Migraine Assessment and Treatment in a Primary Care Setting– Adult– Clinical Practice Guideline (CPG)

The Clinical Practice Guidelines for Adult Migraine Assessment and Treatment was reviewed and re-approved on -XO\, 201. The guideline was previously approved by Unity’s Clinical Quality Improvement Committee on 0D\November 17, 2006, September 16, 2005, September 17, 2004, and September 11, 2003. The UW Medical Foundation, UW Hospitals and Clinics, Unity Health Insurance and Group Health Cooperative participated in the development of this guideline. The task force was a multidisciplinary work group comprised of physicians, pharmacists and a nurse practitioner.

Migraine – Adult – Ambulatory/Emergency Department Clinical Practice Guideline Note: Active Table of Contents – Click to follow link EXECUTIVE SUMMARY .............................................................................................................. 3 SCOPE ......................................................................................................................................... 4 METHODOLOGY ......................................................................................................................... 4 DEFINITIONS ............................................................................................................................... 5 INTRODUCTION .......................................................................................................................... 5 RECOMMENDATIONS ................................................................................................................ 5 Headache Evaluation and Diagnosis ..................................................................................... 5 Additional Evaluation ............................................................................................................. 8 Development of a Comprehensive Migraine Treatment Plan ................................................ 8 Follow Up and Referral ........................................................................................................ 12 UW HEALTH IMPLEMENTATION ............................................................................................. 13 REFERENCES ........................................................................................................................... 15 APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................. 18 APPENDIX B. DEVELOPMENT OF A COMPREHENSIVE TREATMENT PLAN..................... 19 APPENDIX C. ACUTE TREATMENT AT A HEALTH CARE FACILITY. .................................. 20 APPENDIX D. MIGRAINE MEDICATION AND DOSAGE TABLE ............................................ 21 APPENDIX E. MIGRAINE DISABILITY ASSESSMENT TEST (MIDAS) .................................. 23 APPENDIX F. MIGRAINE TREATMENT OPTIMIZATION QUESTIONNAIRE (MTOQ-6) ........ 24

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Contact for Content: Name: Douglas Dulli, MD, MS – Neurology Phone Number: (608) 263-9058 Email Address: [email protected] Contact for Changes: Name: Janna Lind, MSN – Center for Clinical Knowledge Management Phone Number: (608) 890-6695 Email Address: [email protected] Coordinating Team Members: Allan Rifkin, MD – Clinical Professor, University Health Services Nathan Rudin, MD – Pain Management Dana Resop, MD – Emergency Medicine Alison Miller, MD – Family Medicine Matthew Anderson, MD – Internal Medicine Steven Tyska, MD – Urgent Care Nicole Mendolla, RN – Chemotherapy Services Sara Shull, PharmD – Drug Policy Program Carin Endres, PharmD – Drug Policy Program Michael Ochowski, RPh – Group Health Cooperative Megan Weimer, NP – Group Health Cooperative Elaine Rosenblatt, NP – Unity Health Insurance Philip Bain, MD – Internal Medicine, Dean Health System Review Individuals/Bodies: Ahmed Afifi, MD – Plastic Surgery Committee Approvals/Dates: Clinical Knowledge Management (CKM) Council (Last Periodic Review: 05/26/16) Release Date: May 2016 |

Next Review Date: May 2019

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Executive Summary Guideline Overview The purpose of treating migraine is to provide relief of symptoms, reduce patients’ disability due to headache, and to reduce patient reliance on Emergency Department/Urgent Care for headache management. This guideline has been developed to assist in the assessment and treatment of adult patients diagnosed with migraine or probable migraine headaches. The recommendations include abortive therapy, preventive therapy, and lifestyle modifications. Medication overuse headache and chronic migraine are also discussed. Key Revisions (2016 Periodic Review) 1. Emphasized recommendations against opioid use 2. Removed basic drug information and contraindications, which can be found elsewhere 3. Eliminated use of the term “washout,” which implies a medication may be restarted in the future, and removed detailed washout procedure 4. Added the mTOQ-6, which may be used to evaluate the effectiveness and tolerability of current treatments Key Practice Recommendations 1. If no warning signs and symptoms are present, the evaluation should focus on the diagnosis of primary headache type (migraine, cluster, or tension-type) in order to determine the most appropriate treatment plan for the patient (see Table 3, International Headache Society (HIS) Diagnostic Criteria of Primary Headache). (UW Health Moderate quality evidence, strong recommendation)

2. For patients with moderate to severe migraine headaches, it is recommended to use a migraine-specific medication as initial abortive treatment.1 (UW Health GRADE Moderate quality evidence, strong recommendation)

3. Because most patients seeking care for migraine experience moderate to severe headache, it is reasonable to start with an initial triptan dose on the high end of the range, for example, sumatriptan 100 mg oral or rizatriptan 10 mg, rather than starting with a low dose and escalating to therapeutic effect.1 (UW Health GRADE Moderate quality evidence, weak/conditional recommendation)

4. Tricyclic antidepressants, such as amitriptyline (UW Health GRADE Moderate quality evidence, strong recommendation), or beta blockers, such as propranolol or metoprolol (UW Health GRADE High quality evidence, strong recommendation), are recommended as first line preventive therapy, if indicated. 5. Patients should be advised to take abortive medications no more than two days per week to avoid development of medication overuse headache and chronification of migraine.2,3 (UW Health GRADE Moderate quality evidence, strong recommendation) Medication overuse is a particular concern with butalbital and opioids; do not use these medications to treat migraine.3-6 (UW Health GRADE Strong quality evidence, strong recommendation) 6. Following treatment, patients who present to urgent care or emergency departments for treatment of migraine should be referred to primary care or a headache specialist to be evaluated for chronic migraine/medication overuse and initiation of preventive treatment if indicated.7,8 (UW Health GRADE Moderate quality evidence, strong recommendation) Companion Documents 1. Development of a Comprehensive Migraine Treatment Plan in Primary Care (Algorithm) 2. Acute Treatment for Migraine at a Health Care Facility (Algorithm) 3. Migraine Medication and Dosage Table 4. Migraine Disability Assessment Test (MIDAS) 3

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

5. Migraine Treatment Optimization Questionnaire (mTOQ-6)

Scope Disease/Condition(s): Migraine Headache Clinical Specialty: Family Medicine, Internal Medicine, Pharmacy, Urgent Care, Emergency Medicine Intended Users: Primary Care Physicians, Advanced Practice Providers, Pharmacists, Registered Nurses Objective(s): To provide an evidence-based guideline to assist clinicians in the evaluation and treatment of patients with migraine headaches. Target Population: Nonpregnant, non-breastfeeding, adults (ages 18 years and over) with migraine headaches. UW Health has a separate guideline for pediatric migraine management. Interventions and Practices Considered: 1. Assessment of headache symptoms, headache frequency, degree of disability, and effectiveness of treatment using validated assessment tools 2. Pharmacotherapy for abortive and preventive treatment 3. Factors related to lifestyle behaviors, possible triggers, and comorbid conditions Major Outcomes Considered: 1. Relief of migraine symptoms 2. Reduction of migraine-associated disability 3. Reduction of frequency of recurrent migraines 4. Reduced patient reliance on Emergency Department/Urgent Care and non-scheduled visits for headache management 5. Increased usage of preventive medications for frequent migraine sufferers

Methodology Methods Used to Collect/Select the Evidence: Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and workgroup members to collect evidence for review. Expert opinion and clinical experience were also considered during discussions of the evidence. Methods Used to Formulate the Recommendations: The workgroup members agreed to adopt recommendations developed by external organizations and/or arrived at a consensus through discussion of the literature and expert experience. All recommendations endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or committees (as appropriate). Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations: Recommendations developed by external organizations maintained the evidence grade assigned within the original source document and were adopted for use at UW Health.

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 in Appendix A). Rating Scheme for the Strength of the Evidence/Recommendations: See Appendix A for the rating scheme(s) used within this document. Recognition of Potential Health Care Disparities: According to the National Health Interview Survey (NHIS), the average prevalence of severe headache or migraine from 2005 to 2012 was 17.7% for Native Americans, 15.5% for Whites, 14.5% for Hispanics, 14.45% for African Americans, and 9.2% for Asians. As compared to Whites, African American were less likely to utilize the health-care setting for migraine treatments and to have been prescribed acute migraine medication. Lower rates of diagnosis in some groups may indicate racial and ethnic disparities in access and quality of care for minority patients. 9,10 Due to the large spectrum of the cost of medications used to treat migraine, sensitivity should be given to socioeconomic status and coverage of medication costs.

Definitions Primary Headache is a headache due to a headache condition itself and not caused by another medical condition. Secondary Headache is a headache resulting from another medical condition. Abortive Medications are taken at the first sign of an impending migraine headache. They work to stop the migraine process itself.11 Preventive Medications are taken daily to reduce the frequency and severity of migraine headache.11

Introduction Migraines affect approximately 36 million people in the United States.12 Although migraines are treatable, missed diagnoses frequently lead to under-treatment in this population.13 Of those diagnosed with migraine, approximately 25% are candidates for preventive therapy, yet only 13% report current daily use of a preventive agent.12 The disability, lost productivity, decreased quality of life, and increased use of emergent and acute care associated with under-recognized disease and missed treatment opportunities is substantial.

Recommendations Headache Evaluation and Diagnosis Evaluation for patients presenting with headache should include a medical history, a headache history, and a physical exam (see Table 1, Headache Evaluation). All patients presenting with headache, especially those presenting for the first time or with a change in headache symptoms, should be evaluated for possible indicators of a serious 5

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condition that may require immediate action or further evaluation and referral (see Table 2, Warning Signs and Symptoms). (UW Health Moderate quality evidence, strong recommendation)

Table 1: Headache Evaluation Look for evidence of meningeal irritation, papilledema, bruits, or neurological signs, which suggest the need for further investigation. Physical Exam. At minimum, evaluate the following: Vital signs, including temperature Cardiac exam Evidence of sinus etiology Scalp arteries Carotid arteries Cervical paraspinal muscles Cervical range of motion Neurological evaluation, including cranial nerves, cranial vasculature, mental status, reflexes, funduscopic exam

Table 2: Warning Signs and Symptoms Potentially ominous headache warning signs and symptoms may indicate intracranial infection, bleed, mass, or temporal arteritis. Refer to appropriate emergency or specialty care provider if indicated. Atypical headache; worst headache in patient’s life Fever, nuchal rigidity, marked increase in blood pressure Neurological symptoms, especially if new onset Altered mental status Sudden onset of severe headache Cognitive/behavioral changes Abnormality in neurological exam New onset severe headache after age 40 Abrupt onset headaches triggered by (not exacerbated by) exertion, cough, sexual activity, straining Progressive daily headache, especially if progressing over days or weeks If no warning signs and symptoms are present, the evaluation should focus on the diagnosis of primary headache type (migraine, cluster, or tension-type) in order to determine the most appropriate treatment plan for the patient (see Table 3, International Headache Society (IHS) Diagnostic Criteria of Primary Headache).2 (UW Health Moderate quality evidence, strong recommendation)

If no warning signs and symptoms are present and primary headache type is unclear, consider a diagnosis of probable migraine (migraine that does not fully meet IHS criteria for a diagnosis of migraine).2 Patients with frequent migraine headaches should be evaluated for chronic migraine (15 days per month or more) and medication overuse (10-15 times per month for 3 months), as these conditions often occur concomitantly and require a different treatment approach (see Table 4, Medication Overuse Headache and Chronic Migraine).2 (UW Health Moderate quality evidence, strong recommendation)

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

In chronic migraine, many headaches are characterized by pressing/tightening quality, mild to moderate intensity, bilateral location, no aggravation by physical activity, and absence of vomiting, making the headaches indistinguishable from tension-type headaches. The provider should be alert to the possibility that the presentation of frequent tension-type headaches in a migraine sufferer may represent transformation of episodic to chronic migraine.2

Table 3: International Headache Society Diagnostic Criteria of Primary Headache Migraine Headache2 5 or more headache attacks, each attack lasting 4-72 hours if untreated Any 2 of the following:  unilateral  pulsatile  moderate to severe intensity (the most important differentiation from tension headache)  worse with exertion And at least one of the following:  nausea and/or vomiting  photo and phonophobia Secondary headache types not suggested or confirmed Cluster Headache2 Severe unilateral pain in the orbit and/or surrounding areas lasting 15-180 minutes untreated Headache is associated with at least one of the following signs on the side of the pain:  conjunctival injection (reddened eyeball) lacrimation (excessive tears from the eye) nasal congestion (stuffy nose)  rhinorrhea (runny nose) facial sweating  miosis (smaller pupil)  ptosis (lowered upper eyelid)  eyelid edema (lid becomes puffy) Frequency of attacks: from 1 every other day to 8 per day Restlessness; need to keep moving Secondary headache types neither suggested nor confirmed Tension-Type Headache2 Patients with this disorder (in the absence of other headache types) typically self-medicate, without the advice or assistance of a care provider. At least 2 of the following pain characteristics:  pressing (non-pulsating) quality  mild or moderate intensity (may inhibit, but does not prohibit activities)  bilateral location  no aggravation by walking stairs or similar routine physical activity None of the following:  nausea or vomiting  photophobia or phonophobia Secondary headache types not suggested or confirmed 7

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Table 4: Medication Overuse Headache and Chronic Migraine Medication Overuse Headache2 Headache occurring on 15 or more days per month in a patient with a pre-existing headache disorder Regular overuse (10 to 15 times per month, depending on the medication) for greater than 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache Secondary headache types neither suggested nor confirmed Chronic Migraine2 Headache occurring on 15 or more days per month for greater than 3 months Headaches have migrainous features on at least 8 days per month Secondary headache types neither suggested nor confirmed

Additional Evaluation Once migraine headache has been diagnosed, evaluate severity, frequency, and disability due to migraine headache to establish a baseline prior to initiating new therapy. The patient questionnaire Migraine Disability Assessment Score (MIDAS) may be used for this purpose.14 A score of 21 or greater on the MIDAS indicates severe disability and likely medication overuse headache and/or chronic migraine. In patients with experience using medication to treat migraine headache, determine previous therapies used and response to treatment. The Migraine Treatment Optimization Questionnaire (mTOQ-6) may be used to evaluate the effectiveness and tolerability of current treatment and subjectively guide modifications to the treatment plan to better meet the treatment goals.15

Development of a Comprehensive Migraine Treatment Plan The goals of an effective treatment plan are15,16:  Migraine-free in 2 hours or less, including relief of vomiting and other associated symptoms  Sustained relief of migraine for 24 hours  Tolerability of medications (avoidance of adverse drug effects)  Treatment of comorbid conditions  Reduced dependance on treatment at urgent care centers, emergency departments, and/or unscheduled clinic visits An algorithm for Development of a Comprehensive Migraine Treatment Plan in the Primary Care Setting is included in Appendix B. An algorithm for Acute Treatment for Migraine at a Clinic, Urgent Care Center, or Emergency Department is included in Appendix C. See Appendix D, Migraine Medication and Dosage Table for additional information on abortive therapies, supportive therapies including antiemetics, and preventive therapies. 8

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Abortive Therapy There are several over the counter analgesics that have been shown to effectively treat the symptoms of migraine headache, for example, acetaminophen, ibuprofen, aspirin, and acetaminophen/aspirin/caffeine combination products.17 The majority of patients seeking care for migraine headache, however, have moderate to severe symptoms and have already tried over the counter treatment. Therefore, for patients with moderate to severe migraine headaches, it is recommended to use a migraine-specific medication as initial abortive treatment.1 (UW Health GRADE Moderate quality evidence, strong recommendation) Triptans: Triptans have consistently been shown to be effective in the abortive treatment of migraine and are recommended as first line therapy for home use.17 (UW Health GRADE High quality evidence, strong recommendation) Oral triptans are most effective when taken early in an attack. Therefore, patients should be instructed carry their medication with them at all times and to take their medication at the first sign of an impending attack. Because most patients seeking care for migraine experience moderate to severe headache, it is reasonable to start with an initial triptan dose on the high end of the range, for example, sumatriptan 100 mg oral or rizatriptan 10 mg, rather than starting with a low dose and escalating to therapeutic effect.1 (UW Health GRADE Moderate quality evidence, weak/conditional recommendation)

Triptans taken with naproxen sodium have been shown to be more effective than triptans alone. Unless there are contraindications to NSAID therapy, it is recommended to advise patients to take naproxen sodium with a triptan in the early phase of an attack.17 (UW Health GRADE High quality evidence, weak/conditional recommendation)

