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Migraine through Migraine through casescases

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Mrs SmithMrs Smith

• Age 33, headaches for some time “on and Age 33, headaches for some time “on and off” for which she has to take regular off” for which she has to take regular painkillers. Someone has told her it could painkillers. Someone has told her it could be migraine so she has come to you for be migraine so she has come to you for advice. She is not on any other medication.advice. She is not on any other medication.

• What are the common causes of headache?What are the common causes of headache?

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Headache TypesHeadache Types

•Tension type headache

•Migraine

•Cluster headache

•Chronic Daily headache

•Medication misuse headache

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Mrs SmithMrs Smith

• You think she has migraine. How do you You think she has migraine. How do you classify migraine?classify migraine?

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Migraine ClassificationMigraine Classification

• In 1988 The International Headache Society In 1988 The International Headache Society published its classification and operational published its classification and operational diagnostic criteria for all headache disorders. diagnostic criteria for all headache disorders. This remains the gold standard and is due to be This remains the gold standard and is due to be revised in 2002. Its section on migraine covers:revised in 2002. Its section on migraine covers:

• Migraine without aura Migraine without aura • Migraine with aura Migraine with aura • Ophthalmoplegic migraine Ophthalmoplegic migraine • Retinal migraine Retinal migraine • Childhood periodic syndromes Childhood periodic syndromes

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Migraine without aura Migraine without aura (common migraine)(common migraine)• This is an idiopathic, recurring disorder This is an idiopathic, recurring disorder

involving attacks that last 4-72 hours. involving attacks that last 4-72 hours. • The headache is typically unilateral, pulsating, The headache is typically unilateral, pulsating,

of moderate or severe intensity, and is of moderate or severe intensity, and is aggravated by normal physical activity. aggravated by normal physical activity.

• It is associated with nausea, vomiting, It is associated with nausea, vomiting, photophobia, and phonophobia. photophobia, and phonophobia.

• Five or more attacks are required to make the Five or more attacks are required to make the diagnosis. diagnosis.

• Seventy-five per cent of sufferers have this Seventy-five per cent of sufferers have this form. form.

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Migraine with aura (classical Migraine with aura (classical migraine)migraine)• This is an idiopathic, recurring disorder with attacks of This is an idiopathic, recurring disorder with attacks of

neurological symptoms that arise in the cerebral cortex neurological symptoms that arise in the cerebral cortex or the brain stem, creating the aura. or the brain stem, creating the aura.

• The aura usually develops gradually over 5-20 minutes, The aura usually develops gradually over 5-20 minutes, lasts less than 60 minutes, and is completely reversible. lasts less than 60 minutes, and is completely reversible.

• Typical examples of an aura are: Typical examples of an aura are: – Homonymous visual disturbance (the most common type), Homonymous visual disturbance (the most common type),

usually a fortification spectrum - a spreading, scintillating usually a fortification spectrum - a spreading, scintillating scotoma in the shape of a jagged crescent scotoma in the shape of a jagged crescent

– Unilateral paraesthesia or numbness Unilateral paraesthesia or numbness – Unilateral weakness Unilateral weakness – Dysphasia Dysphasia – A combination of the above A combination of the above

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Migraine with aura (classical Migraine with aura (classical migraine)migraine)• The headache usually starts within 60 minutes of The headache usually starts within 60 minutes of

resolution of the aura, and lasts 4-72 hours. However, it resolution of the aura, and lasts 4-72 hours. However, it may begin before the aura, or at the same time as the may begin before the aura, or at the same time as the aura, or it may even be absent. aura, or it may even be absent.

• The headache is typically unilateral, pulsating, of The headache is typically unilateral, pulsating, of moderate or severe intensity, and is aggravated by moderate or severe intensity, and is aggravated by normal physical activity. normal physical activity.

• It is associated with nausea, vomiting, photophobia, It is associated with nausea, vomiting, photophobia, phonophobia and osmophobiaphonophobia and osmophobia

• Two or more attacks are required to make the Two or more attacks are required to make the diagnosis. diagnosis.

• Twenty-five per cent of sufferers have this form. Twenty-five per cent of sufferers have this form.

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The Economic Cost of The Economic Cost of MigraineMigraine

Approximately 1 in 10 members of the UK population suffer from migraine, resulting in the loss of 18 million working days each year.

The cost of lost production, replacement staff and the times when migraine sufferers are working below par is estimated at £750 million per annum

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IncidenceIncidence

• The prevalence of migraine is 16%;The prevalence of migraine is 16%; it is it is higher in women (25%) than in men (8%) higher in women (25%) than in men (8%) [Rasmussen et al, 1991]. [Rasmussen et al, 1991].

• Only a minority of sufferers consult their Only a minority of sufferers consult their GP.GP.

• In a practice of 2000 peopleIn a practice of 2000 people there are there are likely to be 5 newly diagnosed cases of likely to be 5 newly diagnosed cases of migraine each year, and 40 consultations for migraine each year, and 40 consultations for existing migraine [MeReC, 1997]. existing migraine [MeReC, 1997].

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Mrs SmithMrs Smith

• So why do I get migraine?So why do I get migraine?

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Migraine TriggersMigraine Triggers

Migraine is believed to be triggered by a fall in the levels of Serotonin (5HT) but what actually causes this fall is still unknown.

For most sufferers there is not just one trigger but a combination or accumulation of factors which individually can be tolerated but, when several occur together, a personal threshold is passed.

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Migraine Triggers Migraine Triggers (continued)(continued)• Stress – emotional or physical• Relief of stress• Insufficient food or long gaps between food• Certain foods• Environmental factors: loud noise,

bright, flickering or flashing lights/glare, strong smells

• Changes in routine – weekend lie-ins, shift work etc.

• Hormonal factors – menstruation, menopause, the pill, HRT

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‘‘THRESHOLD’ THEORYTHRESHOLD’ THEORY

Raised or loweredby internal and external factors

or ? by medication

threshold

MENSTRUAL PERIODMENSTRUAL PERIOD

MISSED LUNCHMISSED LUNCH

STRESS OF OVERWORKSTRESS OF OVERWORK

LONG JOURNEY TO WORKLONG JOURNEY TO WORK

LATE NIGHTLATE NIGHT

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Warning signsWarning signs

Yawning

Unusual hunger/craving for certain foods

Heightening of the senses

Irritability

Exhilaration/excitability

Confusion

Speech difficulties

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Mrs SmithMrs Smith

• How do I treat my migraine?How do I treat my migraine?

• What self help treatments are available? What self help treatments are available? What can she buy over the counter and What can she buy over the counter and what is prescribablewhat is prescribable

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Self-help MeasuresSelf-help Measures Keep a diary

Avoid triggers to which you know you are sensitive

Eat regularly, avoid sugary snacks and include slow release carbohydrate foods in your diet

Drink plenty of water

Limit your intake of drinks containing caffeine and alcohol

Take regular exercise

Get plenty of fresh air and practise deep breathing

Ensure that ventilation indoors is good and try to keep rooms at a constant temperature

Avoid strong perfumes etc

Avoid bright, flashing or flickering lights (e.g. fluorescent)

Avoid large reflective surfaces (e.g. plain white walls)

Wear sunglasses and/or a hat in bright sunlight

Ensure that computer screens are properly adjusted and fitted with anti-glare filters

Take regular breaks, especially if you are working at a VDU or if your work is repetitive

Take care with your posture

Ensure that your working environment is as ergonomically designed as possible

Learn relaxation techniques

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Treatment - AcuteTreatment - Acute

• In the UK a stepwise approach In the UK a stepwise approach to to migraine care is generally recommended: migraine care is generally recommended: – A first-line analgesic with or without an anti-A first-line analgesic with or without an anti-

emetic is used initially. emetic is used initially. – If this consistently fails to relieve migraine, If this consistently fails to relieve migraine,

treatment with a 5-hydroxytryptamine (5-treatment with a 5-hydroxytryptamine (5-HT1)-receptor agonist (a triptan) is the next HT1)-receptor agonist (a triptan) is the next step. step.

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Treatment - AcuteTreatment - Acute

• Starting acute treatment early Starting acute treatment early in the attack is beneficial in the attack is beneficial because gastric stasis during the migraine reduces drug because gastric stasis during the migraine reduces drug absorptionabsorption

• Aspirin 900 mg, paracetamol 1000 mg, or ibuprofen 400 Aspirin 900 mg, paracetamol 1000 mg, or ibuprofen 400 mg mg are suitable first choices for the acute treatment of migraineare suitable first choices for the acute treatment of migraine with or withour anti-emetic Domperidone, Metoclopramide (not in young)

• Aspirin 900 mg plus metoclopramide was found to give relief similar to sumatriptan 100 mg. The combination was superior for the first attack studied, but sumatriptan was superior for the second and third attacks [Thompson, 1992].

• Soluble forms Soluble forms are preferred as these are absorbed faster. are preferred as these are absorbed faster. • 5HT Agonists (triptans)• Ergotamine

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5-Hydroxytryptamine 5-Hydroxytryptamine receptor agonists (triptans)receptor agonists (triptans)• 5-Hydroxytryptamine(5-HT1)-receptor agonists, or triptans, should be 5-Hydroxytryptamine(5-HT1)-receptor agonists, or triptans, should be

taken as soon as possible after the onset of headache. taken as soon as possible after the onset of headache. • People who do not respond to a particular triptan are likely to respond People who do not respond to a particular triptan are likely to respond

to anotherto another [Stark et al, 2000; Mathew et al, 2000]. [Stark et al, 2000; Mathew et al, 2000]. • EfficacyEfficacy

– Triptans provide headache relief for about 30% more people than placebo at 2 Triptans provide headache relief for about 30% more people than placebo at 2 hours (placebo response about 30%) [Ferrari et al, 2001]. Headache relief is hours (placebo response about 30%) [Ferrari et al, 2001]. Headache relief is defined as reduction in headache pain from moderate or severe to mild or defined as reduction in headache pain from moderate or severe to mild or none. none.

• Headache recurrence is an issue with all triptans. About 20-40% of Headache recurrence is an issue with all triptans. About 20-40% of people who experience pain relief by 2 hours experience headache people who experience pain relief by 2 hours experience headache recurrence within 24 hours [Ferrari et al, 2001]. recurrence within 24 hours [Ferrari et al, 2001].

• A pain-free response is sustained for 24 hours in about 20% of A pain-free response is sustained for 24 hours in about 20% of responders. A recent meta-analysis of placebo-controlled studies found responders. A recent meta-analysis of placebo-controlled studies found that rizatriptan 10 mg and almotriptan 2.5 mg had higher sustained that rizatriptan 10 mg and almotriptan 2.5 mg had higher sustained pain-free rates than other triptans [Ferrari et al, 2001]. Similar results pain-free rates than other triptans [Ferrari et al, 2001]. Similar results were found in a meta-analysis of studies comparing rizatriptan 10 mg to were found in a meta-analysis of studies comparing rizatriptan 10 mg to other triptans [Adelman et al, 2001]. other triptans [Adelman et al, 2001].

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5-Hydroxytryptamine 5-Hydroxytryptamine receptor agonists (triptans)receptor agonists (triptans)• Adverse effectsAdverse effects are generally mild and self-limiting for all are generally mild and self-limiting for all

triptans. They include nausea, dizziness, somnolence, and dry triptans. They include nausea, dizziness, somnolence, and dry mouth. Asthenia, dizziness, drowsiness, and somnolence may be mouth. Asthenia, dizziness, drowsiness, and somnolence may be more common with rizatriptan 10 mg and zolmitriptan 5 mg [Fox, more common with rizatriptan 10 mg and zolmitriptan 5 mg [Fox, 2000]. 2000].

• 'Triptan sensations''Triptan sensations' include a warm-hot sensation, tightness, include a warm-hot sensation, tightness, tingling, flushing, and feelings of heaviness or pressure in areas tingling, flushing, and feelings of heaviness or pressure in areas such as the face and limbs, and occasionally the chest. They such as the face and limbs, and occasionally the chest. They occurr in less than 3% of people in clinical studies. occurr in less than 3% of people in clinical studies.

• People with ischaemic heart disease, cerebrovascular People with ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, or uncontrolled disease, peripheral vascular disease, or uncontrolled hypertension should not use triptans. People with risk hypertension should not use triptans. People with risk factors for ischaemic heart disease should be evaluated factors for ischaemic heart disease should be evaluated carefully before starting a triptancarefully before starting a triptan [Welch et al, 2000; Evans [Welch et al, 2000; Evans and Martin, 2000]. and Martin, 2000].

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Mrs SmithMrs Smith

• She comes back to see you having tried She comes back to see you having tried hard to reduce her triggers but is still hard to reduce her triggers but is still getting migraines almost once a week. getting migraines almost once a week.

• What else can you do?What else can you do?

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Migraine prophylaxisMigraine prophylaxis

• Prophylaxis should be considered Prophylaxis should be considered for for people with: people with: – More than two attacks per month More than two attacks per month – Less frequent but severe or prolonged attacks Less frequent but severe or prolonged attacks – Frequent use of acute treatment (to prevent Frequent use of acute treatment (to prevent

development of medication-overuse headache)development of medication-overuse headache)

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Migraine prophylaxisMigraine prophylaxis

• Acute treatments are still required; Acute treatments are still required; the the severity and frequency of attacks is only severity and frequency of attacks is only reducedreduced by prophylaxis. by prophylaxis.

• Prophylactic drugs may need to be tried for Prophylactic drugs may need to be tried for 1-3 months before the full effect is seen.1-3 months before the full effect is seen.

• Prophylactic drugs that are effective should Prophylactic drugs that are effective should be used for 4-6 monthsbe used for 4-6 months and then withdrawn and then withdrawn gradually to establish whether they are still gradually to establish whether they are still required. required.

• It is difficult to make firm suggestions for one It is difficult to make firm suggestions for one prophylactic drug over another because there is a prophylactic drug over another because there is a lack of robust clinical studieslack of robust clinical studies

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Treatment - ChronicTreatment - Chronic

•Beta-blockers (e.g. propanolol, atenolol)

•Anti-depressants (e.g. amitriptyline start low dose and maintain at 50-75mg)

•Feverfew (Bandolier)

•5HT Antagonists (e.g. pizotifen but poor)

•Others - Calcium channel blockers, , Clonidine, Lisinopril, SSRIClonidine, Lisinopril, SSRI

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Mrs SmithMrs Smith

• Her migraines are well controlled on Her migraines are well controlled on prophylaxis and she now wants to be prophylaxis and she now wants to be started on the pill for contraception. started on the pill for contraception.

• Discuss the issues that you will need to Discuss the issues that you will need to consider with regard to this request and consider with regard to this request and her migraine.her migraine.

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ComplicationsComplications

• Migraine is associated with increased risk Migraine is associated with increased risk of ischaemic (but not haemorrhagic) stroke.of ischaemic (but not haemorrhagic) stroke.– Migraine with aura poses a higher risk than migraine Migraine with aura poses a higher risk than migraine

without aura [MacGregor, 2001]. without aura [MacGregor, 2001]. – A recent case-control study confirmed that a personal A recent case-control study confirmed that a personal

history of migraine was associated with a more than history of migraine was associated with a more than three-fold risk of ischaemic stroke. Coexistence of risk three-fold risk of ischaemic stroke. Coexistence of risk factors for stroke (e.g. use of combined oral factors for stroke (e.g. use of combined oral contraceptives, high blood pressure, or smoking) had contraceptives, high blood pressure, or smoking) had more than multiplicative effects on the odds ratio for more than multiplicative effects on the odds ratio for ischaemic stroke associated with migraine [Chang et ischaemic stroke associated with migraine [Chang et al, 1999]. al, 1999].

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Migraine and COCMigraine and COC

• Contraindications to the use of combined oral Contraindications to the use of combined oral contraceptives (COCs) contraceptives (COCs) in women with migraine are based on in women with migraine are based on expert opinion because there is limited evidence in this area. expert opinion because there is limited evidence in this area. These recommendations are intended to enable most women These recommendations are intended to enable most women with migraine to use COCs safely, with minimal risk of ischaemic with migraine to use COCs safely, with minimal risk of ischaemic stroke, while protecting those at risk [MacGregor, 2000]. The stroke, while protecting those at risk [MacGregor, 2000]. The contraindications apply whether the conditions are present contraindications apply whether the conditions are present before starting COCs, or arise during the use of COCs: before starting COCs, or arise during the use of COCs: – Migraine with aura Migraine with aura – Migraine without aura when there is a history of more than one Migraine without aura when there is a history of more than one

additional risk factor for stroke (e.g. age 35 years or over, diabetes additional risk factor for stroke (e.g. age 35 years or over, diabetes mellitus, close family history of arterial disease in those under 45 mellitus, close family history of arterial disease in those under 45 years of age, hyperlipidaemia, hypertension, obesity, or smoking) years of age, hyperlipidaemia, hypertension, obesity, or smoking)

– Status migrainosus (headache phase lasting more than 72 hours) Status migrainosus (headache phase lasting more than 72 hours) – Migraine treated with ergot derivativesMigraine treated with ergot derivatives