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Migraine Management, Songkra Hospital 13
Migraine Management, Songkra Hospital 13
Migraine Management, Songkra Hospital 13
Surat Tanprawate, MD, MSc(Lond.), FRCPT The Northern Neuroscience Centre in collaboration with Division of Neurology, Faculty of Medicine Chiang Mai University
Tension-type headache and migraine are the 2nd and 3rd most prevalent medical disorders on the planet
!
Migraine accounts for 30% of the global burden and more than 50% of the disability burden attributable to all neurological disease worldwide
!
Overall, it is the 4th ranking cause among women and the 7th ranking cause of all disease-associated disability worldwide.
Patient presents with complaint of a headache Critical rst step:! Hx taking, physical exam Red ag signs or alarming signs Meets criteria for primary headache disorder?
Red ag signs
(+)
Investigation
(-)
(+)
Migraine! headache
Cluster headache and other TACs
Tension-type headache Chronic daily headache (CDH) Other (rare) headache disorder Secondary headache disorder
Focal neurologic s/s other than typical visual or sensory aura Papilledema Neck stiffness
Concurrent event
Pregnancy, post partum! -Cerebral vein thrombosis, carotid dissection, pituitary apoplexy Headache with cancer, HIV, systemic illness (fever, arteritis, collagen vascular disease)
Provoking activity
Triggered by cough, exertion or Valsava! -SAH, mass lesion
Age> 50
ICHD-III Cephalalgia.2013
Aura in migraine
Visual Aura
Zig-zag lines (fortication)
Mosaic Illusion
Podoll & Robinson, Migraine Art - The Migraine Experience from Within, 2008
Aura
CSD is a wave of neuronal and glial depolarization, followed by long-lasting suppression of neural activity
Hadjikhani PNAS 2001 98(8): 46874692
Pain characteristics and location of the acute migraine attack: A study of 1283 migraine patients
! Time of headache: morning in 18.7%, afternoon 13.5%, evening 4.0%, during night 9.4%, and "anytime" 54.3%" ! Headache character: throbbing (73.5%), aching (73.8%), pressure (75.4%), and stabbing (42.6%)" ! Headache increased by activity: 90.2% of patients" ! Headache location: eyes (67.1%), temporal (58.0%), and frontal (55.9%), di#usely (17.5%) and vertex (24.1%)" ! Hemi-cranial location: 66.6% of patients,
Kelman L. Headache 2005 Sep;45(8):1038-47. Kelman L. Headache 2006 Jun;46(6):942-53.
New diagnostic criteria of Vestibular migraine (A1.1.6) : ICHD-III Beta version 2013
A. At least ve episodes fullling criteria C and D" B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura" C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours D. At least 50% of episodes are associated with at least one of the following three migrainous features:"
1. headache with at least two of the following four characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity" 2. Photophobia/phonophobia" 3. Visual aura"
E. Not better accounted for by another ICHD-III diagnosis or by another vestibular disorder ICHD-III Beta 2013
Cause
Genetic
Pathophysiology! - Aura" - vasodilatation" - neurogenic inammation" - peripheral and central sensitization" - Trigemino vascular system" Neurotransmitter! - Serotonergic system" - Dopaminergic system" Structural and functional brain change" - Brain stem activation
constant
acute on chronic
Clinical: chronic and transform migraine, allodynia, neck pain" ! Anatomical: PAG, central sensitization
Evolution of Migraine
No migraine
Chronic Migraine
Migraine management
Avoiding triggers to prevent attack! Non-phamacologic treatment! Treating the acute attack! Long-term preventive therapy! Physical and alternative medicine
Silberstein SD. Wolffs headache. 2008
Successful treatment
Life style
+ Prophylaxis medication
Treatment fail
Inadequate treatment
- Life style modication?! - Right drug, dose, duration?
Specic!
Ergotamine
Ergot
Cock spur The ergot of Rye
The word ergot is derived from argot, old French for cock spur
Fungus Claviceps
purpurea
400 BC: ergotism was reported ! - vasospasm! - gangrene! - abortion 1862: ergot use to treat migraine
Triptans
(Imigran)
(Zomig)
(Relpax)
Preventive Medication
Aim!
Reduce attack frequency, severity, and duration! Improve responsiveness to acute headache therapies! Improve function and reduce disability! Reduce overall cost associated with migraine treatment
Frequency of migraine attacks > 1/weeks Frequency of acute medication use>2/week Failure of, contraindication to, or trouble AE from acute
medication
Concept
Right drug Right person Right dose
Right duration
Preventive medication that was proven the efcacy Consider patient proles, and co-morbidities Titrate into the appropriated dose On the preventive therapy long enough
Drugs
Amytriptiline (TCA)! ! ! ! ! Propranolol (Bblocker)! ! ! ! Flunarizine (CCB)! ! ! Valproic acid (AED)! ! ! ! Topiramate (AED)
Relative indications
Relative contraindication
Adverse effect
Other pain disorders, Mania, urinary Drowsiness, dry depression, anxiety, retention, heart mouth, increase insomnia! blocks, glaucoma! appetite, weight gain! ! ! ! ! ! ! Hypertension, angina! Asthma, depression, Fatique, lethargy, ! CHF, Raynauds nausea, depression, ! disease! dizziness! ! ! ! ! ! ! Hypertension, vertigo! Obesity, depression, Drowsiness, weight ! PD! gain, depression, PD! ! ! ! Epilepsy, mania, Liver disease, Nausea dyspepsia, anxiety! bleeding disorder! sedation, increase ! ! appetite, weight gain! ! ! ! Epilepsy, mania, Renal calculosis, liver Paresthesia, weight anxiety disease loss, alter taste, language disturbance
F. Galletti et al. Progress in Neurobiology 89 (2009) 176192
Proposed mechanism!
obesity = pro-inammatory state! adepocyte secrete IL-6, TNF! increase plasma CGRP; elevate brain CGRP??
Bigal ME, et al. Neurology. 2006;66:545-550 Bigal ME, and Lipton RB. Neurology. 2006;67:252-257
Proportion of migraineurs with 10 or more headache days per month according to the body mass index
BigalME, et al. Neurology. 2006;66:545-550.
Poster presented at the American Headache Society 46th meeting. Vancouver, 2004
Weight management
Maintain the weight or decrease it! Drug used for reducing weight! Drug for migraine prevention affecting to weight!
neutral weight: beta-blocker, Ca-blocker! increase weight: Valproic acid, TCA! reduce weight: Topiramate
Inuence of anxiety and depression (HAD scores) on migraine-related disability (MIDAS grade)! in FRAMIG study
using depression, anxiety screening tool: Hospital Anxiety Depression Scale (HADS)!
Consult psychiatrist
Topiramate
50 mg/d! (n=235) 100 mg/d! (n=386) 200 mg/d! (n=514)
6 11 6 8 4 1 1
35 14 9 9 9 6 15
51 15 15 13 11 9 8
49 19 14 14 11 11 12
Poster presented at the American Headache Society 46th meeting. Vancouver, 2004
Public
What we gain from pain, what we fail from pills: TEDx Talk Chiang Mai
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