1. Migraine

2. What is migraine? www.cks.library.nhs.uk/migraine MeReC Bulletin 2002; 13: 5-8 www.cks.library.nhs.uk/migraine Primary episodic headache disorder Characterised by various combinations of: – Neurological – Gastrointestinal – Autonomic changes Diagnosis is based on headache characteristics and associated symptoms

3. Migraine classification International Classification of Headache Disorders 2 nd Ed (1 st revision) (ICHD-IIR1) Migraine without aura (common migraine) Migraine with aura (classic migraine) Childhood periodic syndromes that are commonly precursors of migraine (eg cyclical vomiting, abdominal migraine) Retinal migraine Complications of migraine eg chronic migraine Probable migraine – fills all but one of the criteria for a definitive diagnosis

4. How common is it? Goadsby PJ, et al. N Engl J Med 2002; 346: 257-70 MeReC Bulletin 2002; 13: 5-8 1 year prevalence is 11% – 6% men – 15-18% women Median attack frequency – 1.5 per month – 10% have weekly attacks Median attack duration – 24 hours – In 20% attacks can last 2-3 days In a 2000 patient practice – 5 new cases per year – 40 consultations per year

5. Implications Clinical Evidence. Migraine headache Goadsby PJ, et al. N Engl J Med 2002; 346: 257-70 MSGP4. Office for National Statistics Acute migraine is self-limiting It only rarely results in permanent neurological complications Most patients do not see a doctor However: Chronic recurrent migraine may cause disability through pain and may affect daily functioning and quality of life Severe episodes can last 3 days during which the person is unable to carry out normal daily activities 1 in 3 believe the condition controls their life Migraine is underdiagnosed and undertreated

6. The WHO judged that a day with severe migraine is as disabling as a day with quadriplegia

7. History – the key to diagnosis www.cks.library.nhs.uk/migraine Migraine is diagnosed by history – Examination normal after an attack – There are no diagnostic tests – Ixs not required and often reveal no abnormalities There may be a family history Attack can be divided into 4 phases: – Premonitory – Aura – Headache – Headache resolution

8. Headache history www.cks.library.nhs.uk/migraine Headache usually: – Frontotemporal – Unilateral – Of gradual onset, peaking after 2-12 hours, then gradually subsiding Attacks often begin in the morning, possibly waking the person but may begin at any time The frequency of attacks is extremely variable: – Some have several attacks a week – Others may go for years between attacks Other features include: – Anorexia, blurred vision, impaired consciousness, nasal stuffiness, hunger, pallor, sweating, heat or cold sensations

9. Predisposing factors www.cks.library.nhs.uk/migraine Different from trigger factors Their treatment may reduce migraine frequency They include: – Depression and anxiety – Head or neck trauma – Hormonal changes – menstruation and menopause – Stress (and relaxation after periods of stress)

10. Trigger factors www.cks.library.nhs.uk/migraine Most attacks have no obvious trigger They include: – Bright lights – Foods (certain alcoholic drinks, cheese, citrus fruits, chocolate) – Extremes of weather (v. hot or cold, strong winds) – Long distance travel – Loud noise – Missing meals – Strenuous unaccustomed exercise – Too much or too little sleep

11. Aura www.cks.library.nhs.uk/migraine Complex of focal neurological symptoms that precedes, accompanies, or rarely, follows an attack Develops over 5-20 mins and usually lasts < 60 minutes Headache usually develops within 60 mins of the end of the aura Visual aura is the most common type with fortification spectra, scotoma, simple flashes, specks and shimmerings Paraesthesia is the second most common type – Usually numbness in the hand, which migrates up the arm, then involves the face,lips and tongue Speech disturbances are the third most common type – Usually dysphasia Most people who have migraine with aura also have episodes of migraine without aura

