Migraine

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Slide 1 :

MANAGAMENT OF MIGRAINE

Slide 2 :

Migraine Facts Migraine is one of the common causes of recurrent headaches According to IHS, migraine constitutes 16% of primary headaches Migraine afflicts 10-20% of the general population More than 2/3 of migraine sufferers either have never consulted a doctor or have stopped doing so Migraine is underdiagnosed and undertreated Migraine greatly affects quality of life. The WHO ranks migraine among the world’s most disabling medical illnesses

Slide 3 :

Burden Of Migraine World - 15-20% of women and 10-15% of men suffer from migraine In India, 15-20% of people suffer from migraine Adults – Female: Male ratio is 2 : 1 In childhood migraine, boys and girls are affected equally until puberty, when the predominance shifts to girls. NEJM 2002; 346(4): 257-269; XI Congress of the IHS, 2004

Slide 4 :

Migraine - Definition “Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting” -World Federation of Neurology

Slide 5 :

Migraine Triggers Food Disturbed sleep pattern Hormonal changes Drugs Physical exertion Visual stimuli Auditory stimuli Olfactory stimuli Weather changes Hunger Psychological factors

Slide 6 :

Phases of Acute Migraine Prodrome Aura Headache Postdrome

Slide 7 :

PRODROME Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache Symptoms include Yawning Excitation Depression Lethargy Craving or distaste for various foods Duration – 15 to 20 min

Slide 8 :

AURA Aura is a warning or signal before onset of headache Symptoms Flashing of lights Zig-zag lines Difficulty in focussing Duration : 15-30 min

Slide 9 :

HEADACHE Headache is generally unilateral and is associated with symptoms like: Anorexia Nausea Vomiting Photophobia Phonophobia Tinnitus Duration is 4-72 hrs

Slide 10 :

POSTDROME (RESOLUTION PHASE) Following headache, patient complains of Fatigue Depression Severe exhaustion Some patients feel unusually fresh Duration: Few hours or up to 2 days

Slide 11 :

MIGRAINE – CLASSIFICATION According to Headache Classification Committee of the International Headache Society, Migraine has been classified as: Migraine without aura (common migraine) Migraine with aura (classic migraine) Complicated migraine

Slide 12 :

MIGRAINE: CLINICAL FEATURES

Slide 13 :

MIGRAINE - PATHOPHYSIOLOGY VASCULAR THEORY Intracerebral blood vessel vasoconstriction – aura Intracranial/Extracranial blood vessel vasodilation – headache SEROTONIN THEORY Decreased serotonin levels linked to migraine Specific serotonin receptors found in blood vessels of brain PRESENT UNDERSTANDING Neurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation

Slide 14 :

NEUROVASCULAR PROCESS

Slide 15 :

Arterial Activation Release of Neurotransmitter Worsening of Pain

Slide 16 :

MIGRAINE: DIAGNOSIS Medical History Headache diary Migraine triggers Investigations (only to exclude secondary causes) EEG CT Brain MRI

Slide 17 :

DIFFERENTIATING COMMON PRIMARY HEADACHES Strictly unilateral Tension headaches: Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate Cluster headaches: Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men

Slide 18 :

THE TREATMENT APPROACH TO MIGRAINE

Slide 19 :

LONG-TERM TREATMENT GOALS FOR THE MIGRAINE SUFFERER Reducing the attack frequency and severity Avoiding escalation of headache medication Educating and enabling the patient to manage the disorder Improving the patient’s quality of life

Slide 20 :

MIGRAINE MANAGEMENT Non-pharmacological treatment Identification of triggers Meditation Relaxation training Psychotherapy Pharmacotherapy non-specific Abortive therapy specific Preventive therapy

Slide 21 :

MIGRAINE: ABORTIVE THERAPY Non-specific treatment

Slide 22 :

ABORTIVE THERAPY FOR MIGRAINE Specific treatment

Slide 23 :

ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT

Slide 24 :

