MI MIGRAI AINES A A b r i e f o v e r v i e w f o r p h p h - - PowerPoint PPT Presentation

MI MIGRAI AINES

A A b r i e f o v e r v i e w f o r p h p h y s i c i c i a i a n s a n d s c i e i e n t i s i s t s

MI MIGR GRAINES S VS.

• S. HE

HEADACHE HES

Migraines should not be considered to be “strong” headaches They are different in their genesis and symptoms

MI MIGR GRAINES S VS.

• S. HEADACHES

At least five attacks fulfilling the above criteria REC RECURREN RRENCE1 Last between 4 and 72 hours DU DURATIO ION1

• Nausea, vomiting, photophobia, phonophobia
• Visual, sensory, or motor symptoms
• Pulsating quality
• Unilateral Location (generally)
• Aggravated by physical activity

PRE PRESEN ENCE E OF ADDITIONAL SYMPTOMS1 Migraines are considered incapacitating to the individual IM IMPAC ACT2

Accessed 2018.

PR PREVALE LENCE CE

UN UNITE TED STATE TES 39 39 million

• n

(1 (12% of the e population)1

PR PREVALE LENCE CE ( (CON ONT’D)

10% of children suffer from migraines1 CH CHILDREN Migraines impact three times more women than men (18% vs. 6%)1 WO WOMEN More than 4 million adults experience chronic daily migraines (at least 15 migraine days monthly)1 CH CHRONIC C MIGRAINES

CO COSTS TO SOCIETY

6th highest cause of disability worldwide1 20% of chronic migraine sufferers are disabled2 $36 billion annually are lost in health care and lost productivity costs in the U.S.2 $5.4 billion was spent in 2015 to treat chronic migraine2 13 billion is lost by employers yearly due to lost workdays Anxiety and depression are more common in those with chronic migraines1,2

MI MIGR GRAINE PHASE SES

MIGRAINE NES CAN N HAVE FOUR PHASES, ALTHOUGH A PATIENT NT MAY NO NOT EX EXPERI PERIEN ENCE E EV EVER ERY ONE E OF THEM EM WHEN EN HAVING G A MIGR GRAINE

https://americanmigrainefoundation.org/understanding-migraine/understanding-migraine-aura. Accessed 2018.

https://americanmigrainefoundation.org/understanding-migraine/timeline-migraine-attack Accessed 2018.

migraine/migraine-and-aura. Accessed 2018.

Early signs and symptoms include food cravings, unexplained mood changes, uncontrollable yawning, fluid retention, and increased

• urination. Begins up to 24 hours before a migraine.1

PR PRODOME Visual, motor, or sensory motor symptoms including flashing or bright lights, zig-zag lines, muscle weakness, tingling in one side of the body, and inability to speak clearly. Usually lasts 20 to 60 minutes.1,2 AU AURA

1 2

MI MIGR GRAINE PHASE SES S (CONT’D)

https://americanmigrainefoundation.org/understanding-migraine/understanding-migraine-aura. Accessed 2018.

https://americanmigrainefoundation.org/understanding-migraine/timeline-migraine-attack Accessed 2018.

migraine/migraine-and-aura. Accessed 2018.

Characterized by throbbing, drilling, or pulsating pain usually on one side

• f the head (although both sides can be affected). Can be accompanied by

photophobia, phonophobia, osmophobia, nausea, and vomiting. Pain is worsened by physical activity. Lasts 4 to 72 hours.1,3,4 HE HEADACHE HE

3 4

Fatigue, body aches, depression/euphoria, inability to concentrate. Follows the headache phase. Length varies (24-48 hours).1,3 PO POSTDROME

TR TRIG IGGERS

WH WHIL ILE THERE AR ARE NO UNIV IVERSAL AL TRIG IGGERS, MIG IGRAIN AINE ATTAC ACKS CAN AN BE TR TRIGGERED IN SOME PEOPLE BY : Lack of sleep Hormonal changes Stress Anxiety Bright or flashing lights Skipped meals Weather changes Loud noises Strong smells Certain medications

1 Migraine Research Foundation. https://migraineresearchfoundation.org/about-migraine/migraine-triggers. Accessed 2018. 2 MedlinePlus. Migraine. https://medlineplus.gov/migraine.html. Accessed 2018.

GEN GENET ETIC PRED EDISPOSITION

Approximately 80% of migraine patients have a family history of migraines1 FA FAMILY HISTORY A genetic anomaly on chromosome 19 for Familial Hemiplegic Migraine has been determined1 CH CHROMOSOME ABNORMALITIES A A GENETIC PREDISPOSITION TO TO MIGRAINES EXISTS1

https://americanheadachesociety.org/resources/headache-fact-sheets. Accessed 2018.

MI MIGR GRAINE TYPES

MIGRAINES WITH AURA Characterized by transient focal neurological symptoms preceding or accompanying the

• headache. Some patients also experience a

prodomal and/or postdomal phase. 1 MIGRAINE NES PRIMARILY PRESENT NT IN N ONE NE OF TWO FORMS1 MIGRAINES WITHOUT AURA A clinical syndrome characterized by headache with specific features and associated symptoms, but no aura.1

DI DIAGNOSTIC CRITERIA A FOR MIGRAI AINE WITHOUT UT AUR URA

• Nausea and/or vomiting
• Photophobia and phonophobia

Dur During ng he head adache ache at at leas ast one

• ne of
• f the

he fol

• llowi
• wing

ng occur

• ccurs:

No Not a accounted f for b r by a another d r diagnosis He Headache a attacks t that l last 4 4–72 72 hour hours (whe hen n unt untreated or

• r uns

unsucce uccessful fully treated) He Headache h has a at l least t two o

• f t

the f following f four r cha charact cteristics cs:1 AT AT LEAST FIV FIVE AT ATTACKS FULFILLING THE CR CRITERIA BELOW (1-4) 4):1 1

2 3 4

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity, and/or
• Aggravation by or causing avoidance of routine physical

activity (e.g. walking or climbing stairs)

DI DIAGNOSTIC CRITERIA A FOR MIGRAI AINE WITH AUR URA

No Not a accounted f for b r by a another d r diagnosis On One or more of the following fully reversible aura sy symptoms: s: At At least three of the following six characteristics: AT AT LEAST TW TWO AT ATTACKS FULFILLING THE CR CRITERIA BELOW (1-3) 3):1 1

1 International Headache Society. “The International Classification of Headache Disorders, 3rd Edition.” (2018)

2 3

• At least one aura symptom spreads gradually over 5 mins
• Two or more aura symptoms occur in succession
• Each individual aura symptom lasts 5–60 minutes
• At least one aura symptom is unilateral
• At least one aura symptom is positive
• Thee aura is accompanied, or followed within 60 minutes,

by headache

• Visual
• Sensory
• Motor
• Brainstem
• Retinal
• Speech and/or language

DI DIAGNOSTIC CRITERIA A FOR CHRONIC MIGRAI AINE

CH CHRONIC C MIGRAINES ARE DEFINED AS:1

1 International Headache Society. “The International Classification of Headache Disorders, 3rd Edition.” (2018)

A headache occurring on 15 or more days/month for more than three months, which on at least eight days/month has the features of migraine headaches

TR TREATM TMENTS

No absolute cure exists, sine the pathophysiology remains to be fully understood1 Treatments include pharmacotherapy and behavioral therapies1

www.ninds.nih.gov/disorders/all-disorders/migraine-information-page. Accessed 2018.

Used in conjunction with pharmacotherapy1 Therapies include relaxation training, biofeedback, stress management, trigger management1,2

BE BEHAVIORAL THERAPI PIES

TR TREATM TMENT APPROACHE HES

. www. www.medscap ape.com/vi viewar warticle/804034_14. . Accessed 2018.

CO CONSIDERATIONS FOR PREVENTIVE TREATMENT1 TW TWO APPROACHE HES FOR THE THE TR TREATM TMENT OF MIGRAINES:

• Suffering >1 migraine attacks per week
• Attacks resulting in significant disability
• Poor response to acute care medications
• Significant triptan side effects
• Use of symptomatic treatment more than 3 days per week

DA DAILY PREVENTIVE TREATMENT INDICATED FOR PATIENTS1,

1,2

• Preventive – used daily prior to the attack
• Symptomatic – relieves symptoms during the attack
• Medications should be chose based on co-occurrent conditions
• Both desirable and undesirable side effects

PR PREVENTIVE ANTIMIGRAINE THERAPY

FD FDA-AP APPROVED D PREVENT NTIV IVE MEDIC DICATIO IONS NS FOR MIG IGRAINE AINE INC INCLUDE DE:1,

1,2,3,4

• ß

ß blockers – atenolol, metoprolol, nadolol

• Ca

Calcium channel antagonists – verapamil, lisinopril, nimodipine, nifedipine, cyclandelate, nicardipine

• An

Antidepressants – amitriptyline

• An

Anticonvulsants – sodium valproate, gabapentin, lamotrigine

• NS

NSAIDs – naproxen, naproxen sodium for short-term use, may cause Medication Overuse (Rebound) Headache OF OFF-LA LABE BEL MEDICATIONS USED INCLUDE:1,

1,2,3

• Ca

Calcitonin gene-re related d peptide de – erenumab (approved 2018)

• An

Anticonvulsants – divalproex sodium, topiramate, valproate

• ß

ß blocker – propranolol, timolol

• Bo

Botulinum toxi xin – onabotulinumtoxinA (for chronic migraine only)

SY SYMPTOMATIC MIGRAINE THERAPY

TR TRIPTANS AND ERGOTS ARE CONSIDERED THE THE STANDARD OF CARE. FD FDA-AP APPROVED D MEDIC DICATIO IONS NS FOR TREATMENT NT OF AC ACUTE MIGRAINE NES IN N ADULTS INC NCLUDE:1

• Tr

Triptans (tablets) – almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan

• Tr

Triptans (nasal spray) – sumatriptan, zolmitriptan

• Er

Ergo got t alkaloids (sublingu gual ta tabs) – ergotamine tartrate

• Er

Ergo got t alkaloids (ampules or spray) – dihydroergotamine mesylate (ampules or spray) SY SYMPTOMATIC TREATMENT IS MOST EFFECTIVE WHEN TAKEN EARLY IN THE THE HE HEADACHE HE2

TAKE AWA WAYS

Migraines are more than just “strong” headaches They last 4-72 hours and can have 4 phases There is a genetic predisposition to migraines Migraines impact three times more women than men

TAKE AWA WAYS

Diagnostic criteria exist for migraines with/without aura and chronic migraine Both pharmacological and behavioral interventions are available FDA-approved preventive treatment drugs include ß blockers, anticonvulsants, a calcitonin gene-related peptide, and a botulinum toxin FDA-approved symptomatic treatment drugs include triptans and ergots

THAN THANK YOU