Wright, 2013 1 Management of Adult and Pediatric Migraines in Primary Care Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Adult/Family Nurse Practitioner Owner - Wright & Associates Family Healthcare Amherst, New Hampshire Owner – Wright & Associates Family Healthcare Concord, NH Partner – Partners in Healthcare Education Wright, 2013 Disclosures • Speaker Bureau: Novartis, GSK, Sanofi- Pasteur, Merck, Takeda, Vivus • Consultant: Vivus, Sanofi-Pasteur, Takeda Wright, 2013 Objectives • Upon completion, the participant will be able to: – Discuss current research regarding the etiology of primary headaches – Identify the signs and symptoms of migraines, tension, and cluster headaches – Discuss the various pharmacologic and non- pharmacologic treatments available for individuals with migraines, tension and cluster headaches Wright, 2013 Migraine Prevalence (American Migraine Study II) • There are currently 28 million migraine sufferers age 12+ in the United States • 21 million females: approximately 18.2% of women • 7 million males: approximately 6.5% of men • Migraine prevalence peaks in the 25-55 age range – These are the most productive years of the lifespan • One in 4 households has at least 1 migraine sufferer Lipton et al. Headache. 2001;41:638-657. Wright, 2013 Prevalence of Migraines • Children/adolescents/women suffer from migraine at a 3:1 ratio over men after puberty – Before puberty: 60% of all children with migraines are male • 1 in 6 American women suffer from migraines • Familial disorder – 70% of pediatric patients with migraines have a family history Wright, 2013 Migraine Prevalence Data from the CDC, US Census Bureau, and the Arthritis Foundation. Disease Prevalence in the US Population More common than asthma & diabetes combined Wright, 2013
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Wright, 2013 1
Management of Adult and Pediatric
Migraines in Primary Care
Wendy L. Wright, MS, RN, ARNP, FNP, FAANP
Adult/Family Nurse Practitioner
Owner - Wright & Associates Family Healthcare
Amherst, New Hampshire
Owner – Wright & Associates Family Healthcare
Concord, NH
Partner – Partners in Healthcare EducationWright, 2013
Disclosures
• Speaker Bureau: Novartis, GSK, Sanofi-
Pasteur, Merck, Takeda, Vivus
• Consultant: Vivus, Sanofi-Pasteur, Takeda
Wright, 2013
Objectives
• Upon completion, the participant will be able to:
– Discuss current research regarding the etiology of
primary headaches
– Identify the signs and symptoms of migraines,
tension, and cluster headaches
– Discuss the various pharmacologic and non-
pharmacologic treatments available for individuals
with migraines, tension and cluster headaches
Wright, 2013
Migraine Prevalence
(American Migraine Study II)
• There are currently 28 million migraine sufferers
age 12+ in the United States
• 21 million females: approximately 18.2% of women
• 7 million males: approximately 6.5% of men
• Migraine prevalence peaks in the 25-55 age range
– These are the most productive years of the lifespan
• One in 4 households has at least 1 migraine sufferer
Lipton et al. Headache. 2001;41:638-657. Wright, 2013
Prevalence of Migraines
• Children/adolescents/women suffer from migraine
at a 3:1 ratio over men after puberty
– Before puberty: 60% of all children with migraines
are male
• 1 in 6 American women suffer from migraines
• Familial disorder
– 70% of pediatric patients with migraines have a family
history
Wright, 2013
Migraine Prevalence
Data from the CDC, US Census Bureau, and the Arthritis Foundation.
