Migraine Diagnosis and Treatment
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1 Lehigh Valley Health Network LVHN Scholarly Works Neurology Update for the Non-Neurologist 2013 Neurology Update for the Non-Neurologist Feb 20th, 6:30 PM - 7:00 PM Migraine Diagnosis and Treatment Vitaliy Koss MD Lehigh Valley Health Network, vitaliy.koss@lvhn.org Follow this and additional works at: neurology_update_non_neurologist Part of the Diagnosis Commons, Nervous System Diseases Commons, Neurology Commons, and the Neurosciences Commons Koss, V. (2013). Migraine Diagnosis and Treatment. Neurology Update for the Non-Neurologist,. Retrieved from february_20/9 This Presentation is brought to you for free and open access by the Conferences and Symposia Collection at LVHN Scholarly Works. It has been accepted for inclusion in Neurology Update for the Non-Neurologist by an authorized administrator of LVHN Scholarly Works. For more information, please contact LibraryServices@lvhn.org.
2 Migraine Diagnosis and Treatment Dr. Vitaliy Koss, MD Neurologist Lehigh Valley Health Network
3 Diagnostic Criteria A. At least 5 attacks fulfilling criteria B through D B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (ie. walking or climbing stairs) D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and/or Phonophobia E. Not attributed to another disorder
4 Pillars of Acute Migraine Treatment NSAIDs (IV Ketorolac, Ibuprofen, Diclofenac) Neuroleptics (Reglan, Compazine, Droperidol, Thorazine, Haldol) Migraine specific (DHE, Triptans)
5 Additional Considerations Steroids (Methylprednisolone, Dexamethasone) Anticonvulsants (Valproic Acid, Levitiracetam) Magnesium Sulfate
6 Opioids In almost all cases of primary headache, Opioids must be avoided! Most primary headache disorders are made worse by Opioid exposure
7 New Treatments??
8 Population-Based Study Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study Marcelo E. Bigal, MD, PhD; Daniel Serrano, MA; Dawn Buse, PhD; Ann Scher, PhD; Walter F. Stewart, PhD; Richard B. Lipton, MD
9 Population-Based Study Cont d Compounds containing barbiturates and opiates were associated with a twofold increased risk of TM in 2006 vs. maintaining an episodic migraine status (barbiturates OR = 2.06, 95% CI = ; opiates OR = 1.98, 95% CI = )
10 Admission Avoid PRN medications during admission
11 Abortive and Preventative Treatments
12 Abortive Medications Triptans Almotriptan (Axert) Eletriptan (Relpax) Frovatriptan (Frova) Naratriptan (Amerge) Rizatriptan (Maxalt) Sumatriptan (Imitrex) Zolmitriptan (Zomig) Sumatriptan/Naproxen (Treximet)
13 Preventative Treatments Antihypertensives Antidepressants Antiepileptics
14 Evidence-based guideline update: Treatment for episodic migraine prevention
15 Level A: Established Efficacy Antiepileptic drugs: Divalproex sodium, Topiramate Beta-blockers: Metoprolol, Propranolol, Timolol Triptans (MRM): Frovatriptan
16 Level B: Probably Effective Antidepressants: Amitriptyline, Venlafaxine Beta- blockers: Atenolol, Nadolol Triptans (MRM): Naratriptan, Zolmitriptan
17 Level C: Possibly Effective ACE inhibitors: Lisinopril Angiotensin receptor blockers: Candesartan Alpha- Agonists: Clonidine, Guanfacine Antiepileptic drugs: Carbamazepine Beta-blockers: Nebivolol, Pindolol Antihistamines: Cyproheptadine
18 Level U: Inadequate or Conflicting Data Carbonic anhydrase inhibitor: Acetazolamide Antithrombotics: Acenocoumarol, Coumadin, Picotamide Antidepressants: Fluvoxamine, Fluoxetine, Protriptyline Antiepileptic: Gabapentin Beta-blockers: Bisoprolol Ca blockers: Nicardipine, Nifedipine, Nimodipine, Verapamil Direct vascular smooth muscle relaxants: Cyclandelate
19 Other Medications Possibly or Probably Ineffective Lamotrigine (Level A negative) Clomipramine (level B negative) Acebutolol (level C negative) Clonazepam (level C negative) Nabumetone (level C negative) Oxcarbazepine (Level C negative) Telmisartan (level C negative)
20 Evidence- based guideline update: NSAIDs and other complimentary treatments for episodic migraine prevention
21 Level A: Established Efficacy Herbal: Butterbur
22 Level B: Probably Effective NSAIDs: Fenoprofen, Ibuprofen, Ketoprofen, Naproxen Herbal/ minerals: Magnesium, feverfew, Riboflavin Histamines: Histamine SC
23 Level C: Possibly Effective NSAIDs: Flurbiprofen, Mefenamic Acid Herbal/ minerals: CoQ10, Estrogen Antihistamines: Cyproheptadine
24 Level U: Inadequate or Conflicting Data NSAIDs: Aspirin, Indomethacin Herbal/ minerals: Omega-3 Other: Hyperbaric Oxygen
25 Other: Established Possibly or Probably Ineffective Leukotriene receptor antagonist: Montelukast (level B negative)
26 Chronic Migraine Treatment Botox
27 In Summary: Acute treatment of intractable headache should include NSAIDs, Neuroleptics, and Migraine specific medications. Opioids and Barbiturates make primary headache disorders worse. Preventive medications should be considered.
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