MANAGAMENT_OF_MIGRAINE.ppt - MANAGAMENT OF MIGRAINE Migraine Facts Migraine is one of the common causes of recurrent headaches According to IHS migraine

MANAGAMENT_OF_MIGRAINE.ppt - MANAGAMENT OF MIGRAINE...

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Unformatted text preview: MANAGAMENT OF MIGRAINE Migraine Facts Migraine is one of the common causes of recurrent headaches According to IHS, migraine constitutes 16% of primary headaches Migraine afflicts 10-20% of the general population More than 2/3 of migraine sufferers either have never consulted a doctor or have stopped doing so Migraine is underdiagnosed and undertreated Migraine greatly affects quality of life. The WHO ranks migraine among the world’s most disabling medical illnesses Burden Of Migraine World - 15-20% of women and 10-15% of men suffer from migraine In India, 15-20% of people suffer from migraine Adults – Female: Male ratio is 2 : 1 In childhood migraine, boys and girls are affected equally until puberty, when the predominance shifts to girls. NEJM 2002; 346(4): 257-269; XI Congress of the IHS, 2004 Migraine - Definition “Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting” -World Federation of Neurology Migraine Triggers Food Disturbed sleep pattern Hormonal changes Drugs Physical exertion Visual stimuli Auditory stimuli Olfactory stimuli Weather changes Hunger Psychological factors Phases of Acute Migraine Prodrome Aura Headache Postdrome PRODROME Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache Symptoms include Yawning Excitation Depression Lethargy Craving or distaste for various foods Duration – 15 to 20 min AURA Aura is a warning or signal before onset of headache Symptoms Flashing of lights Zig-zag lines Difficulty in focussing Duration : 15-30 min HEADACHE Headache is generally unilateral and is associated with symptoms like: Anorexia Nausea Vomiting Photophobia Phonophobia Tinnitus Duration is 4-72 hrs POSTDROME (RESOLUTION PHASE) Following headache, patient complains of Fatigue Depression Severe exhaustion Some patients feel unusually fresh Duration: Few hours or up to 2 days MIGRAINE – CLASSIFICATION According to Headache Classification Committee of the International Headache Society, Migraine has been classified as: Migraine without aura (common migraine) Migraine with aura (classic migraine) Complicated migraine MIGRAINE: CLINICAL FEATURES Migraine Without Aura No aura or Prodrome Migraine With Aura Aura or prodrome is present Unilateral throbbing headache Unilateral throbbing headache may be accompanied by nausea and later becomes generalised and vomiting During headache, patient complains of phonophobia and photophobia Patient complains of visual disturbances and may have mood variations MIGRAINE - PATHOPHYSIOLOGY VASCULAR THEORY Intracerebral blood vessel vasoconstriction – aura Intracranial/Extracranial blood vessel vasodilation – headache SEROTONIN THEORY Decreased serotonin levels linked to migraine Specific serotonin receptors found in blood vessels of brain PRESENT UNDERSTANDING Neurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation NEUROVASCULAR PROCESS Arterial Activation Release of Neurotransmitter Worsening of Pain MIGRAINE: DIAGNOSIS Medical History Headache diary Migraine triggers Investigations (only to exclude secondary causes) EEG CT Brain MRI DIFFERENTIATING COMMON PRIMARY HEADACHES Strictly unilateral Tension headaches: Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate Cluster headaches: Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men THE TREATMENT APPROACH TO MIGRAINE LONG-TERM TREATMENT GOALS FOR THE MIGRAINE SUFFERER Reducing the attack frequency and severity Avoiding escalation of headache medication Educating and enabling the patient to manage the disorder Improving the patient’s quality of life MIGRAINE MANAGEMENT Non-pharmacological treatment Identification of triggers Meditation Relaxation training Psychotherapy Pharmacotherapy non-specific Abortive therapy specific Preventive therapy MIGRAINE: ABORTIVE THERAPY Non-specific treatment Drug Dose Route Aspirin Paracetamol Ibuprofen Diclofenac 500-650 mg 500 mg-4 g 200- 300 mg 50-100 mg Oral Oral Oral Oral/IM Naproxen 500-750 mg Oral ABORTIVE THERAPY FOR MIGRAINE Specific treatment Drug Dose Route