1. New Study Finds Americans Need 6 Hours Of Sleep At Work

2. “…And then a throb hits you on the left side of the head so hard that your head bobs to the right…There's no way that came from inside your head, you think. That's no metaphysical crisis. God just punched you in the face.” --Andrew Levy, A Brain Wider Than the Sky: A Migraine DiaryAndrew LevyA Brain Wider Than the Sky: A Migraine Diary

3. Migraine Prevention LT Sara Pope, MD 7 February 2013

4. Objectives Briefly reviewed treatment of migraines Explored the importance of prophylaxis Assessed when to start prophylaxis Discussed treatment types

5. Migraines: In Brief Common, complex and recurrent >30 million people have 1+ migraines/year 13% prevalence, 75% female 80% have a 1 st degree relative with a history Environmental, behavioral triggers

6. Migraines: Sensitive CNS? Intracranial vasoconstriction + rebound dilation Neurogenic process w/2°changes in cerebral perfusion –Classic: +AURA, gradual, unilateral, pulsating, +sensory –Common: NO AURA, episodic vs. chronic

7. True Migraine? Head pain + nausea + sensory sx >4 h, <72h Starts young, rare >50 yo Common in reproductive years Predictable triggers Red flags

8. Why Prophylaxis? Reduce frequency, severity and duration Improve responsiveness to acute tx Improve function, reduce disability, +QOL Reduce costs Only 13% on preventive therapy

9. When to Start? Recurrent, interfere w/ADL’s despite tx >4 attacks/month Contraindications or failure/overuse of acute tx Adverse events to acute tx Hemiplegic, basilar, prolonged aura, infarction Menstrual: mini-prophylaxis

10. How? Several medications Varied mechanisms of action No ‘gold standard’, pt specific Success: reduction in migraine frequency by 50% in first 3 months

11. What does the evidence say?

12. Small Groups Three Groups Three Medication Categories Three Teaching Points Three Cases

13. Anti-Hypertensives

14. Propanolol, metoprolol,timolol: Effective Verapamil, nimodipine: Insufficient Lisinopril, candesarta: Possibly effective Telmisartan: Possibly not effective

15. Anti-Convulsants

16. Topiramate: Effective, as good as BB, VA, TCA Divalproex, valproate: Effective Gabapentin: Insufficient Lamotrigine, oxcarbazepine: Ineffective

17. Anti-Depressants & Others

18. Anti-Depressants Fluoxetine: Limited, conflicting data Venlafaxine: Probably Effective Amitriptyline: Probably Effective, as good as topiramate, maybe Venlafaxine

19. Others… Triptans Botox Butterbur Co-enzyme q10 Feverfew Magnesium Methylsergide Riboflavin Acupuncture Relaxation, biofeedback CBT Hypnosis TENs Hyperbaric oxygen

20. Principles of Prophylaxis Start low, go slow Adequate trial in duration, dosage Avoid overuse: analgesics, opioids, triptans Caution: women of child bearing age Address expectations, preferences, side effects, commitment Slowly taper w/improvement, recommend 6-9 months

21. Objectives Briefly reviewed treatment of migraines Explored the importance of prophylaxis Assessed when to start prophylaxis Discussed treatment types

22. Questions?