Migraine in Primary Care Evidence based from the Headache Consortium

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Migraine in Primary CareEvidence basedfrom the
Headache Consortium

• G. Barry Robbins, Jr., D.O.
• Department Chair of Neurobehavioral Sciences
• ATSU-KCOM
• Hawaii 2008

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International Headache SocietyClassification

• 13 categories
• 128 distinct headache syndromes
• Primary HA diagnosis made on history alone and
  not associated with underlying abnormalities
• Secondary HA due to a pathologic cause

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Primary Headache Syndromes

• Migraine with and without aura
• Tension Type
• Cluster

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Secondary Headache SyndromesWarning Signs

• Sudden onset of severe headache
• Headache accompanied by impaired mental status,
  fever, seizures, or focal neurologic signs
• New headaches beginning after age 50
• Headaches worsened by Valsalva maneuver
• Headache that awakens the patient
• Progressively worsening headache

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Case 1

• A 38-year-old woman presents with pulsatile,
  unilateral headaches that occur twice a month.
  The headaches last between 4 and 14 hours and are
  disabling to the point that she has to lie down
  and go to sleep. She has no visual auras. The
  neurologic examination is entirely normal. Does
  this patient have migraines?

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MIDAS QuestionnaireDisability Rating

• On how many days in the last 3 months did you
  miss work or school because of your headaches?
• How many days in the last 3 months was your
  productivity at work or school reduced by half or
  more because of your headaches? (Do not include
  days you counted in Question 1 where you missed
  work or school)
• On how many days in the last 3 months did you not
  do household work because of your headaches?
• How Many days in the last 3 months was your
  productivity in household work reduced by half or
  more because of your headaches? (Do not include
  days you counted in question 3 where you did not
  do household work)

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MIDAS Questionnaire (cont.)

• On how many days in the last 3 months did you
  miss family, social or leisure activities because
  of your headaches?
• Your rating______________ Total__days

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MIDAS Questionnaire (cont.)

• A. On how many days in the last 3 months did you
  have a headache? (If a headache lasted more than
  1 day, count each day)
• On a scale of 0-10, on average how painful were
  these headaches?
• (Where 0 no pain at all, and 10 pain as
  bad as it can be)
• Your rating______________ Total__days

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Grade Definition Score

• Minimal or infrequent disability 0-5
• Mild or infrequent disability 6-10
• Moderate disability 11-20
• Severe disability 21
  

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Migraine DiagnosisPOUNDing

• Pulsatile quality
• Duration 4-72 hOurs
• Unilateral location
• Nausea and vomiting
• Disabling intensity

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Results of Clinical Prediction Rules for Migraine
Diagnosis by International Headache Society
Criteria as Applied by a Neurologist
Detsky, M. E. et al. JAMA 20062961274-1283.
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Screening Tool for Migraine(5 Questions)

• Is it a pulsating headache?
• Does it last between 4 and 72 hours?
• Is it unilateral?
• Is there nausea?
• Is the headache disabling?
• Likelyhood ratio
• - If yes to 4 questions LR 24 (definite or
  possible migraine vs not migraine
• - If yes to 3 questions LR 3.5
• - If yes to

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Suggested Algorithm for the Approach to Headache
Detsky, M. E. et al. JAMA 20062961274-1283.
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Case 1

• This woman has 4 features of the POUNDing
  mnemonic, and therefore the positive LR for
  having a definite migraine or possible
  migraine-type syndrome is 24.
• She should therefore be diagnosed as having
  migraine headache, and proper migraine therapy
  should be initiated.
• In the absence of any other findings,
  neuroimaging is not indicated.

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Case 2

• A 27-year-old man developed a severe, rapid-onset
  headache and mild neck stiffness while performing
  pushups. He reports no prior illness. The
  neurologic examination identifies no abnormal
  findings, but the symptoms persist 2 hours after
  onset. Should you request neuroimaging for this
  patient?

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Studies of the Accuracy of the Clinical
Examination in Predicting Significant
Intracranial Abnormality
Detsky, M. E. et al. JAMA 20062961274-1283.
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Suggested Algorithm for the Approach to Headache
Detsky, M. E. et al. JAMA 20062961274-1283.
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Case 2

• The young man with a thunderclap headache has a
  very high pretest probability ( 43) of serious
  pathology (ie, subarachnoid hemorrhage).
• Despite not having any features that
  significantly increase his posttest probability,
  he is clearly at significant risk and merits
  urgent CT scanning and lumbar puncture.

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Case 3

• A 45-year-old man tells his family physician,
  again, about his 10-year history of intermittent
  unilateral headache of grade 5 (of 10) severity
  and 4 to 5 hours' duration. An aura does not
  herald the onset, and no vomiting or photophobia
  occur. You reassess his physical examination only
  to find mild weakness (power, grade 4 of 5) and
  increased reflexes in the right leg and arm. What
  features distinguish this case from the preceding
  2 cases?

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Case 3

• The history suggests some features of migraine
  headache, but only 2 features (unilateral
  headaches that last more than 4 hours) of the
  POUNDing mnemonic are present (LR for "definite"
  migraine, 0.45).
• The absence of nausea and photophobia can be
  assessed in combination with the lack of
  disability, also suggesting that migraines are
  less likely (LR 0.25). Thus, the clinician should
  be considering other diagnoses.
• This patient has chronic headaches, based on this
  alone, the pretest probability of having a
  significant intracranial abnormality is  1.

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Case 3

• However, he has abnormal findings on neurologic
  examination (positive LR,  5) and therefore a
  posttest probability of  5.
• The difference between this case and the
  preceding 2 cases is that there is an important
  neurologic finding on the physical examination.
  Since this is a chronic headache scenario, the
  pretest probability of a finding is low LR 1.
• However, the finding on examination increases the
  suspicion of intracranial pathology, and most
  physicians would obtain neuroimaging.

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Diagnosis and Testing
Detailed History and Examination
Primary Headache? Preliminary diagnosis
Red Flag
No
Yes
Secondary Headache
Atypical Features
Diagnostic Testing
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Guidelines for Neuroimaging in Patients
Presenting With Migraine Headaches

• Non acute headache and unexplained findings on
  neurologic examination neuroimaging
• Neurologic symptoms (headache that is worsened
  with use of Valsalva's maneuver, awakens the
  patient from sleep, is newly onset in an older
  person, or is progressively worsening)
  neuroimaging
• Normal neurologic examination - neuroimaging
• If the headache has atypical features or does not
  meet the strict definition of migraine /-
  neuroimaging

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Acute Migraine Therapy

• Non-specific therapy
• Specific therapy
• Special considerations

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US Headache Consortium Goals for Acute Migraine
Treatment

• Treat attacks rapidly and consistently and
  prevent recurrence
• Restore the patient's ability to function
• Minimize the use of backup and rescue medications
  
• Optimize self-care and reduce subsequent use of
  resources
• Be cost-effective in overall management
• Have minimal or no adverse events

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Headache Consortium

• American Academy of Neurology
• American Academy of Family Physicians
• American Headache Society
• Americal College of Emergency physicians
• American College of Physicians
• American Society of Internal Medicine
• American Osteopathic Association
• The National Headache Foundation

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5-step acute treatment strategy

• Identify components of migraine symptomatology
  that allow for intervention as early as possible
  in the migraine process.
• Select the best pharmacologic options for each
  patient.
• Instruct patients in the proper use of their
  medications.
• Encourage use of a headache diary to monitor
  treatment and medication usage.
• Provide information resources for patient
  education.

Recommended by the Primary Care Network and is
endorsed by the National Headache Foundation
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Evidence Based Levels of Evidence

• Substantial empirical evidence and pronounced
  clinical benefit (A)
• Moderate empirical evidence and clinical benefit
  (B)
• Conflicting or inconsistent evidence (C)
• Empirical evidence indicating clinically
  ineffective (D)

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Non-specific Acute TreatmentsAnalgesics and
NSAIDs

• Aspirin (A) - 500-1000mg
• Diclofenac (B) - 50-100 mg
• Flurbiprofen (B) - 100-300 mg
• Ibuprofen (A) - 400-2400 mg
• Naproxen (A) - 750-1250 mg
• Ketorolac (B) - 200 mg
• Combination with caffeine

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Non-specific Acute Treatments Antiemetics

• Successful single agent therapies
• Chlorpromazine (B) - 25-50mg IM
• Metoclopramide (B) - 10mg PO, IV or IM
• Prochlorperazine (B) - 10mg IV or IM,

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Nonspecific RecommendationsControlled Substances

• Butorphanol - NS (A)
• Opiate containing compounds
• PO (A)
• IV, IM (B)
• Barbiturate containing compounds (B)

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Responsible use of analgesics can be difficult!
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Specific Acute Treatments

• Triptans (A)
• Ergot alkaloids (A)
• Dihydroergotamine mesylate (DHE) - Nasal Spray
• Dihydroergotamine 1 mg IM
• Isometheptene containing compounds (B)

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Cutaneous allodynia

• Pain resulting from an innocuous stimulus to
  normal skin or scalp (not normally painful). The
  pain can be provoked by
• combing or brushing the hair, shaving, showering,
  wearing glasses or earrings.
• The pressure of a single strand of hair
  reportedly can feel like a jab with a white-hot
  knife.
• Cutaneous allodynia is believed due to a
  transient increase in the responsiveness of
  central pain neurons that process information
  arising from the skin.

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Triptans
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Triptans
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Contraindications of Triptans

• Uncontrolled hypertension,
• History of myocardial infarction (MI)
• Ischemic or structural heart disease
• Cerebrovascular disease
• Peripheral vascular disease
• And basilar or hemiplegic migraine.
• Triptans should not be used within 24 hours of
  treatment with ergot-type drugs and other Triptan
  drugs

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Proposed Rationale for Triptan Use

• Appropriate for first line use (A)
• Almotriptan 12.5 mg
• Eletriptan 40 mg
• Sumatriptan 50 mg
• Zolmitriptan 2.5 mg
• When greater efficacy is needed
• Eletriptan 80 mg or rizatriptan 10 mg
• Sumatriptan 100 mg or Zolmitriptan 2.5 mg
• Sumatriptan 20 mg nasal spray

Oral
Oral
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Proposed Rationale (cont.)

• When a rapid response is important above all or
  when nausea or vomiting precludes oral therapy
• Sumatriptan 6 mg
• Zolmitriptan 5 mg
• When side effects are troublesome with other
  triptans
• Naratriptan 2.5 mg
• Almotriptan 12.5 mg
• Fovatriptan 2.5 mg

Intranasal
Oral
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Proposed Rationale (cont.) Early vomiting

• Sumatriptan 25 mg suppository,
• Sumatriptan 6 mg subcutaneous injection
• Sumatriptan 20 mg nasal spray
• Zolmitriptan 5 mg nasal spray
• Rizatriptan 10 mg dissolvable wafer
• Zolmitriptan 2.5 mg dispersible

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Proposed Rationale (cont.) Menstrually Related

• Prevention
• Ergotamine tablet taken at night?
• Estrogen patches
• Treatment
• Triptans
• Dihydroergotamine nasal (DHE) spray

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5 General RecommendationsFor the Treatment of
Acute Migraine

• Educate patients with migraine about their
  condition and its treatment and encourage them to
  participate in their own management
• Use migraine-specific agents in patients with
  more severe migraine and in those whose headaches
  respond poorly to NSAIDs or combination
  analgesics such as aspirin plus acetaminophen
  plus caffeine

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Recommendations (cont)

• Select a nonoral route of administration for
  patients whose migraines are characterized by
  nausea or vomiting early in the course of an
  attack
• Consider use of a self-administered rescue
  medication for patients with severe migraines
  that fail to respond well to other treatments

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Recommendations (cont)

• Guard against medication-overuse headache
• Acute therapy- for 2 or more headache days/
  week.
• Preventive therapy- in patients suspected of
  medication overuse or at risk for overuse

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Preventative Therapy

• Pharmacological
• Non pharmacological

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Indications for Prophylaxis

• Recurrent migraine that, in the patients
  opinion, significantly interferes with his or her
  daily routine in spite of acute treatment
• Frequent headaches
• Cost considerations
• Patient preference

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Indications for Prevention

• The presence of uncommon migraine conditions that
  may predispose to permanent neurological sequelae
  (such as hemiplegic migraine, basilar migraine,
  migraine with prolonged aura or migrainous
  infarction)
• Acute therapies cannot be used because of
• Contraindications
• Failure
• Overuse
• Adverse effects

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General Principles (cont.) Patient Education

• Maximize compliance discuss rationale for a
  particular treatment, when and how to use it and
  the possible adverse events.
• Address the patients expectations
• Discuss the expected benefits of therapy and how
  long it will take to achieve them
• Create a formal management plan

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General Principles (cont.)Evaluation

• Patient should maintain a headache diary
• (The Gold Standard for evaluation of headache
  attacks)
• Diary should be user friendly and provide
  information on the frequency, severity, and
  duration of attacks, disability, response to
  treatment and adverse effects of medication
• Reevaluate therapy, and after a period of
  stability, consider tapering or discontinuing
  therapy

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Sample Headache Calendar
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Food Restriction

• Alcohol
• Chocolate
• Aged cheese
• Onions
• Yogurt
• Canned figs
• Avocado
• Hot dogs
• Bacon
• Dry soup mixes, and similar products (MSG)
• Chicken livers
• Fermented sausages
• Chinese food (MSG)

• Citrus fruits (oranges, lemons, limes,
  grapefruit, and their juices)
• Coffee (including decaffeinated coffee)
• Tea
• Bananas
• Nuts

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General Principles (cont.) Common Coexisting
Disorders

• May limit therapy (stroke, myocardial infarction,
  Raynauds phenomenon, epilepsy, affective
  disorders and anxiety disorders
• Select a drug that will treat both disorders
• Select a drug that is not contraindicated or
  exacerbates either disorder
• Beware of drug interactions and pregnancy

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Guidelines (cont.)Appropriate Medication

• Start with medications that have the highest
  level of evidence-based efficacy
• Start with the lowest dose that has been shown to
  be effective, and increase it slowly until
  clinical benefits are achieved for the patient in
  the absence of, or until limited by, adverse
  effects.
• Give each medication an adequate trial, which may
  mean 2-3 months in some cases.

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General Principles of Prevention Medication Use

• Start low and increase dose slowly
• Use long-acting formulations if compliance is an
  issue
• Adequate trial (2-3 months) at an appropriate
  dosage
• Avoid drugs that interfere with efficacy of
  preventative therapy
• Consider reducing the dose or even discontinuing
  the medication if, after 3-6 months, headaches
  are well controlled
• Long-lasting formulations may improve compliance

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Prophylactic Medications Beta-blockers

• 60-80 effective in reducing headaches 50
• Propranolol 20 - 160 mg/day (A)
• Timolol 10 -30 mg/day (A)
• Nadolol 20 -120 mg/day (B)
• Metoprolol 50 -200 mg/day (B)
• Atenolol 25 -100 mg/day (B)
• Beta-blockers with intrinsic sympathomimetic
  activity not effective
• Acebutlol and pindolol

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Prophylactic MedicationsAntidepressants

• Amitriptyline 10 150 mg/day (A)
• strongest evidence supporting use
• Particularly effective in mixed migraine and
  muscle tension type headaches
• SSRIs
• Fluoxetine 10-40 mg/day (B)
• some evidence supporting use
• Other SSRIs no better than placebo

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Prophylactic MedicationsAntiepileptic
drugs/neuromodulators

• Divalproex sodium 125-200mg/day (A)
• Supported in 5 studies
• Titration is required
• Adverse side-effects
• Topiramate 50 100 mg/day (A)
• Supported in 3 studies

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Prophylactic MedicationsCalcium-channel blockers

• Verapamil 20 - 480 mg/day (B)
• Nimodipine 30 mg TID (B)
• Used in SAH 60 mg q 4 hours for 21 days

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Prophylactic MedicationsHerbs and Vitamins

• Feverfew (B)
• Riboflavin (B) 400 mg
• Significantly superior 59 to placebo 15
• Coenzyme Q10 (COQ10) 100mg/TID
• Superior response 47.6 to placebo 14.4
• Magnesium 400 mg (B)
• Further large and rigorously conducted trials
  are needed before can be recommended

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Prophylactic MedicationsNSAIDs

• Aspirin 325 mg/day (B)
• Fenoprofen 600 mg TID (B)
• Ketoprofen 75 mg tid (B)
• Naproxen 200-550 mg BID (B)

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Migraine Prevention in Special Populations

• Elderly Neurontin TCAs Beta Blockers
• Pregnancy non pharmacological Mg B12
• Pediatrics/ Adolescents
• Topiramate (2-6mg/kg/day) up to 200mg/day
• Cyproheptadine (2-10mg/day)
• Amitriptyline

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Nonpharmacologic Treatment Indicators

• Patient preference
• Poor tolerance, response or contraindication to
  drug therapy
• Pregnancy, planned pregnancy, or nursing
• History of overuse
• Significant life stress or deficient
  stress-coping skills

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Nonpharmacologic Treatment

• Effective (A)
• Relaxation training
• Thermal biofeedback with relaxation training
• EMG biofeedback
• Cognitive behavioral therapy
• The benefit of behavioral therapy are in addition
  to preventative drug therapy (B)
• Insufficient evidence to recommend (C)
• Acupuncture Hypnosis
• Cervical manipulation Hyperbaric oxygen
• TENS Occlusal adjustment

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6 Goals in the Long-TermTreatment of Migraine

• Reduce the frequency and severity of attacks by
  50.
• Reduce disability from the attacks
• Improve the patients quality of life
• Prevent disease (headache) progression
• Avoid escalation of medication use
• Educate patients and enable them to manage their
  headaches

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Summary of Prevention

• Use preventative medication when needed
• Treat long enough
• Avoid acute medication overuse
• Take coexisting conditions into account
• Use drug with the best efficacy for individual
  patient

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Preventive Treatment

• On average, 2/3 of patients will have a 50
  reduction in headache frequency with most
  preventive drugs.
• They can then choose between the potential for
  sleepiness, exercise intolerance, erectile
  impotence, nightmares, dry mouth, weight gain,
  tremor, hair loss, or fetal deformities as
  possible side effects.
• The fact that migraineurs are prepared to accept
  such side effects indicates the level of
  disability they experience.
• None of the range of options for prevention is
  ideal.

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Resources

• International Headache Society (IHS)
  Classification and Diagnostic Criteria under the
  IHS Guidelines http//www.i-h-s.org/
• National Headache Foundationhttp//www.headaches
  .org/
• The Complete Guide to Headache from the National
  Headache Foundationhttp//www.headaches.org/consu
  mer/educationmoduleindex.html
• American Headache Society (AHS formerly
  AASH)http//ahsnet.org/
• U.S. Headache Consortium Guidelineshttp//ahsnet.
  org/guidelines.php
• American Medical Association Migraine Site
  http//www.ama-assn.org/
• Canadian Medical Association Guidelineshttp//www
  .cma.ca/cmaj/