MANAGEMENT OF FIBROMYALGIC SYNDROME

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MANAGEMENT OF FIBROMYALGIC SYNDROME
Prof. A.V. SRINIVASAN Emeritus Professor The
Tamil Nadu Dr. MGR Medical University RAILWAY
HOSPITAL
30th July 2010
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Prevalence

• Familial
• Young, healthy women FgtM 31
• 17 18.2 of adult females
• 6 6.5 adult males
• 2-3rd decade onset can occur sooner
• Peaks ages 22-55.
• ½ migraine sufferers not diagnosed.
• 94 pts seen in primary care settings for HA
  have migraines

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• Common misdiagnoses for migraine
• Sinus HA
• Stress HA
• Referral to ENT for sinus disease and facial pain.

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• Migraineurs more likely to have motion sickness.
• Half of Menieres patients claim to have
  migrainous symptoms.
• BPPV

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• 13 billion/year in lost productivity
• 1/3 participants in American Migraine Study II
  missed work in prior 3 months

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Migraine Definition

• IHS Diagnostic criteria migraine w/o aura
• HA lasting for 4-72 hrs
• HA w/2 of following
• Unilateral
• Pulsating
• Mod/severe intensity.
• Aggravated by routine physical activity.
• During HA at least 1 of following
• N/V
• Photophobia
• Phonophobia

• IHS criteria Migraine/aura (3 out of 4)
• One or more fully reversible aura symptoms
  indicates focal cerebral cortical or brainstem
  dysfunction.
• At least one aura symptom develops gradually over
  more than 4 minutes.
• No aura symptom lasts more than one hour.
• HA follows aura w/free interval of less than one
  hour and may begin before or w/aura.

• History, PE, Neuro exam show no other organic
  disease.
• At least five attacks occur

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Migraine Subtypes

• Basilar type migraine
• Dysarthria, vertigo, diplopia, tinnitus,
  decreased hearing, ataxia, bilateral
  paresthesias, altered consciousness.
• Simultaneous bilateral visual symptoms.
• No muscular weakness.
• Retinal or ocular migraine
• Repeated monocular scotomata or blindness lt 1 hr
• Associated with or followed by a HA

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Migraine Subtypes

• Menstrual migraine
• Hemiplegic migraine
• Unilateral motor and sensory symptoms that may
  persist after the headache.
• Complete recover
• Familial hemiplegic migraine

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Migrainous vertigo

• Vertigo sole or prevailing symptom.
• Benign paroxysmal vertigo of childhood.
• Prevalence 7-9 of pts in referral dizzy and
  migraine clinics.
• Not recognized by the IHS
• Diagnosis (proposed criteria)
• Recurrent episodic vestibular symptoms of at
  least moderate severity.
• One of the following
• Current of previous history of IHS migraine.
• Migrainous symptoms during two or more attacks of
  vertigo.
• Migraine-precipitants before vertigo in more than
  50 of attacks.
• Response to migraine medications in more than 50
  of attacks

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Migraine mechanism

• Neurovascular theory.
• Abnormal brainstem responses.
• Trigemino-vascular system.
• Calcitonin gene related peptide
• Neurokinin A
• Substance P
• Extracranial arterial vasodilation.
• Temporal
• Pulsing pain.
• Extracranial neurogenic inflammation.
• Decreased inhibition of central pain
  transmission.
• Endogenous opioids.

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• Important role in migraine pathogenesis.
• Mechanism of action in migraines not well
  established.
• Main target of pharmacotherapy.

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Aura Mechanism

• Cortical spreading depression
• Self propagating wave of neuronal and glial
  depolarization across the cortex
• Activates trigeminal afferents
• Causes inflammation of pain sensitive meninges
  that generates HA through central/peripheral
  reflexes.
• Alters blood-brain barrier.
• Associated with a low flow state in the dural
  sinuses.

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• Auras
• Vision most common neurologic symptom
• Paresthesia of lips, lower face and fingers 2nd
  most common
• Typical aura
• Flickering uncolored zigzag line in center and
  then periphery
• Motor hand and arm on one side
• Auras (visual, sensory, aphasia) 1 hr
• Prodrome
• Lasts hours to days

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Clinical manifestations

• Clinical manifestations
• Lateralized in severe attacks 60-70
• Bifrontal/global HA 30
• Gradual onset with crescendo pattern.
• Limits activity due to its intensity.
• Worsened by rapid head motion, sneezing,
  straining, constant motion or exertion.
• Focal facial pain, cutaneous allodynia, GI
  dysfunction, facial flushing, lacrimation,
  rhinorrhea, nasal congestion and vertigo

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Precipitating factors

• stress
• head and neck infection
• head trauma/surgery
• aged cheese
• dairy
• red wine
• nuts
• shellfish
• caffeine withdrawal
• vasodilators
• perfumes/strong odors
• irregular diet/sleep
• light

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Treatment

• Abortive
• Stepped
• Stratified
• Staged
• Preventive

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Abortive Therapy

• Reduces headache recurrence.
• Alleviation of symptoms.
• Analgesics
• Tylenol, opioids
• Antiphlogistics
• NSAIDs
• Vasoconstrictors
• Caffeine
• Sympathomimetics
• Serotoninergics
• Selective - triptans
• Nonselective ergots
• Metoclopramide

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Abortive care strategies

• Stepped
• Start with lower level drugs, then switch to more
  specific drugs if symptoms persist or worsen.
• Analgesics Tylenol, NSAIDs
• Vasoconstrictors sympathomimetics
• Opioids (try to avoid) - Butorphanol
• Triptans sumatriptan (oral, SQ, nasal),
  naratriptan, rizatripatan, zomatriptan.
• Limited by patient compliance.
• Stratified
• Adjusts treatment according to symptom intensity.
• Mild analgesics, NSAIDs
• Moderate analgesic plus caffeine/sympathomimetic
  
• Severe opioids, triptans, ergots
• Severe sx treatment limited due to concomitant GI
  sxs.
• Staged
• Bases treatment on intensity and time of attacks.
• HA diary reviewed with patient.
• Medication plan and backup plans.

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Preventive therapy

• Consider if pt has more than 3-4 episodes/month.
• Reduces frequency by 40 60.
• Breakthrough headaches easier to abort.
• Beta blockers
• Amitriptyline
• Calcium channel blockers
• Lifestyle modification.
• Biofeedback.

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Botox

• 51 migraineurs treated had complete prophylaxis
  for 4.1 months.
• 38 had prophylaxis for 2.7 months.
• Randomized trial showed significant improvement
  in headache frequency with multiple treatments.

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Conclusions

• Migraine is common but unrecognized.
• Keep migraine and its variants in the
  differential diagnosis.

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Dedicated to my family for making everything
worthwhile
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READ not to contradict or confute Nor to Believe
and Take for Granted but TO WEIGH AND CONSIDER
THANK YOU

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