2020 Symposia Series 1
Embracing New Treatment Options in the Management of Migraine Headache
Learning Objectives • Apply current diagnostic criteria for differential diagnosis of migraine to increase early recognition and treatment • Employ current migraine guideline recommendations and management strategies to establish improved patient treatment plans • Identify the appropriate use of established and emerging treatment options for migraine and related monitoring and safety options 3
Migraine Is Common US Prevalence (%) 30 Female 25 Female Male Migraine Prevalence (%) Male 20 Sex 17 6 15 Race White 17 6 10 Black 14 4 5 Highest prevalence Age 30 to 39 years 24 7 0 0 20 30 40 50 60 70 80 100 Age (years) 4 Lipton RB, et al. Headache. 2001;41:646-657; Lipton RB, et al. Neurology . 2007;68:343-349.
Migraine Is Debilitating • 2nd most disabling episodic Attendance at work 8 18 47 condition after lower back pain Family situation 4 23 38 • Migraine is a chronic disease Leisure time 8 14 37 with episodic manifestations Pursuing studies 8 12 27 7 8 28 Sexual life Social position 3 10 24 Very negative influence 3 6 22 Quite negative influence Love Some negative influence 4 20 Finances 6 Pursuing career 3 8 16 Finding friends 2 8 0 20 40 60 80 Percentage of Migraineurs (N = 423) Feigin VL et al. Lancet Neurol. 2019, 18:459-480; Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease 5 Study 2017. Seattle, WA: IHME, 2018; Linde M, et al. Cephalalgia. 2 004;24:455-465.
Pathophysiology of Migraine — Implications for Management Pain perception Cortex • Cortical spreading depolarization, altered connectivity • Migraine aura and cognitive symptoms Hypothalamus • Target for neuromodulation • Activation in premonitory phase Thalamus • Premonitory symptoms • Sensitization of alteration of thalamocortical circuits • Target for hypothalamic • Sensory sensitivity and allodynia peptides and modulators • Target for neuromodulation Upper Cervical Nerves Trigeminocervical Complex • Pain transmission or • Pain transmission or sensitization sensitization • Headache and neck pain Throbbing • Neck and head pain • Target for medications and neuromodulation pain • Target for local injections and neuromodulation Release of CGRP • Multiple potential sources or sites of action • Headache and other symptoms • Target for small-molecule antagonists and antibodies 6 Charles A. Lancet Neurol. 2018;17:174-182.
What Happens During a Migraine Attack? Clinical Phases of Migraine ~4 to 72 hours ≤1 hour Prodrome Headache Postdrome Aura (if present) • • • • Fatigue Localization Fatigue Visual • • • – Food craving Throbbing GI upset Scintillating • • • scotoma Muscle pain Nausea Cognitive • • • change Sensory Cognitive change Vomiting • • • • Muscle pain Motor Mood change Photophobia • • • Mood change Sensory disruption Phonophobia Adapted from: American Migraine Foundation. americanmigrainefoundation.org/understanding-migraine/timeline-migraine-attack/. 7 Accessed Apr 13, 2020.
Case Study: Colleen, a 42-Year-Old Call Center Operator Presenting Complaint History • “Tension headaches” that have become • Minor headaches since she was in her teens more frequent and debilitating in the past • No history of trauma or unusual stresses 10 years • Bilateral tubal ligation • Current headaches not relieved by • Works from home most days nonprescription NSAIDs Physical Exam and Medications • Recurrent insomnia, occasional • Height: 5 ft 6 in; weight: 186 lb; BMI: 30.0 kg/m 2 constipation • Hypertension controlled with amlodipine 5 mg/d 8 NSAID = nonsteroidal anti-inflammatory drug.
What to Ask About When Taking a Thorough Headache History • Frequency and patterns ‒ Any significant changes • Location • Duration • Quality and intensity • Time to peak intensity • Preceding symptoms (eg, how the headache begins; triggers) • Warning symptoms and aura • Associated symptoms and level of disability • Aggravating or relieving factors Weatherall MW. Ther Adv Chronic Dis. 2015;6:115-123. 9
Case Study (cont’d): Colleen’s History • Unilateral pattern of pain, sometimes behind browbone • Headaches often worse around menses • Headaches 4 to 6 times a month for the last 2 years, lasting from a few hours to up to a day • Severity varies but is usually moderate or severe • Interfere with work and household needs about 1 or 2 days a week • Loud noises and bright lights make headaches worse; sometimes her neck becomes sore • Sometimes feels congested and has a runny nose • Headaches often accompanied by nausea • Neurologic exam within normal limits 10
Typical Presentations of Common Forms of Headache TENSION TYPE MIGRAINE CLUSTER “SINUS” • Pain “like a band” • • Unilateral pain Pain in and around one • Pain behind browbone squeezing the head • eye Often with nausea and and/or cheekbones • • Primary headache visual changes Primary headache • Secondary headache per • per ICHD-3 per ICHD-3 Primary headache ICHD-3 per ICHD-3 • Unless clear signs of active infection, often is a migraine headache ICHD-3 = International Classification of Headache Disorders, 3rd edition. Cady RK, Schreiber CP. Otolaryngol Clin North Am . 2004;37:267-288; Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38:1-211; brgeneral.org www.brgeneral.org/healthy-lifestyle-blog/2018/november/4-major-types-of-headaches-and-where- they-hurt/. Accessed Apr 22, 2020. 11
Typical Presentations of Common Forms of Headache TENSION TYPE MIGRAINE CLUSTER “SINUS” • Pain “like a band” • • Unilateral pain Pain in and around one • Pain behind browbone squeezing the head • eye Often with nausea and and/or cheekbones • • Primary headache visual changes Primary headache • Secondary headache per • per ICHD-3 per ICHD-3 Primary headache ICHD-3 per ICHD-3 • Unless clear signs of active infection, often is a migraine headache ICHD-3 = International Classification of Headache Disorders, 3rd edition. Cady RK, Schreiber CP. Otolaryngol Clin North Am . 2004;37:267-288; Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38:1-211; brgeneral.org www.brgeneral.org/healthy-lifestyle-blog/2018/november/4-major-types-of-headaches-and-where- they-hurt/. Accessed Apr 22, 2020. 12
Migraine vs Tension-type Headache: A Common Misdiagnosis Migraine Tension-type ≥2 of the following ≥2 of the following • • Unilateral (59% of migraines) Bilateral • • Pulsating (85% of migraines) Not pulsating • • Moderate to severe intensity lasting between 4 and Mild to moderate intensity 72 hours • Not aggravated by routine physical activity • Aggravation by routine physical activity ≥1 of the following • No nausea/vomiting • • Nausea/vomiting (73% of migraines) One or neither: photophobia/phonophobia • Photophobia/phonophobia (~80% of migraines) Not attributable to another disorder Not attributable to another disorder Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38:1-211; Lipton RB, et al. Headache. 2001;41:646-657. 13
Landmark Study: How Likely Is it That an Episodic Headache Is Migraine? • Prospective, open-label study of patients with episodic headache (N = 1203) Probable • >90% seen in primary care migraine Episodic tension-type • (n = 67) 18% Self-report or physician diagnosis of migraine (n = 11) 3% almost always correct Unclassifiable (n = 11) 3% • Self-report or physician diagnosis of Migraine nonmigraine almost always later found (n = 288) 76% out to be migraine Tepper SJ, et al. Headache. 2004;44:856-864. 14
ID Migraine™: Simplified Diagnostic Criteria for Migraine Symptoms in the last 3 months: Light sensitivity with ❑ headache Nausea with headache ❑ Decreased ability to ❑ function with headache Any 2 of the 3 above symptoms = migraine Lipton RB, et al. Neurology. 2003;12:375-382. 15
Red Flags: SNOOP S Systemic involvement (fever, myalgias, weight loss) Systemic disease (cancer, AIDS) N Neurologic symptoms or signs O Onset sudden (thunderclap headache) O Onset after age 50 years Pattern of change: progressive headache/fewer headache-free periods; change in P type of headache; headache associated with pregnancy; headache related to body position Be alert to signs/symptoms of secondary headache. Dodick DW. Adv Stud Med . 2003;3:87-92; Dodick DW. N Engl J Med. 2006;354:158-165. 16
Headache Impact Test (HIT)-6 and Migraine Disability Assessment (MIDAS) Test HIT-6 • Measures the impact headaches have on job, school, home and social situations • Total score ≥50 suggests significant impact MIDAS • Measures how migraines affect everyday functioning Kosinski M, et al . Qual Life Res . 2003;12:963-974. 17
Case Study (cont’d) • Clinical findings are consistent with migraine without aura • Colleen is surprised because she thought migraines were always associated with an aura • Says that she is “just happy to know what is going on” • Headaches have a significant impact on her daily activity 18
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