1. Migraine Management • Dr David PB Watson • Hamilton Medical Group Aberdeen

2. Contents • Theories of Migraine • Acute Treatment • Prevention • Case Studies

3. Cortical events Meninges and other peripheral structures TNC Trigeminal ganglion Brainstem Neuropeptides What Is Migraine? • A chronic disorder with episodic attacks • Complex changes in the brain • During attacks • Headache • Several associated symptoms • Functional disability • In-between attacks • Enduring predisposition to future attacks • Anticipatory anxiety TGS = trigeminal system; TNC = trigeminal nucleus candalis. Bigal ME et al. Neurology. 2008;71:848–855; Brandes JL. Headache.2008;48:430–441; Coppola G et al. Cephalalgia. 2007;27:1429–1439; Goadsby PJ et al. N Engl J Med. 2002;346:257–270; Haut SR et al. Lancet Neurol. 2006;5:148–157; Lovati C et al. Headache.2008;48:272–277; Pietrobon D. Neuroscientist. 2005;11:373–386.

4. Premonitory Advanced Headache Postdrome Mood changes Fatigue Cognitive changes Muscle pain Food craving Unilateral Throbbing Nausea Photophobia Phonophobia Osmophobia Fatigue Cognitive changes Muscle pain Early Headache Aura Dull headache Nasal congestion Muscle pain Fully reversible Neurological changes: Visual somatosensory Migraine: A Continuum of Symptoms Time Preheadache Mild Moderate Severe Post headache Headache Cady R et al. Headache. 2002;42:204–216. Linde M. Acta Neurol Scand. 2006;114:71–83. Linde M. Cephalgia. 2006; 26; 712–721.

5. Advanced Headache Unilateral Throbbing Nausea Photophobia Phonophobia Migraine: Headache Not Always Gradual Time Preheadache Severe Postheadache Headache Phase Cady R et al. Headache. 2002;42:204–216. Linde M. Acta Neurol Scand. 2006;114:71–83. Linde M. Cephalgia. 2006; 26; 712–721.

6. Triggers Suggest That Migraine Is a Disorder of the brain (CNS) • The case for the sensitive migraine brain • Normal life events trigger or are associated with attacks in those predisposed Dehydration Sleep disturbance Diet Environmental stimuli Hunger Changes in oestrogen level in women Stress CNS = central nervous system. Coppola G et al. Cephalalgia. 2007;27:1429–1439; Kelman L. Cephalalgia. 2007; 27:394–402; Pietrobon D et al. Nat Rev Neurosci. 2003;4:386–398.

7. Headache Threshold • Headache threshold variability • Patient 4 • Patient 3 • Patient 2 • Patient 1 • Trigger

8. Medication Overuse Headache • Beware of using painkillers more than 2 days a week

9. Acute Treatment • Medicines taken during a headache to reduce or put the pain away and to help sickness • Painkillers • Anti-sickness medications • Migraine specific medicines • Triptans • Ergotamine (Cafergot, Migril includes cyclizine and caffeine)

10. Painkillers • Best evidence ASPIRIN 900 mg • IBUPROFEN 400 mg • In pregnancy PARACETAMOL 1000mg • Take early in headache • May be combined with anti-sickness medicines such as Domperidone, Metoclopramide and Prochloroperazine

11. Migraine Licensed Painkillers • Migraleve = paracetamol, codeine, (yellow) buclizine (pink) • MigraMax = aspirin and metoclopramide • Paramax = paracetamol and metoclopramide • Clotam Rapid = Tolfenamic Acid

12. Triptans (5HT1 Agonists) • Almotriptan • Eletriptan • Frovatriptan • Naratriptan • Rizatriptan • Sumatriptan • Zolmitriptan Nerve Brain Blood Vessel Decreased pain transmission Decreased pain transmission Decreased pain transmission Decreasain transmissioned p Decreased pain transmission BBbBion

13. Triptans How to Use • Early in the headache phase • Not during aura • Can repeat after 2hours if migraine recurs • No response, don’t repeat • Response idiosyncratic

14. Triptan routes of administration • Tablet ( gastric absorption) • Melts (gastric absorption) • Nasal Spray ( Gastric and nasal absorption) • Injection ( subcutaneous)

15. Triptan Side Effects • Most patients have few problems • Sensations of tingling, heat, heaviness, pressure, tightness of throat or chest • Flushing • Dizziness • Feeling of weakness, fatigue • Nausea and vomiting

16. Acute Treatment Tips • Take early in headache phase • Rescue Treatment (include rectal) • Naproxen

17. Medicines for Migraine Prevention • Consider if frequent debilitating migraine • Not a cure • Good response is works in 50 out of 100 patients to reduce headache frequency and severity by half • Can be combined • Need adequate doses

18. ? Headache Threshold Shifts • Headache threshold variability • Patient 4 Patient 1 Preventer • Patient 3 • Patient 2 • Patient 1 • Trigger

19. Medicines Used For Prevention • B Blockers • Tricyclic Antidepressants • Anti Epileptics • Pizotifen • Venlafaxine • Candesartan • (Flunarazine) • (Methysergide)

20. B Blockers • Propranolol 80-240 mg • Avoid in asthma • Side Effects (rarely a problem) • Fatigue • Coldness of extremities • Sleep disturbance and nightmares • Gastro intestinal disturbance • Dizziness • Headache

21. Tricyclics • Amitriptyline 10 -125 mg • Nortriptyline 10-125 mg • Patient Information Leaflet = anti-depressant • Side effects • Sedation • Dry mouth • Constipation • Headache

22. Anti-Epileptics • Sodium Valproate 600-1200 mg daily • Weight gain • Hair Loss • Nausea, Diarrhoea • Topiramate 50-150 mg daily • Weight Loss • Sedation and slowed thinking • Irritability and Depression • Pins and Needles

23. Prevention Top Tips • Start low and aim high • Combinations can be effective • Consider reducing/stopping in 6-12 months

24. Case Study 1 • 25 year old lady • Migraine with aura twice a month, always with menstruation. Can vomit late in headache. Menstrual migraine can be 2 days • Never misses work • Migraine can be present on waking • Aspirin 2 tabs partially helps some headaches

25. Case Study 1 • Consider • Dose. Aspirin 900 mg helps day time migraine • Timing. Taken early in headache works better • Nausea/vomiting . Required triptan for menstrual migraine • Rescue = triptan

26. Case Study 2 • 37 year old lady, 4 migraine without aura a month, last 2 days each • Misses 3 days of work a month • Can vomit within 2 hours • Naratriptan helps some time

27. Case Study 2 • Consider • Take triptan early • Faster acting triptan • Nasal triptan • Naproxen • Rescue Rx suppositories