understanding migraine

Understanding Migraine

MigraineMigraine

Migraine is a Migraine is a recurrent headache recurrent headache that lasts 4that lasts 4--72 hours72 hours

18% of women18% of women

6% of men6% of men

Typical Features of MigraineTypical Features of Migraine

Usually one sidedUsually one sided

Pulsating, throbbing, poundingPulsating, throbbing, pounding

Aggravated by routine physical Aggravated by routine physical activityactivity

Associated with nausea and Associated with nausea and vomitingvomiting

Sensitivity to light / noiseSensitivity to light / noise

“ ID Migraine ““ ID Migraine “

Has a headache limited Has a headache limited your activities for a day or your activities for a day or more in the last 3 more in the last 3 months?months?

Are you nauseated or sick Are you nauseated or sick to your stomach when you to your stomach when you have a headache?have a headache?

Does light bother you Does light bother you when you have a when you have a headache?headache?

MigraineMigraine

Aura Aura ------ 15%15%

Warning signs Warning signs ------ 70%70%•• FatigueFatigue

•• Mood changesMood changes

•• Food cravingsFood cravings

•• Poor concentrationPoor concentration

Pathophysiology of MigrainePathophysiology of Migraine

The nervous system is The nervous system is more sensitive and more sensitive and vigilant to the vigilant to the environmentenvironment

Pathophysiology of MigrainePathophysiology of Migraine

Vasoconstriction of Vasoconstriction of vessels vessels

Vasodilatation of Vasodilatation of vesselsvessels

Inflammation of Inflammation of vesselsvessels

Approach to TreatmentApproach to Treatment

Goal is to give the Goal is to give the patient control over patient control over their headaches their headaches instead of the instead of the headaches headaches controlling the controlling the patient’s life.patient’s life.

Principles of TreatmentPrinciples of Treatment

Prevention Prevention (prophylactic (prophylactic measures)measures)

Abortive treatmentAbortive treatment

Elimination of Elimination of intractable migrainesintractable migraines

Preventive MeasuresPreventive Measures

DietDiet

SleepSleep

ExerciseExercise

Weight lossWeight loss

Caffeine regulationCaffeine regulation

Smoking cessationSmoking cessation

MedicationsMedications

DietDiet

Don’t Skip Meals!!!Don’t Skip Meals!!!

Big Four: chocolate, Big Four: chocolate, nutrasweet, caffeine nutrasweet, caffeine and MSGand MSG

Keep a headache Keep a headache diarydiary

SleepSleep

Goal is 7Goal is 7--8 hrs of 8 hrs of restful sleeprestful sleep

Increased frequency Increased frequency with < 6 hrs of sleepwith < 6 hrs of sleep

Increased frequency Increased frequency with > 9 hrs of sleepwith > 9 hrs of sleep

Regulate sleep 7 days Regulate sleep 7 days per weekper week

Disorders of SleepDisorders of Sleep

Poor sleep hygienePoor sleep hygiene

Sleep apneaSleep apnea

DepressionDepression

Exercise / Weight LossExercise / Weight Loss

Adipose tissue secretes Adipose tissue secretes proteins & hormones that proteins & hormones that help regulate immunity & help regulate immunity & inflammation inflammation (adiponectin, interleukin(adiponectin, interleukin--6)6)

Dieting and exercise can Dieting and exercise can improve headachesimprove headaches

Weight may affect choice Weight may affect choice of medicationsof medications

CaffeineCaffeine

Positive and negative Positive and negative effects on health and effects on health and headacheheadache

Blocks adenosine Blocks adenosine receptorsreceptors

Mild analgesic effectMild analgesic effect

Promotes absorption of Promotes absorption of other analgesicsother analgesics

Therapeutic levels in Therapeutic levels in brain in 20 minutesbrain in 20 minutes

Negative Effects of CaffeineNegative Effects of Caffeine

Amounts > 200 mg Amounts > 200 mg daily can produce daily can produce anxiety, dysphoria and anxiety, dysphoria and panic attackspanic attacks

Caffeinism = Caffeinism = nervousness, nervousness, agitation, severe agitation, severe anxiety , panic attacksanxiety , panic attacks

CaffeineCaffeine

Average intake Average intake –– 200 200 ––300 mg daily300 mg daily

Coffee (brewed) Coffee (brewed) –– 115 115 mgmg

Tea Tea –– 40 mg40 mg

Chocolate Chocolate –– 35 mg35 mg

Energy drinks Energy drinks –– 48 48 ––300 mg300 mg

CaffeineCaffeine

Caffeine in MedicationsCaffeine in Medications

Excedrin Excedrin –– 65 mg65 mg

Anacin Anacin –– 32 mg32 mg

Midol Midol –– 32 mg32 mg

Fiorinal/ FioricetFiorinal/ Fioricet–– 40 mg 40 mg

Wigraine Wigraine –– 100 mg100 mg

Norgesic Forte Norgesic Forte -- 60 mg60 mg

Darvon Compound 65 Darvon Compound 65 –– 32.4 mg32.4 mg

Typical Dose Related ReactionsTypical Dose Related Reactionsof Caffeineof Caffeine

100 100 –– 200 mg = well being200 mg = well being

300 300 –– 400 mg = anxiety, dysphoria400 mg = anxiety, dysphoria

340 340 –– 750 mg = severe anxiety, panic 750 mg = severe anxiety, panic attacksattacks

5 5 –– 10 grams ( 75 cups of coffee ) = lethal 10 grams ( 75 cups of coffee ) = lethal dosedose

Caffeine Withdrawal Caffeine Withdrawal SymptomsSymptoms

After 24 hrs of caffeine After 24 hrs of caffeine withdrawal may withdrawal may experience: experience: Headache ( increased Headache ( increased cerebral blood flow )cerebral blood flow )Nausea / vomitingNausea / vomitingDepressionDepressionAnxietyAnxietyDrowsiness/ impaired Drowsiness/ impaired concentrationconcentrationMuscle achesMuscle aches

Official Criteria for CaffeineOfficial Criteria for CaffeineWithdrawal HeadacheWithdrawal Headache

Monthly caffeine intake of 15 gramsMonthly caffeine intake of 15 grams

Headache occurs within 24 hours of last Headache occurs within 24 hours of last caffeine intakecaffeine intake

Head pain relieved within one hour after Head pain relieved within one hour after consuming 100 mg of caffeineconsuming 100 mg of caffeine

Prevention of Caffeine Prevention of Caffeine WithdrawalWithdrawal

Limit consumption to 2 cups of coffee per Limit consumption to 2 cups of coffee per day ( 200 mg )day ( 200 mg )

Withdrawal more likely if consuming > 500 Withdrawal more likely if consuming > 500 mg per daymg per day

Gradually decrease consumptionGradually decrease consumption

SmokingSmoking

Smoking increases Smoking increases frequency of frequency of headachesheadaches

Smoking cessation:Smoking cessation:•• ChantixChantix

•• ZybanZyban

•• Nicotine patches/gumNicotine patches/gum

•• HypnosisHypnosis

PreventionPrevention

When to Consider PreventionWhen to Consider Prevention

Headache occurs more than 2 days per weekHeadache occurs more than 2 days per week

Use of acute medications more than 2 days per Use of acute medications more than 2 days per weekweek

Headache attacks that are disabling despite Headache attacks that are disabling despite treatment treatment

Prolonged aura, complex aura or migraineProlonged aura, complex aura or migraine--induced strokeinduced stroke

Patient desires to reduce frequencyPatient desires to reduce frequency

Principles of PreventionPrinciples of Prevention

Reduce frequency of attacks by more than 50%Reduce frequency of attacks by more than 50%

Start low ; Go slowStart low ; Go slow

Often requires lower dosagesOften requires lower dosages

May take 2May take 2--3 months to see benefit3 months to see benefit

Maintain for 6Maintain for 6--12 months once 50% reduction 12 months once 50% reduction achieved, then taperachieved, then taper

Reduces cortical spreading depression (CSD)Reduces cortical spreading depression (CSD)

OTC Medications for OTC Medications for PreventionPrevention

MagnesiumMagnesium

Riboflavin (Vit B2)Riboflavin (Vit B2)

MelatoninMelatonin

MagnesiumMagnesium

Relaxant effect on Relaxant effect on smooth musclessmooth muscles

Part of messenger Part of messenger system in the system in the serotonin cascadeserotonin cascade

Daily HA sufferers and Daily HA sufferers and pts. with menstrually pts. with menstrually related migraines related migraines benefitbenefit

