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MANAGAMENT OF MIGRAINE

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Migraine is one of the common causes of recurrent headaches ... The WHO ranks migraine among the world's most disabling medical illnesses. Burden Of Migraine ... – PowerPoint PPT presentation

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Title: MANAGAMENT OF MIGRAINE


1
MANAGAMENT OF MIGRAINE
2
Migraine Facts
  • Migraine is one of the common causes of recurrent
    headaches
  • According to IHS, migraine constitutes 16 of
    primary headaches
  • Migraine afflicts 10-20 of the general
    population
  • More than 2/3 of migraine sufferers either have
    never consulted a doctor or have stopped doing so
  • Migraine is underdiagnosed and undertreated
  • Migraine greatly affects quality of life. The WHO
    ranks migraine among the worlds most disabling
    medical illnesses

3
Burden Of Migraine
  • World - 15-20 of women and 10-15 of men suffer
    from migraine
  • In India, 15-20 of people suffer from migraine
  • Adults Female Male ratio is 2 1
  • In childhood migraine, boys and girls are
    affected equally until puberty, when the
    predominance shifts to girls.

NEJM 2002 346(4) 257-269 XI Congress of the
IHS, 2004
4
Migraine - Definition
  • Migraine is a familial disorder characterized by
    recurrent attacks of headache widely variable in
    intensity, frequency and duration. Attacks are
    commonly unilateral and are usually associated
    with anorexia, nausea and vomiting
  • -World Federation of Neurology

5
Migraine Triggers
  • Food
  • Disturbed sleep pattern
  • Hormonal changes
  • Drugs
  • Physical exertion
  • Visual stimuli
  • Auditory stimuli
  • Olfactory stimuli
  • Weather changes
  • Hunger
  • Psychological factors

6
Phases of Acute Migraine
  • Prodrome
  • Aura
  • Headache
  • Postdrome

7
PRODROME
  • Vague premonitory symptoms that begin from 12 to
    36 hours before the aura and headache
  • Symptoms include
  • Yawning
  • Excitation
  • Depression
  • Lethargy
  • Craving or distaste for various foods
  • Duration 15 to 20 min

8
AURA
  • Aura is a warning or signal before
  • onset of headache
  • Symptoms
  • Flashing of lights
  • Zig-zag lines
  • Difficulty in focussing
  • Duration 15-30 min

9
HEADACHE
  • Headache is generally unilateral and is
    associated with symptoms like
  • Anorexia
  • Nausea
  • Vomiting
  • Photophobia
  • Phonophobia
  • Tinnitus
  • Duration is 4-72 hrs

10
POSTDROME (RESOLUTION PHASE)
  • Following headache, patient complains of
  • Fatigue
  • Depression
  • Severe exhaustion
  • Some patients feel unusually fresh
  • Duration Few hours or up to 2 days

11
MIGRAINE CLASSIFICATION
  • According to Headache Classification
  • Committee of the International
  • Headache Society, Migraine has been
  • classified as
  • Migraine without aura (common migraine)
  • Migraine with aura (classic migraine)
  • Complicated migraine

12
MIGRAINE CLINICAL FEATURES
13
MIGRAINE - PATHOPHYSIOLOGY
  • VASCULAR THEORY
  • Intracerebral blood vessel vasoconstriction
    aura
  • Intracranial/Extracranial blood vessel
    vasodilation headache
  • SEROTONIN THEORY
  • Decreased serotonin levels linked to migraine
  • Specific serotonin receptors found in blood
    vessels of brain
  • PRESENT UNDERSTANDING
  • Neurovascular process, in which neural events
    result in activation of blood vessels, which in
    turn results in pain and further nerve activation

14
NEUROVASCULAR PROCESS
15
Arterial Activation
Release of Neurotransmitter
Worsening of Pain
16
MIGRAINE DIAGNOSIS
  • Medical History
  • Headache diary
  • Migraine triggers
  • Investigations (only to exclude secondary causes)
  • EEG
  • CT Brain
  • MRI

17
DIFFERENTIATING COMMON PRIMARY HEADACHES
Strictly unilateral
Tension headaches Do not have the associated
features like nausea, vomiting, photophobia,
phonophobia. The muscle contraction leads to
headache. Headache quality is of a tightening
(non-pulsating) quality. Usually bilateral.
Intensity is mild or moderate
Cluster headaches Severe unilateral pain.
Headache associated with lacrimation, nasal
congestion, rhinorrhea, facial sweating or eyelid
edema. Pain lasts for 15 to 180 minutes. More
common in men
18
THE TREATMENTAPPROACH TO MIGRAINE
19
LONG-TERM TREATMENT GOALS FOR THE MIGRAINE
SUFFERER
  • Reducing the attack frequency and severity
  • Avoiding escalation of headache medication
  • Educating and enabling the patient to manage the
    disorder
  • Improving the patients quality of life

20
MIGRAINE MANAGEMENT
  • Non-pharmacological treatment
  • Identification of triggers
  • Meditation
  • Relaxation training
  • Psychotherapy
  • Pharmacotherapy

  • non-specific
  • Abortive therapy
  • specific
  • Preventive therapy

21
MIGRAINE ABORTIVE THERAPY
Non-specific treatment
22
ABORTIVE THERAPY FOR MIGRAINE
Specific treatment
23
ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT
24
WHY THE NEED FOR PROPHYLAXIS ?
  • Abortive drugs should not be used more than 2-3
    times a week
  • Long-term prophylaxis improves quality of life by
    reducing frequency and severity of attacks
  • 80 of migraineurs may require prophylaxis

25
WHEN IS PROPHYLAXIS INDICATED?
  • According to the US Headache Consortium
    Guidelines,
  • indications for preventive treatment include
  • Patients who have very frequent headaches (more
    than 2 per week)
  • Attack duration is 48 hours
  • Headache severity is extreme
  • Migraine attacks are accompanied by prolonged
    aura
  • Unacceptable adverse effects occur with acute
    migraine treatment
  • Contraindication to acute treatment
  • Migraine substantially interferes with the
    patients daily routine, despite acute treatment
  • Special circumstances such as hemiplegic migraine
    or attacks with a risk of permanent neurologic
    injury
  • Patient preference

26
PREVENTIVE THERAPY FOR MIGRAINE
27
PREVENTIVE THERAPY FOR MIGRAINE (CONTD.)
28
ROLE OF BETA BLOCKERS IN MIGRAINE PROPHYLAXIS
  • Gold standard in migraine prophylaxis
  • Established efficacy and safety in migraine
    prophylaxis
  • Especially preferred if hypertension or anxiety
    co-exist

29
ROLE OF PROPRANOLOL IN MIGRAINE PROPHYLAXIS
30
PROPRANOLOL MECHANISMS OF ACTION
  • Mechanisms proposed
  • Vasoconstriction
  • Anxiolytic action
  • Decreased sympathetic activity

31
LIMITATIONS OF IMMEDIATE-RELEASE PROPRANOLOL
  • Short t½ of 3-5 hrs
  • Multiple daily dosing required to maintain
    adequate degree of beta-receptor blockade
    throughout 24 hr
  • Poor patient compliance may compromise efficacy

32
ADVANTAGES OF EXTENDED-RELEASE PREPARATION OF
PROPRANOLOL
  • Migraine patients are asymptomatic between
    attacks
  • Important to minimize number of daily doses
    during prophylactic treatment
  • Once-daily administration improves compliance
  • Stable drug concentration for 24 hrs

33
PROPRANOLOL-LACLINICAL EFFICACY IN MIGRAINE
34
PROPRANOLOL REDUCES THE FREQUENCY OF ATTACKS PER
MONTH IN BOTH COMMON AS WELL AS CLASSIC MIGRAINE
PATIENTS
n 51 Duration 12 weeks
Propranolol-LA 80 mg appears to have adequate
prophylactic effect for migraine and may be
better tolerated than propranolol-LA 160 mg,
which appears to offer no additional benefits.

Cephalalgia 1990 10 101-105
p 35
Propranolol long-acting reduces the attack
severity
p 0.003
n 48
Headache 1998 28 607-611
36
Propranolol vs. Flunarizine
70
No. of attacks reduced by more than 50
60
50
48
50
40
of Patients
30
20
10
0
Flunarizine (pPropranolol (pHeadache 1989 29 218-223
37
Propranolol showed a significant reduction in the
severity of attacks
1.8
1.6
1.6
1.6
1.4
1.4
1.2
1.2
1
Baseline
Severity score
16 weeks
0.8
0.6
0.4
0.2
0
Flunarizine
Propranolol
pHeadache 1989 29 218-223
38
Propranolol significantly reduced the number of
analgesics used
7
6.3
6

5
4.5
4.1
No of analgesics/month
4
3.4
Baseline
16 weeks
3
2
1
0
Flunarizine
Propranolol
pHeadache 1989 29 218-223
39
DOSAGE OF PROPRANOLOL
  • Starting dose 40-80 mg once daily
  • Max. dose/day 240 mg
  • If satisfactory response is not obtained within
    4-6 weeks, after reaching the maximal dose,
    therapy should be discontinued
  • Taper slowly to avoid rebound headache and
    adrenergic side effects
  • Max. duration 9 to 12 months

40
SHIFTING PATIENT FROM IR TO ER
  • Propranolol extended-release produces low blood
    levels as compared to immediate-release
  • The dose of the long-acting formulation may need
    to be higher than the total daily dose of the
    conventional formulation
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