simply migraine

8/6/2019 Simply Migraine

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How Common is Migraine?How Common is Migraine?30,000,000 Americans20% of women

7% of men at any given timeMost of us have some migrainemanifestations occasionally


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R ecognizing MigraineR ecognizing MigrainePounding unilateral headachePreceded by visual or other aura

Nausea, vomitingLight and sound sensitivity


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W hat is migraine?W hat is migraine?Migraine without aura(MO) Migraine with aura

(MA)

Headache Classification Committee of IHS (1988)Headache Classification Committee of IHS (1988)

At least five attacks fulfillingthese criteria:

Headache lasting 472 h

(248 h in children)

At least two attacks fulfillingthese criteria:

At least three of thefollowing:

one or more fully reversibleaura symptoms

gradually developing orsequential aura symptoms

no one aura symptom lastslonger than 1 h

headache shortly follows oraccompanies aura

Accompanied by at least one of: nausea vomiting photophobia and/or

phonophobia

No evidence of organicdisease

W ith at least two of: unilateral location pulsating quality moderate/severe intensity aggravated by activity

No evidence of organicdisease


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W orld prevalence of migraine:W orld prevalence of migraine:A disorder of First W orldA disorder of First W orld

11--year prevalence ratesyear prevalence ratesPopulationPopulation- -based studiesbased studiesIHS criteria (or modified)IHS criteria (or modified)

USA 12%USA 12%

Chile 7%Chile 7%

Japan 8%Japan 8%Italy 16%Italy 16%

Denmark 10%Denmark 10%

France 8%France 8%

Switzerland 13%Switzerland 13%

Rasmussen and Olesen (1994); Rasmussen (1995);Rasmussen and Olesen (1994); Rasmussen (1995);

LiptonLipton et al ( et al ( 1994); Lavados and Tenhamm (1997);1994); Lavados and Tenhamm (1997);Sakai and Igarashi (1997)Sakai and Igarashi (1997)Prevalence measured over a few yearsPrevalence measured over a few years


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Cady (1999); WarshawCady (1999); Warshaw et al et al (1998)(1998)

D iagnosis of migraineD iagnosis of migraineD iagnosis depends on patient historyNo specific tests or clinical markers

Positive diagnosis if attack history fulfils IHScriteria for migraineOther pointers include: family history of migraine age of onset


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FLAGSFLAGS

SNOOP SNOOP

O lder: new onset and progressive headache, especiallyin middle-age >50 (giant cell arteritis)

S ystemic symptoms (fever, weight loss) or S econdary risk factors (HIV, systemic cancer)

N eurologic symptoms or abnormal signs (confusion,impaired alertness, or consciousness)

O nset: sudden, abrupt, or split-second

P revious headache history: first headache or different(change in attack frequency, severity, or clinical features)


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Prevalence of migraine byPrevalence of migraine bysex and agesex and age

FemalesFemalesMalesMales3030

2525

2020

1515

1010

55

002020 3030 4040 5050 6060 7070 8080 100100

Migraine prevalence (%)Migraine prevalence (%)

Age (years)Age (years)

Lipton and Stewart (1993)Lipton and Stewart (1993)The American Migraine Study (The American Migraine Study ( nn =2479 migraine sufferers)=2479 migraine sufferers)


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PhysiologyPhysiologyVasospasm LanceSpreading W ave of D epression

LeaoTrigeminocentricAllodynia


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VasospasmVasospasmI. Aura: Arteries Spasm Visual and focal neurological symtoms

Pial and Occipital small artery branchesII. Headache: CompensatoryVasodilation Pounding unilateral sick headache

III. Inflammation and musclespasm: second pain phase


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Phases of MigrainePhases of MigraineVague Prodrome: psychic changeand cravings e.g. chocolateAura: Focal symptoms and visionHeadache: Throbbing unilateral painInflammation: Prolonged phase andTTHPostdromeMigraine related stroke


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Trigeminal TheoryTrigeminal TheorySerotonin againTrigeminal Afferents: sensory

function of face and meningesTrigeminal efferents to vesselsCause vessel spasm and sensitivity

This theory primarily explains actionof Triptans: 5-HT 1b,d agonists


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Migraine Pathophysiology

Goadsby NEJM 346:257-70,2002


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Allodynia TheoryAllodynia TheoryMigraine is a state of hypersensitivityLight, sounds, smells, touch (head in

headache)Need for dark roomBest preventives decrease

sensitivity.Anticonvulsants, tricyclics, beta andcalcium channel blockers


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Each of these Theories explains somemigraine phenomena


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Migraine PhenomenaMigraine PhenomenaFocal and paroxysmal onset of symptomsSpecific visual phenomenaSpreading numbness and moving visualphenomena and sensory distortions.Nausea, vomiting sick headachePounding unilateral or bilateral painPsychic changesLight and sound sensitivity even between attacksEffectiveness of triptansEffect of anticonvulantsR ole of serotonin


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Some D ictaSome D ictaAny paroxysmal headache is likely tobe migraine unless proven otherwise

Sinus headaches and tension headaches are almost alwaysmigraine headachesFirst ever severe headache orsudden thunderclap headachesmay be SAH


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TreatmentTreatmentEffective treatment of attackPrevention

Address comorbidities


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Mechanisms for treatmentMechanisms for treatment

CGRPCGRPNKNKSPSP

55--HTHT1F1F55--HTHT1D1D

55--HTHT1B1B

Blood vesselBlood vessel

TrigeminalTrigeminalnervenerve

Adapted from Goadsby (1997)Adapted from Goadsby (1997)

CGRPCGRP calcitonin genecalcitonin generelated peptiderelated peptide

NKNK neurokinin Aneurokinin A

SPSP substance Psubstance P

triptantriptan

CONSTRICTIONCONSTRICTION

INHIBITIONINHIBITION


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Acute AttackAcute Attack

Triptans: sumatriptan, zolmitriptan, almotriptan, naratriptan,

frovatriptan, elitriptriptan, riaztriptanNSAI D sFioricetMidrin (isometheptane, chlorphenoxazone, apapOTC: Caffeine, apap, phenacitin, asaErgots: Caffergot, D HE nasal, injected

NarcoticsD epacon


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TR IPTANSTR IPTANS

As a class, relative to nonspecific therapies,triptans provideR apid onset of actionHigh efficacy

Favorable side effect profile

A dverse events and contraindications

Selective 5-HT 1B/1D/1F agonists

Silberstein SD. Neurology . 2000.


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TriptansTriptansLearn to use one or twoEffective medicines


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TR IPTANS:TR IPTANS:TR EATMENT CHOICESTR EATMENT CHOICES

Are there differencesbetween the triptans?

If one triptan fails, willanother triptan work?

Z olmitriptanTablet (2.5, 5 mg)Nasal spray (5 mg)

R izatriptanTablet (5, 10 mg)

NaratriptanTablet (1, 2.5 mg)

Question and Answer

A lmotriptanTablet (6.25, 12.5 mg )

FrovatriptanTablet (2.5 mg)

SumatriptanTablet (25, 50, 100 mg)Injection (6 mg)Nasal spray (5, 20 mg*)

* Pediatric efficacy shown Ferrari MD et al. Lanc et . 2001.

EletriptanTablet (20, 40 mg)


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Elitriptan or R elpaxElitriptan or R elpaxAdvantagesAdvantages

Quick oral absorptionR eliable oral absorptionR elatively long half lifeNumerous Clinical trials where proven

superior to ImitrexGets in fast, and stays aroundLow rebound recurrence rateW orks for all migraine phenonena

Pain, photosonophobia, nausea


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R elpax CautionsR elpax CautionsAvailable only in oral formCYP 3A4 D o not give within 72 hours of: Ketoconazole,

Nefazadone, clarithromycin, rotonavir,nelfinavir, others. caution with verapamil,erythromycin.

Contraindications (all triptans) Suspected Coronary disease Basilar or hemiplegic, ophthalmoplegic

migraine Uncontrolled hypertension 65 W ithin a day of any other triptan

Hypersensitivity to the drug


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Migraine visual Aura fromMigraine visual Aura fromclassic oph textbookclassic oph textbook


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Autoscopy


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R elpax D osingR elpax D osing40 mg. May repeat X1 in 2 hoursMax dose in 24 hours is 80 mg

R epeating dose most efficacious if headache returns


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Parenteral triptans Parenteral triptansImitrex injections: Very good fastreliable onset but peaks quickly withshort half lifeImitrex and Zomig nasal: absorptionnot reliable, taste not so good butmay be tried if a lot of nausea

Zomig ZMT and Maxalt MLT ontongue: not strictly parenteralabsorbed thru gut


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Triptan worriesTriptan worriesNot released under age 18If you even suspect CA D don t use or getproper exclusionary tests. Man or woman of a certain age Smoker or other risk factors

Cerebrovascular disease or complicatedmigraine - contraindicatedW atch for overuse. These are rescuemedicines


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Consider CombinationsConsider CombinationsTriptan + NSAI D

Triptan + anti-nausea

Unconventional agentsPhenergan, Compazine alone or incombination. Zyprexa or atypicals

W e don t have enough alternatives


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ProphylaxisProphylaxisAnticonvulsants: topiramate, valproate,Keppra, gabapentinTricyclics Amitriptylene, nortriptylene, trazodone

Beta Blockers Timolol, propranolol, nadolol

Calcium channel blocker verapamilACE inhibitorsSS R I sAtypicals


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PleaPleaListen to patientsMigraine is mixed up with a lot of things Emotional factors: ennui, husbands, bosses,

general dissatisfaction with life Sleep disturbances Hormonal changes

If you do not address these you will not be

treating your patientsD on t just throw drugs at your patientsBe attentive and empathetic

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