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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