Professional Documents
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Dawe
Dawe
Diagnosis &
Management
J Dawe MD FRCPC
(Neurology)
April 29, 2022
Disclosures
• There is more to discuss about migraine and migraine management than can be
discussed in 20 minutes
• Email: jessica.dawe@dal.ca
Red Flags for secondary causes of headache.
Objectives
About Migraine in Primary Care
• Although the most common primary headache worldwide is TTH, the most likely
headache disorder to be seen in any health care setting is migraine
o 94% of primary headache in clinical practice is migraine or probable migraine
Determine Primary
Headache D/o Based on Any Unusual
No Pattern / Features Features?
+ Screen for Comorbidities
No
Develop Appropriate
Treatment Plan for
Primary Headache
Disorder
“SNOOP” 4 Red Flags
• Systemic symptoms, signs, disease
• Neurologic symptoms/signs
• Onset
• Older
• Pattern change
• Papilledema
• Postural/positional/provoked
• Pregnancy and postpartum
Adapted from Dodick D.W., Adv Stud Med 2003; Semin Neurol 2010
Migraine without Aura (ICHD-3)
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully
treated)
C. Headache has at least two of the following four characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg,
walking or climbing stairs)
D. During headache at least one of the following:
1. Nausea and/or vomiting
2. photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis.
https://ichd-3.org/1-migraine/
Migraine with Aura (ICHD-3)
A. At least two attacks fulfilling C. At least three of the following six
criteria B and C characteristics:
B. One or more of the following 1. At least one aura symptom spreads
fully reversible aura gradually over ≥5 minutes
symptoms: 2. Two or more aura symptoms occur in
succession
1. Visual 3. Each individual aura symptom lasts 5-60
2. Sensory minutes
3. Speech and/or language 4. At least one aura symptom is unilateral
4. Motor 5. At least one aura symptom is positive
5. Brainstem 6. The aura is accompanied, or followed
6. Retinal within 60 minutes, by headache
D. Not better accounted for by
another diagnosis.
https://ichd-3.org/1-migraine/
Screener for Migraine in Patients Complaining of Headache
(ID Migraine)
• Migraine
• Cranial autonomic symptoms (congestion, rhinorrhoea, and facial pain)
are very common in migraine, ranging from 26-71.3%
• Osmophobia with headache – 87.6% PPV for migraine
Comprehensive Acute
Migraine Headache
Management Management
Preventative
Headache
Management
Using a Migraine Diary
• Frequency, duration and severity of headaches
• How many headaches in total
• Associated features (aura, nausea, photophobia, etc.)
• Identify patterns/triggers
• Consider relationship to menstrual cycle
• Medication use and response
• Monitor for Medication Overuse
Lifestyle Counselling
• Adequate and good-quality sleep
• Sleep hygiene strategies; always screen for sleep apnea
• Maintaining good hydration
• 1.5-2L water daily
• Avoid irregular or skipped meals
• No specific diet has any evidence for efficacy, but individual patients may find
a specific diet helpful; protein with breakfast
• Caffeine limited to a modest level
• Regular physical activity
• Consistency is key; type irrelevant (yoga, cardio, strength/conditioning, etc.)
• Stress management
Acute Migraine
Medication
Principles of Acute Migraine Management
• Goal → Pain freedom 2hrs after treatment (or at least able to function at 2hrs)
• Evidence-based treatments should be used when possible
• Migraine attacks should be treated early
• Consider:
• Cost of medication – paying out of pocket vs. insurance; generic options
• Safety and tolerability – consider patient co-morbidities
• Patient preference
Strategies – Stepwise vs. Stratified
▪ Common Side Effects: Nausea, vomiting, palpitations, chest tightness, chest pain, dizziness,
light-headedness, flushing, and worsening headache, tingling in fingertips, somnolence
▪ Options:
• Two separate pills taken at the same time - Sumitriptan 50mg + Naproxen 500 mg
• RCT → 46% pain freedom at 2hrs
• One combination pill – Sumitriptan / Naproxen 85mg / 500mg
• 2xRCT → 57-65% pain freedom at 2 hrs
Medication Overuse Headache (MOH)
▪ Always educate patient on the risks of MOH
▪ Headache occurring on ≥15 d/mo. in a patient with a pre-existing headache
disorder and regular overuse for >3 months of one or more drugs that can be
taken for acute and/or symptomatic treatment of headache
▪ ≥ 10 d/mo. for ergot derivatives, triptans, opioids, combination analgesics, and a
combination of drugs from different classes that are not individually overused.
