in the diagnosis (PPV)? What acute treatment do you recommend? Would you advise preventive therapy? What class of preventive treatment would you

advise?

Definition (International Headache Society)

1. Recurrent headache lasting 4-72 hours2. Nausea/vomiting and/or photo-phonophobia 3. At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion

4. No alternative explanation for symptoms

Several subtypes based on symptoms

Office Diagnostic Tools:When you have a headache do you have…….

PIN Photophobia, Incapacity, Nausea(PPV 2 symptoms 93%, 3=98%) or

POUNDPulsating, One day, Unilateral, Nausea,

Pounding(PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

Ideas for acute treatment? Patient information Address triggers/exacerbators Stress reduction (esp exercise) Analgesic plan – provide effective relief - minimize adverse effects - prevent conversion to chronic daily headache

What medication would you advise?

1 2 3 4 5 6 7 8 9 10

0% 0% 0% 0% 0%0%0%0%0%0%

1. None2. Propranolol3. Amytriptyline4. Sodium valproate5. Topiramate6. Verapamil7. Fluoxetine8. Butterbur extract9. Feverfew10.Riboflavin

VOTE!!!

Selecting a Preventive Medication

Efficacy (new AAN guidelines) Potential adverse effects Potential added benefits (eg HBP, seizure) Compliance Willingness to collaborate in management PATIENT beliefs and expectations

AAN Guidelines for Migraine Prevention  B-blockers Antiepileptics Antidepressants Others

Level Aestablished efficacy

Metoprolol (Lopressor)1

(100-200 mg/day)

Propranolol (Inderal)(40-320 mg/day)

Timolol (Blocadren)(10-15 mg bid)

Divalproex sodium (Depakote ER)(750-1500 mg/day)

Sodium valproate (Depakene)1

(800-1500 mg/day)

Topiramate (Topamax)(50-200 mg/day)

  Frovatriptan (Frova)1

(2.5 mg daily or bid short term only)

Petasits(Butterbur) (50-75mg bid)

AAN Guidelines for Migraine Prevention  B-blockers Altern

ativesAntidepres

santsOthers

Level BProbably effective 

Atenolol (Tenormin)1

(50-200 mg/day)

Nadolol (Corgard)1

(20-160 mg/day)

MIG99(feverfew 6.25 tid)

Magnesium(400-600mg)

Riboflavin (400mg)

Amitriptyline (Elavil)1

(30-150 mg/day)

Venlafaxine (Effexor)1

(150 mg XR/day)

Fenoprofen (Nalfon)1

(1800 mg/day)Ibuprofen (Motrin)1

(dosage not established)Ketoprofen (Orudis)1

(150 mg/d)Naproxen (Naprosyn)1

(dosage not established)Naproxen sodium (Anaprox)1

(1100 mg/day)Naratriptan (Amerge)1

(1 mg bid x 5 days premenses)Zolmitriptan (Zomig)1

(2.5 mg bid or tid short term only)

AAN Guidelines for Migraine Prevention  B-blockers Anti

epileptics

AntiDepressants

Others

Level CPossibly effective

Nebivolol (Bystolic)1

(5 mg/day)

Pindolol (Visken)1

(dosage not established)

Carbamazepine (Tegretol)1

(600 mg/day)

  Mefenamic acid (Ponstel)1

(1500 mg/day)

Flurbiprofen (Ansaid)1

(200 mg/day)

Cyproheptadine (Periactin)1

(dosage not established)

Lisinopril (Prinivil)1

(dosage not established)

Candesartan (Atacand)1

(dosage not established)Clonidine (Catapress)1

(0.075-0.15 mg/day)Guanfacine1

(1 mg/day)

What medication would you advise now?

1 2 3 4 5 6 7 8 9 10

0% 0% 0% 0% 0%0%0%0%0%0%

1. None2. Propranolol3. Amytriptyline4. Sodium valproate5. Topiramate6. Verapamil7. Fluoxetine8. Butterbur extract9. Feverfew10.Riboflavin

VOTE!!!

Final Thoughts Migraine is not cured but can

be managed Address beliefs, lifestyle etc Specific individual strategies,

adjusted over time Update acute therapy (new guidelines 2012) Consider preventive therapy Recognize/avoid/manage

comorbidities Physician is the “coach”