Understanding Migraine
Understanding Migraine
MigraineMigraine
Migraine is a Migraine is a recurrent headache recurrent headache that lasts 4that lasts 4--72 hours72 hours
18% of women18% of women
6% of men6% of men
Typical Features of MigraineTypical Features of Migraine
Usually one sidedUsually one sided
Pulsating, throbbing, poundingPulsating, throbbing, pounding
Aggravated by routine physical Aggravated by routine physical activityactivity
Associated with nausea and Associated with nausea and vomitingvomiting
Sensitivity to light / noiseSensitivity to light / noise
“ ID Migraine ““ ID Migraine “
Has a headache limited Has a headache limited your activities for a day or your activities for a day or more in the last 3 more in the last 3 months?months?
Are you nauseated or sick Are you nauseated or sick to your stomach when you to your stomach when you have a headache?have a headache?
Does light bother you Does light bother you when you have a when you have a headache?headache?
MigraineMigraine
Aura Aura ------ 15%15%
Warning signs Warning signs ------ 70%70%•• FatigueFatigue
•• Mood changesMood changes
•• Food cravingsFood cravings
•• Poor concentrationPoor concentration
Pathophysiology of MigrainePathophysiology of Migraine
The nervous system is The nervous system is more sensitive and more sensitive and vigilant to the vigilant to the environmentenvironment
Pathophysiology of MigrainePathophysiology of Migraine
Vasoconstriction of Vasoconstriction of vessels vessels
Vasodilatation of Vasodilatation of vesselsvessels
Inflammation of Inflammation of vesselsvessels
Approach to TreatmentApproach to Treatment
Goal is to give the Goal is to give the patient control over patient control over their headaches their headaches instead of the instead of the headaches headaches controlling the controlling the patient’s life.patient’s life.
Principles of TreatmentPrinciples of Treatment
Prevention Prevention (prophylactic (prophylactic measures)measures)
Abortive treatmentAbortive treatment
Elimination of Elimination of intractable migrainesintractable migraines
Preventive MeasuresPreventive Measures
DietDiet
SleepSleep
ExerciseExercise
Weight lossWeight loss
Caffeine regulationCaffeine regulation
Smoking cessationSmoking cessation
MedicationsMedications
DietDiet
Don’t Skip Meals!!!Don’t Skip Meals!!!
Big Four: chocolate, Big Four: chocolate, nutrasweet, caffeine nutrasweet, caffeine and MSGand MSG
Keep a headache Keep a headache diarydiary
SleepSleep
Goal is 7Goal is 7--8 hrs of 8 hrs of restful sleeprestful sleep
Increased frequency Increased frequency with < 6 hrs of sleepwith < 6 hrs of sleep
Increased frequency Increased frequency with > 9 hrs of sleepwith > 9 hrs of sleep
Regulate sleep 7 days Regulate sleep 7 days per weekper week
Disorders of SleepDisorders of Sleep
Poor sleep hygienePoor sleep hygiene
Sleep apneaSleep apnea
DepressionDepression
Exercise / Weight LossExercise / Weight Loss
Adipose tissue secretes Adipose tissue secretes proteins & hormones that proteins & hormones that help regulate immunity & help regulate immunity & inflammation inflammation (adiponectin, interleukin(adiponectin, interleukin--6)6)
Dieting and exercise can Dieting and exercise can improve headachesimprove headaches
Weight may affect choice Weight may affect choice of medicationsof medications
CaffeineCaffeine
Positive and negative Positive and negative effects on health and effects on health and headacheheadache
Blocks adenosine Blocks adenosine receptorsreceptors
Mild analgesic effectMild analgesic effect
Promotes absorption of Promotes absorption of other analgesicsother analgesics
Therapeutic levels in Therapeutic levels in brain in 20 minutesbrain in 20 minutes
