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Women and Migraine:Women and Migraine:The Hormonal LinkThe Hormonal Link

Annual Review of Family MedicineAnnual Review of Family MedicineApril 12, 2010April 12, 2010

Norma Jo Waxman MDNorma Jo Waxman MD

Associate Professor of Family and Community MedicineAssociate Professor of Family and Community MedicineFaculty in the Bixby Center for Global Reproductive HealthFaculty in the Bixby Center for Global Reproductive HealthUniversity of California San FranciscoUniversity of California San Francisconjwaxman@fcm.ucsf.edunjwaxman@fcm.ucsf.edu

Learning ObjectivesLearning Objectives

�� Recognize migraine with and without aura, Recognize migraine with and without aura, menstrually related migraine, and true menstrual menstrually related migraine, and true menstrual migrainemigraine

�� Utilize behavioral and pharmacologic options for Utilize behavioral and pharmacologic options for acute and prophylactic management of migraineacute and prophylactic management of migraine

�� Understand when hormonal medication is helpful Understand when hormonal medication is helpful and safe for all ages of women with migraineand safe for all ages of women with migraine

�� Decrease incidence of chronic daily headache in Decrease incidence of chronic daily headache in your practiceyour practice

No pharmaceutical No pharmaceutical support or commercial support or commercial disclosuresdisclosures

Member of ARHP Member of ARHP expert advisory expert advisory committee on committee on Hormonal Migraines Hormonal Migraines and developed slide and developed slide set. Many used in this set. Many used in this presentationpresentation

Faculty DisclosureFaculty DisclosureWhy Care About Migraine?Why Care About Migraine?

�� Very Common neurologic Very Common neurologic disorderdisorder

•• UnderrecognizedUnderrecognized•• UndertreatedUndertreated

�� Produces severe disability Produces severe disability 1,21,2

�� Overuse of any drug may lead Overuse of any drug may lead to chronic daily HAsto chronic daily HAs3,43,4

IHS. Headache Classification Subcommittee of the International Headache Society (IHS). The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24(Suppl.1):139-41. 1. Lipton RB, et al. Headache. 2001;41:646–657 2. Bigal ME, et al. Cephalalgia. 2006; 26:43–49 3. Scher AI, et al. Pain. 2003;16:81–89 4. Bigal ME, Lipton RB. Headache 2006;46:1334–1343 5. Kruit MC. et al. JAMA 2004;291:427–434; 6. Kurth T, et al. JAMA 2006;296:283–291.

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Migraine in USAMigraine in USA

�� 30 million migraine sufferers30 million migraine sufferers

�� 1 in 10 persons a migraineur1 in 10 persons a migraineur

�� 1 of 4 households include a migraineur1 of 4 households include a migraineur

�� 99thth leading disability, more common than leading disability, more common than diabetes or asthmadiabetes or asthma

•• 30% of migraineurs have 3+ attacks/mo.30% of migraineurs have 3+ attacks/mo.•• 75% have reduced ability to function75% have reduced ability to function

•• 50% are severely impaired50% are severely impaired

Lipton RB, et al. Headache. 2001;41:646–657

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men�� 20 million women in USA 20 million women in USA �� 40% of women in their lifetime40% of women in their lifetime

•• Before puberty: equally prevalent in both sexes Before puberty: equally prevalent in both sexes •• After puberty: 3x more women than menAfter puberty: 3x more women than men•• Peaks in midlifePeaks in midlife•• ↓↓ after menopauseafter menopause

Lipton RB. Headache. 2001. Lipton RB. Neurology. 2007. Stewart. Cephalalgia. 2008.

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

�� At least 5 attacks with: At least 5 attacks with:

�� Headache lasts 4Headache lasts 4––72 hours w/o treatment 72 hours w/o treatment or without successful treatmentor without successful treatment

�� At least 2 of the following four symptoms:At least 2 of the following four symptoms:•• Unilateral pain (60%)Unilateral pain (60%)•• Throbbing (70%)Throbbing (70%)•• Aggravation by movementAggravation by movement•• Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from , Cephalalgia. 2004;8(suppl 1):S24-26.

more…

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (cont’d)(cont’d)

�� And at least 1 of the following 2 symptoms:And at least 1 of the following 2 symptoms:

•• Nausea and/or vomitingNausea and/or vomiting

•• Photophobia and/or phonophobiaPhotophobia and/or phonophobia

�� Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS, Cephalalgia. 2004.

