Evidence based Approach to Migraine Treatment

Transcription

1 Evidence based Approach to Migraine Treatment FAMILY MEDICINE UPDATE 04/09/2016 ANDY PATEL, FAMILY MEDICINE PGY 3 fcm algo.umh.edu 1

2 LEARNING OBJECTIVES 1. What is an easy, well validated way to diagnose migraines? 2. What are the best evidence based acute migraine treatments? 3. What are the best evidence based prophylactic migraine treatments? OUTLINE I. Introduction I. Epidemiology II. Pathophysiology II. Literature Review III. Diagnosis & Assessment I. Diagnosis II. Migraine types III. Severity assessment IV. Treatment I. Acute therapy II. Prophylactic therapy III. Ineffective treatments 2

3 OUTLINE I. Introduction I. Epidemiology II. Pathophysiology II. Literature Review III. Diagnosis & Assessment I. Diagnosis II. Migraine types III. Severity assessment IV. Treatment I. Acute therapy II. Prophylactic therapy III. Ineffective treatments Epidemiology 3

4 Pathophysiology Neurovascular Model Cortical spreading depression Wave of depolarization spreads throughout cerebral hemisphere at rate of 2 5mm/min Correlates with scintillating scotoma (aura) Stimulates release of pro inflammatory peptites Substance P, Calcitonin gene related peptide (CGRP) from trigiminocervical nerve terminals Pro inflammatory peptides induce vasodilation and plasma protein extravasion, leading to headache Inadequate serotonin & excessive dopamine also felt to play a role OUTLINE I. Introduction I. Epidemiology II. Pathophysiology II. Literature Review III. Diagnosis & Assessment I. Diagnosis II. Migraine types III. Severity assessment IV. Treatment I. Acute therapy II. Prophylactic therapy III. Ineffective treatments 4

5 Literature Review Practice Guidelines American Academy of Neurology 2000: Practice Parameter: Evidence based Guidelines for Migraine Headache 2012: Evidence based guideline update: Pharmacologic treatment for episodic migraine prevention American Headache Society 2015: The Acute Treatment of Migraine in Adults: The American Headache Society Evidence American Academy of Family Physicians 2006: Medications for Migraine Prophylaxis 2011: Treatment of Acute Migraine Headache Literature Search PubMed search for meta analysis & RCTs over the past 5 years OUTLINE I. Introduction I. Epidemiology II. Pathophysiology II. Literature Review III. Diagnosis & Assessment I. Diagnosis II. Migraine types III. Severity assessment IV. Treatment I. Acute therapy II. Prophylactic therapy III. Ineffective treatments 5

6 Warning Signs INDICATIONS FOR LP Fever Altered mental status Meningismus INDICATIONS FOR NEUROIMAGING Occipitonuchal location >55 years of age Abnormal neuro exam Focal neurologic symptoms Atypical features Increased headache frequency Headache causing awakening from sleep 6

7 IHS Criteria for Diagnosis Patients must have 5 headache attacks lasting 4 72 hours, and the HA must have at least 2 of the following characteristics Unilateral location Pulsating quality Moderate/severe pain intensity Aggravation by or causing avoidance of routine physical activity In addition, during the headache, the patient must have at least 1 of the following: Nausea/vomiting Photophobia and phonophobia Pound Criteria 7

8 Migraine Types Migraines Migraine with aura, classic migraine Migraine without aura, common migraine Chronic migraine Chronic migraine associated with analgesic overuse Migraine Variants Basilar type migraine Hemiplegic migraine Opthalmoplegic migraine Retinal/ocular migraine 8

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10 OUTLINE I. Introduction I. Epidemiology II. Pathophysiology II. Literature Review III. Diagnosis & Assessment I. Diagnosis II. Migraine types III. Severity assessment IV. Treatment I. Acute therapy II. Prophylactic therapy III. Ineffective treatments 10

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13 NNT 5 for 1 hour HA reduction NNT 12 for 2 hour HA resolution 13

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15 IBUPROFEN 400mg NNT 3 for 2h HA relief. NNT 7 for 2h HA resolution. NNH mg = 400mg > 200mg 200mg ibuprofen > 1000mg Tylenol. 15

16 ASPIRIN 1000mg NNT 5 for 2h HA relief. NNT 8 for 2h HA resolution. NNH 34 DICLOFENAC 50mg NNT 6 for 2h HA relief. NNT 9 for 2h HA resolution. NNH 50 16

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19 Attempted to answer the questions: 1) How effective are triptans? 2) Which triptans are more effective? 1) Triptans are effective for treatment of migraines 42 76% experience 2 hour headache relief 29 50% experience 24 hour sustained relief 2) Different triptans have roughly equivalent efficacy. Top performers appear to be: Sumatriptan Rizatriptan Zolmitriptan Eletriptan 3) Triptans outperformed ergots and were equal or better than PO NSAIDs 4) Combination of triptan + NSAID or triptan + PO antiemetic slightly outperforms triptan monotherapy 5) Higher doses more effective, more side effects 6) Different people respond to different triptans 19

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22 Alternative Treatments ORAL THERAPIES Vitamin B2 (riboflavin) 400mg PO daily 1998 RDB RCT J Neurol, 80 adults. NNT 3 Coenzyme Q10 300mg PO daily 2005 RDB RCT J Neurol, 43 adults, NNT 3 Simvastatin 20mg daily & Vitamin D IU daily 2015 RDB RCT Ann Neurol, 57 adults. NNT 4 NON PHARMACOLOGIC THERAPIES Regular aerobic exercise Relaxation exercises/tapes/yoga Acupuncture Therapeutic patient education 22

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26 Zolmitriptan 2.5mg tid NNT 3 Frovatriptan 2.5mg bid NNT 4 NNH ~10 26

27 TOPAMAX mg total daily dose NNT 4 for 50% reduction in headache frequency NNH 3 25, mostly mild 27

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30 DEPAKOTE NNT 4 NNH 7 14 Topamax slightly superior to Depakote. 30

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32 Ineffective Treatments ACUTE IV MgSO4? Naproxen Manual manipulative therapies Biofeedback Intranasal lidocaine* PROPHYLACTIC Gabapentin Lamotrigine Botox (except for chronic migraine) Summary Migraines are a common, disabling condition that can generally be treated by the PCP. For mild moderate headaches, treatment should generally start with Excedrine Migraine or NSAIDs. PO antiemetics can be used adjunctively for nausea. Consider Tylenol or ginger powder for patients who are NSAID intolerant. For disabling headaches, treatment should start with triptans, or in the office setting, IM Toradol. Non responders should be given a higher dose or different triptans. NSAIDs and PO antiemetics can be used adjunctively and may improve treatment response. In the ED setting, IV Compazine, Thorazine or Reglan are effective for treatment of migraine. IV dexamethasone may help prevent recurrence. Propranolol, timolol, metoprolol succinate, Topamax, and Depakote are 1 st line medications for migraine prevention. Other 2 nd & 3 rd line meds may be considered for non responders or for other reasons. Consider trigger avoidance and alternative treatments. If effective, continue treatment for at least 2 years. 32

33 Special Thanks Dr. Anne Fitsimmons Susan Meadows Dr. Laura Morris Dr. Jim Stevermer Algorithm Review Committee 33