TREATMENT OF MIGRAINE & CLUSTER HEADACHE

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2 TREATMENT OF MIGRAINE & CLUSTER HEADACHE

3 Management of Migraine Principles Adequate relief of pain during the acute attack Measures to prevent recurrence of attacks Identification and management of triggers General measures There is no cure

4 Management of migraine General measures Rest in a dark, quiet room Adequate rehydration May need antiemetic

5 Management of Migraines Pharmacological A. Treatment of the acute attack B. Prophylactic therapy Non-Pharmacological Trigger management, Stress Management, Lifestyle modifications, Exercises, Relaxation methods, etc

6 Drug groups: Migraines-management Acute attack A. Analgesics: NSAIDs & Opoids,etc. B. Anti emetics: Metoclopramide (Maxolon), Dromperidone (motilium), Stemetil, etc. C. Ergot Alkaloids: Ergotamine tartarate, etc. D. Triptans: Zolmatriptan(Zomig), Sumatriptan, etc E. Miscellaneous Diazepam, steroids, etc.

7 Migraines-management -Acute attack Analgesics and anti-emetics Both NSAIDS and opoid group of analgesics are useful in the treatment of pain in the acute migraine attack. IV/IM preparations in moderate to severe attacks Use along with anti-emetics improves absorption, reduces nausea, and potentiates headache relief.

8 Migraines-management -Acute attack Analgesics NSAIDS: ibuprofen mg. daily naproxen diclofenac mg. daily mg. daily -IM 75 mg. Opoids: dextropropoxyphene, pentazocine mg. PO/IV petihdine/morphine Others: paracetamol, mefanemic acid, acetaminophen, etc.

9 Migraines-management -Acute attack The ergot alkaloids. non-selective 5HT1 agonists very useful in the management of acute migraine attacks use restricted at times by acute and chronic side effects (vomitting and ergotism) best when used early in the attack much better effects, when administered IV, PR (only oral form available in Pakistan)

10 Migraines-management -Acute attack The ergot alkaloids. Preparations: Ergotamine tartarate: Dihydroergotamine: Caffergot, Migril, etc. Dose 1-2 mg, max 6 mg/day DHE,-IV and nasal spray dose-1mg, max 3-4 mg. more effective, useful in any stage of the attack Ergots are preferably used with antiemetics

11 Migraines-management -Acute attack The Triptans The triptans are specific and selective medications used in the treatment of acute attacks of migraines These have affinity only to 5HT1B/1D receptors. They are therefore cleaner drugs with a more specifically directed effect, and lesser side effects

12 Migraines-management -Acute attack The Triptans Preparations: (1) Sumatriptan tabs -50 mg. (Imigran) sc -6 mg. nasal spray (2) Zolmatriptan tabs -2.5/5mg. (Zomig) nasal spray - 20 mg. (3) Others Naratriptan, Rizatriptan Eletriptan, etc

13 Optimization of pain relief Administration of a Triptan along with an NSAID (naproxen) gives much better relief from acute migraines than triptan or NSAID alone (Brandes JL et al, JAMA 2007) For best relief, treatment for the acute attack should be started as soon as possible after the onset of the headache phase within half hour. Not to start treatment during aura or anytime before the onset of actual headaches

14 Contraindications of triptans Untreated arterial hypertension, Coronary heart disease Raynaud s disease History of ischaemic stroke Pregnancy Lactation Severe liver or renal failure.

15 Migraines-management -Acute attack: Clinical approach Clinical practices vary. Broad principles can be stratified according to the severity of the acute attack. mild attack moderate attack severe attack very severe attack, including status migrainosus

16 Migraines-management -Acute attack: Clinical approach Mild attack Moderate attack Severe attack Very severe attacks simple analgesics, NSAIDS, NSAIDS, oral ergots, oral triptans, antiemetics ergots IV/IM/sc, nasal, PR triptans oral/sc, antiemetics IV NSAIDS, IV DHE, steroids, IV opiods, IV antiemetics, dopamine antagonists (bromocriptine)

17 Triptans available in Pakistan: Sumatriptan 50mg oral Zolmitriptan 2.5-5mg oral

18 Treatment of Migraines - Prophylaxis

19 Indications for prophylaxis More than 4 headaches/month headaches lasting > 12 hours If the headaches are frequent, long lasting and amount to a significant amount of total disability Uptodate Nov 2012

20 Indications for prophylaxis To prevent neurologic damage in the presence of uncommon migraine conditions including Hemiplegic migraine Basilar type migraine Migraine with prolonged aura Migrainous infarction Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754.

21 Migraine prophylaxis Avoidance of trigger factors Lifestyle modification Prophylactic medications

22 Goals of prophylaxis Reduce the attack frequency, severity, and disability. Avoid acute medication overuse that may lead to medication overuse headache Improve the quality of life. Reduce headache-related distress and psychological symptoms.

