1. Management of migraine headaches in adults for primary care physician
Meghana Doreswamy MD
Neurology and Sleep Medicine
September 6, 2015

2. Objectives
Diagnostic criteria and pathophysiology of migraine headache.
Epidemiology and impact of migraine headache
Treatment of acute migraine headache.
Preventive therapy for migraine headaches. .

3. What type of headache is this?
A 32-year-old male presents with worsening headache
He has had headaches since 23, they have always been under and around eyes
He has a history of sinus trouble
Headaches are associated with photophobia/osmophobia/occasional loss of appetite
Pain is a dull pulsing pain, better with sleeping.
Diagnosis???
No history of fever, bleeding or rhinorrheae.

4. Migraine vs. Sinus headache
Studies show that about 85% of people with self described sinus headaches actually have migraine headaches.
Sinus problems, like many other things trigger migraine headaches
Bottom line– the majority of headaches severe enough to cause a person to seek medical attention are Migraines
45% of migraine patients report sinus symptoms including rhinorrhea, nasal congestion and lacrimation.

5. Case 2 A 36 yr female presents with worsening headaches.
Started 2 years ago, occurred 2x per month, associated with N/V/photophobia/phonophobia
She has constant, background, holocephalic headache associated with continuous photophobia for three months, rated 6/10
Exacerbations- 4x /week, severe throbbing with worsened photophobia, phonophobia and nausea, last up to 24 hrs
Sumatriptan 100 mg has not been effective

6. Diagnosis? Cluster headache Rebound headache Chronic migraine headache
Chronic tension headache

7. Tension-type Headache or Migraine
Mild
Moderate
Severe
Aura
Unilateral
Vomiting
Bilateral
Aggravated
by Activity
Photophobia
Nausea
Throbbing
Pressure
Tension-Type
Migraine
© 2002 Primary Care Network

8. Dilemma in diagnosis of migraine headaches
Visual aura
only 15-20% of migraineurs
Head pain can be non-throbbing
in ~40% of patients
Head pain can be bilateral
in ~ 43% of patients
Sinus pain and pressure, stuffiness, rhinorrhea & weather association is often present
in up to 97% of migraine attacks
Neck pain is often present
in up to 75% of migraine attacks

9. Migraine without aura Diagnostic criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following characteristics:
unilateral location
pulsating quality
moderate or severe pain intensity
aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
nausea and/or vomiting
photophobia and phonophobia
Not attributed to another disorder
ICHS classification

10. Migraine with Aura A. At least 2 attacks fulfilling criterion B
Diagnostic criteria:
A. At least 2 attacks fulfilling criterion B
B. Migraine aura fulfilling criteria B and C for one of the subforms
C. Not attributed to another disorder.
Note:
History and physical and neurological examinations do not suggest any of secondary disorders , or history and/or physical and/or neurological examinations do suggest such disorder but it is ruled out by appropriate investigations, or such disorder is present but attacks do not occur for the first time in close temporal relation to the disorder.
Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, headache lacks migrainous features or is completely absent.

11. Migraine aura subforms
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with non-migraine headache
1.2.3 Typical aura without headache
1.2.4 Familial hemiplegic migraine
1.2.5 Sporadic hemiplegic migraine
1.2.6 Basilar migraine

12. Retinal migraine
Diagnostic criteria: A. At least 2 attacks fulfilling criteria B and C B. Fully reversible monocular positive and/or negative visual phenomena (eg, scintillations, scotomata or blindness) confirmed by examination during an attack or (after proper instruction) by the patient's drawing of a monocular field defect during an attack C. Headache fulfilling criteria B-D for 1.1 .Migraine without aura begins during the visual symptoms or follows them within 60 minutes D. Normal ophthalmological examination between attacks E. Not attributed to another disorder. Comment: Some patients who complain of monocular visual disturbance in fact have hemianopia. Other causes of transient monocular blindness (amaurosis fugax), such as optic neuropathy or carotid dissection, must be excluded.
Repeated attacks of monocular visual disturbance, including scintillations, scotomata or blindness, associated with migraine headache.

13. Negative scotoma. Loss of local awareness of local structure
Zigzag structure
Positive Scotoma. Additional structures One side loss of perception.

14. Phases of migraine

15. Chronic migraine headaches
Migraine headache occurring on 15 or more days per month for more than 3 months in the absence of medication overuse.
Diagnostic criteria:
Headache fulfilling criteria C and D for  Migraine without aura on ≥15 days/month for >3 months
Not attributed to another disorder.

16. Figure 2. One-year period prevalence of migraine by age and sex adjusted for demographics.
R. B. Lipton et al. Neurology 2007;68:
©2007 by Lippincott Williams & Wilkins

17. Figure 3. One-year period prevalence of migraine by sex and household income.
R. B. Lipton et al. Neurology 2007;68:
©2007 by Lippincott Williams & Wilkins

18. Prevalence of primary headache types in waiting room

19. Migraine Burden in U.S. Migraineur in one in four households
28 million migraineurs in the US
Estimated annual cost of labor lost to migraine greater than $ 13 billion per year
Peak prevalence ages 25-55
Often ineffectively treated.