MagnesiumMagnesium

Sources Sources –– nuts, whole nuts, whole grains, tomatoesgrains, tomatoes

Supplements Supplements –– 500 500 ––750 mg daily750 mg daily

40 40 –– 90 % average 90 % average headache reductionheadache reduction

Riboflavin (VIT B2)Riboflavin (VIT B2)

Assists with Assists with production of ATP in production of ATP in nerve cells nerve cells –– energy energy moleculemolecule

At least three trials At least three trials suggest it reverses suggest it reverses “energy crisis” during “energy crisis” during migrainemigraine

Riboflavin (Vit B2)Riboflavin (Vit B2)

Sources Sources –– bread, bread, cereals, milk, meat cereals, milk, meat and poultryand poultry

Recommended daily Recommended daily dose is 400 mg dose is 400 mg

Improvement seen in Improvement seen in 50% of patients50% of patients

MelatoninMelatonin

Sleep is one of Sleep is one of nature’s ways of nature’s ways of dealing with migrainedealing with migraine

Melatonin is also used Melatonin is also used as a sleep aidas a sleep aid

MelatoninMelatonin

Migraine Migraine –– 1 mg 1 mg starting dose; titrate starting dose; titrate up to 3 mg daily if up to 3 mg daily if neededneeded

Cluster Cluster –– 9 9 –– 12 mg 12 mg daily; use with daily; use with medical supervisionmedical supervision

EvidenceEvidence--based Recommendations based Recommendations for Preventive Treatmentfor Preventive Treatment

Major Classes of Medications for Major Classes of Medications for PreventionPrevention

BetaBeta--adrenergic blockersadrenergic blockers

AntidepressantsAntidepressants

Anticonvulsants Anticonvulsants (neurostabilizers)(neurostabilizers)

Calcium antagonistsCalcium antagonists

NSAIDsNSAIDs

Medications with High Efficacy and Medications with High Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events

Amitriptyline (10Amitriptyline (10--150mg/day)150mg/day)

Depakote (125Depakote (125--200 mg/day)200 mg/day)

Propranolol (20Propranolol (20--160mg/day)160mg/day)

Timolol (10Timolol (10--30mg/day)30mg/day)

Topiramate (50Topiramate (50--150mg/day)150mg/day)

Medications with Lower Efficacy and Medications with Lower Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events

Atenolol (25Atenolol (25--100mg/day)100mg/day)

Metoprolol (50Metoprolol (50--200mg/day)200mg/day)

Gabapentin (300Gabapentin (300--2400mg/day)2400mg/day)

Prozac (10Prozac (10--80mg/day)80mg/day)

Botox (25Botox (25--100 units/3 months)100 units/3 months)

Medications with Lower Efficacy and Medications with Lower Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events

NSAIDs (naproxen, NSAIDs (naproxen, ketoprofen, ketoprofen, fenoprofen)fenoprofen)

Verapamil (120 Verapamil (120 –– 480 480 mg/d)mg/d)

ASA (325mg/day)ASA (325mg/day)

Medication Use Based on OpinionMedication Use Based on Opinion

Antidepressants ( zoloft, doxepin, paxil, Antidepressants ( zoloft, doxepin, paxil, nortriptyline)nortriptyline)

DiltiazemDiltiazem

Periactin ( cyproheptadine)Periactin ( cyproheptadine)

Methergine (methylergonovine)Methergine (methylergonovine)

Principles of Abortive Principles of Abortive TherapyTherapy

Use the most effective Use the most effective therapy at the onset of therapy at the onset of the migraine the migraine

Must always have Must always have medication with you!medication with you!

Try to limit acute Try to limit acute treatments to 3x per treatments to 3x per weekweek

Common Abortive MedicationsCommon Abortive Medications

NSAIDsNSAIDs

Combination analgesics with caffeineCombination analgesics with caffeine

Midrin (acetaminophen, dichloralphenasone, Midrin (acetaminophen, dichloralphenasone, isometheptene)isometheptene)

Triptan plus Naproxen (500 mg)Triptan plus Naproxen (500 mg)

AntiemeticsAntiemetics

TriptansTriptans

Use with Naproxen Use with Naproxen 500 mg at onset of 500 mg at onset of migrainemigraine

Use most appropriate Use most appropriate delivery modedelivery mode

Failure = no response Failure = no response to three different to three different triptanstriptans

EvidenceEvidence--based Recommendations based Recommendations for Acute Treatment of Migrainefor Acute Treatment of Migraine

Triptans as initial Triptans as initial treatment for moderate to treatment for moderate to severe migraine severe migraine –– Grade AGrade A

Triptans as initial Triptans as initial treatment for migraine of treatment for migraine of any severity when any severity when nonspecific treatment nonspecific treatment has failed has failed –– Grade CGrade C


DHE nasal spray for moderate DHE nasal spray for moderate to severe migraine to severe migraine -- Grade AGrade A

DHE (IM,SC) for moderate to DHE (IM,SC) for moderate to severe migraine severe migraine –– Grade BGrade B

DHE ( IV ) plus antiemetic ( IV ) DHE ( IV ) plus antiemetic ( IV ) for severe migraine for severe migraine –– Grade BGrade B

Ergomar for moderate to severe Ergomar for moderate to severe migraine migraine –– Grade BGrade B


Reglan ( IV / IM ) to control Reglan ( IV / IM ) to control nausea nausea –– Grade CGrade C

Reglan ( IV ) as Reglan ( IV ) as monotherapy for migraine monotherapy for migraine pain relief pain relief –– Grade BGrade B

Compazine ( IV, IM, PR ) for Compazine ( IV, IM, PR ) for migraine in appropriate migraine in appropriate setting setting –– Grade BGrade B


Acetaminophen not recommended Acetaminophen not recommended –– Grade BGrade B

NSAIDs and combination NSAIDs and combination analgesics with caffeine as firstanalgesics with caffeine as first--line treatment for mildline treatment for mild--moderate moderate attacks attacks –– Grade AGrade A

Midrin for mild to moderate Midrin for mild to moderate headaches headaches –– Grade BGrade B

Corticosteroids (dexamethasone Corticosteroids (dexamethasone 16 mg IV or PO) for rescue therapy 16 mg IV or PO) for rescue therapy for status migrainosus for status migrainosus –– Grade CGrade C

Efficacy but Adverse Events ConcernEfficacy but Adverse Events Concern

MethylsergideMethylsergide

Vitamin A Vitamin A –– overuse overuse associated with associated with pseudotumor cerebripseudotumor cerebri

Pyridoxine (Vit B6) Pyridoxine (Vit B6) ––may be toxic in doses may be toxic in doses exceeding 150mg/dayexceeding 150mg/day

Difficult to Treat MigrainesDifficult to Treat Migraines

Migranal nasal sprayMigranal nasal spray•• One spray each nostril One spray each nostril

•• May repeat in 15 mins.May repeat in 15 mins.

•• Max: 4 sprays / attack Max: 4 sprays / attack 6 sprays / 24 hrs 6 sprays / 24 hrs 8 sprays / week8 sprays / week

•• Use with an antiemeticUse with an antiemetic

Difficult to Treat MigrainesDifficult to Treat Migraines

D.H.E. 45 D.H.E. 45 (dihydroergotamine)(dihydroergotamine)

•• 1 mg IM / IV1 mg IM / IV

•• May repeat in 1 hr x 2May repeat in 1 hr x 2

•• Max: 3 mg / attack Max: 3 mg / attack 6 mg / week6 mg / week

•• Use with an antiemeticUse with an antiemetic

Intractable MigraineIntractable Migraine

Inflammation !!!Inflammation !!!

Dexamethasone 8mg /16 Dexamethasone 8mg /16 mg IM, IV or oralmg IM, IV or oral

Prednisone 50 mg daily x Prednisone 50 mg daily x 3 days3 days

Solumedrol 80 mg IMSolumedrol 80 mg IM

Toradol 60 mg IMToradol 60 mg IM

Intractable MigraineIntractable Migraine

D.H.E. 45 D.H.E. 45 -- 1 mg IM /IV with 1 mg IM /IV with an antiemetican antiemetic

Magnesium sulfate 2 Magnesium sulfate 2 grams IV over 30 minutesgrams IV over 30 minutes

Benadryl 50 mg IV/IMBenadryl 50 mg IV/IM

Antiemetics Antiemetics –– zofran, zofran, phenergan, compazine , phenergan, compazine , reglan (IV / IM)reglan (IV / IM)

Inpatient TreatmentInpatient Treatment

IV antiemetic followed IV antiemetic followed by D.H.E. 45 1 mg IV by D.H.E. 45 1 mg IV

Repeat every 8 hours x Repeat every 8 hours x 3 days3 days

The EndThe End

understanding migraine

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