Migraine: Overview of Diagnosis and Management Brennen Bittel, DO Clinical Assistant Professor Department of Neurology University of Kansas Medical Center

Overview     

Diagnostic Criteria Epidemiology Proposed pathophysiology Utility of neuroimaging Pharmacotherapy in the outpatient setting  Abortive  Preventative  Non-pharmacological therapy

Primary Headache Disorders  Tension HA  Autonomic cephalgias  Hemicrania Continua  Cluster HA  Migraine  New persistent daily HA  Etc.

Migraine Subtypes  w/ aura  w/o aura  Ocular/retinal  Chronic  Menstrual/Catamenial  Hemiplegic  Basilar  Achephalgic

DIAGNOSTIC CRITERIA

Migraine

IHS criteria- w/o Aura  Headache attacks lasting 4-72 hours  At least two of the following characteristics:    

Unilateral Pulsating/throbbing Moderate or severe Aggravation by/causing avoidance of routine physical activity

 During headache at least one of the following:  Nausea and/or vomiting  Photophobia and/or phonophobia

 Not attributed to another disorder

IHS Criteria – w/ Aura  Aura consisting of at least one of the following, but no motor weakness:  Fully reversible visual symptoms: positive and/or negative  Fully reversible sensory symptoms: positive and/or negative  Fully reversible dysphasic speech disturbance

 At least two of the following:  Homonymous visual symptoms and/or unilateral sensory symptoms  At least one aura symptom develops gradually over >5 minutes  Each symptom lasts >5 and > absenteeism  93% of total economic burden

Cause of Disability

PATHOPHYSIOLOGY Migraine

Proposed Mechanisms  Vasodilation  Cortical Spreading Depression  Brainstem Generator (?)

Series of Events

Series of Events

NEUROIMAGING Migraine

Neuroimaging  11 studies: 28-169 migraine pts w/ nml exam  Prevalence of significant intracranial abnormalities on imaging  0% to 3.1%

 Combined meta-analysis  Summary prevalence of ~ 0.2%

When to obtain imaging  Odds of significant intracranial abnormality are low  Less than 1/100

 Odds of such an abnormality in the face of an abnormal neurological examination is still low  Roughly 3/100

 Abnormal neuro exam triples the odds of finding a significant intracranial abnormality

When to obtain imaging  Factors shown to increase the odds of finding a significant abnormality on neuroimaging:      

Rapidly increasing headache frequency History of dizziness or lack of coordination History of subjective numbness or tingling History of headache causing awakening from sleep Headache worsened on Valsalva New onset headache in an older patient

Level of Evidence  Grade A

 Established as effective, ineffective or harmful

 Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings

 Grade B

 Probably effective, ineffective or harmful

 Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal

 Grade C

 Possibly effective, ineffective or harmful

 The US Headache Consortium achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

 Grade U

 Data inadequate or conflicting; treatment is unproven

AAN Recommendations  Neuroimaging is not usually warranted for patients with migraine and normal neurological examination (B)  Should be considered in patients with non-acute headache and an unexplained abnormal finding on the neurological examination (B)  Atypical headache features or patients who do not fulfill the strict definition of migraine, a lower threshold for neuroimaging may be applied (C)

Imaging Modality  MRI:  Sensitive in finding DVA, low grade brain tumors, and white matter changes

 Use of contrast:  If looking for enhancement (infection, neoplasm), tumor, demyelination

 CT:  Best for bone evaluation (fracture) and acute blood (SDH, SAH)

PHARMACOLOGICAL STRATEGIES Migraine

Strategies  Abortive  Rare attacks with reasonable response to therapies

 Preventative/Prophylactic  ≥ 2 attacks/mo that significantly effects pt’s daily     

activity/produce disability for ≥4 days/mo Unsatisfactory or scarce response to acute therapy Contraindication to acute treatments and adverse effects Use of abortive medications ≥ 2x/week Hemiplegic migraine Migraine with prolonged aura

