Chronic Migraine Treatments. Objectives. Objectives 4/17/2013. Betty J Harris, PharmD, FASCP, FAPhA Husson University College of Pharmacy

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1 Chronic Migraine Treatments Betty J Harris, PharmD, FASCP, FAPhA Husson University College of Pharmacy Objectives Describe the prevalence and incidence of migraines. List the chronology of a migraine. Delineate the prophylactic and symptomatic drug regimens of migraines. Objectives Identify self-treating patients with migraines who are appropriate for physician referral. Assist patients in the selection and use of nonpharmacologic treatment strategies for preventing migraines. Describe novel classes of selected investigational migraine therapies. 1

2 Prevalence/Incidence Headache in the US affects 30 million people 1. 75% of these are women. Chronic headaches (headaches for more than 15 days per month) affects up to 4%. Overuse of analgesics risk factors increased. Onset between ages Prevalence increases between then decreases. 1. Ethaj BR. Migraine headaches Percentage of persons aged 18yrs reporting severe headache or migraine during the preceding 3 mos US Migraine Chronology Progression usually lasts 4 72 hour 1. 5 distinct phases: Prodrome Aura Headache Resolution Postdrome 1. Ethaj BR. Migraine headaches 2

3 Tools for assessment Patient questions about symptoms: triggers, family history and medication. Migraine Disability Assessment Scale (MIDAS) Henry Ford Headache Disability (HDI): Migraine Prevention Questionaire 5 (MPQ-5) Prophylactic and symptomatic drug regimens Wenzel et al. pharmacist 4 question algorithm: 1. What percentages of your headaches prohibit you from performing your daily tasks and/or are accompanied by vomiting? 2. How many days per month are you completely headache free? 3. What are the symptoms of your attacks? 4. What OTC products have you tried in the past, and how have they worked? Identify self treating patients Diagnosis migraine Disability assessment MIDAS/HDI Low need -consider OTCs Moderate need consider OTCs, Rx High need consider abortive Rx, preventive Rx 3

4 Prophylatic pharmacotherapy 4

5 Acute Migraine OTCs Acetaminophen APAP/ASA/Caffeine ASA or APAP with butalbital/caffeine Isomethepten 65mg/ dicloralphenazone 100mg/ APAP 325mg (Midrin ) Ibuprofen Naproxen sodium Diclofenac Potassium Acute Migraine Rx Ergotamine tartrate PO, SL, rectal Dihydroergotamine IM, IV, SC, nasal spray Serotonin agonists (triptans) Miscellaneous Butorphanol nasal spray Metoclopramide IV Prochlorperazine IV, IM 5

6 Educating patients Incorporate the questions MIDAS, etc. Discuss modifiable risk factors. Analgesic overuse Obesity Caffeine use Sleep patterns Alcohol consumption Missing meals Educating patients Discuss potential triggers Food triggers chocolate, monosodium glutamate, diet foods, processed meats Environmental triggers glaring lights, loud noises, strong smells, smoke, weather changes Behavioral physiologic triggers excess or insufficient sleep, fatigue, menstruation, menopause, stress. Educating Patients Follow-up on evaluation of risks and or triggers with a migraine diary. What was the cause How did you treat the migraine Route of administration for abortive therapies Maximum drug dose and frequency 6

7 Discussing goals Motivational interview techniques. Migraine management and quality of life. Migraine management and work productivity. Investigational therapies Abortive therapies: Serotonin 5-HT IF agonist Lasmiditan 5-HT 1 receptor agonist and neuronal nitric oxide synthase inhibitor - NXN-188 Preventive therapies: ACE inhibitors - Lisinopril Sartans- telmisartan, candesartan Treatment of chronic migraine: Hormone - Intranasal oxytocin References 1. ElhajBR. DopheideJ. Gill MA. Migraine Headaches. Accessed: 3/18/ Prevalence and incidence of migrane Jacobson GP. Ramadan NM. Aggrawal SK. et al. The Henry Ford Hospital Headache Disability Inventory (HDI). Neurology.1994;May:44(5): Wenzel RG. Sarvis CA. Krause ML. Over-the-counter drugs for acute migraine attacks. Pharmacotherapy.2003;23: Minor DS. Chapter 70. Headache Disorders. In: Talbert RL, DiPiroJT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; Accessed April 17,

8 References 6. A. Burch R. Sheikh H. LoderE. The prevalence, impact, and treatment of migraine and severe headaches in the US. Headache.2013;Jan: OTC Supplement May Aid in Migraine Prevention. Medscape. Mar 25, Silberstein DS. Emerging target-based paradigms to prevent and treat migraine.clinpharmacol& Therap.2013;93(1): Kelley NE. TepperDE. Rescue therapy for acute migraine, Part 3. Headache.2011; /j: CutrerFM. Smith JH. Human studies in the pathophysiology of migraine. Headache.2012;Feb: References 11. BuseDC. RupnowMFT. Lipton RB. Assessing and managing all aspects of migraine. Mayo Clin Proc.2009.May;84(5):