Disease Prevalence in the US Population
More common than asthma &
diabetes combined
Wright, 2013
Wright, 2013 2
Mig rain e Prevalen ce:
US Female Po pulation
Wright, 2013
Headaches in Children
• Very common complaint among children
– 37 – 51% prevalence during elementary school years
– 57-82% - prevalence during high school years
• Most common recurrent headache in childhood is
migraine
• More common in boys before puberty
– After puberty, headaches are more common in girls
Wright, 2013
Headache Diagnosis: Primary
Versus Secondary Headache
Diagnose
Treat
Diagnose
Treat and/or
Refer
Secondary
Headache
Primary
Headache
Evaluate for Signs or Symptoms of Secondary Headache
Wright, 2013
Secondary Headaches:
Prevalence
• 1% of office HA presentations
• 3.8% of ED HA presentations
Bigal M, et al. Headache 2000;40:241-247. • Ramirez-Lassepas M, et al. Arch Neurol 1997;54:1506-1509.Wright, 2013
• Disease process: Average time to disease remission is 12-24
months; Range is 1-10 years
• Side effects of prednisone
– Calcium 1500mg qd
– Ophthamologic examinationWright, 2013
Additional Issues
• Given high/prolonged dosage of prednisone,
must consider risks of osteoporosis,
cataracts, glaucoma, diabetes, and obesity
• Increased incidence of depression
Wright, 2013
Waiting Room Study: Results
Compared with General Population
29%
36.9%
17.5%
12.6%
18.2%
6.5%
0
10
20
30
40
Overall Women Men
Pa
tie
nts
(%
)
Patients Visiting PCPs
General Population
Couch JR et al. Presented at: American Headache Society; June 19-22, 2003; Chicago, Ill. Wright, 2013
Wright, 2013 7
Diagnosed
Migraine
Undiagnosed
Migraine
Diagnosed
Migraine
Undiagnosed
Migraine
38%
62%
52%
48%
1989198919991999
The Diagnosis of Migraine Has
Increased Modestly (Using IHS
Criteria)
Lipton et al. Headache. 2001;41:638-645.
14.6 million migraine sufferers
remain undiagnosed
14.6 million migraine sufferers
remain undiagnosed
Wright, 2013Adapted from Lipton et al. Headache. 2001;41:638-645.
Diagnosed with
Tension HeadacheOther/No diagnosis
Undiagnosed Migraine Sufferers Often
Report Receiving a Diagnosis
of Tension Headache
Wright, 2013
In the Presence of Neck Pain
Tension Headache is Frequently Diagnosed
% o
f P
ati
ents
82%
18%
0%
20%
40%
60%
80%
100%
No YesPrevious Diagnosis of Tension Headache
Kaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.
n=108
Wright, 2013
Stress is the Most Frequently
Reported Trigger of Migraine% of Migraine Patients with Triggers
Scharff et al., Headache 1995; 35:397-403
n = 69
68%
55%
52%46% 45% 45%
72%
Wright, 2013
Adapted from Lipton et al. Headache. 2001;41:638-645.
Diagnosed with
Sinus HeadacheOther/No diagnosis
Undiagnosed Patients Often Report
Receiving a Diagnosis
of Sinus Headache
Wright, 2013
Migraine Can Be Triggered by
Weather
% of Migraine Patients with Triggers
Scharff et al., Headache 1995; 35:397-403
(n = 69)
Wright, 2013
Wright, 2013 8
Like Sinus Headache, Migraine May Present With Autonomic Symptoms
46% of patients had at least 1 autonomic symptom during
migraine attacks.
Of these,• 14% had only nasal symptoms
• 41% had only ocular symptoms• 46% had both nasal & ocular
symptomsBarbanti P, et al. Cephalalgia 2002;22:256-259.
Autonomic Symptoms
46%
Nasal&
Ocular46% Ocular
41%
Nasal14%
Wright, 2013
Summary of Clinical Data
• Most patients with self-described “sinus” headache:
– May actually have migraine and migrainous headache
as defined by IHS criteria (90%)
– Experience sinus pain and pressure, nasal symptoms,
ocular symptoms and weather as a trigger
– Are disabled by their headaches
– Are dissatisfied with Rx and OTC medications
they are using to treat these headaches
Wright, 2013
Female Life Ev en ts That
In flu en ce Migraine
Wright, 2013
Mig rain e an d Men arche
Wright, 2013
Men stru al Migrain e: Definition s
Wright, 2013
Ch aracteristics o f
Men stru ally -Asso ciated Migraine Attack s
Wright, 2013
Wright, 2013 9
Mig rain e Vulnerab ility During th e Menstrual Cy cle
Wright, 2013
Ho rmo n e Lev els Du ring Menstrual Cycle
Wright, 2013
Imp act o f Ho rmon es o n Migraine
Wright, 2013
New Insights into Migraine
Pathophysiology
A Scientific Hypothesis for the
“Tension-Like” and “Sinus Like”
Presentation of Migraine
Wright, 2013
The Migraine Process:
Activation of Nerves and Blood Vessels
Wright, 2013
The Migraine Process: Activation of the
Trigeminal Nucleus Caudalis (TNC)
Wright, 2013
Wright, 2013 10
Activation of the TNC can
Result in Referred Pain
Trigeminal Nucleus Caudalis (TNC):
Processing and Relaying Migraine Pain
Wright, 2013
Activation of the TNC May Result in
Referred Pain that Could be Perceived
Anywhere along the Trigeminocervical
Network
Activation of the TNC May Result in
Referred Pain that Could be Perceived
Anywhere along the Trigeminocervical
Network
Wright, 2013
Activation of the TNC May Result in Reflex
Activation of Cranial Parasympathetic Nerves
Extending into Sinus Cavities and Tear Ducts
Wright, 2013
Cranial Parasympathetic Activation May Explain
“Sinus-Like” Symptoms in Migraine
Wright, 2013
Pathophysiology of Migraine is No Longer Just
Neurovascular:
Multiple Mechanisms of Migraine Exist
Bolay H et al. Nature Medicine. 2001;8(2):136-142. Burstein R. Pain. 2001;89:107-110. Cady RK and Biondi DM. Postgraduate Medicine. 2006; Suppl (April):5-13. Hargreaves RJ, Shepheard SL. Can J Neurol Sci. 1999;26(suppl3):S12-19. Silberstein SD. Cephalalgia. 2004;24(Suppl 2):2-7. Williamson DJ, Hargreaves RJ. Microsc Res Tech. 2001;53(3):167-78. Woolf CJ. Ann Intern Med. 2004;140:441-451.