23 Duration of Prophylaxis Preemptive: pre-treat before a known trigger e.g high altitude, exercise Short term e.g menstrual migraine Long term when migraine interferes with ADL

24 Lifestyle modifications maintain a regular lifestyle, adequate sleep, timely meals, regular exercise manage stress Identify triggers and avoid them. adequately control their migraine attacks.

25 Principles of Prophylaxis Initiate medications with the best evidence-based efficacy the lowest effective dose of the drug titrate dose slowly until clinical benefits are achieved without any adverse events give adequate trial of 2-3 m to each drug Avoid multiple prophylactic agents long-acting formulations may improve compliance

26 Prophylactic agents for migraine Beta-blockers Propranolol Atenolol Metoprolol Antiserotonin Pizotifen Calcium-channel blockers Verapamil Flunarizine (Sibelium) Antidepressants Tricyclics SSRI Anticonvulsants Valproate Topiramate (Topamax)

27 Peer C. Tfelt-Hansen & Anders Hougaard. Migraine:New US guidelines for preventive treatment of migraine. Nature Reviews Neurology 8, (August 2012)

28 Migraine prophylaxis suggested dosages of common drugs Propranolol 30 to 240 mg/day in divided doses Topiramate 50 to 100 mg/day in divided doses Amitryptiline 25 to 75 mg/day single dose at night Valproate 500 to 1000mg/day in 2 divided doses

29 Migraine prophylaxis suggested dosages of common drugs Flunarizine 5 to 10 mg/day single night time dose Pizotifen 1 to 3 mg/day single night time dose Gabapentin 900 to 1800 mg/day in 3 divided doses

30 Choosing the right prophylactic agent Co-morbid condition Cost Compliance Family history

31 Drugs of choice for co-morbid conditions Co-morbid condition Depression Insomnia Bipolar mood disorder Neuralgic pain HTN Hypotension Asthma Obesity Anorexia Drug suggested Amitryptaline, SSRI s, avoid beta blockers Amitryptaline Divalpr Na, Topiramate Amitryptaline Beta blockers Divalpr Na, Topiramate. Avoid Amytryptaline Beta blockers contra indicated Topiramate Amitryptalne, Flunarizine, Pizotifen Shukla R, Sinha M. Migraine :Prophylactic Treatment SUPPLEMENT OF JAPI april 2010 VOL. 58

32 Migraines-prophylaxis General principles of management Start small, go slow. Adequate trial of one drug in an optimum dose for at least 3 months, before pronouncing it as ineffective. Withdraw medication gradually Response varies from individual to individual At times combination therapy is helpful

33 Duration of migraine prophylaxis Variable Don t rush in discontinuing therapy Counsel about need of long term treatment at the beginning? 3 months to 2 years

34 Take home message Migraine prophylaxis is effective but underused Prophylaxis may be pre-emptive, short-term mini-prophylaxis or long term Choose the agent according to established guidelines as far as possible Tailor the therapy according to your patient s need and co-morbid condition Counsel your patient when you start therapy

35 Cluster headaches Acute Treatment

36 Cluster headaches - Prophylaxis

37 Trigeminal Neuralgia - Medical Treatment Carbamezapine to 1200 mg daily Oxcarbazepine (better tolerated, less well studied) 600 to 2400 mg daily Gabapentin to 2400 mg daily Lioresal (Baclofen) - 10 mg to 60 mg daily Phenytoin 200 to 600 mg. daily as tolerated Others Lamotrigine, Pregabalin, Botulinum toxin, etc

38 Trigeminal Neuralgia Surgical Treatment Microvascular decompression (Jannetta s Procedure) Decompression of the trigeminal nerve from the compression / pulsating artery in the brainstem 75% pain relief at 5 years Percutaneous procedures (not available in Pakistan) 1. PC retrogasserian glycerol rhizotomy 2. PC balloon microcompression Gamma Knife Surgery (available in Karachi) minimally invasive, high rate of pain relief

39 THANK YOU Become a member of Pakistan Headache Society(PHS) by downloading form from

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43 Outline Clinical Scenario Goals Duration Principles Indications Comparison of American & European guidelines Take home Message

44 Clinical Scenario 47 year old male. Hx of migraine headaches since 24 years age. Maternal aunt, and brother suffer from similar headaches. Severe, L>R, throbbing, nausea, photo and phonophobia. Rarely visual aura zig zag scintillations. Precipitated by sleep deprivation, hunger (first 1-2 days of Ramadan), Pizza, sweet melon Frequency 2-3/week

45 Epidemiology Approximately 38% of migraineurs need preventive therapy But only 3% 13% currently use it. Ref:Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF; The American Migraine Prevalence and Prevention Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007; 68: