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“Say Something About Migraine” ( Freelove 2012) Anne Walling MB, ChB

“Say Something About Migraine” ( Freelove 2012) Anne Walling MB, ChB. “Say Something About Migraine”. It Hurts!! “Under-diagnosed” in primary care “Under-treated” in primary care especially Low use of prophylaxis. Objectives participants will be able to.

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“Say Something About Migraine” ( Freelove 2012) Anne Walling MB, ChB

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  1. “Say Something About Migraine”(Freelove 2012)Anne Walling MB, ChB

  2. “Say Something About Migraine” It Hurts!! “Under-diagnosed” in primary care “Under-treated” in primary care especially Low use of prophylaxis

  3. Objectivesparticipants will be able to Describe diagnostic criteria and tools Discuss new recommendations for preventive therapy Select and manage preventive therapy in migraine patients

  4. Under-diagnosis? FPs very good at positive diagnosis (95% accurate) Alleged to mis-diagnose 25% of migraine mainly as tension or sinus

  5. Definition (International Headache Society) Recurrent headache lasting 4-72 hours Nausea/vomiting and/or photo-phonophobia At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion 4. No alternative explanation for symptoms Several subtypes based on symptoms

  6. Office Diagnostic Tools:When you have a headache do you have……. PIN Photophobia, Incapacity, Nausea (PPV 2 symptoms 93%, 3=98%) or POUND Pulsating, One day,Unilateral, Nausea, Pounding (PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

  7. On treating acute attacks: Stratified Therapybased on severity/disability Mild – analgesics & symptomatic therapy Moderate – consider triptans or ergots Treat early in attack Monitor for transformed migraine New US Headache Consortium guidelines due this year

  8. Preventive Therapy: indications Significant disability (impact on quality of life) Medication overuse or contraindication High risk of serious migraine complication (rare) Estimate 39% “need” 3-13% use Basically a PATIENT decision

  9. Preventive Therapy for Migraine Potential 50% reduction in attacks May reduce attack severity Multiple agents & mechanisms (esp anti-hypertensives, -depressants,-convulsants, NSAIDs, herbs) - Can’t predict response by migraine/patient type - Quality problems in studies New guidelines (AAN 2012)

  10. Patient Mrs. Smith 24 yr old teacher. Married G0P0 No significant PMH, FH, SH, RoS c/o recurrent headaches used to be every 4-6 weeks for 2-3 hours , now nearly every 10-14 days and lasting longer (entire day or longer) Temple/eye area mostly right side, sometimes left Nausea, some vomiting, can’t stand smell of food Noise & light make worse Feels exhausted & can’t concentrate during episode Feels headache coming on but no clear warning signs Takes tylenol & goes to bed. Recently taking excedrin <6/day Stress over time off work, student loans/mortgage, husband’s job, decisions about starting a family – feeling miserable several days/week Physical - normal except vitals 130/90, 70, 210lbs, 63”

  11. Exercise: Does she have migraine? What is your evidence? How confident can you be in the diagnosis (PPV)? What acute treatment do you recommend? Would you advise preventive therapy? What class of preventive treatment would you advise?

  12. Definition (International Headache Society) Recurrent headache lasting 4-72 hours Nausea/vomiting and/or photo-phonophobia At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion 4. No alternative explanation for symptoms Several subtypes based on symptoms

  13. Office Diagnostic Tools:When you have a headache do you have……. PIN Photophobia, Incapacity, Nausea (PPV 2 symptoms 93%, 3=98%) or POUND Pulsating, One day,Unilateral, Nausea, Pounding (PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

  14. Ideas for acute treatment? • Patient information • Address triggers/exacerbators • Stress reduction (esp exercise) • Analgesic plan – provide effective relief - minimize adverse effects - prevent conversion to chronic daily headache

  15. What medication would you advise? • None • Propranolol • Amytriptyline • Sodium valproate • Topiramate • Verapamil • Fluoxetine • Butterbur extract • Feverfew • Riboflavin VOTE!!!

  16. Selecting a Preventive Medication Efficacy (new AAN guidelines) Potential adverse effects Potential added benefits (eg HBP, seizure) Compliance Willingness to collaborate in management PATIENT beliefs and expectations

  17. AAN Guidelines for Migraine Prevention

  18. AAN Guidelines for Migraine Prevention

  19. AAN Guidelines for Migraine Prevention

  20. What medication would you advise now? • None • Propranolol • Amytriptyline • Sodium valproate • Topiramate • Verapamil • Fluoxetine • Butterbur extract • Feverfew • Riboflavin VOTE!!!

  21. Final Thoughts Migraine is not cured but can be managed Address beliefs, lifestyle etc Specific individual strategies, adjusted over time Update acute therapy (new guidelines 2012) Consider preventive therapy Recognize/avoid/manage comorbidities Physician is the “coach”

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