Ergot alkaloids Ergotamine 1-2 mg/d; max-6 g/d Oral Dihydroergotamine 0.75-1 mg SC 5-HT receptor agonists Sumatriptan 25-300 mg 6 mg Orally SC Rizatriptan 10 mg Orally ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT Drug Dose (mg)/d Route Domperidone 10-80 mg Oral Metoclopramide 5-10 mg Oral/IV Promethazine 50-125 mg Oral/IM Chlorpromazine 10-25 mg Oral/IV WHY THE NEED FOR PROPHYLAXIS ? Abortive drugs should not be used more than 2-3 times a week Long-term prophylaxis improves quality of life by reducing frequency and severity of attacks 80% of migraineurs may require prophylaxis WHEN IS PROPHYLAXIS INDICATED? According to the US Headache Consortium Guidelines, indications for preventive treatment include: Patients who have very frequent headaches (more than 2 per week) Attack duration is > 48 hours Headache severity is extreme Migraine attacks are accompanied by prolonged aura Unacceptable adverse effects occur with acute migraine treatment Contraindication to acute treatment Migraine substantially interferes with the patient’s daily routine, despite acute treatment Special circumstances such as hemiplegic migraine or attacks with a risk of permanent neurologic injury Patient preference PREVENTIVE THERAPY FOR MIGRAINE Drugs Dose (mg/d) 1. 2. 3. 4. Betablockers Propranolol Calcium Channel Blockers Flunarizine Verapamil 40-320 10-20 120-480 TCAs Amitriptyline 10-20 SSRIs Fluoxetine 20-60 PREVENTIVE THERAPY FOR MIGRAINE (CONTD.) Drugs 5. Anti-convulsant 6. Dose (mg/d) Sodium valproate 600-1200 Anti-histaminic Cyproheptadine 4-8 ROLE OF BETA BLOCKERS IN MIGRAINE PROPHYLAXIS ‘Gold standard’ in migraine prophylaxis Established efficacy and safety in migraine prophylaxis Especially preferred if hypertension or anxiety co-exist ROLE OF PROPRANOLOL IN MIGRAINE PROPHYLAXIS PROPRANOLOL – MECHANISMS OF ACTIONproposed Mechanisms Vasoconstriction Anxiolytic action Decreased sympathetic activity LIMITATIONS OF IMMEDIATERELEASE PROPRANOLOL Short t½ of 3-5 hrs Multiple daily dosing required to maintain adequate degree of beta-receptor blockade throughout 24 hr Poor patient compliance may compromise efficacy ADVANTAGES OF EXTENDED-RELEASE PREPARATION OF PROPRANOLOL Migraine patients are asymptomatic between attacks Important to minimize number of daily doses during prophylactic treatment Once-daily administration improves compliance Stable drug concentration for 24 hrs PROPRANOLOL-LA CLINICAL EFFICACY IN MIGRAINE PROPRANOLOL REDUCES THE FREQUENCY OF ATTACKS PER MONTH IN BOTH COMMON AS WELL AS CLASSIC MIGRAINE PATIENTS n = 51 Duration = 12 weeks Variable Frequency (per month) Side effects Placebo (run in) 6.1 Propranolol-LA 160 Propranolol-LA 80 3.4* 3.9* n = 27 n = 18 Propranolol-LA 80 mg appears to have adequate prophylactic effect for migraine and may be better tolerated than propranolol-LA 160 mg, which appears to offer no additional benefits. *p < 0.001 Cephalalgia 1990; 10: 101-105 Propranolol long-acting reduces the attack severity Parameter Severity score Baseline End-period 11.1 6.7* * p = 0.003 n = 48 Headache 1998; 28: 607-611 Propranolol vs. Flunarizine 70 % of Patients 60 50 No. of attacks reduced by more than 50% 48 50 Flunarizine (p<0.01) Propranolol (p<0.0005) 40 30 20 10 0 Headache 1989; 29: 218-223 Propranolol showed a significant reduction in the severity of attacks 1.8 1.6 1.6 1.4 1.4 Severity score 1.6 1.2* 1.2 1 Baseline 16 weeks 0.8 0.6 0.4 0.2 0 Flunarizine * p<0.05 Propranolol Headache 1989; 29: 218-223 No of analgesics/month Propranolol significantly reduced the number of analgesics used 7 6.3 6 5 4.5 4.1 4 * 3.4 3 2 1 0 Flunarizine *p<0.0005 Propranolol Headache 1989; 29: 218-223 Baseline 16 weeks DOSAGE OF PROPRANOLOL Starting dose: 40-80 mg once daily Max. dose/day: 240 mg If satisfactory response is not obtained within 4-6 weeks, after reaching the maximal dose, therapy should be discontinued Taper slowly to avoid rebound headache and adrenergic side effects Max. duration: 9 to 12 months SHIFTING PATIENT FROM IR TO ER Propranolol extended-release produces low blood levels as compared to immediaterelease The dose of the long-acting formulation may need to be higher than the total daily dose of the conventional formulation ...
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