Abortive: Mild-Moderate  Level A: The most consistent evidence exists for NSAIDS:  Aspirin  Ibuprofen  Naproxen sodium  Excedrin migraine (ASA, acetaminophen, caffeine)  More than 10-15 dose/month can lead to medication overuse headaches

Abortive: Mild-Moderate  Level B  Midrin: isometheptene/acetaminophen/dichloralphenazone  1-2 caps q4 (max 8 caps/hour)

Abortive: Moderate-Severe  Level A: Triptans  Sumatriptan (Imitrex): 50-100mg (Max 200mg/d)  

SQ (4-6mg) > oral (Max 12mg) Nasal: 5, 20mg (Max 40mg/d)

 Rizatriptan (Maxalt): 5-10 mg 

Best results at higher doses (30mg max daily)

 Zolmitriptan (Zomig): 2.5-5 mg  SEs: flushing, dizziness, paresthesia/tingling. Rare transient chest symptoms

 Ergots: Peripheral ischemia black box for combo with macrolides or protease inhibitors

 Cafergot

 1-2 tabs PO q30min PRN (max 6/d, 10/wk)

 Available generic:  Zolmitriptan, Sumatriptan, Rizatripatan, Naratriptan

Triptans- Efficacy  Rizatriptan 10mg more effective in relieving pain within 1 hour  vs 100 mg sumatriptan, 2.5 mg naratriptan, and 2.5 mg zolmitriptan  P40% improvement*

 Biofeedback training  Thermal and electromyographic (EMG) biofeedback  >35% improvement*

Modalities  Cognitive-behavioral (or stress-management) therapy  ~ 50% improvement

 Hypnosis  Benefit over 6-12 months

 Combinations of above  Thermal + relaxation: >30%  Thermal + relaxation + CBT = propranolol

Physical Treatments  Acupuncture  Mixed results

 Transcutaneous electrical nerve stimulation (TENS)  Limited data, little benefit

 Occlusal adjustment  Benefit for tension HA, not migraine

Physical Treatments  Cervical manipulation  Post-treatment scores significantly better than pre-treatment scores for headache frequency, severity, and disability

 Personal preference:  Direct and Indirect soft tissue techniques  Myofascial release  Strain/counter strain  Facilitated positional release

Goals  Reduction in HA frequency and severity  Tailor treatment based on:  Pt comorbidities  Pt preference  SE profile

 Realistic expectation for improvement

Thank you Questions/comments?

Case 55 y/o F with classic migraine x 35y  HPI: dysphasic speech,

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nausea, tingling R arm. Severe HA + vomiting. 4/year. PMHx: Depression Meds: Lexapro ROS: none VS: 118/70, HR 70 Exam: non-focal

Plan  Imaging: defer  Abortive:  Triptan (nasal, SQ)  Antiemetic (PR)  PPx:  Not necessarily indicated

Case 24 y/o F- common migraine x 8y  HPI: 4 HA days/mo +N  PMHx: None  ROS: constipation, anxiety  Meds: prenatal vit, PRN tylenol  VS: 125/72, HR 87  Exam: non-focal

Plan  Imaging: defer  PPx:  OTC: Mag 400mg  +/- Rx: Propranolol  Abortive:  Tylenol + benadryl +/- reglan  OMM  HA diary

Case 35 y/o M- common migraine x12 y

Plan

 HPI: 1/wk, mod-severe,

 Imaging: defer +n/photo, wakes with HA  PPx: Topamax  PMHx: obesity  Abortive: midrin trial +  ROS: snoring, EDS, neck Compazine

pain  Meds: PRN Aleve, takes  OMM  Refer: PSG 4-5/week  VS: 145/90, HR 95  Counsel: Med overuse HA  Exam: Mallampati 3, nonfocal, paraspinal TTP

Case 60 y/o with 1y of headache  HPI: Daily HA

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intermittently severe with n/v, +p/p and intermittent arm weakness PMHx: no regular care ROS: weight loss, dark stools Meds: PRN ASA VS: BP 155/89, HR 88 Exam: unilateral hyperreflexia, up-going toe, pronator drift

Plan:  Headache red flags!!  Imaging: MRI/MRA