1. Migraine: Clinical Overview, Medication Overuse and Treatment Options
Esther Tomkins
Clinical Nurse Specialist

2. Institutions & Organisations
National organizations – Migraine Association of Ireland (MAI) & Migraine Trust (UK)
European Headache Federation (EHF)
World Health Organization (WHO)
European Brain Council
Lifting The Burden (LTB)
Focus on the high prevalence and high disability of headache

3. Clinical Burden of Headache
Tension-type headache and migraine are the second and third most prevalent medical disorders on the planet
Account for 4% of consultations in primary care in the UK1
GP’s refer 2% to neurology clinics
Accounts for 30% neurology outpatient consultations in the UK1
Migraine is the most common primary headache seen by doctors (population prevalence of 15%)1
Affects over 500,000 people in Ireland2
Cause severe disability in some patients3
NICE Clinical Guideline 150. Headaches costing report. September 2012
The Irish Nurses & Midwives Organisation Accessed OCTOBER 2013
World Health Organization. The Global Burden of Disease: 2004 update, Part 3, p28–37. last accessed October 2013

4. Burden of Migraine
World Health Organisation (WHO) – in 2000, migraine ranked as the 12th most disabling medical condition for women
WHO (Global Burden of Disease study, 2010) - migraine ranked as the 4th most disabling medical condition for women (7th most disabling overall)2
Chronic Daily Headache >15 days per month (affects 3-4% of people in the UK)3
In lower socioeconomic populations, higher prevalence of CDH (for example, 10% Russia & 8% Georgia)
WHO (2001) The World Health Report 2001: Mental health, new understanding new hope. World Health Organization, Geneva, Switzerland Accessed October 2013
World Health Organization and Lifting The Burden. Atlas of headache disorders and resources in the world WHO, Geneva; 2011.
NHS UK Accessed October 2013

5. Burden of Migraine Estimated migraine costs
Direct costs – medication, out patient visits, healthcare1-2
Indirect costs - work, productivity, impaired quality of life, financial burden1-2
Annual cost per patient - €1,200/year (plus medication overuse €3,500/year)
Migraine - in the EU, migraine is estimated to cost €50,000,000,000 per annum (plus 37 billion per annum for medication overuse headache)
1. Steiner TJ et al. Cephalalgia 2003;23:519–527.
2. Hawkins K et al. Headache 2008;48:553−563.

6. Lancet 2012; 380: 2197–223
Tension-type headache and migraine are the 2nd and 3rd most prevalent medical disorders on the planet
Migraine accounts for 30% of the global burden and more than 50% of the disability burden attributable to all neurological disease worldwide.
Overall, it is the 4th ranking cause among women and the 7th ranking cause of all disease-associated disability worldwide.

7. How to Classify Headache
Migraine (episodic V chronic)
Tension-type Headache (TTH)
Trigeminal Autonomic Cephalgias (TAC) – Cluster Headache, Hemicrania (Paroxysmal & Hemicrania Continua), SUNA/SUNCT
Secondary Headache – bleed, stroke, infection (meningitis), tumours, CSF pressure (low/high), seizure related
Cranial neuralgias (trigeminal neuralgia)
Central causes of facial pain (neuropathic facial pain)

8. Migraine Neurological Condition - brain disorder
Complex syndrome - not just Headache
Headache with associated features
Dysfunction of nerve cells in the brain
Causes brain hypersensitivity
Genetic factors - family history
Three genes for familial hemiplegic migraine (FHM) are known

9. Migraine – How common? Very common Prevalence 4/10 Women, 2/10 Men
90% patients attending GP with headache were diagnosed with Migraine (Tepper et al., 2004)
Patients are often diagnosed with tension-type headache, neck problems or sinusitis

10. Migraine – Diagnostic Criteria
Classification (2004)
Repeated attacks lasting 4-72 hours:
- Normal physical examination
- No other reasonable cause for the H/A
- At least 2 of: pain on one side, throbbing/pounding pain, movement aggravation, moderate/severe intensity
- Nausea, vomiting, photophobia or phonophobia

11. Migraine – Human Cost
Patients – 25% will have four or more severe attacks per month (lasting 24 hours)
Episodic migraine often changes into a chronic daily headache (CDH – defined as headache on more than 15 days per month – often daily)
The headache is usually mild for most of that time – superimposed severe episodes
Transformed migraine or chronic migraine

12. Most Important Clinical Points
Patients history – all important
Aim is to get a definite diagnosis and exclude secondary causes of headache
Inadequate history is the cause of most misdiagnosis
Most headache groups have developed standard questions to help with history taking (for example, the Headache Information Board in Beaumont)

13. Tools to Aid the Clinical History
Almost all headache experts use headache diaries and appropriate assessment questionnaires to diagnose and manage headache
Headache Impact Test (HIT/HIT6) & Migraine Disability Assessment (MIDAS)
ID Migraine

14. Migraine – Patients Symptoms
Headache – pounding, tight, pressure, dull ache, muzziness, fullness or abnormal sensation
Headache may not be a prominent feature
Location: top, front or back of head – not always one sided
Photophobia, Phonophobia & Osmophobia
Nausea/Vomiting – travel sickness, repeated abdominal pain
Unsteadiness/dysequilibrium – like being on a boat or drinking alcohol (without the alcohol)

15. Migraine – Symptoms
Eyes – drooping eyelids, swelling around eyes, tearing or conjunctival injection (bloodshot)
Visual – wavy lines, visual loss of part of vision (eg. tunnel vision)
Nose – stuffed (nasal congestion) in 87% of people with migraine - confused with sinusitis
Face – neuropathic facial pain: pain in teeth, jaw, cheeks, TMJ
Limbs – pain, tingling, numbness, “heaviness”, weak (hemiplegic migraine)
Ears – pain, fullness, deafness or tinnitus
Neck/back – stiff neck, shoulder & back pain

16. Symptoms - Summary
Migraine patients often have a variety or constellation of different symptoms affecting head, vision, balance, neck, ears, nose, eyes, scalp, face & limbs
Headache may NOT be the most prominent symptom
Often labelled as depressed, tension type headaches, neck related headaches, jaw/teeth problems or sinusitis

17. Migraine – Triggers Change in routine Stress Hormonal changes Alcohol
Sleep habits – sleeping in, sleep deprivation
Eating habits – going hungry (low sugar levels)
Stress
Hormonal changes
Alcohol
Weather – stormy weather
Food and drinks

18. Migraine – Hormonal Factors
70-80% of our patients are female
Migraine usually worse from teens to 50’s
Often worse perimenstrually
Migraine with aura, smoking and COCP not good combination – higher risk of stroke
Hormone manipulation of limited benefit
Mirena and progesterone only pill (POP)

19. COMMON TRIGGERS (Kelman 2007)

20. Primary Headache Disorders: Frequency Classification1,2
After Secondary Causes Are Ruled Out
Silberstein Neurol 1996, p872
Dodick NEJM 2006, p158, 159/Table 1
Primary Headache Disorders
Chronic Headache
Frequency ≥15 days/month
Episodic Headache
Frequency <15 days/month
1 / Silberstein Neurol 1996, p872, 873
2 / Dodick NEJM 2006, p159/Table 1, 160/Table 2
p158
3 /Scher 1998 p498, 500
4/Castillo 1999 p 192
5/Lanteri-Minet 2003, p145
Primary chronic daily headache (CDH) of long duration is a syndrome characterized by headaches not attributable to a secondary disorder that last more than 4 hours a day and occur 15 or more days per month.1,2 This syndrome affects 3-5% of the general population worldwide2-5 and approximately 40% of patients seen in headache clinics.6
The criteria most frequently used to classify primary chronic daily headache of long duration are those proposed by Silberstein and Lipton.1 According to these criteria, the chronic daily headache syndrome encompasses 4 main diagnoses1,2:
Chronic Migraine
Chronic tension-type headache
New daily persistent headache
Hemicrania continua
These subgroups are further divided into those with and without medication overuse.1
References:
Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology. 1996;47:
Dodick D. Chronic daily headache. N Engl J Med. 2006;354:
Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998;38:
Castillo J, Munoz P, Guitera V, Pascual JG. Epidemiology of chronic daily headache in the general population. Headache. 1999;39:
Lanteri-Minet M, Auray J-P, El Hasnaoui A, et al. Prevalence and description of chronic daily headache in the general population in France. Pain. 2003;102:
Mathew N, Reuveni U, Perez F. Transformed or evolutive migraine. Headache. 1987;27:
Short-Duration Chronic Daily Headache
Duration <4 hours or multiple discrete episodes
Chronic Daily Headache
(Long Duration)
Daily or near-daily headache lasting ≥4 hours
With or Without Medication Overuse
1 / Silberstein Neurol 1996, p872
1. Silberstein SD et al. Neurology. 1996;47:
2. Dodick D. N Engl J Med. 2006;354:
6 / Mathew 1987, p103 table 1

21. Differential Diagnosis of Chronic Daily Headache
New Daily Persistent Headache1,2
Includes at least 2 of the following characteristics:
Defined by new onset (within 3 days) and persistency
Bilateral location
Pressing/tightening (non- pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs
Chronic Migraine1,2
Unilateral location
Pulsating quality
Moderate/severe pain intensity
Aggravated by routine physical activity
1 / ICHD-2 - HCC; Olesen 2004, p52
2 / Dodick NEJM 2006, p160/Table 2
1 / ICHD-2 - HCC; Olesen 2004, p52
2 / Dodick NEJM 2006, p160/Table 2
1 / ICHD-2 - HCC; Olesen 2004, p39
2 / Dodick NEJM 2006, p160/Table 2
1 / ICHD-2 - HCC; Olesen 2004, p24-25, 31-32
2 / Dodick NEJM 2006, p159
Hemicrania Continua1,2
Includes all of the following characteristics
Strictly unilateral location
Daily and continuous, without pain-free periods
Moderate intensity, but with exacerbations of severe pain
Indomethacin-responsive
This slide summarizes the differential diagnosis of the types of chronic daily headache: Chronic Migraine, new daily persistent headache, hemicrania continua, and chronic tension-type headache.1,2
References:
1. Headache Classification Committee; Olesen J, Bousser MG, Diener HC, et al. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(suppl 1):9-160.
2. Dodick D. Clinical practice: chronic daily headache. N Engl J Med ;354:
Chronic Tension-Type Headache1,2
Includes at least 2 of the following characteristics:
Bilateral location
Pressing/tightening (non- pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity
1 / ICHD-2 - HCC Olesen 2004, p24-25, 31-32
2 / Dodick NEJM 2006, p159
1. Headache Classification Committee; Olesen J et al. Cephalalgia. 2004;24: Dodick D. N Engl J Med. 2006;354:

22. Migraine, Medication Overuse & Chronic Daily Headache (CDH)
Up to 80% of patients consulting in headache clinics suffer from CDH
Medication overuse reflects an interplay between a therapeutic agent & the mechanism for headache
Also called chronic migraine, transformed migraine and rebound headache

23. Principles of Acute Treatment
Painkillers/analgesics, triptans and NSAID’s are excellent drugs if used infrequently or for short courses
Number of days per month is the key
Regular use of even small doses (more than one/two days per week) is a bad idea
Avoid codeine and opiates
Naproxen (Naprosyn) more frequently

24. Treatment Options for Migraine
Reduce acute medications as much as possible (analgesics/painkillers, non-steroidal anti-inflammatory agents & triptans) – keep diary!
Preventative agents if needed (>8/30)
Greater occipital nerve (GON) blocks
Botox (PREEMPT protocol)
In-patient treatments (IV DHE, lidocaine, etc,)
Neuromodulation

25. Preventative Medication
Every day for at least 4-6 months at a reasonable dose – all have potential side effects
Different classes of preventatives
Flunarizine/Sibelium - can take many months
Tricyclics - Amitriptyline, Nortriptyline
BP medication - Propranolol (Candesartan)
Epilepsy medication - topiramate, valproate, gabapentin (zonisamide)
Pizotifen (Sanomigran)
Pregabalin (Lyrica)

26. Amitriptyline (TCA) Commonest prescribed migraine agent
It is an “old” anti-depressant
Maximium dose of 300mg
For migraine, use mg
Start at 10mg at night for 2-8 weeks
Possible common side effects (dreams, drowsiness, dry mouth, weight)
Use for 4-6 months at maximium tolerated dose before considering changing

27. Topiramate/Topamax
In the top three most commonly prescribed migraine agents
It is also an epilepsy medication
Highest daily dose of 700mg
For migraine, use 25mg to 200mg twice daily
Start at 25mg at night for 2-8 weeks and increase gradually
Common side effects of weight loss, tingling, mood, speech, kidney stones
Use for 4-6 months at highest tolerated dose before considering changing

28. Flunarizine/Sibelium
In the top three most commonly prescribed migraine agents
Highest dose of 15mg daily
Start at 5mg once daily for at least 3 months (often longer)
Common side effects of weight gain, mood disturbance or anxiety
Use for 4-6 months at highest tolerated dose before considering changing

29. Gabapentin (Neurontin)
Second line migraine drug
Also used in epilepsy & pain management
Maximium dose of 4800mg daily
Start at 100mg BD for 1-2/52: aim for 300mg TDS as a starting maintenance dose (may need much higher doses)
Possible common side effects (weight gain, abdominal symptoms)
Use for 6/12 at maximium tolerated dose before considering changing

30. Valproate (Epilim) Second line migraine drug
Also used in epilepsy & psychiatry
Maximium dose of 3000mg daily
Start at 200mg OD for 1-2/52: aim for 400mg – 600mg as a maintenance dose (may need higher doses)
Possible common side effects (weight gain, abdominal symptoms)
May act as a mood stabiliser
Not good for women of child bearing age
Use for 6/12 at maximium tolerated dose before considering changing

31. GON Blocks Greater occipital nerve (GON) blocks
Often used to supplement one or two migraine preventative agents
Migraine patients with at least headache days per month
Also used in other primary headaches (Cluster)
No more than three blocks each side per year
Very little side effects
Suitable for pregnant/breast feeding patients
May need several blocks for prolonged benefit

32. Botox Based on the two PREEMPT studies
31-39 injections (5 units each) per patient
Migraine patients with at least headache days per month
Often used in combination with preventative agents
Every three months
Very little side effects
Suitable for patients considering children
May need several courses of injections

33. Beaumont & Mater Hospital Headache Clinics
Multidisciplinary (doctors, nurses, PT, etc.)
45-60 patients per week
Vast majority of patients have migraine
>50% of patients have chronic daily headache (CDH)

34. Conclusions Migraine is very common & can be very disabling
Migraine can give a variety of different symptoms (headache may not be that prominent)
Affects more women than men
Frequent regular use of acute medications is not good in patients with migraine