Migraine through cases

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Migraine through cases
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Mrs Smith

• Age 33, headaches for some time on and off for
  which she has to take regular painkillers.
  Someone has told her it could be migraine so she
  has come to you for advice. She is not on any
  other medication.
• What are the common causes of headache?

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Headache Types

• Tension type headache
• Migraine
• Cluster headache
• Chronic Daily headache
• Medication misuse headache

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Mrs Smith

• You think she has migraine. How do you classify
  migraine?

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Migraine Classification

• In 1988 The International Headache Society
  published its classification and operational
  diagnostic criteria for all headache disorders.
  This remains the gold standard and is due to be
  revised in 2002. Its section on migraine covers
• Migraine without aura
• Migraine with aura
• Ophthalmoplegic migraine
• Retinal migraine
• Childhood periodic syndromes

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Migraine without aura (common migraine)

• This is an idiopathic, recurring disorder
  involving attacks that last 4-72 hours.
• The headache is typically unilateral, pulsating,
  of moderate or severe intensity, and is
  aggravated by normal physical activity.
• It is associated with nausea, vomiting,
  photophobia, and phonophobia.
• Five or more attacks are required to make the
  diagnosis.
• Seventy-five per cent of sufferers have this
  form.

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Migraine with aura (classical migraine)

• This is an idiopathic, recurring disorder with
  attacks of neurological symptoms that arise in
  the cerebral cortex or the brain stem, creating
  the aura.
• The aura usually develops gradually over 5-20
  minutes, lasts less than 60 minutes, and is
  completely reversible.
• Typical examples of an aura are
• Homonymous visual disturbance (the most common
  type), usually a fortification spectrum - a
  spreading, scintillating scotoma in the shape of
  a jagged crescent
• Unilateral paraesthesia or numbness
• Unilateral weakness
• Dysphasia
• A combination of the above

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Migraine with aura (classical migraine)

• The headache usually starts within 60 minutes of
  resolution of the aura, and lasts 4-72 hours.
  However, it may begin before the aura, or at the
  same time as the aura, or it may even be absent.
• The headache is typically unilateral, pulsating,
  of moderate or severe intensity, and is
  aggravated by normal physical activity.
• It is associated with nausea, vomiting,
  photophobia, phonophobia and osmophobia
• Two or more attacks are required to make the
  diagnosis.
• Twenty-five per cent of sufferers have this form.
  

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The Economic Cost of Migraine
Approximately 1 in 10 members of the UK
population suffer from migraine, resulting in the
loss of 18 million working days each year. The
cost of lost production, replacement staff and
the times when migraine sufferers are working
below par is estimated at 750 million per annum
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Incidence

• The prevalence of migraine is 16 it is higher
  in women (25) than in men (8) Rasmussen et al,
  1991.
• Only a minority of sufferers consult their GP.
• In a practice of 2000 people there are likely to
  be 5 newly diagnosed cases of migraine each year,
  and 40 consultations for existing migraine
  MeReC, 1997.

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Mrs Smith

• So why do I get migraine?

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Migraine Triggers
Migraine is believed to be triggered by a fall
in the levels of Serotonin (5HT) but what
actually causes this fall is still unknown. For
most sufferers there is not just one trigger but
a combination or accumulation of factors which
individually can be tolerated but, when several
occur together, a personal threshold is passed.
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Migraine Triggers (continued)

• Stress emotional or physical
• Relief of stress
• Insufficient food or long gaps between food
• Certain foods
• Environmental factors loud noise, bright,
  flickering or flashing lights/glare, strong
  smells
• Changes in routine weekend lie-ins, shift work
  etc.
• Hormonal factors menstruation, menopause, the
  pill, HRT

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THRESHOLD THEORY
Raised or lowered by internal and external
factors or ? by medication
threshold
MENSTRUAL PERIOD
MISSED LUNCH
STRESS OF OVERWORK
LONG JOURNEY TO WORK
LATE NIGHT
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Warning signs
Yawning Unusual hunger/craving for certain
foods Heightening of the senses Irritability Exhil
aration/excitability Confusion Speech difficulties
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Mrs Smith

• How do I treat my migraine?
• What self help treatments are available? What can
  she buy over the counter and what is prescribable

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Self-help Measures

• Keep a diary
• Avoid triggers to which you know you are
  sensitive
• Eat regularly, avoid sugary snacks and include
  slow release carbohydrate foods in your diet
• Drink plenty of water
• Limit your intake of drinks containing caffeine
  and alcohol
• Take regular exercise
• Get plenty of fresh air and practise deep
  breathing
• Ensure that ventilation indoors is good and try
  to keep rooms at a constant temperature
• Avoid strong perfumes etc

• Avoid bright, flashing or flickering lights (e.g.
  fluorescent)
• Avoid large reflective surfaces (e.g. plain white
  walls)
• Wear sunglasses and/or a hat in bright sunlight
• Ensure that computer screens are properly
  adjusted and fitted with anti-glare filters
• Take regular breaks, especially if you are
  working at a VDU or if your work is repetitive
• Take care with your posture
• Ensure that your working environment is as
  ergonomically designed as possible
• Learn relaxation techniques

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Treatment - Acute

• In the UK a stepwise approach to migraine care is
  generally recommended
• A first-line analgesic with or without an
  anti-emetic is used initially.
• If this consistently fails to relieve migraine,
  treatment with a 5-hydroxytryptamine
  (5-HT1)-receptor agonist (a triptan) is the next
  step.

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Treatment - Acute

• Starting acute treatment early in the attack is
  beneficial because gastric stasis during the
  migraine reduces drug absorption
• Aspirin 900 mg, paracetamol 1000 mg, or ibuprofen
  400 mg are suitable first choices for the acute
  treatment of migraine with or withour anti-emetic
  Domperidone, Metoclopramide (not in young)
• Aspirin 900 mg plus metoclopramide was found to
  give relief similar to sumatriptan 100 mg. The
  combination was superior for the first attack
  studied, but sumatriptan was superior for the
  second and third attacks Thompson, 1992.
• Soluble forms are preferred as these are absorbed
  faster.
• 5HT Agonists (triptans)
• Ergotamine

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5-Hydroxytryptamine receptor agonists (triptans)

• 5-Hydroxytryptamine(5-HT1)-receptor agonists, or
  triptans, should be taken as soon as possible
  after the onset of headache.
• People who do not respond to a particular triptan
  are likely to respond to another Stark et al,
  2000 Mathew et al, 2000.
• Efficacy
• Triptans provide headache relief for about 30
  more people than placebo at 2 hours (placebo
  response about 30) Ferrari et al, 2001.
  Headache relief is defined as reduction in
  headache pain from moderate or severe to mild or
  none.
• Headache recurrence is an issue with all
  triptans. About 20-40 of people who experience
  pain relief by 2 hours experience headache
  recurrence within 24 hours Ferrari et al, 2001.
  
• A pain-free response is sustained for 24 hours in
  about 20 of responders. A recent meta-analysis
  of placebo-controlled studies found that
  rizatriptan 10 mg and almotriptan 2.5 mg had
  higher sustained pain-free rates than other
  triptans Ferrari et al, 2001. Similar results
  were found in a meta-analysis of studies
  comparing rizatriptan 10 mg to other triptans
  Adelman et al, 2001.

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5-Hydroxytryptamine receptor agonists (triptans)

• Adverse effects are generally mild and
  self-limiting for all triptans. They include
  nausea, dizziness, somnolence, and dry mouth.
  Asthenia, dizziness, drowsiness, and somnolence
  may be more common with rizatriptan 10 mg and
  zolmitriptan 5 mg Fox, 2000.
• 'Triptan sensations' include a warm-hot
  sensation, tightness, tingling, flushing, and
  feelings of heaviness or pressure in areas such
  as the face and limbs, and occasionally the
  chest. They occurr in less than 3 of people in
  clinical studies.
• People with ischaemic heart disease,
  cerebrovascular disease, peripheral vascular
  disease, or uncontrolled hypertension should not
  use triptans. People with risk factors for
  ischaemic heart disease should be evaluated
  carefully before starting a triptan Welch et al,
  2000 Evans and Martin, 2000.

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Mrs Smith

• She comes back to see you having tried hard to
  reduce her triggers but is still getting
  migraines almost once a week.
• What else can you do?

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Migraine prophylaxis

• Prophylaxis should be considered for people with
  
• More than two attacks per month
• Less frequent but severe or prolonged attacks
• Frequent use of acute treatment (to prevent
  development of medication-overuse headache)

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Migraine prophylaxis

• Acute treatments are still required the severity
  and frequency of attacks is only reduced by
  prophylaxis.
• Prophylactic drugs may need to be tried for 1-3
  months before the full effect is seen.
• Prophylactic drugs that are effective should be
  used for 4-6 months and then withdrawn gradually
  to establish whether they are still required.
• It is difficult to make firm suggestions for one
  prophylactic drug over another because there is a
  lack of robust clinical studies

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Treatment - Chronic

• Beta-blockers (e.g. propanolol, atenolol)
• Anti-depressants (e.g. amitriptyline start low
  dose and maintain at 50-75mg)
• Feverfew (Bandolier)
• 5HT Antagonists (e.g. pizotifen but poor)
• Others - Calcium channel blockers, Clonidine,
  Lisinopril, SSRI

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Mrs Smith

• Her migraines are well controlled on prophylaxis
  and she now wants to be started on the pill for
  contraception.
• Discuss the issues that you will need to consider
  with regard to this request and her migraine.

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Complications

• Migraine is associated with increased risk of
  ischaemic (but not haemorrhagic) stroke.
• Migraine with aura poses a higher risk than
  migraine without aura MacGregor, 2001.
• A recent case-control study confirmed that a
  personal history of migraine was associated with
  a more than three-fold risk of ischaemic stroke.
  Coexistence of risk factors for stroke (e.g. use
  of combined oral contraceptives, high blood
  pressure, or smoking) had more than
  multiplicative effects on the odds ratio for
  ischaemic stroke associated with migraine Chang
  et al, 1999.

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Migraine and COC

• Contraindications to the use of combined oral
  contraceptives (COCs) in women with migraine are
  based on expert opinion because there is limited
  evidence in this area. These recommendations are
  intended to enable most women with migraine to
  use COCs safely, with minimal risk of ischaemic
  stroke, while protecting those at risk
  MacGregor, 2000. The contraindications apply
  whether the conditions are present before
  starting COCs, or arise during the use of COCs
• Migraine with aura
• Migraine without aura when there is a history of
  more than one additional risk factor for stroke
  (e.g. age 35 years or over, diabetes mellitus,
  close family history of arterial disease in those
  under 45 years of age, hyperlipidaemia,
  hypertension, obesity, or smoking)
• Status migrainosus (headache phase lasting more
  than 72 hours)
• Migraine treated with ergot derivatives