Negative Effects of CaffeineNegative Effects of Caffeine
Amounts > 200 mg Amounts > 200 mg daily can produce daily can produce anxiety, dysphoria and anxiety, dysphoria and panic attackspanic attacks
Caffeinism = Caffeinism = nervousness, nervousness, agitation, severe agitation, severe anxiety , panic attacksanxiety , panic attacks
CaffeineCaffeine
Average intake Average intake –– 200 200 ––300 mg daily300 mg daily
Coffee (brewed) Coffee (brewed) –– 115 115 mgmg
Tea Tea –– 40 mg40 mg
Chocolate Chocolate –– 35 mg35 mg
Energy drinks Energy drinks –– 48 48 ––300 mg300 mg
CaffeineCaffeine
Caffeine in MedicationsCaffeine in Medications
Excedrin Excedrin –– 65 mg65 mg
Anacin Anacin –– 32 mg32 mg
Midol Midol –– 32 mg32 mg
Fiorinal/ FioricetFiorinal/ Fioricet–– 40 mg 40 mg
Wigraine Wigraine –– 100 mg100 mg
Norgesic Forte Norgesic Forte -- 60 mg60 mg
Darvon Compound 65 Darvon Compound 65 –– 32.4 mg32.4 mg
Typical Dose Related ReactionsTypical Dose Related Reactionsof Caffeineof Caffeine
100 100 –– 200 mg = well being200 mg = well being
300 300 –– 400 mg = anxiety, dysphoria400 mg = anxiety, dysphoria
340 340 –– 750 mg = severe anxiety, panic 750 mg = severe anxiety, panic attacksattacks
5 5 –– 10 grams ( 75 cups of coffee ) = lethal 10 grams ( 75 cups of coffee ) = lethal dosedose
Caffeine Withdrawal Caffeine Withdrawal SymptomsSymptoms
After 24 hrs of caffeine After 24 hrs of caffeine withdrawal may withdrawal may experience: experience: Headache ( increased Headache ( increased cerebral blood flow )cerebral blood flow )Nausea / vomitingNausea / vomitingDepressionDepressionAnxietyAnxietyDrowsiness/ impaired Drowsiness/ impaired concentrationconcentrationMuscle achesMuscle aches
Official Criteria for CaffeineOfficial Criteria for CaffeineWithdrawal HeadacheWithdrawal Headache
Monthly caffeine intake of 15 gramsMonthly caffeine intake of 15 grams
Headache occurs within 24 hours of last Headache occurs within 24 hours of last caffeine intakecaffeine intake
Head pain relieved within one hour after Head pain relieved within one hour after consuming 100 mg of caffeineconsuming 100 mg of caffeine
Prevention of Caffeine Prevention of Caffeine WithdrawalWithdrawal
Limit consumption to 2 cups of coffee per Limit consumption to 2 cups of coffee per day ( 200 mg )day ( 200 mg )
Withdrawal more likely if consuming > 500 Withdrawal more likely if consuming > 500 mg per daymg per day
Gradually decrease consumptionGradually decrease consumption
SmokingSmoking
Smoking increases Smoking increases frequency of frequency of headachesheadaches
Smoking cessation:Smoking cessation:•• ChantixChantix
•• ZybanZyban
•• Nicotine patches/gumNicotine patches/gum
•• HypnosisHypnosis
PreventionPrevention
When to Consider PreventionWhen to Consider Prevention
Headache occurs more than 2 days per weekHeadache occurs more than 2 days per week
Use of acute medications more than 2 days per Use of acute medications more than 2 days per weekweek
Headache attacks that are disabling despite Headache attacks that are disabling despite treatment treatment
Prolonged aura, complex aura or migraineProlonged aura, complex aura or migraine--induced strokeinduced stroke
Patient desires to reduce frequencyPatient desires to reduce frequency
Principles of PreventionPrinciples of Prevention
Reduce frequency of attacks by more than 50%Reduce frequency of attacks by more than 50%
Start low ; Go slowStart low ; Go slow
Often requires lower dosagesOften requires lower dosages
May take 2May take 2--3 months to see benefit3 months to see benefit
Maintain for 6Maintain for 6--12 months once 50% reduction 12 months once 50% reduction achieved, then taperachieved, then taper
Reduces cortical spreading depression (CSD)Reduces cortical spreading depression (CSD)
OTC Medications for OTC Medications for PreventionPrevention
MagnesiumMagnesium
Riboflavin (Vit B2)Riboflavin (Vit B2)
MelatoninMelatonin
MagnesiumMagnesium
Relaxant effect on Relaxant effect on smooth musclessmooth muscles
Part of messenger Part of messenger system in the system in the serotonin cascadeserotonin cascade
Daily HA sufferers and Daily HA sufferers and pts. with menstrually pts. with menstrually related migraines related migraines benefitbenefit
MagnesiumMagnesium
Sources Sources –– nuts, whole nuts, whole grains, tomatoesgrains, tomatoes
Supplements Supplements –– 500 500 ––750 mg daily750 mg daily
40 40 –– 90 % average 90 % average headache reductionheadache reduction
Riboflavin (VIT B2)Riboflavin (VIT B2)
Assists with Assists with production of ATP in production of ATP in nerve cells nerve cells –– energy energy moleculemolecule
At least three trials At least three trials suggest it reverses suggest it reverses “energy crisis” during “energy crisis” during migrainemigraine
Riboflavin (Vit B2)Riboflavin (Vit B2)
Sources Sources –– bread, bread, cereals, milk, meat cereals, milk, meat and poultryand poultry
Recommended daily Recommended daily dose is 400 mg dose is 400 mg
Improvement seen in Improvement seen in 50% of patients50% of patients
MelatoninMelatonin
Sleep is one of Sleep is one of nature’s ways of nature’s ways of dealing with migrainedealing with migraine
Melatonin is also used Melatonin is also used as a sleep aidas a sleep aid
MelatoninMelatonin
Migraine Migraine –– 1 mg 1 mg starting dose; titrate starting dose; titrate up to 3 mg daily if up to 3 mg daily if neededneeded
Cluster Cluster –– 9 9 –– 12 mg 12 mg daily; use with daily; use with medical supervisionmedical supervision
EvidenceEvidence--based Recommendations based Recommendations for Preventive Treatmentfor Preventive Treatment
Major Classes of Medications for Major Classes of Medications for PreventionPrevention
BetaBeta--adrenergic blockersadrenergic blockers
AntidepressantsAntidepressants
Anticonvulsants Anticonvulsants (neurostabilizers)(neurostabilizers)
Calcium antagonistsCalcium antagonists
NSAIDsNSAIDs
Medications with High Efficacy and Medications with High Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events
Amitriptyline (10Amitriptyline (10--150mg/day)150mg/day)
Depakote (125Depakote (125--200 mg/day)200 mg/day)
Propranolol (20Propranolol (20--160mg/day)160mg/day)
Timolol (10Timolol (10--30mg/day)30mg/day)
Topiramate (50Topiramate (50--150mg/day)150mg/day)
Medications with Lower Efficacy and Medications with Lower Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events
Atenolol (25Atenolol (25--100mg/day)100mg/day)
Metoprolol (50Metoprolol (50--200mg/day)200mg/day)
Gabapentin (300Gabapentin (300--2400mg/day)2400mg/day)
Prozac (10Prozac (10--80mg/day)80mg/day)
Botox (25Botox (25--100 units/3 months)100 units/3 months)
Medications with Lower Efficacy and Medications with Lower Efficacy and Mild to Moderate Adverse EventsMild to Moderate Adverse Events
NSAIDs (naproxen, NSAIDs (naproxen, ketoprofen, ketoprofen, fenoprofen)fenoprofen)
Verapamil (120 Verapamil (120 –– 480 480 mg/d)mg/d)
ASA (325mg/day)ASA (325mg/day)
Medication Use Based on OpinionMedication Use Based on Opinion
Antidepressants ( zoloft, doxepin, paxil, Antidepressants ( zoloft, doxepin, paxil, nortriptyline)nortriptyline)
DiltiazemDiltiazem
Periactin ( cyproheptadine)Periactin ( cyproheptadine)
Methergine (methylergonovine)Methergine (methylergonovine)
Principles of Abortive Principles of Abortive TherapyTherapy
Use the most effective Use the most effective therapy at the onset of therapy at the onset of the migraine the migraine
Must always have Must always have medication with you!medication with you!
