Hi All,
Here’s a great talk by James U Adleman from the Headache and Wellness Centre in North Carolina about migraine management.
mvertigo.org/audio/migraine_management.mp3
[size=120]SUMMARY[/size]
MANAGING MIGRAINE —James U. Adelman, MD, Associate Clinical Professor of Medicine, Department of Neurology, University of North Carolina, Chapel Hill, and Staff Neurologist, Headache Wellness Center, Greensboro, NC
Introduction: only about one-half of patients with migraine correctly diagnosed; of those diagnosed incorrectly, 42% diagnosed as having sinus-type headache and 32% as having tension-type headache; survey showed that 94% of patients who sought treatment in physicians’ offices had migraine (migraine is type of headache that gets severe enough for patients to seek treatment); although tension-type headache most common in population, it usually responds readily to over- the-counter analgesics, and patients do not seek physicians’ help.
What is migraine? currently defined as episodic headache with any type of disability; disability not necessarily absence from work or school (impaired performance at work or school also qualifies as disability); current approach is to stop individual headaches and to reduce frequency of headaches; order in which to address problems depends on individual patient’s circumstances; rather than asking patient how many headaches he or she has per month, speaker asks how many days per month patient is headache-free (if asked how many headaches per month, patients tend to count only “bad” headaches, but on further questioning, admit to having some degree of headache almost every day); if patient free of headache most days, focus therapy on preventing or stopping individual headaches; if patient has headache most days, focus on reducing frequency.
Components of treatment: education; behavioral therapy (“which is terribly important”); pharmacologic therapy; abortive therapy; preventive treatment; stages of migraine include prodrome, aura (in patients who have auras), mild stage, moderate to severe stage, and postdrome.
Acute care treatment: “window of opportunity” occurs in first hour after patient senses he or she is getting headache (prodrome and mild stage); ≈65% of patients report that headache can be prevented with treatment (speaker prefers nonsteroidal anti-inflammatory drug, “perhaps with metoclopramide”).
Aura: unclear whether to treat during aura stage; 2 studies showed that treating with subcutaneous (SQ) sumatriptan and eletriptan during aura not effective, but in other studies, some patients did benefit from oral triptan during aura; some patients report that treating too early not effective, so speaker recommends that patient wait until mild stage to take oral triptan.
Bottom line: acute care treatment depends on ultimate pain level and on rapidity with which headache develops; if pain rises to moderate to severe level over 0.5 to 1.5 hr, specific (as opposed to nonspecific) pain medications needed, and triptans specific.
Triptans: attack 5HT1B and 1D receptors; because of specificity, side effects fewer; work rapidly and efficiently; SQ injection—most rapid onset with SQ sumatriptan, available in 6-mg and 4-mg injections; only triptan available in injectable form; recommended for patients who awaken with headache, nausea, or vomiting; nasal sprays— sumatriptan available in 20-mg and 5-mg doses; speaker prefers 20-mg dose; zolmitriptan available in 5-mg dose; oral agents—rapidly dissolving tablets include zolmitriptan (Zomig-ZMT) in 2.5- and 5-mg doses and rizatriptan (Maxalt-MLT) in 5- and 10-mg doses; all triptans available in oral form that is not rapidly acting; naratriptan and frovatriptan act slowly, and speaker considers them not very effective.
Efficacy: assessed as moderate to severe pain reduced to mild or no pain in 2 hr; frovatriptan, 2-hr efficacy ≤40%; naratriptan, ≈45% to 49%; almotriptan, eletriptan, “old form of” sumatriptan, ≈60%; sumatriptan rapid-release tablets (RT) ≈70%; “old form of” zolmitriptan, ≈65%; zolmitriptan RT, ≤77%.
Safety: all products similar; early concern about adverse cardiovascular events not supported by more recent data
Preventive treatment: “not as good as the acute care treatment”; consider preventive treatment if headaches occur more than twice weekly on regular basis; behavioral therapy crucial; components of behavioral therapy include diet, regulation of circadian rhythms, exercise, elimination of triggers, elimination of overused substances, fun, and relaxation training.
Preventive medications: only FDA-approved medications methysergide (no longer available in United States), propranolol, timolol, valproic acid, and topiramate; other treatments that may be effective include antidepressants, antihypertensives, neural stabilizers, serotonin antagonists, and alternative therapies; select medication by comorbidity; efficacy of all agents similar and “unfortunately, not as good as we want it to be”; adverse effects difficult to predict for individual patients; once-a-day regimens preferred to bid or tid; oral formulations preferred for ease of administration; “costs can vary tremendously”.
β-Blockers: all nonsympathomimetic β-blockers equally effective; propranolol most commonly used, but speaker prefers atenolol (inexpensive; can be given once daily, typically at night; fewer side effects); end point for β-blockers is pulse rate in low 70s or upper 60s, and dose determined accordingly; in studies, 45% to 60% of patients reported 50% reduction in headaches.
Calcium channel blockers: good for cluster headaches, not good for migraine; use doses higher than those for treatment of hypertension; may be effective if aura prominent feature; in studies, verapamil and amlodipine took up to 3 mo to achieve effect.
Tricyclic antidepressants: low doses effective (for amitriptyline, doxepin, and imipramine, 50 mg/day); with amitriptyline and doxepin, end point is sleep without daytime sedation; side effects with amitriptyline and doxepin include weight gain; with nortriptyline and imipramine, all side effects less; when using nortriptyline, prescribe by generic name, which costs ≈$17/mo (brand name [Pamelor] costs $575/mo); desipramine and protriptyline nonsedating and not associated with weight gain (protriptyline currently available only by brand name [Vivactil]).
Other antidepressants: SSRIs and bupropion not effective in migraine; venlafaxine effective; in study, patients with anxiety benefitted from duloxetine; monoamine oxidase inhibitors effective, but have numerous side effects.
Neural stabilisers: previously called anticonvulsants; divalproex (Depakote) and topiramate FDA-approved; both have significant side effects, including weight gain, hair loss, and fetal neural tube defects; in study, only 36% of patients responded to gabapentin.
Serotonin antagonists: speaker uses cyproheptadine in children; methysergide effective, but no longer available in United States due to side effect profile.
Alternative treatments: riboflavin—in small study, 59% of patients responded; magnesium—should be effective; known that patients with migraine have low levels of magnesium in brain; shown that intravenous magnesium stops headache; feverfew—effectiveness not clear; coenzyme Q10—effective in some studies; butterbur (Petasites hybridus)—in study, efficacy ≤71%, but efficacy of placebo 59%; botulinum toxin type A (Botox)—no clinical profile; anecdotally, some patients respond, others do not; large trial now under way.
Recommendations: clinicians who do not specialize in headache select amitriptyline, imipramine, or venlafaxine as first-line medications; speaker recommends using β-blocker second, and prefers atenolol; use neural stabilizer third (speaker prefers topiramate).
Conclusions: episodic headache with any disability (especially nausea and/or photophobia) is migraine; acute care treatment is race against central sensitization; preventive treatment selected on basis of comorbidity; aggressive treatment prevents progression to chronic migraine.