WHY THE NEED FOR PROPHYLAXIS ? Abortive drugs should not be used more than 2-3 times a week Long-term prophylaxis improves quality of life by reducing frequency and severity of attacks 80% of migraineurs may require prophylaxis

Slide 25 :

WHEN IS PROPHYLAXIS INDICATED? According to the US Headache Consortium Guidelines, indications for preventive treatment include: Patients who have very frequent headaches (more than 2 per week) Attack duration is > 48 hours Headache severity is extreme Migraine attacks are accompanied by prolonged aura Unacceptable adverse effects occur with acute migraine treatment Contraindication to acute treatment Migraine substantially interferes with the patient’s daily routine, despite acute treatment Special circumstances such as hemiplegic migraine or attacks with a risk of permanent neurologic injury Patient preference

Slide 26 :

PREVENTIVE THERAPY FOR MIGRAINE

Slide 27 :

PREVENTIVE THERAPY FOR MIGRAINE (CONTD.)

Slide 28 :

ROLE OF BETA BLOCKERS IN MIGRAINE PROPHYLAXIS ‘Gold standard’ in migraine prophylaxis Established efficacy and safety in migraine prophylaxis Especially preferred if hypertension or anxiety co-exist

Slide 29 :

ROLE OF PROPRANOLOL IN MIGRAINE PROPHYLAXIS

Slide 30 :

PROPRANOLOL – MECHANISMS OF ACTION Mechanisms proposed Vasoconstriction Anxiolytic action Decreased sympathetic activity

Slide 31 :

LIMITATIONS OF IMMEDIATE-RELEASE PROPRANOLOL Short t½ of 3-5 hrs Multiple daily dosing required to maintain adequate degree of beta-receptor blockade throughout 24 hr Poor patient compliance may compromise efficacy

Slide 32 :

ADVANTAGES OF EXTENDED-RELEASE PREPARATION OF PROPRANOLOL Migraine patients are asymptomatic between attacks Important to minimize number of daily doses during prophylactic treatment Once-daily administration improves compliance Stable drug concentration for 24 hrs

Slide 33 :

PROPRANOLOL-LA CLINICAL EFFICACY IN MIGRAINE

Slide 34 :

Cephalalgia 1990; 10: 101-105 n = 51 Duration = 12 weeks PROPRANOLOL REDUCES THE FREQUENCY OF ATTACKS PER MONTH IN BOTH COMMON AS WELL AS CLASSIC MIGRAINE PATIENTS Propranolol-LA 80 mg appears to have adequate prophylactic effect for migraine and may be better tolerated than propranolol-LA 160 mg, which appears to offer no additional benefits. *p < 0.001

Slide 35 :

Propranolol long-acting reduces the attack severity * p = 0.003 Headache 1998; 28: 607-611 n = 48

Slide 36 :

Propranolol vs. Flunarizine 48 50 0 10 20 30 40 50 60 70 Flunarizine (p<0.01) Propranolol (p<0.0005) No. of attacks reduced by more than 50% % of Patients Headache 1989; 29: 218-223

Slide 37 :

Propranolol showed a significant reduction in the severity of attacks 1.6 1.6 1.4 1.2* 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 Flunarizine Propranolol Severity score Baseline 16 weeks * p<0.05 Headache 1989; 29: 218-223

Slide 38 :

Propranolol significantly reduced the number of analgesics used 4.5 6.3 4.1 3.4 0 1 2 3 4 5 6 7 Flunarizine Propranolol Baseline 16 weeks No of analgesics/month * Headache 1989; 29: 218-223 *p<0.0005

Slide 39 :

DOSAGE OF PROPRANOLOL Starting dose: 40-80 mg once daily Max. dose/day: 240 mg If satisfactory response is not obtained within 4-6 weeks, after reaching the maximal dose, therapy should be discontinued Taper slowly to avoid rebound headache and adrenergic side effects Max. duration: 9 to 12 months

Slide 40 :

SHIFTING PATIENT FROM IR TO ER Propranolol extended-release produces low blood levels as compared to immediate-release The dose of the long-acting formulation may need to be higher than the total daily dose of the conventional formulation

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