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Managament Of Migraine

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Managament Of Migraine

  1. 1. MANAGAMENT OF MIGRAINE
  2. 2. Migraine Facts <ul><li>Migraine is one of the common causes of recurrent headaches </li></ul><ul><li>According to IHS, migraine constitutes 16% of primary headaches </li></ul><ul><li>Migraine afflicts 10-20% of the general population </li></ul><ul><li>More than 2/3 of migraine sufferers either have never consulted a doctor or have stopped doing so </li></ul><ul><li>Migraine is underdiagnosed and undertreated </li></ul><ul><li>Migraine greatly affects quality of life. The WHO ranks migraine among the world’s most disabling medical illnesses </li></ul>
  3. 3. Burden Of Migraine <ul><li>World - 15-20% of women and 10-15% of men suffer from migraine </li></ul><ul><li>In India, 15-20% of people suffer from migraine </li></ul><ul><li>Adults – Female: Male ratio is 2 : 1 </li></ul><ul><li>In childhood migraine, boys and girls are affected equally until puberty, when the predominance shifts to girls. </li></ul>NEJM 2002; 346(4): 257-269; XI Congress of the IHS, 2004
  4. 4. Migraine - Definition <ul><li>“ 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” </li></ul><ul><li> -World Federation of Neurology </li></ul>
  5. 5. Migraine Triggers <ul><li>Food </li></ul><ul><li>Disturbed sleep pattern </li></ul><ul><li>Hormonal changes </li></ul><ul><li>Drugs </li></ul><ul><li>Physical exertion </li></ul><ul><li>Visual stimuli </li></ul><ul><li>Auditory stimuli </li></ul><ul><li>Olfactory stimuli </li></ul><ul><li>Weather changes </li></ul><ul><li>Hunger </li></ul><ul><li>Psychological factors </li></ul>
  6. 6. Phases of Acute Migraine <ul><li>Prodrome </li></ul><ul><li>Aura </li></ul><ul><li>Headache </li></ul><ul><li>Postdrome </li></ul>
  7. 7. PRODROME <ul><li>Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache </li></ul><ul><li>Symptoms include </li></ul><ul><ul><li>Yawning </li></ul></ul><ul><ul><li>Excitation </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Craving or distaste for various foods </li></ul></ul><ul><li>Duration – 15 to 20 min </li></ul>
  8. 8. AURA <ul><li>Aura is a warning or signal before </li></ul><ul><li>onset of headache </li></ul><ul><li>Symptoms </li></ul><ul><li>Flashing of lights </li></ul><ul><li>Zig-zag lines </li></ul><ul><li>Difficulty in focussing </li></ul><ul><li>Duration : 15-30 min </li></ul>
  9. 9. HEADACHE <ul><li>Headache is generally unilateral and is associated with symptoms like: </li></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Photophobia </li></ul></ul><ul><ul><li>Phonophobia </li></ul></ul><ul><ul><li>Tinnitus </li></ul></ul><ul><li>Duration is 4-72 hrs </li></ul>
  10. 10. POSTDROME (RESOLUTION PHASE) <ul><li>Following headache, patient complains of </li></ul><ul><li>Fatigue </li></ul><ul><li>Depression </li></ul><ul><li>Severe exhaustion </li></ul><ul><li>Some patients feel unusually fresh </li></ul><ul><li>Duration: Few hours or up to 2 days </li></ul>
  11. 11. MIGRAINE – CLASSIFICATION <ul><li>According to Headache Classification </li></ul><ul><li>Committee of the International </li></ul><ul><li>Headache Society, Migraine has been </li></ul><ul><li>classified as: </li></ul><ul><li>Migraine without aura (common migraine) </li></ul><ul><li>Migraine with aura (classic migraine) </li></ul><ul><li>Complicated migraine </li></ul>