20. Migraine Pain Intensity and Disability
9% Function Normally
>75% Report Severe to Extremely Severe Pain
53%
Severe Impairment or Bed Rest Required
39%
Some Impairment
Patients (%)
The Need for Effective Migraine Prophylaxis
Lipton RB et al. Headache. 2001;41:

21. Pathophysiology of migraine headache
Harold G Wolff, a pioneer of the vascular theory of migraine, proposed that the neurological symptoms of the migraine aura were caused by cerebral vasoconstriction, and the headache by vasodilatation.
This had been replaced by cortical spreading depression theory of Leao(neural theory)
Most recent theory- migraine neurovascular phenomenon

22. Pathophysiology of migraine headache

23. Pathophysiology of migraine headache

24. Genetic predisposition to migraine headaches
The concordance for migraines is higher in monozygotic than dizygotic twins.
The first three types of familial hemiplegic migraine (FHM) are channelopathies. FHM1 is caused by mutations in the CACNA1A gene, FHM2 by mutations in the ATP1A2 gene, and FHM3 by mutations in the SCN1A gene. Mutations in the PRRT2 gene also cause some cases of familial hemiplegic migraine
Genetic basis is more complex- and increases individuals susceptibility to migraine headaches

25. Environmental factors

26. Principles of migraine management
Life style management- with patient education
Avoid medication rebound headache
Abortive therapy
Preventive therapy.

27. Lifestyle Management Sleep 8 hours consistent schedule
Eat 3 regular meals (or more) per day
Drink lots of fluids
Get Aerobic exercise regularly
Limit caffeine (or better yet avoid completely)
Identify your triggers
Keep a headache diary
Manage stress
Use correct posture and pause during repetitive activities

28. Acute (abortive) migraine treatment principles
Treat early, while headache is building, within minutes of onset.
Use correct dose and formulation
Limit to 3 days per week (with exceptions)
Try drug with at least 2 headaches to see if it works before moving on to another agent
Use drug combinations often work when a single agent won’t work

29. Acute treatment options
Nonspecific
NSAIDs
simple analgesics
combination analgesics
Anti-Nausea meds
Promethazine,metoclopramide, prochloroperazine.
Ondansetron
Specific
Triptans
- Faster onset
Sumatriptan, Zolmitriptan,eletriptan, rizatriptan and almotriptan
Triptans Slower Onset
Naratriptan and Frovatriptan
-Ergotamine/DHE; Migranol

30. Triptan therapy
As a class triptan in relation to non specific medications
Rapid onset of relief
Have higher efficacy .
Favorable side effect
Adverse effects- flushing, chest pain.
Contraindicated in patients with coronary artery disease, angina, patients with hemiplegic or basilar migraines, severe uncontrolled hypertension.

31. Formulations Oral therapies- Most medications
Nasal sprays- Sumatriptan, Zolmitriptan, DHE
Butarphanol
Injectables(IM/SC/IV)- Sumatriptan, DHE, neuroleptics,
injectable NSAIDs
Transdermal Patch- Sumatriptan 6.5 mg
Suppositories- antiemetics,ergots, opioids.

32. Proven effective with more than 1 randomized control trial
Adapted -Marmura et al, Headache 2015;55:3-20

33. Resistant acute migraine therapy
If acute treatment is still inadequate
Change formulation or dosage.
Use adjunctive therapy
Consider addition of preventive agent
Evaluate for medication overuse, excessive caffeine use.
Reconsider diagnosis.

34. Mechanism of action of migraine medications

35. When to start migraine preventive therapy
Migraine significantly interferes with patient’s routine despite acute Rx
Frequent headaches> or = 2/ week.
Acute therapy is ineffective, contraindicated or ineffective.
Patient preference.

36. Principles of preventive therapy
In order for preventive meds to be most effective, limit acute meds to 3 days per week
Make sure to use an appropriate dose
At least a 2 month trial at a proper dose is required
Goal is to decrease headache freq by 50%
Evaluate headache therapy(use headache log), attempt to lower and discontinue therapy when well controlled.
Assess for coexisting conditions.

37. AAN/AHS guideline for migraine prophylaxis

38. AAN/AHS guideline for migraine prophylaxis

39. Nonpharmacologic Treatments
Biofeedback
Relaxation therapy
Cognitive Behavioral Therapy
Acupressure
Acupuncture
Physical Therapy
Chiropractic treatment

40. Additional Treatment Measures
Occipital Nerve Stimulators
TENS units
Transcranial Magnetic Stimulator
Special Diets
Botox Injections- Approved by FDA in Oct 2010.
Approved for chronic migraine (migraine headaches more than 15 days/ month)31 injection sites in forehead, temples, shoulders and neck

41. Emerging therapy in migraine management
Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) and its receptor.
5-HT1F receptor agonist lasmiditan and glial cell modulator ibudilast.
Neuro-modulation for migraine headache- sphenopalatine ganglion stimulation, trigeminal nerve stimulation and transcutaneous vagus nerve stimulation.

42. Questions?