Wright, 2013
Using ID Migraine™*
During the last 3 months, did you have the following with your headaches:
1. You felt nauseated or sick to your stomach?
Yes____ No____
2. Light bothered you (a lot more than when you don’t have headaches)?
Yes____ No____
3. Did your headache limit your ability to work, study, or do what you needed to dofor at least 1 day?
Yes____ No____
a. Do your headaches limit your ability to work, study, or enjoy life?
orb. Do you want to talk to your health care professional about your headaches?
Prescreening Questions
Screening Questions
*Physician disclaimer: Answering the questions in the ID Migraine™ screener is not intended to provide a medical diagnosis for migraine. Since the ID Migraine™ screener relies on self-reporting, the health care professional should verify all responses. A definitive diagnosis of migraine is made on clinical grounds by a health care professional taking into account how well the patient understood the questionnaire as well as other relevant information. ID Migraine™ is a trademark of Pfizer Inc. Patent pending.Lipton RB et al. Neurology. 2003;61:375-382.Wright, 2013
Wright, 2013 11
Episodic Migraine Without Aura: Diagnostic Criteria
At Least 5 Attacks Fulfilling the Criteria Below
Associated Symptoms
One of the Following:
Nausea and or vomiting
Photophobia and phonophobia
Description of Headache
Two of the Following:
Unilateral location
Pulsating quality
Moderate or severe intensity(inhibits or prohibits daily activities)
Aggravated by or causing avoidance of routine physical
activity (eg, walking or climbing up stairs)
Headache attack lasting 4 to 72
hours (untreatedor unsuccessfully
treated)
AND
Olesen J et al. Cephalalgia. 2004;24(suppl 1):1-151.
Not attributable to
another disorder
Wright, 2013
Episodic Migraine with Aura:
Diagnostic CriteriaAt Least 2 Attacks Fulfilling the Criteria Below
Recurrent one or more fully reversible visual, sensory, and/or speech symptoms (focal neurological symptoms)
At least 1 aura symptom develops gradually over≥ 5 minutes, or different symptoms occur in succession
over ≥ 5 minutes
Each aura symptom lasts ≥ 5 minutes and ≤ 60 minutes
Migraine headache begins during or within 60 minutes of
aura
Meets the IHS criteria for migraine without aura
Three of the Following:
Olesen J et al. Cephalalgia. 2004;24(suppl 1):1-151.
Not attributable to another disorder
Wright, 2013
Episodic Tension-Type Headache:
Diagnostic CriteriaAt Least 10 Episodes Occurring < 1 Day/mo
Two of the Following:
AND Associated Symptoms
No nausea or vomiting (anorexia may occur)
Either photophobiaor phonophobia
Description of Headache
Pressing/tightening quality(nonpulsating)
Mild or moderate intensity(may inhibit, does not prohibitactivities)
Bilateral location
Not aggravated by physical activity such as walking or climbing stairs
Headache
lasting 30
minutes to 7 days
Both of the Following:
Olesen J et al. Cephalalgia. 2004;24(suppl 1):1-151.
Not
attributable
to another disorder
Wright, 2013
Episodic Cluster Headache:
Diagnostic CriteriaAt Least 5 Attacks Fulfilling the Criteria Below