▪ ≥15 d/mo. for nonopioid analgesics, acetaminophen, and NSAIDs
Newer Options for Acute Management
• Lasmitidan – NOT AVAILABLE IN CANADA
• Comorbidities:
• Increased BMI Strategy: Topiramate
• Hypertension Strategy: Propranolol, nadolol, metoprolol, candesartan,
lisinopril
• Depression/Anxiety Strategy: Amitriptyline, venlafaxine, (nortriptyline)
• Other Monotherapy Options:
• Topiramate, Divalproex, Gabapentin, Flunarizine, Pizotifen, Verapamil
Select Herbal/Nutritional Supplements
* Off-label
(Becker et al., 2015; Holland et al., 2012; Pringsheim et al., 2012)
CGRP Monoclonal Antibodies
• Erenumab, Galcanezumab, Fremanezumab, Epitenezumab
• Newer therapy options, so not in 2012 guidelines
• Efficacy:
• Placebo-controlled RCTs have showed that CGRP monoclonal antibodies are effective for
both episodic and chronic migraine
• On average, 50% responder rates were around 50-60% in treatment groups (similar to
topiramate, propranolol, onabotunlinumtoxinA)
• Sustained benefit over 1-3 years reported (so far)
CGRP Monoclonal Antibodies
• Advantages:
• Does not interact with other medications
• Possibly less side effects or better tolerated
• Convenient – Monthly or Quarterly injections
• Disadvantages:
• Newer medication class; we may not know all adverse effects
• Expensive $$$
• Not tested in peds (trials ongoing) or >70 years of age
• Benefit → About 50-70% of patients have reduction of headache days ≥ 50% after 3 cycles
• Well tolerated; Main adverse effects include ptosis and neck pain
• Administration:
• 115-195 units over 35-39 injection sites based on PREEMPT protocol every 3 months
Final Thoughts
• Migraine is common, debilitating, often underdiagnosed and undertreated
• There are many options for migraine management, including new agents
References:
• Ailani, J. (2021). Acute Migraine Treatment. Continuum (Minneapolis, Minn.), 27(3), 597–612.
• Becker, W. J., Findlay, T., Moga, C., Scott, N. A., Harstall, C., & Taenzer, P. (2015). Guideline for primary care management of headache in adults. In
Canadian Family Physician (Vol. 61, Issue 8).
• Burch. (2021). Preventive Migraine Treatment. Continuum (Minneapolis, Minn.), 27(3), 613–632. https://doi.org/10.1212/CON.0000000000000957
• Diener, H., Holle-Lee, D., Nägel, S., Dresler, T., Gaul, C., Göbel, H., Heinze-Kuhn, K., Jürgens, T., Kropp, P., Meyer, B., May, A., Schulte, L., Solbach, K.,
Straube, A., Kamm, K., Förderreuther, S., Gantenbein, A., Petersen, J., Sandor, P., & Lampl, C. (2019). Treatment of migraine attacks and prevention of
migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. Clinical and Translational Neuroscience,
3(1), 2514183–. https://doi.org/10.1177/2514183X18823377
• Dodick. (2010). Pearls: Headache. Seminars in Neurology, 30(1), 074–081. https://doi.org/10.1055/s-0029-1245000
• Lipton, R. B., Dodick, D., Sadovsky, R., Kolodner, K., Endicott, J., Hettiarachchi, J., & Harrison, W. (2003). A self-administered screener for migraine in
primary care: The ID migraineTM validation study. Neurology, 61(3). https://doi.org/10.1212/01.WNL.0000078940.53438.83
• Lipton, R. B., Stewart, W. F., Stone, A. M., Láinez, M. J. A., & Sawyer, J. P. C. (2000). Stratified Care vs Step Care Strategies for Migraine: The Disability in
Strategies of Care (DISC) Study: A Randomized Trial. JAMA : the Journal of the American Medical Association, 284(20), 2599–2605.
https://doi.org/10.1001/jama.284.20.2599
• Pohl, H., Do, T. P., García‐Azorín, D., Hansen, J. M., Kristoffersen, E. S., Nelson, S. E., Obermann, M., Sandor, P. S., Schankin, C. J., Schytz, H. W., Sinclair, A.,
Schoonman, G. G., & Gantenbein, A. R. (2021). Green Flags and headache: A concept study using the Delphi method. Headache, 61(2), 300–309.
• Pringsheim T., Davenport WP, Mackie G, et al. Canadian Headache Society Guideline for Migraine Prophylaxis. Canadian Journal of Neurological
Sciences. 2012; 39 (2) Suppl 2:S1-62.
• Robblee, J., & Secora, K. A. (2021). Debunking Myths: Sinus Headache. Current Neurology and Neuroscience Reports, 21, 42–42.
https://doi.org/10.1007/s11910-021-01127-w/Published
• The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. (2019). Headache, 59(1), 1–18.
https://doi.org/10.1111/head.13456
• Worthington, I., Pringsheim, T., Gawel, M. J., Gladstone, J., Cooper, P., Dilli, E., Aube, M., Leroux, E., & Becker, W. J. (2013). Canadian Headache Society
Guideline: Acute Drug Therapy for Migraine Headache. Canadian Journal of Neurological Sciences, 40(S3), S1–S3.
https://doi.org/10.1017/S0317167100118943
Bonus Slides
What to Ask About on History
• Headache onset and duration • Relationship of headache attacks to
• Thunderclap, head or neck trauma, precipitating factors
etc. • Stress, posture, cough, exertion, straining,
neck movement, jaw pain, etc
• Previous attacks
• Progression of symptoms • Headache severity/disability
• effect on work and family activities
• Days per month with headache
• Acute and preventive medications tried,
• Pain location response, and side effects
• Unilateral, bilateral, neck pain, etc. • Presence of coexistent conditions that
• Headache-associated symptoms might influence treatment choice
• Nausea, vomiting, photophobia, • Insomnia, depression, anxiety, hypertension,
conjunctival injection, rhinorrhea, etc. asthma, and history of heart disease or
stroke
Physical Exam in Headache
• Screening neurologic examination • Neck examination
• General assessment of mental status • Posture, range of motion, and palpation for
• Cranial nerve examination muscle tender points
• Assessment for unilateral limb weakness, • Blood pressure measurement
reflex asymmetry, and coordination in the
• If indicated by associated jaw complaints, an
arms
examination for temporomandibular disorders
• Assessment of gait and balance, including
• Assessment of jaw opening
tandem gait
• Palpation of muscles of mastication for
tender points
Ubrogepant
▪ Indication: acute treatment of migraine headache
▪ Dosing: 50mg/100mg tablet as needed, may take 2nd dose after 2 hours (Max 200mg/24hrs)
▪ Efficacy in 2 RCTs
▪ 2-hr pain freedom: 50mg = 19%, 100mg = 22% (placebo 12-14%)
▪ 2-hr freedom of MBS: 50mg = 38%, 100mg = 39% (placebo 28%)
▪ 2nd dose provided pain freedom at 2hr in 55% of pts
▪ Efficacy in RCT
▪ Reduction of mean number of migraine days per month of >50% → 55-60% (placebo 29%)
▪ Rapidly reaches peak plasma concentrations in 1-2 hrs
▪ Most common AE → constipation, nausea
▪ Largely eliminated within approximately 2 days