12. What else could it be? www.cks.library.nhs.uk/headache, ICHD-IIR1 www.cks.library.nhs.uk/headache Tension type headache (TTH) – Most common type of headache – Usually mild to moderate severity – More commonly seen in women and those with sedentary lifestyles, is often stress related Cluster headache (CH) – 3-4x more common in men – Pain is excruciating, lasts 15-180 minutes, and may occur from once every other day to 8x daily – Attacks occur in clusters lasting for weeks or months, separated by remission periods lasting months or years Secondary headache – Attributed to underlying organic pathology et trauma, vascular disorder, cancer, psychiatric disorder, medication overuse

13. Migraine Headache lasting 4-72h At least 2 of the following: – Unilateral location – Pulsating character – Moderate to severe – Exacerbated by activity And at least one of the following: – Nausea and/or vomiting – Photophobia and phonophobia Without aura: at least 5 attacks With aura: at least 2 attacks Tension type headache Headache lasting 30 mins to 7 days At least 2 of the following: – Bilateral location – Non-pulsatile character – Mild to moderate – Not aggrevated by activity And neither of the following: – Nausea and/or vomiting – Photophobia and phonophobia (but may have one or the other)

14. Medication overuse headache (MOH) www.cks.library.nhs.uk/migraine Most common cause of intractable headache Affects up to 1 in 50 people – 5x more common in women Results from the chronic overuse of medication used to treat headache – Aspirin, paracetamol (esp combined with codeine), NSAIDs, triptans, opioids, ergotamine Does not develop when the same analgesia is used for other chronic conditions Consider in people with a pre-existing primary headache who says their headaches have worsened, and frequency of headache, and medication use, has, increased A detailed medication history is necessary

15. The POUNDing mnemonic Detsky ME, et al. JAMA 2006; 296: 1274-83 Pulsating headache Duration 4-72 hOurs without medication Unilateral headache Nausea or vomiting Disabling intensity (disrupts daily activities)

16. Rule out serious pathology – red flags NPS News 2005; 38 Goadsby PJ, BMJ 2006; 332: 25-9 Confusion Drowsiness Vomiting Neurological signs that persist between headaches Fever New headache in patient >50 years of age Sudden onset Headache that wakes patient Head injury Severe and debilitating pain Marked change in character or timing Neck stiffness Pain associated with local tenderness eg temporal artery

17. Complications www.cks.library.nhs.uk/migraine www.cks.library.nhs.uk/migraine Status migrainosus – debilitating migraine lasting over 72 hours Migrainous infarction – a cerebral infarction occuring during the course of a typical attack of migraine with aura It is associated with an increased risk of: – Ischaemic (not haemorrhagic) stroke – Cardiovascular disease (CVD) in women with migraine with aura – Depression, anxiety, panic disorder, bipolar disorder

18. Migraine management – overview www.cks.library.nhs.uk/migraine Identify any trigger factors, and avoid them if possible Treat in a stepwise manner until symptoms are controlled – 1 st line Rx is oral analgesia +/- anti-emetics – If 1 st line Rxs are ineffective treat with a triptan – Consider using combination therapy (triptan + analgesia + antiemetic) if triptan alone is ineffective Consider using prophylactic treatment if attacks are frequent and troublesome

19. Simple analgesics www.cks.library.nhs.uk/migraine Aspirin 600-900mg, NSAIDs, paracetamol +/- anti-emetics Start treatment early in the attack Gastric stasis during migraine reduces drug absorption – Soluble forms may be preferable as more quickly absorbed – Anti-emetics increase rate of absorption of analgesic Codeine and other opioid drugs, or combinations containing these should be avoided – Little additional benefit – Risk of medication overuse headache – Adverse effects eg reduced gastric motility

20. Prokinetic agents www.cks.library.nhs.uk/migraine As well as being anti-emetic they increase gastric emptying and increase the rate of absorption of oral analgesics More evidence supports metoclopramide usage but domperidone has fewer adverse effects Effective alone and synergistic in combination with analgesics and triptans A rectal anti-emetic (+/- analgesic) may be useful if a person is vomiting and oral therapy is not being absorbed – Diclofenac 100mg plus domperidone 30mg suppositories

21. Triptans www.cks.library.nhs.uk/migraine http://emc.medicines.org.uk/ www.cks.library.nhs.uk/migraine Do not take too early in an attack unlike standard analgesia – The first dose should be taken when the pain is beginning to develop (ie is mild) but not before this stage (eg during the aura stage) Find the best one for an individual patient by trial and error Sumatriptan is the most established triptan with the greatest associated clinical experience Contraindications include uncontrolled hypertension, CHD or cerebrovascular disease (or at risk of these)

22. Comparison of oral triptans to sumatriptan 100mg Ferrari MD, et al. Lancet 2001; 358: 1668-75 Differences between the triptans was small but may be clinically relevant to the individual patient There was a high degree of variability in individual response to specific triptans – If a particular triptan is not effective in an individual another can be tried which may be effective – If a triptan is poorly tolerated it can be switched If the initial dose of triptan proves ineffective a further dose is unlikely to be effective and should not be taken (except zolmitriptan) If the triptan successfully relieves pain, but there is a relapse, the dose can be repeated within 2-4 hours, in accordance with product licenses Treatment should be individualised for each person

23. Adverse effects www.cks.library.nhs.uk/migraine There is no evidence that any particular triptan is safer than another Triptan sensations include: – Warm-hot sensation – Tightness – Tingling – Flushing – Feelings of heaviness or pressure in face and limbs and occasionally the chest There are theoretical concerns that triptans may increase the likelihood of MI but extensive experience shows this is very rare Discontinue if there are intense chest pains or sensations as this could indicate vasoconstriction or anaphylaxis

24. Prophylactic drug treatment www.cks.library.nhs.uk/migraine Consider in patients with: – ≥ 2 attacks per week – Increasing headache frequency – Significant disability despite acute treatments – Cannot take suitable treatment Propranolol or amitriptyline are suitable first choices: – Good evidence to support use for the prevention of migraine – Metoprolol, timolol and atenolol are alternative beta-blockers Sodium valproate or topiramate are suitable 2 nd line: – Good evidence of efficacy – Clinical utility of topitamate limited and specialist input needed

25. Non-drug interventions www.cks.library.nhs.uk/migraine Lie down in a darkened quiet room Good physical fitness can lower the incidence and exercise should be encouraged Relaxation techniques, stress reduction and coping strategies are 1 st line treatments when stress and anxiety exist

26. Case study

27. Jane is 38 years old with a history of migraine without aura. The migraines started in her late teens. She takes aspirin and domperidone for the attacks which have become more frequent in the last few months since starting work on the check-in desk of a major airport. She has had to take several days off in the last few weeks and has been taking OTC ibuprofen regularly

28. What would you ask?

29. Have the characteristics of the headache pain changed? Has the frequency of the headaches changed? Are there any new associated symptoms? Has she noticed any new trigger factors? Does she take the aspirin and ibuprofen together? Is she fully recovered between attacks?

30. She says her headaches are similar in nature to usual but are happening almost every day. She has no new associated symptoms. She wonders is the stress of her new job isn’t helping. She takes aspirin and domperidone on the days when the headaches start but uses the ibuprofen on subsequent days is symptoms are still present. She has needed ibuprofen on almost every day during the last month

31. What do you think it could be?

32. Medication overuse headache

33. What advice would you offer?

34. Stop taking OTC ibuprofen. Headaches will initially worsen but improvement will be seen in weeks or months If the cause was ibuprofen she could try amitriptyline. If stress is associated advise relacation therapies eg self-help books, tapes, yoga If the patient is using medication more than 2 days per week on a regular basis this requires further Ix. Ask more about the frequency and timing of medication taking in relation to symptoms. The initial diagnosis should be reviewed

35. At what point would you consider prescribing a triptan?

36. Migraine should be managed in a stepwise manner until symptoms are controlled 1 st line is oral analgesia +/- anti-emetics which she has already tried If not tolerating oral medication consider parenteral or rectal medication If 1 st line is not effective consider a triptan Prophylactic treatment can be considered if attacks are frequent and troublesome