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Practice Pearls : Diagnosis & Prophylaxis of Migraine
Prof. A.V. SRINIVASAN,
MD, DM, Ph.D,DSc(HON) F.A.A.N, F.I.A.N.
Emeritus Professor
The Tamilnadu Dr. M.G.R. Medical University
Former Head
Institute of Neurology, Madras Medical College
Adjunct Prof.
IIT Madras
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IHS Guidelines Diagnosis of Migraine
Presence of two or more Head related symptoms
1. Moderate to severe Pain
2. Pain on one side of head
3. Throbbing Pulsating headache
4. Headache exacerbated by routine activities
Presence of one or more Non headache symptoms
1. Aura
2. Nausea during headache
3. Photophobia, Phonophobia during headache
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How to approach the patientwith a headache ?
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Diagnosis
Algorithm
Patients presents with complaint of a headache
Critical first steps :• Detailed history• Focused physical examination• Focused neurological examination• BP, Ocular/Fundus Examination
no
Meets criteria for primary headache
disorder?
yes
Consider secondary headache disorder Specialty consultation
indicated
Migraine
Cluster Headache
Tension-type Headache
Other headaches - sinus
Worrisome Headache: Red Flags – “SNOOP””
no
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SNOOP
• Systemic Symptoms such as fever or weight loss or Secondary Risk
factors as HIV or systemic cancer
• Neurologic Symptoms or abnormal signs such as confusion, impaired
alertness, papilloedema, asymmetry, motor weakness, nuchalrigidity, visual disturbance other than aura, dysphasia
• Onset Sudden, abrupt, split-seconds to minutes, rapid onset of
headache
• Older New headache onset in an older patient or a progressively
worsening headache in a middle-aged patient (>50 years of age)
• Progression Previous headache history-A major change in attack
frequency, severity, or clinical features; a first headache pattern ordifferent headache unlike any experienced before
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Simplifying history taking for migraine diagnosis
Sensitivity to light &/or sound
Unilateral or bilateral
Stomach uneasiness
Pulsating or throbbing headache
Episodic headache
Connected with
Triggers
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Migraine: Triggers
Migraines occur in response to stimuli inup to 85% of patients
Common triggers related to :
• Environment (weatherchanges, smoke, bright lights, certainsmells)
• Emotions (stress, anxiety, crying)
• Change in sleep pattern
• Diet (cheese, red wine, chocolate, nitrates)
• Skipping meals
• Estrogen (menstrual cycle)
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Detailed History
•Characteristics of the headache
•Assess functional impairment
•Past medical history
•Family history of migraines
•Current medications and previous medications for headache (Rx and over-the-counter)
•Social history
•Review of systems – to rule out systemic illness
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Diagnosis of migraine currently based onInternational Headache Society (IHS) classification
Primary headache is headache not caused byanother disorder
Migraine and tension-type account for 75%-90% ofprimary headache
IHS Classification System: Primary Headache
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Migraine Episodic, throbbing, usually unilateral headache
May be preceded by visual, sensory or speechdisturbances and also accompanied bynausea, vomiting
Tends to be disruptive, a significant loss in quality oflife and inability to perform their daily activities
Migraine is a heterogeneous disorder
- attacks vary in theirfrequency, duration, severity and number ofassociated symptoms
Duration : 4 – 72 hrs (average 24 hrs.)
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Tension headaches
• Band-like, bilateral
• Tightness/pressure/dull ache
• Radiates to neck and shoulders
• Mild to moderate
• Not aggravated by movement
• 30 min to several days
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Tension Headache vs Migraine
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Cluster headache
• Rare condition that can be acute orchronic in nature
• Characterized by 1-3 short-lived i.e.15min – 3hrs (avg. 45 min) attacks ofperi-orbital pain
• Occurs in clusters for 2-3 months,followed by pain-free interval of oneyear
• Attack often associated with redtearing eyes, nasal stuffiness andptosis.
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CHARACTERISTIC MIGRAINE TENSION CLUSTER
Age of onset 25 to 55 years 30 to 50 years 20 to 40 years
LocationUnilateral (but may be
bilateral)Bilateral
Unilateral, orbital,
supraorbital, temporal
Duration of episode 4 to 72 hrs 30 min to 7 days 15 to 180 min
Severity Moderate to severe Mild to moderate Extremely severe
Type Pulsating, throbbing Pressing, tightening but not
pulsating
Boring, searing
Pattern 1 to 2 attacks per month <180 attacks per year (or
<15 attacks per month)
1 to 8 attacks per day
separated by pain- free
periods
Associated
symptoms
Nausea, vomiting,
photophobia,
phonophobia (2 of
these)
Either photophobia or
phonophobia, but not both,
no nausea or vomiting
Conjunctival injection
Lacrimation
Forehead/facial swelling
Nasal congestion
Rhinorrhea Ptosis Miosis
Eyelid edema
Comparison of Most Common Primary Headaches
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MIGRAINE MAY OFTEN BE MISDIAGNOSED As
SINUS HEADACHE
– SIMILAR DISTRIBUTION OF PAIN
– MIGRAINES CAN BE SEASONAL
– WITHDRAWAL FROM DECONGESTANTS CAN PRECIPITATE MIGRAINES
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Sinus-related headache may also confuse the diagnosis of migraine
Parameters Sinus headacheMigraine
Face Pain + -
Infection + -
Upper Respiratory Problems + -
Fever, purulent discharge and
postnasal drip + -
Pale or pink nasal mucosa + +/-
Significant sinus fluid levels + -
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Performing the physical exam
• PE should include vital signs, a complete neurologic exam (including funduscopicexam), CV, head, and neck exam
• A complete neurologic examination is essential
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Performing the neurological examination
• mental status
• level of consciousness
• cranial nerve testing
• pupillary responses
• funduscopic exam
• motor strength testing
• deep tendon reflexes
• sensation
• pathologic reflexes (e.g. Babinski's sign)
• cerebellar function and gait testing
• signs of meningealirritation (Kernig's and
Brudzinski's signs).
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Fundoscopic exam
• Papilledema
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Secondary headache disorders are a symptom ofanother disease
A common type of secondary headache is calledrebound headache - the result of overuse of analgesicmedications (MOH)
Another type is sinus headache - sometimesincorrectly diagnosed when condition is really migraine
IHS Classification System: Secondary Disorders
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Treat the migraine attack, Prevent the disorder
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AE Profile Migraine Type
Relative Drug
Efficacy
Coexisting
Conditions
Patient
Preference
Principles of Prevention Factors Influencing Medication Choice
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Acute Therapy: Pros and Cons
POSITIVES:
– Rapid onset of action
– Ideal for occasional migraine
NEGATIVES:
– Doesn’t address frequency of attacks or impact on quality of life
– If not taken at onset, less effective
– Acute therapies not always effective
– Undesirable side effects
– Frequent use can cause medication overuse headache (“rebound” headache)
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MIGRAINE PROPHYLAXIS
Aim of pharmacologic prophylaxis in migraine:
1. reducing the number of migraine days per month,
2. reducing headache pain and associated symptoms,
3. shortening individual attacks,
4. improving the effect of acute medication,
5. preventing medication-overuse headache
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Preventive Therapy: Advantages
• Reduces frequency of migraines, so that thepatients can live more normal & productive life
• Reduces use of acute medications – and possible“rebound” headache
• Reduces overutilization of medical resources,including:• Emergency room visits
• Physician office visits
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Candidates for migraine preventionUS-Guidelines for the use of preventive medication
• Recommendations are based on
1. headache days per month experienced by migraine patients
2. Level of attack-related impairment caused by the headaches
Migraine prevalence, disease burden, and the need for preventive therapy,Lipton et al. Neurology 2007;68;343-349
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Candidates for migraine preventionUS-Guidelines for the use of preventive medication
• II. Prevention should be considered:
– Patients with 4 or 5 migraine days per month with normal functioning,
– 3 migraine days with some impairment, or
– 2 migraine days with severe impairment.
Migraine prevalence, disease burden, and the need for preventive therapy,Lipton et al. Neurology 2007;68;343-349
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Guidelines for migraine prophylaxis Successful therapy
A migraine prophylaxis is considered successful ifthe frequency of migraine attacks per month isdecreased atleast by 50% within 3 months
Evers S et al. Eur J Neurol 2006;13:560-572
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• Preventive therapy to be continued for atleast 1 year
• Preventive therapy needs to be taken everyday because it requires dose-titration and may take several months to achieve the desired effect.
• Therapy from 6 to 12 months may be required, before evaluation ofefficacy
• A full therapeutic trial can take 2 – 6 months
Freitag FG. Clinical Therapeutics 2007; 29: 939-949
Silberstein SD. Trends in Pharmacological Sciences 2006; 27: 410-415
Peterlin BL. Headache 2008;48: 805-819
Guidelines for migraine prophylaxis Duration of therapy
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Potential Mechanisms of preventive medication
Silberstein SD. Trends in Pharmacological Sciences 2006; 27: 410-415
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Prophylactic Treatment Of Migraine
Assess factors that may trigger migraine
First-line treatment:
- Calcium channel blockers (flunarizine)
- Beta-blockers
- Anti-epileptic drugs – (Divalproex & Topiramate)
Successful ?*
Try combination
no
yesContinue treatment for 6-12 months, then reassess
Successful ?*
Refer to Neurologist or Headache Specialist
no
yes Continue treatment for 6-12 months, then reassess
* A migraine prophylaxis is considered successful if thefrequency of migraine attacks per month is decreasedatleast by 50% within 3 months.
Reinforce education and lifestyle management
Consider other therapies (biofeedback, relaxation)
Screen for depression and generalized anxiety
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Techniques in Regional Anesthesia and Pain Management 2009;13:20-27.
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Migraine activity starts in the Cortex
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Patients with migraine exhibit
high cortical excitability
Cortical hyperexcitability
Frequency of migraine Attacks
National Headache Foundation Migraine Prevention Summit Proceedings 2006
Cortical spreading depression (CSD) a main culprit behind migraine attacks
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Migraine - A Channelopathy
Genetic mutations leads to defective Na+ and Ca++ channels which are linked to migraine
Widely used drugs for migraine prevention work by inhibiting the function of one or both of these ion channels(Na+, Ca2+)*
*Cohen et al ,Medical Hypotheses (2005) 65, 114–122
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To prevent CSD
Its necessary to block both the channels:Na+ and Ca++
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Na + and Ca2+ current inhibition by Flunarizine
Concentration-dependent effects of FLN on I CaConcentration-dependent effects of FLN on I Na
Q.Ye,etal., Chinese Medical Journal 2011;124(17):2649-2655
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Beta-blockers compared with Placebo
• Early studies can be criticized from a methodological point of view
• Propranolol, nadolol, timolol, metoprolol and atenolol have shown better efficacy than placebo in RCT
• Some trials failed to show a significant prophylactic effect of propranolol
• Two RCT have not shown any effect in the acutetreatment of attacks
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Beta-blockers compared with Placebo
• Early studies can be criticized from a methodological point of view
• Propranolol, nadolol, timolol, metoprolol and atenolol have shown better efficacy than placebo in RCT
• Some trials failed to show a significant prophylactic effect of propranolol
• Two RCT have not shown any effect in the acutetreatment of attacks
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Beta-blockers: side effects
• Propranolol 80-0-80 mg– With side effects 35 %
– Without side effects 48 %
• Most commonly reported– Fatigue 18 %
– Dizziness 2 %
– Nausea 6 %
– Sleep disturbances 4 %
– Depression 4 %
– Abnormal dreaming 2 %
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Flunarizine vs Propranolol
Post Treatment Benefits
Bordini CA et al. Arquivos de Neuro-Psiquiatria 1997; 55 :536-541.
30
60
50
80
70
0
90
40
N = 45
% o
f re
spo
nd
en
ts
PropranololFlunarizine% of patients with very good or excellent response
in terms of global evaluation after 45 days of drug withdrawal
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Antiepileptic drugsDrug Dose Common side effects Contraindications
Valproic acid 500-1800 mg
Tiredness, cognitive deficits, dizziness, upset stomachnausea, vomiting, hair loss, weight gain, depression, tremor, pancreatitis, hepatitis (test of liver function necessary during treatment)
hepatic disease or significant hepatic dysfunction,childbearing potential, pregnancy
Topiramate 25-100 mg Paresthesia, Dizziness, Asthenia, Weight Decrease, Somnolence, Difficulty with Memory, Depression, Difficulty with Concentration/Attention, Anxiety, Taste Perversion, Upper Respiratory Tract Infection, Suicidal thinking, diabetes, kidney stones
childbearing potential, pregnancy
EFNS guidelines on the drug treatment of migraine. European Journal of Neurology 2009, 16, 968-981
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Migraine progression
- Consequence of CSD
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- Headache 2008;48:7-15)
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Migraine Progression
Clinical
Anatomical
Physiological/ functional
3 Types of Migraine Progression
Increase in attack frequency
Alterations in pain pathways
Neurological damage
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Anatomical progression - Neurological damage in Migraine
• Neuroimaging findings of a large-scale population-based study showed that silent brain damage is more frequent in migraineurs, compared with control subjects.
• Migraine is associated with white matter lesions.
• Clinical studies reported that migraine is a risk factor for ischemic stroke in younger women.
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Reference: Headache 2008;48:1044-1055
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Study detailsJournal of Headache Pain (2011) 12:47–53
Official journal of European Headache Federation
• Study results
• Flunarizine reduced– Number of CSD waves
– Amplitude of CSD waves
– Duration of CSD waves
Flunarizine a potent CSD inhibitor
FLN does not only prevent the migraine disorder but also may reduce complications of migraine like neurological damage
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Prevent the
progression from
Episodic to
Chronic Migraine
StartEarly Effective Migraine
Prophylaxis