Download file (Migraine Article)

Nick Wytiaz
University of Pittsburgh
Elective Rotation - Highmark
November 21, 2011
[email protected]
A to Z: MIGRAINE HEADACHES
A migraine is defined as a headache of intense throbbing or pulsing in one area of the head, commonly
accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Suffered by 12-16% of the
US population, migraines are one of the most common types of headaches. In diagnosing a migraine,
other possible syndromes such as tension headache and cluster headache, must be ruled out. The
differential diagnosis can be made based on the presentation.
Stages / Symptoms
Migraines often progress through four stages: prodrome / premonitory, aura, attack/headache and
postdrome. However, patients will not necessarily experience every stage.
Stage
Prodrome /
Premonitory
Timing
1-2 days before
attack
Presentation
Subtle changes that may signify an oncoming migraine:







Aura
5-30 minutes
before attack
(~20% of patients)
Attack / Headache
4-72 hours
Constipation
Depression
Diarrhea
Food cravings
Hyperactivity
Irritability
Neck stiffness
Visual, sensory, motor disturbances:





Flashing lights
Bright spots
Vision loss or changes
Numbness or tingling in arm or leg
Speech problems

Pain
o
o





Postdrome
Immediately
following attack
One side of head
Pulsating, throbbing
Sensitivity to light, noise
Nausea and vomiting
Blurred vision
Diarrhea
Lightheadedness
Fatigue, irritability, pain recurrence
Nick Wytiaz
University of Pittsburgh
Elective Rotation - Highmark
November 21, 2011
[email protected]
Causes / Triggers
Causes of migraines are not fully understood, but genetics and environmental factors both seem to play
a role. Still, many factors may precipitate an acute attack. Common triggers include:




Hormonal changes
o Pregnancy
o Oral Contraception / Hormone Replacement Therapy
o Before / During Menstrual Periods
Dietary
o Alcohol
o Chocolate
o MSG
o Caffeine (use & withdrawal)
o Nitrate and/or tyramine containg foods (wine, cheese, cured meats, beer)
Behavioral
o Sleep-cycle changes
o Stress (physical and/or emotional)
o Skipped meals
o Fatigue
Environmental
o Bright lights / sun glare
o Loud sounds
o Unusual smells
Risk factors for developing migraines include: female (3x more likely to suffer migraines), family history,
changes in female hormones, age 15-45, comorbid medical conditions associated with headaches
(depression, anxiety, stroke, epilepsy, irritable bowel syndrome, or high blood pressure).
Management
Migraine treatment considerations depend upon the frequency, severity, and symptoms of the
headache. Patients can help their physician choose the best treatment option for them by keeping a
headache diary. The diary can be used to record the attacks (number, severity, and frequency),
suspected causes, and treatments used over the course of a month. The information can help determine
what triggers the migraines and what strategies will most effectively relieve them.
Options can be divided into two categories: acute treatment and preventative treatment. The goal of
acute treatment is to relieve the pain and other headache-related symptoms whereas preventative
treatment aims at reducing the frequency and severity of attacks.
Prior to and/or in combination with drug therapy, patients should attempt to manage their migraines
with lifestyle modifications. Effective non-pharmacological treatment options include dietary changes
(avoid triggers), stress management, sleep regulation, and relaxation techniques.
Nick Wytiaz
University of Pittsburgh
Elective Rotation - Highmark
November 21, 2011
[email protected]
Acute Treatment Options
Class
Non-Opioid
Pain Relievers
Triptans
Ergotamines
(“Ergots”)
*
Medications*
NSAIDs
1. Advil® or Motrin® (ibuprofen)
- Generic available
2. indomethacin
3. Naprosyn® or Aleve®
(naproxen)
- Generic available
------------------------------------------Combinations
1. Excedrin Migraine®
(APAP+caffeine+aspirin)
2. Advil and Motrin Migraine
(ibuprofen+caffeine+aspirin)
1.
2.
3.
4.
5.
6.
7.
Dosage Form(s)
Class Side Effects
Relatively Safe:
- nausea
- vomiting
- headache
- Dizziness, nausea
- GI problems
Recommendation
- 1st Line
IN: bitter / unpleasant
taste
- 1st Line moderate to
severe migraine
PO: nausea, vomiting,
fatigue, dizziness
- 2nd Line (after NSAIDs
/ combo products)
- Non-prescription for
mild-moderate pain
-Prescription NSAID if
severe pain
PO
Imitrex® (sumatriptan)
Generic available
Maxalt®(rizatriptan)
Amerge® (naratriptan)
Generic available
Axert® (almotriptan)
Frova ® (frovatriptan)
Relpax ® (eletriptan)
Treximet®
(sumatriptan-naproxen)
8. Zomig ® (Zolmitriptan)
1. IN, PO, SQ
1. ergotamine-caffeine
2. Migergot®
(ergotamine-caffeine)
3. Cafergot®
(ergotamine-caffeine)
4. D.H.E. ® (dihydroergotamine)
- Generic available
5. Ergomar® (ergotamine)
1. PO
2. Supp
3. SQ
4. PO (SL tab)
5. PO (SL tab)
2. PO
( Rapid-dissolve)
3. PO
4-7.PO
SQ: inj site mild pain,
redness
8. IN, PO
(Rapid-dissolve)
Contraindications in
stroke, heart disease,
uncontrolled HTN,
pregnancy
- Nausea, vomiting
- Dependence
- Ergotism
- muscle cramps
- cold skin
- decreased HR
Highmark Commercial & Medicare Formulary medications
Contraindications in
HTN, CAD, pregnancy,
renal or hepatic
dysfunction, > 60 yo
-3rd Line
- Less effective and
more side effects than
triptans
- May be recommended
for patients with
migraines of long
duration (>48 hrs) or
high frequency
Nick Wytiaz
University of Pittsburgh
Elective Rotation - Highmark
November 21, 2011
[email protected]
Treatment Considerations
Excessive use of acute medications could cause a “rebound” or “medication overuse” headache. Nearly
all analgesics, when used > 2 days/week, have been associated with the rebound effect. In order to
avoid medication overuse and subsequent rebound headaches, migraine prophylaxis via preventative
medications may be needed.
Preventive treatment may be considered for patients with >2 migraine attacks / month and who have
had poor results from acute treatments (no headache relief, drug side effects). 1st line preventative
treatment options include beta-blockers (propanolol, timolol), antidepressants (TCAs and SSRIs such as
amitriptyline and fluoxetine), and anticonvulsants (divalproex sodium, topiramate).
In some cases, both acute treatment and preventive treatment are necessary for adequate control.
Choice of preventative medications must be patient-specific, addressing suspected causes of the attacks,
comorbid conditions, and current drug therapy. Patients requiring both acute and preventative
medications should consult their physician and/or pharmacist about the most appropriate therapies.
References:
Bajwa ZH, Wootton RJ. Patient information: Migraine headaches in adults. In: UpToDate, Swanson JW, Dashe JF (Eds),
UpToDate, 2011. Available at: http://www.uptodate.com+patient-information-migraine-headaches-inadults?source=search_result&search=migraine&selectedTitle=1%7E150#H1
Chawai J. In: Medscape Reference: Drugs, Disease & Procedures. Lutsep HL (Ed), Medscape, 2 5 May 2011. Available at:
http://emedicine.medscape.com/article/1142556-overview#showall
Highmark Blue Shield Formulary. Available at: http://client.formularynavigator.com/clients/highmark/commercial.html
Highmark Blue Shield Medicare-Approved Formulary. Available at:
http://client.formularynavigator.com/clients/highmark/default.html
Mayo Clinic. Migraine. Available at: http://www.mayoclinic.com/health/migraine-headache/DS00120