Understanding Migraine From Diagnosis to Treatment

1
Understanding Migraine From Diagnosis to
Treatment
Sponsored Through an Educational Grant from Merck
Co., Inc.
2
Introduction

• Welcome to a patients guide to
• understanding migraine
• What is migraine?
• How does migraine impact patients and families?
• What causes migraine?
• How is migraine diagnosed?
• What are your treatment options?

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What Is Migraine?

• A neurological disorder characterized by
• hyperexcitability of the nervous system
• You dont get migraines, you have migraine
• Your body is more sensitive to stimuli that can
  cause
• a headache attack
• Defining characteristics
• Recurrent headache attacks lasting 4-72 hours
• One-sided, pulsating, moderate-to-severe pain
• Presence of 2 of 3 key characteristics inability
  to
• function, photophobia/phonophobia,
  nausea/vomiting

International Headache Society classification
criteria (Cephalalgia. 200424, suppl 1).
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Some Common Symptoms of Migraine

• Before or during an attack
• Feeling of well-being or surge of energy
• Talkativeness or restlessness
• Increased appetite
• Drowsiness or depression
• Irritability or tension

• During an attack
• Nausea, vomiting,
• or diarrhea
• Sweating or cold hands
• Sensitivity to light
• or sounds
• Scalp tenderness
• or pressure pain
• Pale color
• Pulsing pain

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Types of Migraine
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Migraine With Aura Example
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How Many People Have Migraine?

• 12 of adults (30 million patients in the US)
• Most common between ages 15 and 55
• More common among women (17) than men (6)

Centers for Disease Control and Prevention and
American Migraine Prevalence and Prevention study
results (Lipton RB et al. Neurology.
200768343-349).
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How Does Migraine Impact Patients and Families?
Headache-Related Impairment During a Severe
Attack
American Migraine Prevalence and Prevention study
results (Lipton RB et al. Neurology.
200768343-349).
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How Does Migraine Impact Patients and Families?
Disability (MIDAS Score)
MIDAS Midgraine Disability Assessment. American
Migraine Prevalence and Prevention study results
(Lipton RB et al. Neurology. 200768343-349).
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How Does Migraine Impact Patients and Families?
School, Work, and Social Impact in Previous 3
Months
American Migraine Prevalence and Prevention study
results (Lipton RB et al. Neurology.
200768343-349).
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What Causes Migraine?
3 Changes in nerve cell activity and blood flow
may result in visual disturbance, numbness or
tingling, and dizziness
4 Chemicals in the brain cause blood vessel
dilation and inflammation of the surrounding
tissue
5 The inflammation irritates the trigeminal
nerve, resulting in severe or throbbing pain
2 Electrical impulses spread to other regions of
the brain
1 Migraine originates deep within the brain
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The Stages of a Migraine Attack
Adapted from Cady, Headache Q.200112(suppl
1)3-8, with permission
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Migraine and Women

• Hormonal fluctuation plays an important role in
  migraine for many women
• 60 of women with migraine experience menstrual
• migraine
• Headaches are associated with changes in estrogen
• levels right before menses and most often occur
  up
• to 2 days before or during menses
• Oral contraceptives may either exacerbate or
  alleviate
• the frequency, severity, and duration of
  headaches
• Headaches are not a normal part of menstruation

Dzoljic. MacGregor EA et al. Neurology.
2006672154-2158. MacGregor EA, Hackshaw A.
Neurology. 200463351-353. NHF. Women
Migraine. www.headaches.org.
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Menstrual Migraine

• Menstrual migraine differs somewhat from
• other migraine
• Pain may persist longer and be more severe
• Headache attack is more likely to be accompanied
• by nausea or vomiting
• Headache occurs more frequently
• Menstrual migraine is more difficult to treat

Granella F et al. Headache. 199333385-389.
Couturier EGM et al. Cephalalgia.
200323302-308. MacGregor EA. J Fam Plan Reprod
Health Care. 20073336-47.
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Migraine and Men

• Recent online survey by NHF showed that
• migraine is the most common headache
• diagnosis in men (36)
• Yet, many men do not discuss migraine with
• their healthcare practitioners
• Nearly 1/3 of men suffering from headache have
• not been diagnosed
• Nearly 1/4 did not visit their doctor because
  they
• felt they should tough it out

NHF. Migraine Not Just a Womans Disease.
www.headaches.org.
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How Is Migraine Diagnosed?

• Complete medical history, including
• headache history
• Physical exam
• Potential additional evaluations
• MRI (magnetic resonance imaging)
• CT (computed tomography) scan
• Other
• Possible referral to a specialist
• Neurologist
• Other specialist

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Communicate Symptoms to Your Healthcare Provider

• Describe the headache
• Where is the pain? How long does it last?
• How often do you have a headache?
• How do you feel before, during, and after?
• Is there an aura?
• Do you have other symptoms?
• Nausea, vomiting or diarrhea
• Sensitivity to light or sound
• Other symptoms

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Keep a Headache Diary

• Record
• Frequency, severity, and duration of headache
• Treatments you used and how well they worked
• Possible triggers (environmental, diet, stress,
  sleep,
• changes in daily routine)
• Keep the diary for at least 1 month
• Look for patterns and share the results with
• your healthcare provider
• Download a diary at www.headaches.org

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Other Information to ShareWith Your Provider

• Are you taking any medications?
• Include prescription, over-the-counter, and
  nutritional
• supplements
• Do others in your family have headaches?
• Is your headache affected by menses?
• Describe your habits
• Sleep, smoking, caffeine and alcohol intake, and
  exercise

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What Are Your Treatment Options?

• Lifestyle modification
• Nonpharmacologic and complementary therapies
• Acute medications
• Preventive medications
• Combinations of treatments

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Lifestyle Modification for Migraine

• Eat healthfully and regularly do not skip meals
• Get enough sleep, but do not oversleep
• Keep a regular sleep schedule
• Keep well hydrated
• Exercise regularly
• Rest during a migraine, and do not overexert
  afterward
• Reduce your stress
• Identify your triggers and avoid when possible

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Nonpharmacologic and Complementary Therapies

• Relaxation training
• Hypnotherapy
• Biofeedback training
• Cognitive/behavioral management
• Acupuncture
• Nutritional supplements (B2 and others)
• Physical therapy and/or massage

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Acute Medications for Migraine

• Triptans
• Almotriptan (Axert) Rizatriptan (Maxalt)
• Eletriptan (Relpax) Sumatriptan (Imitrex)
• Frovatriptan (Frova) Zolmitriptan (Zomig)
• Naratriptan (Amerge)
• Ergotamine derivatives (eg, DHE)
• Over-the-counter pain killers (acetaminophen,
• ibuprofen, naproxen, and combinations of
• aspirin/acetaminophen/caffeine)
• Prescription pain killers (used infrequently)

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When Should You Take Your Acute Migraine Medicine?

• Triptans need to be taken as soon as you
• recognize an attack
• Many patients wait too long
• There is no need to suffer during an attack
• Triptans work best in the first couple of hours
• of an attack
• Dihydroergotamine works at any time during
• an attack
• Do not overuse acute medications
• Talk to your healthcare provider if you take an
• acute medication more than 2 times per week

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Factors That May Influence Choice of Treatment

• Symptoms
• Oral medications will not work if you vomit
• Patient preference
• Injections work fast, but are harder to use
• Nasal spray is convenient, but there are fewer
• choices available
• Maxalt and Zomig do not require water
• How fast the medication works and how long it
• keeps working
• Other medications you are taking

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Preventive Medicationsfor Migraine

• Preventive medications are taken every day
• to reduce the frequency and severity of
• headache attacks
• Approved therapies include
• Beta blockers (propranolol, timolol maleate)
• Anticonvulsants (divalproex sodium, topiramate)
• Serotonin antagonist (methysergide maleate)
• Other (antidepressants, other serotonin
• antagonists, NSAIDs)

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Combination Treatment

• Some patients benefit from a combination of
• acute and preventive therapies
• Even when taking a preventive medication, keep an
• acute medication on hand to treat breakthrough
  attacks
• Menstrual migraine may be treated with short term
• prevention (also known as mini-prophylaxis), or
• preventive treatment before and during menses,
• with acute medication for breakthrough attacks

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Some Medications May Cause Migraine to Become
Chronic

• May cause chronic headaches
• Opiates
• Combination OTC analgesics (including sinus
• medications and combinations that contain
  caffeine)
• Caffeine
• Barbiturate-containing medications
• Ergotamine tartrate, isometheptene
• Triptans
• Others
• Not clearly associated with chronic headaches
• acetaminophen, aspirin, DHE, others

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Summary

• Migraine is a common, chronic condition
• of the nervous system
• Migraine can cause substantial impairment,
  affecting
• both patients and their families
• Migraine is treatable
• Lifestyle modification
• Nonpharmacologic therapies
• Acute and preventive medications
• Learn how to manage your migraine

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The National Headache Foundation

• For more information about headache causes
• and treatments, visit the National Headache
• Foundation (NHF) Web site www.headaches.org
• A online database of NHF physician members is
• available on the NHF Web site