Try to limit acute Try to limit acute treatments to 3x per treatments to 3x per weekweek
Common Abortive MedicationsCommon Abortive Medications
NSAIDsNSAIDs
Combination analgesics with caffeineCombination analgesics with caffeine
Midrin (acetaminophen, dichloralphenasone, Midrin (acetaminophen, dichloralphenasone, isometheptene)isometheptene)
Triptan plus Naproxen (500 mg)Triptan plus Naproxen (500 mg)
AntiemeticsAntiemetics
TriptansTriptans
Use with Naproxen Use with Naproxen 500 mg at onset of 500 mg at onset of migrainemigraine
Use most appropriate Use most appropriate delivery modedelivery mode
Failure = no response Failure = no response to three different to three different triptanstriptans
EvidenceEvidence--based Recommendations based Recommendations for Acute Treatment of Migrainefor Acute Treatment of Migraine
Triptans as initial Triptans as initial treatment for moderate to treatment for moderate to severe migraine severe migraine –– Grade AGrade A
Triptans as initial Triptans as initial treatment for migraine of treatment for migraine of any severity when any severity when nonspecific treatment nonspecific treatment has failed has failed –– Grade CGrade C
EvidenceEvidence--based Recommendations based Recommendations for Acute Treatment of Migrainefor Acute Treatment of Migraine
DHE nasal spray for moderate DHE nasal spray for moderate to severe migraine to severe migraine -- Grade AGrade A
DHE (IM,SC) for moderate to DHE (IM,SC) for moderate to severe migraine severe migraine –– Grade BGrade B
DHE ( IV ) plus antiemetic ( IV ) DHE ( IV ) plus antiemetic ( IV ) for severe migraine for severe migraine –– Grade BGrade B
Ergomar for moderate to severe Ergomar for moderate to severe migraine migraine –– Grade BGrade B
EvidenceEvidence--based Recommendations based Recommendations for Acute Treatment of Migrainefor Acute Treatment of Migraine
Reglan ( IV / IM ) to control Reglan ( IV / IM ) to control nausea nausea –– Grade CGrade C
Reglan ( IV ) as Reglan ( IV ) as monotherapy for migraine monotherapy for migraine pain relief pain relief –– Grade BGrade B
Compazine ( IV, IM, PR ) for Compazine ( IV, IM, PR ) for migraine in appropriate migraine in appropriate setting setting –– Grade BGrade B
EvidenceEvidence--based Recommendations based Recommendations for Acute Treatment of Migrainefor Acute Treatment of Migraine
Acetaminophen not recommended Acetaminophen not recommended –– Grade BGrade B
NSAIDs and combination NSAIDs and combination analgesics with caffeine as firstanalgesics with caffeine as first--line treatment for mildline treatment for mild--moderate moderate attacks attacks –– Grade AGrade A
Midrin for mild to moderate Midrin for mild to moderate headaches headaches –– Grade BGrade B
Corticosteroids (dexamethasone Corticosteroids (dexamethasone 16 mg IV or PO) for rescue therapy 16 mg IV or PO) for rescue therapy for status migrainosus for status migrainosus –– Grade CGrade C
Efficacy but Adverse Events ConcernEfficacy but Adverse Events Concern
MethylsergideMethylsergide
Vitamin A Vitamin A –– overuse overuse associated with associated with pseudotumor cerebripseudotumor cerebri
Pyridoxine (Vit B6) Pyridoxine (Vit B6) ––may be toxic in doses may be toxic in doses exceeding 150mg/dayexceeding 150mg/day
Difficult to Treat MigrainesDifficult to Treat Migraines
Migranal nasal sprayMigranal nasal spray•• One spray each nostril One spray each nostril
•• May repeat in 15 mins.May repeat in 15 mins.
•• Max: 4 sprays / attack Max: 4 sprays / attack 6 sprays / 24 hrs 6 sprays / 24 hrs 8 sprays / week8 sprays / week
•• Use with an antiemeticUse with an antiemetic
Difficult to Treat MigrainesDifficult to Treat Migraines
D.H.E. 45 D.H.E. 45 (dihydroergotamine)(dihydroergotamine)
•• 1 mg IM / IV1 mg IM / IV
•• May repeat in 1 hr x 2May repeat in 1 hr x 2
•• Max: 3 mg / attack Max: 3 mg / attack 6 mg / week6 mg / week
•• Use with an antiemeticUse with an antiemetic
Intractable MigraineIntractable Migraine
Inflammation !!!Inflammation !!!
Dexamethasone 8mg /16 Dexamethasone 8mg /16 mg IM, IV or oralmg IM, IV or oral
Prednisone 50 mg daily x Prednisone 50 mg daily x 3 days3 days
Solumedrol 80 mg IMSolumedrol 80 mg IM
Toradol 60 mg IMToradol 60 mg IM
Intractable MigraineIntractable Migraine
D.H.E. 45 D.H.E. 45 -- 1 mg IM /IV with 1 mg IM /IV with an antiemetican antiemetic
Magnesium sulfate 2 Magnesium sulfate 2 grams IV over 30 minutesgrams IV over 30 minutes
Benadryl 50 mg IV/IMBenadryl 50 mg IV/IM
Antiemetics Antiemetics –– zofran, zofran, phenergan, compazine , phenergan, compazine , reglan (IV / IM)reglan (IV / IM)
Inpatient TreatmentInpatient Treatment
IV antiemetic followed IV antiemetic followed by D.H.E. 45 1 mg IV by D.H.E. 45 1 mg IV
Repeat every 8 hours x Repeat every 8 hours x 3 days3 days
The EndThe End