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ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

� At least 2 attacks with

� At least 1 fully reversible symptom w/o motor� Visual (flickering lights, zigzags, spots or lines, and/or loss of vision) + and/or � Sensory (“pins and needles” and/or numbness) + and/or � Dysphasic speech

Adapted from IHS, Cephalalgia. 2004.

more…

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (cont’d)(cont’d)

•• Symptoms of aura develop gradually over Symptoms of aura develop gradually over >5min or different symptoms occur in >5min or different symptoms occur in succession over >5 min succession over >5 min

•• Each symptom last >5 and <60 min Each symptom last >5 and <60 min

•• Migraine begins with aura or within <60 min Migraine begins with aura or within <60 min

•• Symptoms are fully reversibleSymptoms are fully reversible

•• No organic diseaseNo organic disease

Adapted from IHS, Cephalalgia. 2004.

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

(%)

Lipton RB, et al. Headache. 2001.

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF, et al. Neurology. 2000.

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pat

ient

s w

ith H

A (

%)

Migraine without aura

Tension type

Migraine with aura

−16 −14 −12 −10 12 14 161086420−8 −6 −4 −2

HA = headache

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Menstrual Migraines Subtypes(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)�� Attacks fulfill criteria for Attacks fulfill criteria for 1.1 Migraine without aura1.1 Migraine without aura�� Attacks occur days 1 Attacks occur days 1 ±± 2 (i.e., days 2 (i.e., days --2 to +3) of 2 to +3) of menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle�� ~46% of women with migraine~46% of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)�� Attacks fulfill criteria for Attacks fulfill criteria for 1.1 Migraine without aura1.1 Migraine without aura�� Attacks occur days 1 Attacks occur days 1 ±± 2 (i.e., days 2 (i.e., days --2 to +3) of 2 to +3) of menstruation in at least 2/3 cycles, and at no other time of menstruation in at least 2/3 cycles, and at no other time of the cyclethe cycle�� ~14% of women with migraine ~14% of women with migraine

IHS, Cephalalgia. 2004.

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

• 40% non-menstrual migraine

• 60% menstrual migraine – MRM comprises the

majority of MM (46% of 60%)

Female MigraineursMRM = menstrually related migraine; MM = menstrual migraine.

MRM 46%

Non-menstrual Migraine

40%

Pure MM 14%

Mannix LK, Calhoun AH. Curr Treat Options Neurol. 2004.

Menstrual MigrainesMenstrual Migraines

�� Compared with attacks at other times of Compared with attacks at other times of the cycle, menstrual attacks are:the cycle, menstrual attacks are:

•• More disablingMore disabling

•• Longer in durationLonger in duration•• Less responsive to acute treatmentLess responsive to acute treatment•• More likely to relapseMore likely to relapse

MacGregor EA, Hackshaw A. Neurology. 2004. Dowson AJ, et al. Headache. 2005.

NonNon--HormonalHormonalMigraine Triggers Migraine Triggers

•• HungerHunger•• Certain FoodsCertain Foods•• DehydrationDehydration•• SleepSleep•• Head and neck Head and neck

painspains

•• EmotionalEmotional•• Environmental: smoke, Environmental: smoke,

bright lights, change in bright lights, change in weather weather

•• Concomitant diseaseConcomitant disease•• SexSex

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Hormonal Migraine Triggers Hormonal Migraine Triggers

•• Estrogen withdrawal, or change in level Estrogen withdrawal, or change in level �� MenstruationMenstruation

�� Placebo days with combined hormonal Placebo days with combined hormonal contraceptivescontraceptives

�� PregnancyPregnancy

�� PeriPeri--menopausemenopause

�� Hormone replacement therapyHormone replacement therapy

Case 1: SarahCase 1: SarahNew Patient VisitNew Patient Visit

�� 2424--yearyear--old nonold non--smoker smoker

�� Sexually activeSexually active

�� On intake: checks off On intake: checks off “headaches,” which she “headaches,” which she says are worse with her says are worse with her periodsperiods

�� Presents for contraceptionPresents for contraception

Does Sarah have migraine?...

Case 1: SarahCase 1: Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of

estrogenestrogen--containing OCPs.containing OCPs.

Sarah has migraine Sarah has migraine without without aura. She has no aura. She has no other risk factors for stroke.other risk factors for stroke.

OCP = oral contraceptive pillsOCP = oral contraceptive pills

Case 1: SarahCase 1: Sarah

Is Sarah eligible for estrogenIs Sarah eligible for estrogen--containing OCPs?containing OCPs?