  12. 12. MIGRAINE: CLINICAL FEATURES Patient complains of visual disturbances and may have mood variations During headache, patient complains of phonophobia and photophobia Unilateral throbbing headache and later becomes generalised Unilateral throbbing headache may be accompanied by nausea and vomiting Aura or prodrome is present No aura or Prodrome Migraine With Aura Migraine Without Aura
  13. 13. MIGRAINE - PATHOPHYSIOLOGY <ul><li>VASCULAR THEORY </li></ul><ul><li>Intracerebral blood vessel vasoconstriction – aura </li></ul><ul><li>Intracranial/Extracranial blood vessel vasodilation – headache </li></ul><ul><li>SEROTONIN THEORY </li></ul><ul><li>Decreased serotonin levels linked to migraine </li></ul><ul><li>Specific serotonin receptors found in blood vessels of brain </li></ul><ul><li>PRESENT UNDERSTANDING </li></ul><ul><li>Neurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation </li></ul>
  14. 14. NEUROVASCULAR PROCESS
  15. 15. Arterial Activation Release of Neurotransmitter Worsening of Pain
  16. 16. MIGRAINE: DIAGNOSIS <ul><li>Medical History </li></ul><ul><li>Headache diary </li></ul><ul><li>Migraine triggers </li></ul><ul><li>Investigations (only to exclude secondary causes) </li></ul><ul><ul><li>EEG </li></ul></ul><ul><ul><li>CT Brain </li></ul></ul><ul><ul><li>MRI </li></ul></ul>
  17. 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
  18. 18. THE TREATMENT APPROACH TO MIGRAINE
  19. 19. LONG-TERM TREATMENT GOALS FOR THE MIGRAINE SUFFERER <ul><li>Reducing the attack frequency and severity </li></ul><ul><li>Avoiding escalation of headache medication </li></ul><ul><li>Educating and enabling the patient to manage the disorder </li></ul><ul><li>Improving the patient’s quality of life </li></ul>
  20. 20. MIGRAINE MANAGEMENT <ul><li>Non-pharmacological treatment </li></ul><ul><ul><li>Identification of triggers </li></ul></ul><ul><ul><li>Meditation </li></ul></ul><ul><ul><li>Relaxation training </li></ul></ul><ul><ul><li>Psychotherapy </li></ul></ul><ul><li>Pharmacotherapy </li></ul><ul><li>non-specific </li></ul><ul><ul><li>Abortive therapy </li></ul></ul><ul><ul><li>specific </li></ul></ul><ul><ul><li>Preventive therapy </li></ul></ul>
  21. 21. MIGRAINE: ABORTIVE THERAPY Non-specific treatment Oral 500 mg-4 g Paracetamol Oral 500-650 mg Aspirin Route Dose Drug Oral 500-750 mg Naproxen Oral/IM 50-100 mg Diclofenac Oral 200- 300 mg Ibuprofen
  22. 22. ABORTIVE THERAPY FOR MIGRAINE Specific treatment Orally 10 mg Rizatriptan Orally SC 25-300 mg 6 mg Sumatriptan 5-HT receptor agonists SC 0.75-1 mg Dihydroergotamine Oral 1-2 mg/d; max-6 g/d Ergotamine Ergot alkaloids Route Dose Drug
  23. 23. ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT Oral/IV 10-25 mg Chlorpromazine Oral/IM 50-125 mg Promethazine Oral/IV 5-10 mg Metoclopramide Oral 10-80 mg Domperidone Route Dose (mg)/d Drug
  24. 24. WHY THE NEED FOR PROPHYLAXIS ? <ul><li>Abortive drugs should not be used more than 2-3 times a week </li></ul><ul><li>Long-term prophylaxis improves quality of life by reducing frequency and severity of attacks </li></ul><ul><li>80% of migraineurs may require prophylaxis </li></ul>
  25. 25. WHEN IS PROPHYLAXIS INDICATED? <ul><li>According to the US Headache Consortium Guidelines, </li></ul><ul><li>indications for preventive treatment include: </li></ul><ul><li>Patients who have very frequent headaches (more than 2 per week) </li></ul><ul><li>Attack duration is > 48 hours </li></ul><ul><li>Headache severity is extreme </li></ul><ul><li>Migraine attacks are accompanied by prolonged aura </li></ul><ul><li>Unacceptable adverse effects occur with acute migraine treatment </li></ul><ul><li>Contraindication to acute treatment </li></ul><ul><li>Migraine substantially interferes with the patient’s daily routine, despite acute treatment </li></ul><ul><li>Special circumstances such as hemiplegic migraine or attacks with a risk of permanent neurologic injury </li></ul><ul><li>Patient preference </li></ul>
  26. 26. PREVENTIVE THERAPY FOR MIGRAINE 20-60 <ul><li>SSRIs </li></ul><ul><ul><li>Fluoxetine </li></ul></ul>10-20 <ul><li>TCAs </li></ul><ul><ul><li>Amitriptyline </li></ul></ul>10-20 120-480 <ul><li>Calcium Channel Blockers </li></ul><ul><ul><li>Flunarizine </li></ul></ul><ul><ul><li>Verapamil </li></ul></ul>40-320 <ul><li>Betablockers </li></ul><ul><ul><li>Propranolol </li></ul></ul>Dose (mg/d) Drugs
  27. 27. PREVENTIVE THERAPY FOR MIGRAINE (CONTD.) 4-8 <ul><li>Anti-histaminic </li></ul><ul><ul><li>Cyproheptadine </li></ul></ul>600-1200 <ul><li>Anti-convulsant </li></ul><ul><ul><li>Sodium valproate </li></ul></ul>Dose (mg/d) Drugs
  28. 28. ROLE OF BETA BLOCKERS IN MIGRAINE PROPHYLAXIS <ul><li>‘ Gold standard’ in migraine prophylaxis </li></ul><ul><li>Established efficacy and safety in migraine prophylaxis </li></ul><ul><li>Especially preferred if hypertension or anxiety co-exist </li></ul>
  29. 29. ROLE OF PROPRANOLOL IN MIGRAINE PROPHYLAXIS
  30. 30. PROPRANOLOL – MECHANISMS OF ACTION <ul><li>Mechanisms proposed </li></ul><ul><li>Vasoconstriction </li></ul><ul><li>Anxiolytic action </li></ul><ul><li>Decreased sympathetic activity </li></ul>
  31. 31. LIMITATIONS OF IMMEDIATE-RELEASE PROPRANOLOL <ul><li>Short t½ of 3-5 hrs </li></ul><ul><li>Multiple daily dosing required to maintain adequate degree of beta-receptor blockade throughout 24 hr </li></ul><ul><li>Poor patient compliance may compromise efficacy </li></ul>
  32. 32. ADVANTAGES OF EXTENDED-RELEASE PREPARATION OF PROPRANOLOL <ul><li>Migraine patients are asymptomatic between attacks </li></ul><ul><li>Important to minimize number of daily doses during prophylactic treatment </li></ul><ul><li>Once-daily administration improves compliance </li></ul><ul><li>Stable drug concentration for 24 hrs </li></ul>
  33. 33. PROPRANOLOL-LA CLINICAL EFFICACY IN MIGRAINE
  34. 34. PROPRANOLOL REDUCES THE FREQUENCY OF ATTACKS PER MONTH IN BOTH COMMON AS WELL AS CLASSIC MIGRAINE PATIENTS Cephalalgia 1990; 10: 101-105 n = 51 Duration = 12 weeks 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 n = 18 n = 27 Side effects 3.9* 3.4* 6.1 Frequency (per month) Propranolol-LA 80 Propranolol-LA 160 Placebo (run in) Variable
  35. 35. Propranolol long-acting reduces the attack severity * p = 0.003 Headache 1998; 28: 607-611 n = 48 6.7* 11.1 Severity score End-period Baseline Parameter
  36. 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
  37. 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
  38. 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
  39. 39. DOSAGE OF PROPRANOLOL <ul><li>Starting dose: 40-80 mg once daily </li></ul><ul><li>Max. dose/day: 240 mg </li></ul><ul><li>If satisfactory response is not obtained within 4-6 weeks, after reaching the maximal dose, therapy should be discontinued </li></ul><ul><li>Taper slowly to avoid rebound headache and adrenergic side effects </li></ul><ul><li>Max. duration: 9 to 12 months </li></ul>
  40. 40. SHIFTING PATIENT FROM IR TO ER <ul><li>Propranolol extended-release produces low blood levels as compared to immediate-release </li></ul><ul><li>The dose of the long-acting formulation may need to be higher than the total daily dose of the conventional formulation </li></ul>

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