Tools for Successful Migraine Management Educational Objectives At - PDF document

Tools for Successful Migraine Management Educational Objectives At the conclusion of this activity, participants should be able to demonstrate the ability to: Tools for Successful  Describe current diagnostic criteria for diagnosing headache and migraine Migraine Management  Apply patient education protocols to teach migraine patients about the prevention and management of migraine disorders, especially regarding the need for compliance with pharmacologic and non-pharmacologic approaches M. Susan Burke, MD, FACP  Explain the currently approved therapeutic options for migraine, and formulate individual Clinical Associate Professor of Medicine management plans for treating migraine by combining pharmacologic and non- Sidney Kimmel Medical College at Thomas Jefferson University pharmacologic approaches Senior Advisor , Lankenau Medical Associates Lankenau Medical Center Wynnewood, PA Burden of Disease: An Old Problem A Seven Class Disability Rating System  Trepanation to relieve headache carried out since 7,000 years BC Disability Severity Indicator conditions Class Weight  20-cm long stone chisel used to penetrate skull to relieve pain; some 1 0.00-0.02 Vitiligo of face, weight for height less than 2 SDs have had multiple procedures done  Hippocrates wrote specific instructions 2 0.02-0.12 Watery diarrhea, severe sore throat, severe anemia Radius fracture in a stiff cast, infertility, erectile regarding methods to performing 3 0.12-0.24 dysfunction, rheumatoid arthritis, angina trepanation for headache 4 0.24-0.36 Below-the-knee amputation, deafness Rectovaginal fistula, mild mental retardation, 5 0.36-0.50 Down syndrome 6 0.50-0.70 Unipolar major depression, blindness, paraplegia Active psychosis, dementia, severe migraine, 7 0.70-1.00 quadriplegia International Trepanation Advocacy Group. http://www.trepan.com/understanding-trepanation. Menken M et al. Arch Neurol . 2000;57:418-420. Migraines in Primary Care: Why We Should Care?  Migraine is:  An indication of a patient population at high risk for decades of medical need Differentiating Migraine from  A potentially chronic disease associated with high disability Other Types of Headache  4 th leading cause of disability in women worldwide  14% transform to chronic annually Murray CJL et al. Lancet . 2012;380:2197 – 2223. Katsarava Z et al. Neurology . 2004;62:788-790. 1

Tools for Successful Migraine Management Headache Screening: Sara, a 31-year-old Mother Traditional History Method  Asks for help with her sinus headaches. She has Timing/Frequency Associated symptoms  First onset/duration/time of been getting them for several years but they are  Visual day/relationship to menses occurring almost daily now  Motor Exacerbating factors/triggers  Predominantly frontal and maxillary in location;  Sensory  Activity, cough, neck position, foods,  GI not throbbing alcohol, sleep, etc  Nasal Location  Takes acetaminophen almost daily, along with  Variable, fixed site, hemicranial pseudoephedrine preparations and occasional loratadine Intensity when she has watery eyes and nasal congestion  Severity, disability Nature  Pulsatile, “ice pick,” steadily increasing Diagnosis and Treatment of Headache. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2009. Headache Screening: Indications for Diagnostic Testing: Standard Examination Red Flags and SSNOOP  S ystemic symptoms: fever, weight loss  Observe the patient walking  S econdary risk factors: HIV, cancer  Assess symmetry of CN, motor, sensory, coordination, DTRs  N eurologic symptoms or signs  Observe patient’s body language (eye contact, mood)  O nset: new, sudden, abrupt, or split-second  Palpate head, arteries, trigger points  O lder: especially >40 years  Examine neck for stiffness and ROM  P attern change  Progressive HA with loss of HA-free  Perform fundoscopic exam  Examine oral cavity/TMJ Diagnostic testing indicated if any red flags are present Diagnosis and Treatment of Headache. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2009. Dodick D. Adv Stud Med . 2003;3:87-92. Green Flags and Comfort Signs If Indicated, Which Diagnostic Test? CT or MRI? With or without contrast?  Stable pattern >6 months  Yield minimal without neurologic signs: <1% identify cause for HA  Long-standing HA history  MRI: greater detail, more false positives  Family history of similar HA  MRI for posterior fossa disease  Normal exams  MRI + MRA for suspected aneurysm/other vascular lesions  Consistently triggered by  CT without contrast to R/O subarachnoid hemorrhage  Hormonal cycle  Weigh radiation exposure with CT, renal contrast concerns with CT and MRI vs  Specific sensory input potential yield of study  Weather changes CHOOSING WISELY : Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine Diagnostic testing not indicated if only green flags present Ropper A, Brown R, eds. Adams and Victor’s Principles of Neurology . Eighth ed. New York, NY: McGraw-Hill; 2005:16-21; Avitzur O. Neurology Today . 2013;13:22-24; American Headache Society. http://www.choosingwisely.org/as-part-of-choosing-wisely-campaign-american-headache-society-releases-list- of-commonly-used-tests-and-treatments-to-question. 2

Tools for Successful Migraine Management Sinus Headache = Criteria for True “Sinus” Headache Migraine With Sinus Symptoms  Major factors Summit 1 SAMS 2  Purulence in nasal cavity on exam Sinus Allergy & Migraine Study  Facial pain/pressure/congestion Self-Diagnosis Sinus Study  Nasal obstruction/blockage/discharge  100 with self-diagnosed  2,971 with self-diagnosed recurrent sinus headache  Fever (in acute only) recurrent sinus headache  Hyposmia/anosmia  Minor factors 86%-88% with self-diagnosis of sinus headache actually have ICHD*  Headache  Dental pain migraine or probable migraine headache  Cough  Fever  Ear pain/pressure/fullness  Halitosis *International Conference Headache Disorders/International Headache Classification from International Headache Society (ICS) 3  Fatigue 1. Schreiber CP et al. Arch Intern Med. 2004;164:1769-1772. 2. Eross E et al. Headache. 2007;47:213-224. 3. International Headache Society. IHS Classification ICHD-II. http://ihs-classification.org/en/02_klassifikation/01_inhalt. American Academy of Otolaryngology – Head and Neck Surgery. Lanza et al. Otolaryngol Head Neck Surg. 1997;117(pt 2):S1-S7. Migraine – The Most Common Headache Seen in Clinical Practice  Prevalence of all HAs that prompt patients to see their PCP  IHS diagnosis based on diary review Acute Migraine Migraine-type 94% Episodic Tension- type n = 377 Unclassifiable 3% 3% IHS = International Headache Society Tepper SJ et al. Headache . 2004;44:856-864. Migraine Recognition by ICHD Criteria Migraine without Aura (1.1) Migraine with Aura (1.2.1-6 ) At least 5 attacks with: At least 2 attacks with:  At least 2 of the following  At least 1 fully reversible symptom Recurring moderate without motor  Unilateral  Visual + and/or -  Pulsating to severe headache  Sensory + and/or -  Moderate to severe pain  Dysphasic speech is migraine until  Aggravated by or avoidance  At least 2 of the following of routine physical activity proven otherwise  At least one aura symptom  At least 1 of the following develops gradually over  5 min  or different symptoms occur in Nausea and/or vomiting succession over  5 min  Photo and phonophobia Each symptom lasts  5 and   No organic disease  60 min  1.1 begins with aura or in  60 min  No organic disease ICHD = International Classification of Headache Disorders; International Headache Society. Cephalalgia . 2013;33:629-808. 3