A. B.

11%

89%A.A. YesYesB.B. NoNo

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Case 1: SarahCase 1: Sarah

• Is Sarah eligible for estrogen-containing contraceptives? Might she opt for a patch or ring?

A) Yes: Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke.

B) No: OCPs should never be used in women who have migraine.

WHO: Headaches and CHCWHO: Headaches and CHC

InitiateInitiate ContinueContinueNonNon--migrainous (mild or severe)migrainous (mild or severe) 11 22MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge < 35Age < 35 22 33Age > 35Age > 35 33 44

(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 44(at any age)(at any age)

Prodrome = photo/phonophobia, N/V Prodrome = photo/phonophobia, N/V –– These are not focalThese are not focalFocal symptoms = vision changes, numbness, parasthesiasFocal symptoms = vision changes, numbness, parasthesias

http://www.who.int/reproductive-health/publications/RHR_00_2_medical_eligibility_criteria_3rd/

Treatment of MigrainesTreatment of Migraines

�� Education and behavior modificationEducation and behavior modification�� Identify and avoid or modify triggersIdentify and avoid or modify triggers

�� Acute treatmentAcute treatment

�� Prophylactic treatment Prophylactic treatment •• ShortShort--termterm•• LongLong--termterm

Treatment of MigrainesTreatment of Migraines�� TriptansTriptansTriptansTriptansTriptansTriptansTriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesicscombination analgesics-- warn about SEswarn about SEs

�� NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

�� Phenothiazines, PO or PR, great for nausea & Phenothiazines, PO or PR, great for nausea & painpain

�� Think nonThink non--oral meds with nausea & vomiting oral meds with nausea & vomiting

�� Sleep can abolishes headache Sleep can abolishes headache

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Options for Acute TherapyOptions for Acute Therapy�� AspirinAspirin

�� IbuprofenIbuprofen

�� Naproxen sodiumNaproxen sodium

�� Combination AnalgesicsCombination Analgesics

�� Acetaminophen, aspirin and caffeineAcetaminophen, aspirin and caffeine

�� TriptansTriptans

�� PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

�� When acute tx failsWhen acute tx fails

�� When H/A returns in <24 hrs or continues When H/A returns in <24 hrs or continues for daysfor days

�� IV/IM phenothiazines in addition to DHE or IV/IM phenothiazines in addition to DHE or a triptan work better than narcoticsa triptan work better than narcotics--

Prophylaxis of MigrainesProphylaxis of MigrainesProphylaxis of MigrainesProphylaxis of MigrainesProphylaxis of MigrainesProphylaxis of MigrainesProphylaxis of MigrainesProphylaxis of Migraines�� Consider prophylaxis if acute meds used > Consider prophylaxis if acute meds used >

4x/mo, rescue meds > 1x/mo, or headaches 4x/mo, rescue meds > 1x/mo, or headaches are functionally limitingare functionally limiting

�� Start prophylaxis at low dose and titrate up Start prophylaxis at low dose and titrate up over 2over 2--3 months3 months

�� TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

�� Limited studies show biofeedback, relaxation Limited studies show biofeedback, relaxation training, spinal manipulation and physical training, spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisMedications for ProphylaxisConsider hx, coConsider hx, co--morbidities and hormonal statemorbidities and hormonal state

�� TCAsTCAs-- Amitrip best Amitrip best �� SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs)�� BetaBeta-- blockersblockers--

�� Propranolol most studied and successfulPropranolol most studied and successful-- Nadolol and Nadolol and Timolol tooTimolol too

�� Valproate, Topiramate, Gabapentin and other Valproate, Topiramate, Gabapentin and other “anti“anti--convulsants” and “mood stabilizers”convulsants” and “mood stabilizers”

�� BotoxBotox�� Verapamil and CCBVerapamil and CCB-- less effectiveless effective�� Hormonal Tx Hormonal Tx

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Preventive Options with Non-pharmacologic Modalities

Supplements�Magnesium�Vitamin B2- riboflavin�Feverfew�Butterbur (Petadolex)�Coenzyme Q10 �Omega-3 Fatty Acids� Isoflavones

chelated magnesium at 400chelated magnesium at 400--600 mg/d for 3600 mg/d for 3--4 months works as prophylaxis 4 months works as prophylaxis (best in pt. w/ aura or perimenstrual migraine, and those not responding to (best in pt. w/ aura or perimenstrual migraine, and those not responding to triptans). Riboflavin, 400mg/d for 3 months decreas e migraine frequency.triptans). Riboflavin, 400mg/d for 3 months decreas e migraine frequency.

Preventive Options with Preventive Options with NonNon--pharmacologic Modalitiespharmacologic Modalities

Cognitive/behavioral ModalitiesCognitive/behavioral Modalities�� ���� MeditationMeditation�� Recognize and Avoid TriggersRecognize and Avoid Triggers�� Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities�� Massage Massage �� Yoga Yoga �� AcupunctureAcupuncture�� ���� Osteopathic manipulationOsteopathic manipulation�� Peppermint oil (? Helpful for acute)Peppermint oil (? Helpful for acute)

Red FlagsRed Flags

�� Headaches begin after age 50Headaches begin after age 50

�� Very sudden onset of HeadacheVery sudden onset of Headache

�� First or worstFirst or worst�� Change in frequency or severityChange in frequency or severity

�� ImmunosuppressionImmunosuppression

�� Fever, stiff neck, rash, traumaFever, stiff neck, rash, trauma�� Focal neurologic symptoms or signsFocal neurologic symptoms or signs

�� PapilledemaPapilledema

Case 1: SarahCase 1: SarahRecommended ApproachRecommended Approach

��Migraine diaryMigraine diary

��Counseling about migraine triggers and nonCounseling about migraine triggers and non--pharmacologic treatment optionspharmacologic treatment options

��Her choice of hormonal / nonHer choice of hormonal / non--hormonal hormonal contraceptioncontraception

��Acute treatment with triptanAcute treatment with triptan

��Schedule 2Schedule 2--3 mo f/u to review diary3 mo f/u to review diary

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Case 1: SarahCase 1: SarahReturn VisitReturn Visit

�Headache diary confirms menstrual related migraine � 2–3 attacks/mo. without aura� Severe attack during pill-free week

What do you do next?...

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

Rescue/Emergency treatments

�IM/IV phenothiazines or DHE

Prophylactic perimenstrual treatments

�NSAIDs

�Supplemental estrogen�Triptans

�Extended cycle combined hormonal contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives� Dedicated product� Monophasic product throw away placebo� Continuous cycling with ring

Estrogen back in hormone-free interval� Mircette� Yaz� Supplemental estrogen

Migraine, OCPs, and StrokeMigraine, OCPs, and Stroke�� 6 per 100,000 6 per 100,000 ♀♀ / year / year –– healthyhealthy�� 12 per 100,000 12 per 100,000 ♀♀ / year / year –– migrainemigraine�� 18 per 100,000 18 per 100,000 ♀♀ / year / year –– migraine with auramigraine with aura

�� 12 per 100,000 12 per 100,000 ♀♀ / year / year –– healthy and COChealthy and COC�� 19 per 100,000 19 per 100,000 ♀♀ / year / year –– migraine and COCmigraine and COC�� 30 per 100,000 30 per 100,000 ♀♀ / year / year –– migraine with aura and COCmigraine with aura and COC

�� 34 per 100,000 34 per 100,000 ♀♀ / year / year –– stroke in pregnancystroke in pregnancy

Attributable risk: 7Attributable risk: 7--19 per 100,000 women per year19 per 100,000 women per year ~ ~ 4000 / year4000 / year

So, What about estrogen containing contraception in women with Migraine?So, What about estrogen containing contraception in women with Migraine?•• IHS: lowIHS: low--dose estrogen in women with simple visual auradose estrogen in women with simple visual aura

•• ACOG: progestin only, intrauterine or barrier contraceptionACOG: progestin only, intrauterine or barrier contraception

•• WHO: absolute contraindication in all women with auraWHO: absolute contraindication in all women with aura

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Case 2: PamCase 2: Pam

�35-year-old woman�6th week of pregnancy�Menstrual migraine diagnosed 10 years ago�Migraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy

��60% 60% –– 70% of migraineurs improve 70% of migraineurs improve during pregnancy during pregnancy

��NonNon--pharmacologic treatment is pharmacologic treatment is preferredpreferred

��BiofeedbackBiofeedback

��Relaxation therapyRelaxation therapy��CognitiveCognitive--behavioral therapybehavioral therapy��MagnesiumMagnesium

MacGregor EA. MacGregor EA. J Fam Plann Reprod Health Care. J Fam Plann Reprod Health Care. 2007.2007.