There are multiple triptan medications on the market, each with unique pharmacokinetic profiles. Some patients may find one medication to be more effective with fewer side effects than another medication. If other triptans are poorly tolerated, consider naratriptan as it often has milder side effects.18 (UW Health GRADE low quality evidence, weak/conditional recommendation) Sumatriptan is available as a subcutaneous injection and may be considered for home use for rapidly progressive, severe, or nocturnal migraine, as well as for patients with severe nausea and vomiting who cannot tolerate oral medications. Sumatriptan subcutaneous injection is also recommended to treat patients presenting with severe migraine at a clinic, urgent care center, or emergency department.17 (UW Health GRADE High quality evidence, strong recommendation) Dihydroergotamine (DHE): DHE injection is an excellent choice for the treatment of migraine headache at a healthcare facility such as an infusion center, urgent care center, or emergency department.17 (UW Health GRADE Moderate quality evidence, strong recommendation) DHE is effective regardless of the duration of the headache; it does not need to be administered early in an attack to be effective. DHE nasal spray can be considered as home treatment for triptan nonresponders but may be cost prohibitive.17 (UW Health GRADE High quality evidence, weak/conditional recommendation) Please note DHE should not be used if a triptan has been taken in the previous 24 hours. Triptans and DHE should also be avoided in patients with uncontrolled hypertension or a history of any type of vascular disease. Supportive therapies: Antiemetics can be used to treat symptoms of nausea and vomiting and/or as a prophylactic treatment for patients who will receive DHE (nausea and vomiting is a 9

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

potential side effect of this medication). There is also evidence that suggests dopamine receptor antagonists (e.g., metoclopramide, prochlorperazine, haloperidol) may help abort the migraine process itself.17,19-21 Use of an antiemetic is recommended in the treatment of migraine. (UW Health GRADE High quality evidence, weak/conditional recommendation)

Administration of diphenhydramine may be considered, as it has antiemetic properties and may mitigate the potential extrapyramidal side effects of dopamine-blocking antiemetics. (UW Health GRADE Low quality evidence, weak/conditional recommendation) Evidence suggests diphenhydramine reduces akathisia associated with prochlorperazine IV administration; however there may be no benefit when administering diphenhydramine to prevent akathisia resulting from low doses of IV metoclopramide.22-24 Additional abortive medications: If there has been an inadequate response to supportive therapies and/or DHE or triptans, then consider administration of one of the following based on individual patient factors (e.g., bleed risk, renal disease) and previous response to treatment: ketorolac IV (UW Health GRADE Moderate quality evidence, weak/conditional recommendation), magnesium IV (UW Health GRADE Moderate quality evidence, strong recommendation), or valproate sodium IV (UW Health GRADE Weak quality evidence, weak/conditional recommendation). Opioids: Opioid use for the treatment of migraine is associated with development of medication overuse headache, the progression of episodic migraine to chronic migraine, greater headacherelated disability, more severe symptoms, and greater use of health care resources. Close to 17% of patients who take opioids for migraine headache meet criteria for probable dependance. Opioids and barbiturates are NOT recommended for treatment of migraine, except as a last resort in extraordinary circumstances.3-5,7,25,26 (UW Health GRADE High quality evidence, strong recommendation) This includes butorphanol, tramadol, and the barbiturate, butalbital. Preventive Therapy The indications for starting preventive therapy include:  Patient has 3 or more severe migraine attacks per month that fail to respond adequately to abortive or symptomatic therapy  The migraine attacks are severe enough to impair the patient’s quality of life  In any patient who has more than 2 headaches/week that require pharmacologic intervention.12 The primary goals of effective preventive therapy are to reduce migraine attack frequency, reduce the number of migraine days, and/or reduce the severity and duration of the attacks.8 Additional goals are to improve the responsiveness to treatment of acute attacks, improve function and reduce disability, and prevent transformation of episodic migraine to chronic migraine.27 The underlying principle in prescribing preventive medication is to use the least amount of medication with the fewest side effects to gain control of symptoms until the preventive treatment can be stopped. The preventive medications are better tolerated when started slowly and escalated to therapeutic doses. The medication should be continued for an adequate period, usually several months, to determine effectiveness.14 Tricyclic antidepressants, such as amitriptyline (UW Health GRADE Moderate quality evidence, strong recommendation), or beta blockers, such as propranolol or metoprolol (UW Health GRADE High quality evidence, strong recommendation), are recommended as first line therapy.8 10

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Anti-epileptic medications, such as topiramate and divalproex, have been shown to be effective and may be considered as a second line therapy.8 (UW Health GRADE High quality evidence, weak/conditional recommendation) However, these medications are associated with a historically high rate of adverse effects, including cognitive impairment and teratogenicity, and are not recommended without a discussion of the risks and benefits. (UW Health GRADE High quality evidence, weak/conditional recommendation) Women of childbearing age should use an effective form of birth control if these medications are prescribed. If two or more preventive medications are ineffective or poorly tolerated, consider a referral to a headache specialist. After evaluating the patient, a headache specialist may recommend further interventions such as onabotulinumtoxinA for chronic migraine.28,29 Refer to the UW Health Botulinum Toxin – Adult/Pediatric – Ambulatory Guideline. Lifestyle Behaviors and Comorbid Conditions Multiple lifestyle, behavioral, and environmental factors are associated with migraine or transition from episodic to chronic migraine. Patients should be advised to follow regular patterns of sleep, exercise, mealtimes, and hydration status.30 (UW Health GRADE Moderate quality evidence, strong recommendation) Patients should be aware of possible migraine triggers, for example, certain foods, cigarette smoke, lighting, and other environmental factors.31 Anxiety and depression, sleep apnea, obesity, cigarette smoking, and medication overuse are all comorbid conditions and behaviors associated with episodic or chronic migraine.32-36 It is advised to discuss and treat these conditions as changes may improve migraine symptoms, prevent transition to chronic migraine, or help convert a patient with chronic back to episodic migraine. (UW Health GRADE Moderate quality evidence, strong recommendation) Additional Therapies There are many complimentary and alternative therapies for migraine treatment and prevention that can be considered based on individual patient preferences and potential benefits. (UW Health GRADE Low quality evidence, weak/conditional recommendation) Complementary techniques such as biofeedback, relaxation training, massage, and acupuncture can be helpful for many patients. 37-39 Nutraceuticals such as magnesium oxide, riboflavin, coenzyme Q10, and extract of butterbur root are occasionally useful as supplemental or alternative therapy. 40,41 Evidence supporting the effectiveness of these therapies is not robust, however they are generally safe and well tolerated. Migraine surgery is available at UW Health for patients who have not adequately responded to medical treatment. There is evidence to support the effectiveness of migraine surgery; however there is some controversy about the quality and robustness of the evidence. Patients should not routinely be referred for migraine surgery without a careful discussion of the likelihood of effectiveness and possible adverse effects, some of which may be permanent (e.g. temporal hollowing).42,43 (UW Health GRADE Moderate quality evidence, weak/conditional recommendation) Not all patients are candidates for migraine surgery, and patients should be adequately evaluated by a neurologist or primary care doctor before being referred for a surgical evaluation. Medication Overuse/Chronic Migraine Medication overuse headache (MOH) is associated with the transformation from episodic to chronic migraine and can decrease the responsiveness to both abortive and preventive 11

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medications. Overuse of any medication used to treat migraine can result in MOH, including over the counter analgesics and triptans. Patients should be advised to take abortive medications no more than two days per week to avoid development of medication overuse headache and chronification of migraine.2,3 (UW Health GRADE Moderate quality evidence, strong recommendation) Medication overuse is a particular concern with butalbital and opioids; do not use these medications to treat migraine.3-6 (UW Health GRADE Strong quality evidence, strong recommendation)

Chronic Migraine is the most common underlying cause of frequent presentations to urgent care and emergency department settings, due to the very high frequency of severe migraine headaches that accompany this condition. It is also the most prominent cause of disability associated with headache disorders. Chronic migraine complicated by medication overuse, especially opioids, can be especially challenging to treat in both the primary care and urgent care/emergency department settings.25 Following treatment, patients who present to urgent care or emergency departments for treatment of migraine should be referred to primary care or a headache specialist to be evaluated for chronic migraine/medication overuse and initiation of preventive treatment if indicated.7,8 (UW Health GRADE Moderate quality evidence, strong recommendation) Initiation of preventive treatment and weaning off overused medications may decrease usage of urgent/emergency care for migraine treatment. There is still debate as how best to approach treatment for a patient with frequent headaches who is overusing medication. It is a reasonable approach to start a preventive medication and begin weaning off of the overused medication.36 (UW Health GRADE Moderate quality evidence, weak/conditional recommendation) The preferred method for weaning a patient off an overused medication will vary greatly based on the type and dose of medication in use and patient specific factors and preferences. If a patient with medication overuse is not improving on preventive medication, the patient may need to completely stop using the overused medication(s) before effective treatment can be achieved.

Follow Up and Referral Patients should be advised to use a headache diary to track symptoms, severity, and frequency of headache, possible triggers, treatments used, and response to treatment.16 (UW Health GRADE Low quality evidence, weak/conditional recommendation) A sample headache diary can be found on uwhealth.org. The patient should be instructed to contact the clinic for a change in headache pattern or new symptoms, adverse effects to medications, or if medications are ineffective. If starting a new preventive medication, consider a follow up visit in about 4-6 weeks to discuss response to medication. (UW Health Very low quality evidence, weak/conditional recommendation) Follow up visits may include use of the MIDAS and/or mTOQ-6 patient questionnaires to evaluate migraine frequency, severity, disability, and effectiveness of treatment (including need for adjustments in medication therapy). Referral to a headache specialist should be considered for atypical headache features, a concerning change in headache pattern, or for chronification of migraine. A referral is also advised if there are excessive side effects or a lack of effect in at least two preventive medications.

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

UW Health Implementation Potential Benefits:  Increased recognition and diagnosis of migraines in the primary care setting  Optimized treatment in adults with migraine headaches Potential Harms:  Adverse events associated with therapies  Medication overuse headaches Pertinent UW Health Policies & Procedures UW Health Clinical Policy #1.2.3 Opiate Management Patient Resources 1. Health Facts For You #5355 – Migraine Headaches 2. Health Facts For You #6764 – Migraine Headaches – Spanish Version 3. Health Facts For You #5896 – Medication Overuse Headaches 4. Health Facts For You #6765 – Medication Overuse Headaches – Spanish Version 5. Health Facts For You #6473 – Headache, Working with Your Doctor to Avoid the Emergency Room 6. Health Facts For You #6766 – Headache, Working with Your Doctor to Avoid the Emergency Room – Spanish Version 7. Healthwise – Migraine Headaches 8. Healthwise – Migraine Headache Triggers 9. Healthwise – Migraines: Finding and Avoiding Triggers 10. Healthwise – Headache Diary 11. Healthwise – Headaches: Should I Take Medicines to Prevent Migraines? 12. Healthwise – Headaches: Should I have imaging test to find out what’s causing my headaches? 13. Healthwise – Ergotamines for Migraine Headaches 14. Healthwise – Antidepressants for Migraine Headaches 15. Healthwise – Seizure Medicine to Prevent Migraine Headaches 16. Healthwise – Headaches: Managing a Headache 17. Healthwise – Headaches 18. Healthwise – Headaches 19. Lexicomp – Migraine Headache Discharge Instructions Guideline Metrics 1. Number of patients with a reason for visit of “migraine” or “headache” who received an opioid in the clinic or a prescription for opioids during that visit 2. % of patients discharged from the emergency department with a diagnosis of migraine who had a follow up visit arranged with PCP or headache specialist 3. % of patients on a preventive medication for migraine. Could benchmark with national data. Implementation Plan/Clinical Tools 1. Guideline will be posted on U-Connect in a dedicated location for Clinical Practice Guidelines. 2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter. 3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline recommendations (such as the following) will be reviewed for consistency and modified as appropriate. 13

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Delegation Protocols Prescription Renewal Protocol for UW Health Pain and Headache Clinics for Medications eConsults eConsult to Neurology – Established Diagnosis – Headache Migraine [5386] eConsult to Neurology – New/Changed Headache [5415] Order Sets & Smart Sets Headache – Specialty [3363] Headache [80] ED – Headache – Adult [631] Headache – Adult – e-Visit [4912] Headache Trigger injections [4255] Injection – Headache [171] Injection – Headache [3593] Rehab Medicine – Botox [2302] Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem.

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References 1. 2. 3. 4. 5. 6. 7. 8.

9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

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19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015;49(3):326-334. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others. Headache. 2012;52(2):292-306. Eken C. Critical reappraisal of intravenous metoclopramide in migraine attack: a systematic review and meta-analysis. Am J Emerg Med. 2015;33(3):331-337. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med. 2008;52(4):399-406. Vinson DR. Diphenhydramine in the treatment of akathisia induced by prochlorperazine. J Emerg Med. 2004;26(3):265-270. Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med. 2001;37(2):125-131. Buse DC, Pearlman SH, Reed ML, Serrano D, Ng-Mak DS, Lipton RB. Opioid use and dependence among persons with migraine: results of the AMPP study. Headache. 2012;52(1):18-36. Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83(14):1277-1284. Loder E, Biondi D. General principles of migraine management: the changing role of prevention. Headache. 2005;45 Suppl 1:S33-47. U.S. Food and Drug Administration. FDA approves Botox to treat chronic migraine. 2010. Aurora SK, Winner P, Freeman MC, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 2011;51(9):1358-1373. Woldeamanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a prevalence case-referent study. J Neurol. 2016;263(4):669-676. Borkum JM. Migraine Triggers and Oxidative Stress: A Narrative Review and Synthesis. Headache. 2016;56(1):12-35. Seng EK, Seng CD. Understanding migraine and psychiatric comorbidity. Curr Opin Neurol. 2016;29(3):309-313. Harnod T, Wang YC, Kao CH. Association of Migraine and Sleep-Related Breathing Disorder: A Population-Based Cohort Study. Medicine (Baltimore). 2015;94(36):e1506. Ornello R, Ripa P, Pistoia F, et al. Migraine and body mass index categories: a systematic review and meta-analysis of observational studies. J Headache Pain. 2015;16:27. Qi Gan W, Estus S, Smith JH. Association Between Overall and Mentholated Cigarette Smoking With Headache in a Nationally Representative Sample. Headache. 2016;56(3):511-518. Chiang CC, Schwedt TJ, Wang SJ, Dodick DW. Treatment of medication-overuse headache: A systematic review. Cephalalgia. 2015. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009(1):Cd001218. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain. 2007;128(1-2):111-127. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. 2011;12(2):127-133. Tepper SJ. Nutraceutical and Other Modalities for the Treatment of Headache. Continuum (Minneap Minn). 2015;21(4 Headache):1018-1031. 16

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Sun-Edelstein C, Mauskop A. Alternative headache treatments: nutraceuticals, behavioral and physical treatments. Headache. 2011;51(3):469-483. American Headache Society. American Headache Society Urges Caution in Using Any Surgical Intervention in Migraine Treatment. Mt Royal, NJ2012. Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009;124(2):461-468.

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix A. Evidence Grading Scheme(s) Figure 1. GRADE Methodology adapted by UW Health

GRADE Ranking of Evidence High

We are confident that the effect in the study reflects the actual effect.

Moderate

We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different.

Low

The true effect may differ significantly from the estimate.

Very Low

The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice Strong

The net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision.

Weak/conditional

Recommendation may be conditional upon patient values and preferences, the resources available, or the setting in which the intervention will be implemented.

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix B. Development of a Comprehensive Migraine Treatment Plan in the Primary Care Setting

Diagnosis of Migraine or Probable Migraine

Further evaluation required (outside of guideline scope)

YES

Change in headache pattern or new symptoms?

Last Reviewed: 05/2016 Contact CCKM for questions. Migraine – Adult – Ambulatory/ Emergency Department Clinical Practice Guideline

NO

Additional Migraine Evaluation1 · Evaluate severity, frequency, and disability due to migraine (may use MIDAS) · Evaluate previous response to treatment (may use mTOQ-6) · Evaluate for headache medication overuse (10-15 times per month for > than 3 months)

1

Consider referral to a headache specialist if: · Atypical features or change in headache pattern · If headache becomes chronic (15 or more days/month) · Excessive side effects or lack of effect in at least 2 preventive medications. For effective treatment of chronic migraine, patient must first wean off opioid medication, if applicable

Wean off overused medication.

Select/Modify the Abortive Treatment Plan2 FIRST LINE: ORAL TRIPTANS · Sumatriptan 100 mg, rizatriptan 10 mg, zolmitriptan, almotriptan, or eletriptan. To be taken at the onset of mild pain · Add naproxen sodium 220 to 440 mg oral unless contraindicated MODIFICATIONS: · For rapidly progressive, severe, or nocturnal migraine, consider sumatriptan subcutaneous injection 6 mg · Consider naratriptan if other triptans are poorly tolerated. FOR NON-TRIPTAN RESPONDERS: · Consider DHE nasal spray

Goals of Treatment Plan: · Migraine-free in 2 hours or less · Migraine-free for 24 hours · Tolerability of medications · Treatment of comorbid conditions · Reduced dependance on treatment at clinic/ urgent care/ED

Indications for Preventive Therapy: · Patient has 3 or more severe migraine attacks/month that fail to respond adequately to treatment · Migraine attacks are severe (impair the patient’s quality of life) · In any patient who has > 2 headaches/week that require pharmacologic intervention

Medication Overuse Likely?

NO

2

3

YES

Initiate Preventive Therapy if Indicated3 Preventive medications are better tolerated when started slowly and escalated to therapeutic doses. FIRST LINE: Tricyclic antidepressants (e.g., amitriptyline or nortriptyline 25-75 mg/day) OR beta blockers (e.g., propranolol 60-120 mg/day) SECOND LINE: Antiepileptics (e.g., topiramate 50-200 mg/day or divalproex 500-1500 mg/day). Associated with a high rate of adverse effects including teratogenicity. Female patients should be cautioned to use adequate birth control.

· · ·

Discuss Behaviors and Comorbid Conditions that May Contribute to Headache Lifestyle factors (e.g., sleep, activity level, skipping meals, stress) Be aware of possible headaches triggers (e.g., certain foods, cigarette smoke, lighting, other things in the environment) Other behaviors and comorbid conditions (e.g., anxiety/depression, sleep apnea, obesity, cigarette smoking, medication overuse (OTC, prescription, and illicit drugs, especially cannabis)

Follow Up · Advise patient to use a headache diary to track symptoms/severity, possible triggers, treatments used, and response to treatment · If starting a new preventive medication, arrange for follow up in about 4-6 weeks · Instruct patient to contact the clinic for a change in headache pattern or new symptoms, adverse effects of medications, or if medications are ineffective

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix C. Acute Treatment of Migraine at a Clinic, Urgent Care Center, or Emergency Department

Patient presents to a Health Care Facility with Severe/Disabling Headache

Secondary headache suspected?

Secondary Headache · Example conditions that may cause secondary headache include intracranial infection, bleed, or mass, temporal arteritis, sinusitis, and febrile illness Primary Headache · Types include cluster, tensiontype, and migraine · Tension-type headache is by definition of mild or moderate intensity · If secondary headache is not suspected, and primary headache type is unclear, consider a diagnosis of probable migraine

Last Reviewed: 05/2016 Contact CCKM for questions. Migraine – Adult – Ambulatory/ Emergency Department Clinical Practice Guideline

YES

NO

Further evaluation, treatment, referral, and follow up as indicated (outside of guideline scope)

Diagnose primary headache type

Diagnosis of cluster or tension-type headache

Diagnosis of Migraine or Probable Migraine

Dihydroergotamine (DHE) · Effective regardless of the duration of headache · If DHE IV injection is not available at a particular UW Health facility, it may be ordered for administration at the UW Health Infusion Center. Call the Infusion Center to schedule.

Administer Supportive Medications 1. IV fluid rehydration therapy 2. Anti-nausea therapy (e.g., metoclopramide 5-10 mg IV, ondansetron 4 mg IV) 3. May also consider diphenhydramine 25-50 mg IV 4. May also consider lorazepam 0.5 mg IV and/or haloperidol 0.5 mg IV

· · · ·

Any Contraindications to DHE or Triptans? Taken a triptan or DHE within previous 24 hours* Poorly tolerated or inadequate response to triptans or DHE in the past Uncontrolled hypertension History of any type of vascular disease

NO

*Exception: May use sumatriptan injection in patients who have taken oral sumatriptan in the previous 24 hours.

Medication Overuse and Chronic Migraine · Often occur together and are a common cause of multiple presentations to urgent care/ED for acute migraine treatment · Follow up with primary care or a headache specialists is recommended

YES

Administer First Line Medication · DHE 1 mg injection (IV or IM) if available at facility OR · Sumatriptan 4-6 mg subcutaneous injection

If Inadequate Response to Previous Therapy, Consider · Ketorolac 15-30 mg IV unless contraindicated OR · Magnesium 1 g, IV infusion over 30-60 min OR · Valproate sodium 500 mg IV

To Reduce Repeated Visits, Follow Up with PCP or Headache Specialist Should be Scheduled Before the Patient Leaves

Opioids for Headache · Opioids are NOT recommended and should only be given only as a last resort in extraordinary circumstances · Use of opioids to treat migraine pain is associated with development of medication overuse headache and chronification of migraine

Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix D. Migraine Medication and Dosage Table Product

How supplied

Dosage Ranges

Generic Available?

Abortive or Rescue Therapy Triptans Almotriptan

6.25, 12.5mg tab

Eletriptan

20, 40mg tab

Frovatriptan

2.5mg tab

Naratriptan

1, 2.5mg tab

Rizatriptan

5, 10mg tab 5, 10mg ODT

Sumatriptan

25, 50, 100mg tablet 5, 20mg nasal spray 6mg/0.5mL, 4mg/0.5mL, 3mg/0.5mL subcutaneous injection

Zolmitriptan

6.25-12.5mg once, may repeat after 2 hours; Max 25mg/24hr 20-40mg once, may repeat after 2 hours; Max 80mg/24hr 2.5mg once, may repeat after 2 hours; Max 7.5mg/24hr 1-2.5mg once, may repeat after 4 hours; Max 5mg/24hr 5-10mg once, may repeat after 2 hours; Max 3 mg/24hr Tab: 25-100mg once, may repeat after 2 hours; Max 200mg/24hr Nasal: 5-20mg once, may repeat after 2 hours; Max 40mg/24hr

Yes No No Yes Yes Tab: Yes Nasal: Yes SubQ: Yes but not 3mg/0.5mL pen TransD: No

SubQ: 1-6mg once, may repeat after 1 hr; Max 12mg/24hr

6.5mg/4 hr transdermal patch

TransD: 1 patch once, may apply second patch at least 2 hours after activation of first; Max 2 patches/24hr

2.5, 5mg tab 2.5, 5mg ODT 2.5, 5mg nasal spray

Tab: 1.25-2.5mg once, may repeat after 2 hours; Max 10 mg/24hr

Tab: Yes Nasal: No

Nasal: 2.5 mg once, may repeat after 2 hours; Max 10 mg/24hr

Ergot Derivatives Dihydroergotamine (DHE)

4mg/mL nasal spray 1mg/mL injection solution

IM/SQ/IV: 1mg once, may repeat at 1 hour intervals; Max 3mg (2mg IV) per 24hr

Yes

Nasal: 1 spray (0.5mg) in each nare, may repeat in 15 minutes; Max 4 spray (2mg)/24hr

NSAIDs Naproxen sodium

220mg (OTC), 275mg, 550mg tab

Tab: 220 to 440mg once

Yes

Ketorolac

15, 30mg/mL injection solution

IM: 30-60mg once IV: 15-30mg once

Yes

Valproate sodium

100mg/mL injection solution (must be diluted)

400-1000mg IV once

Magnesium sulfate

500mg/mL injection solution (must be diluted)

1-2 grams IV once

Anti-epileptics Yes

Other* Yes

*Butorphanol is FDA approved for migraine, however, it is NOT recommended due to high abuse potential and association with chronification of migraine.

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Product

How supplied

Dosage Ranges

Generic Available?

Supportive Therapy Antiemetics Chlorpromazine

25mg/mL injection solution

INJ: 12.5mg IV once

Diphenhydramine

50mg/mL injection solution

INJ: 25-50mg IV once

Metoclopramide

5, 10mg tab 5mg/mL injection solution 4, 8mg tab 4, 8mg ODT 4mg/5mL oral solution 2mg/mL injection solution 5, 10mg tab 5mg/mL injection solution 25mg rectal suppository 12.5, 25, 50mg tab 6.25mg/5mL oral syrup 12.5, 25mg rectal suppository 2mg/1mL, 4mg/1 mL injection solution 5mg/1mL injection solution

TAB & INJ: 5-10mg q6h PRN

Yes

PO: 4-8mg q12h PRN INJ: 4mg IV/IM ONCE

Yes

PO: 5-10mg q6h PRN INJ: 10mg IV/IM ONCE SUPP: 25mg q6h PRN PO: 25-50mg q6h PRN SUPP: 25-50mg q6h PRN

Yes

IV: 0.5mg ONCE

Yes

IV: 0.5mg ONCE

Yes

Ondansetron

Prochlorperazine Promethazine

Lorazepam Haloperidol

Yes

Yes

Preventative Therapy Beta-blockers Propranolol

10, 20, 40, 60, 80mg tab 60, 80, 120, 160mg ER cap

IR tab & solution: 40-240mg 2-3 times per day in divided doses

Yes

ER tab: 80-240mg once daily

Metoprolol

20mg/5mL, 40mg/5mL oral solution 25, 37.5, 50, 75, 100mg tab

IR tab: 25-100mg twice daily

Yes

Timolol

5, 10, 20mg tab

10 -15mg twice daily

Yes

Atenolol

25, 50, 100mg tab

50-100mg once daily

Yes

Amtriptyline

10, 25, 50, 75, 100, 150mg tab

Tricyclic Antidepressants 25-150mg HS Start low and titrate dose upward

Yes

SNRIs Venlafaxine

25, 37.5, 50, 75, 100mg tab 37.5, 75mg, 150mg ER cap 37.5, 75, 150, 225mg ER tab

IR tab: 75-150mg divided 2-3 times per day

Yes

ER tab & cap: 37.5-150mg daily

Anti-epileptics Divalproex

125, 250, 500mg DR tab

DR tab: 250-500mg twice daily

Yes

Topiramate

250, 500mg ER tab 25, 50, 100, 200mg tab

ER tab: 500-1000mg once daily 25mg once daily. Titrate by 25mg weekly up to 50mg twice daily

Yes

OTC/Supplements Magnesium

Various OTC preparations

250-500mg twice daily

Yes

Riboflavin

Various OTC preparations

400mg once daily

Yes

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix E. Migraine Disability Assessment Test (MIDAS)

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Appendix F. Migraine Treatment Optimization Questionnaire (mTOQ-6) The following questions refer to the times when you take treatment for your migraine headaches. Please circle the frequency that best fits your experience in the past 4 weeks (Please answer all the questions below.) 1. Are you able to quickly return to your normal activities (i.e. work, family, leisure, and social activities) within 2 hours after taking your migraine medications? Never Rarely Less than half the time Half the time or more 2. After taking you migraine medication are you pain free within 2 hours for most attacks? Never Rarely Less than half the time Half the time or more 3. Does one dose of your migraine medication relieve your migraine headaches and keep them away for at least 24 hours, for most attacks? Never Rarely Less than half the time Half the time or more 4. Is your migraine medication well tolerated? Never Rarely Less than half the time Half the time or more 5. Are you comfortable enough with your migraine medication to be able to plan your daily activities? Never Rarely Less than half the time Half the time or more 6. After taking your migraine medication do you feel in control of your migraines enough so that you feel there will be no disruption to your daily activities? Never Rarely Less than half the time Half the time or more

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]

Recommended Solutions for Patient Reported Migraine Treatment Optimization Questionnaire (mTOQ-6) Deficits in Treatment Optimization Deficit areas (mTOQ-6 item) Quick return to function

2 hour pain free

Sustained 24-hour pain relief Tolerability Comfortable to make plans

Clinical Action                  

Perceived Control

     

Add migraine-specific acute treatment Change route of administration (non-oral) Raise dose Change to more effective and/or faster agent Add migraine specific acute treatment Change route of administration (non-oral) Raise dose Change to more effective and/or faster agent Use agenda with favorable recurrence rate and/or longer half life Consider preventive pharmacologic treatments , behavioral treatments Switch to more tolerable agent Change route of administration (non-oral) Add migraine specific acute treatment Change route of administration (non-oral) Raise dose Change to more effective and/or faster agent Consider preventive pharmacologic treatments, behavioral treatments Add cognitive behavioral therapy to enhance self=efficacy, decrease anxiety, and enhance adherence Add migraine specific acute treatment Change route of administration (non-oral) Raise dose Change to more effective and/or faster agent Consider preventive pharmacologic treatments, behavioral treatments Add cognitive behavioral therapy to enhance self=efficacy, decrease anxiety, and enhance adherence

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Copyright © 201 University of Wisconsin Hospitals and Clinics Authority Contact: Lee Vermeulen, [email protected] Last Revised: 05/2016 [email protected]