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm= no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm?(Y) ?(Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data= insufficient data* = for emergency treatment of migraine* = for emergency treatment of migrainenot responding to standard measuresnot responding to standard measures

MacGregor EA. J Fam Reprod Health Care. 2007

Case 2: PamTreatment and Outcome�� ReassuranceReassurance

•• Migraine may improve by the 2Migraine may improve by the 2ndnd trimester, trimester, particularly in women w/ history of menstrual particularly in women w/ history of menstrual migraine migraine

•• No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

�� AcuteAcute•• Acetaminophen, NSAIDS, Acetaminophen, NSAIDS, •• Triptans ??? (1Triptans ??? (1--2nd trimester2nd trimester-- may be safemay be safe-- need need

more studies)more studies)

�� ProphylacticProphylactic•• If possible, delay treatment until 2If possible, delay treatment until 2ndnd trimester trimester

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Case 2: Pam Case 2: Pam Treatment and OutcomeTreatment and Outcome (cont’d)(cont’d)

�� Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

•• Use lowest effective dose Use lowest effective dose

•• Stop 2 to 3 days before deliveryStop 2 to 3 days before delivery•• Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

�� AmitriptylineAmitriptyline is another option is another option �� (FDA C)(FDA C)

Case 3: HannahCase 3: Hannah

�52-year-old woman�Presents with headache�5-year history of menstrual

migraine and occasional attacks of migraine with aura

�Hot flashes, mood swings�Asks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

� Lowest and Non oral routes are best

� Evaluate risk factors for stroke and CAD

� Migraine with aura is not a contraindication to HT in low risk women (no RCTs, expert opinion)

� If aura 1st appears after start of HT, reduce estrogen and consider work up for TIA

Macgregor EA. Migraine, the menopause and hormone replacement therapy: a clinical review. J Fam Plann Reprod Health Care. 2007;33(4):245-9.. Macgregor EA. Estrogen replacement and Migraine, Maturitas Volume 63, Issue 1, 20 May 2009, Pages 51-55

Case 3: HannahCase 3: HannahTreatment and OutcomeTreatment and Outcome

�� Acute treatment with NSAIDS & triptansAcute treatment with NSAIDS & triptans

�� LowLow--dose nondose non--oral estradiol AND continuous oral estradiol AND continuous progestin (if needed)progestin (if needed)

�� Hannah’s migraine attacks increase when HT is Hannah’s migraine attacks increase when HT is initiated but improve with continued useinitiated but improve with continued use

�� Fluoxetine & venlafaxime useful migraine prophylaxis Fluoxetine & venlafaxime useful migraine prophylaxis and treat hot flashesand treat hot flashes

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Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

�� Diagnostic CriteriaDiagnostic CriteriaDiagnostic CriteriaDiagnostic CriteriaDiagnostic CriteriaDiagnostic CriteriaDiagnostic CriteriaDiagnostic Criteria: Headache 15 or more : Headache 15 or more days/month for at least 6 monthsdays/month for at least 6 months

�� Preventable with accurate medication Preventable with accurate medication history history

�� Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

�� Depression, anxiety and drug abuse may Depression, anxiety and drug abuse may complicate presentationcomplicate presentation1. Cephalalgia. 2004;8 (suppl 1):S24–26; 2. Bigal ME, et al. Cephalalgia. 2007;27:568.

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

�� AKA: rebound headache,AKA: rebound headache, chronic tensionchronic tension--type, medication induced, transformed type, medication induced, transformed migrainemigraine

�� CDH caused by CDH caused by overuse of acuteoveruse of acute medsmeds

�� Unrecognized epidemicUnrecognized epidemic : majority of : majority of referrals to headache clinicsreferrals to headache clinics

�� Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

�� Taper off acute medications Taper off acute medications

�� Overuse of NSAIDs, tylenol, narcotics Overuse of NSAIDs, tylenol, narcotics typicaltypical

�� May require hospitalization May require hospitalization

�� 6 RCTs showed sig improvement w/ 6 RCTs showed sig improvement w/ AmitriptylineAmitriptyline

�� The longer one has CDH, the harder it is to The longer one has CDH, the harder it is to treattreat

�� Steroids may be helpful during taper Steroids may be helpful during taper

Summary: Behavioral and Summary: Behavioral and Lifestyle Modifications Lifestyle Modifications

�� Avoid dietary, emotional, and Avoid dietary, emotional, and environmental triggersenvironmental triggers

�� Eat regular, healthful mealsEat regular, healthful meals

�� Get the right amount of sleepGet the right amount of sleep�� Get regular exerciseGet regular exercise

�� Learn stress management techniquesLearn stress management techniques

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A range of behavioral and drug options exist for the management of severe migraine

TakeTake--Home PointsHome PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses