You are on page 1of 23

Migraine: Approach for

prevention
Ehab Ahmed Hashish
Assistant lecturer of Neurology
Faculty of medicine
Suez canal university

Migraine Epidemiology

Go Back to Main Menu

Migraine Prevalence

One in 4 households has at least 1 with


migraine

Lipton RB, et al. Neurology. 2007; 68(5):343-349.


National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.

Migraine Prevalence:
Age
and
Gender
Migraine prevalence peaks in the 25-55 age range

Lipton RB, et al. Neurology. 2007;68(5):343-349.

Migraine Diagnosis
and Treatment

Go Back to Main Menu

International Headache Society


Criteria for Migraine
Migraine Is an Episodic Recurrent Headache
Lasting 4-72 Hours with:
Any 2 of these pain qualities:

Any 1 of these
associated symptoms:

unilateral pain
throbbing pain
pain worsened by
movement
moderate or severe pain

nausea
vomiting
photophobia and
phonophobia

Features such as osmophobia and posterior head and neck pain can also be present in a
headache that meets IHS criteria for migraine.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders.
2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

Many Migraine Sufferers Remain


Undiagnosed

56%
Diagnosed Migraine

44%
Undiagnosed Migraine

Diamond S et al. Headache. 2007;47(3):355-363.

Patients with Recurrent Headache May


Meet Criteria for Migraine

87% of patients presenting to OPD with recurrent headache


met IHS criteria for migraine
Episodic Tension-type Headache (n=1)

0.4%
Probable Migraine
(n=31)

Other (n=3)

1%

11%
Migraine
(n=237)

87%

Tepper SJ et al. Headache. 2004;44(9):856-864.

Focusing on Migraine Diagnosis


Opportunities for accurate diagnosis of migraine
patients still exist:
80% of sinus headache patients met IHS criteria for
migraine
85% of tension/stress headache patients met IHS criteria
for migraine

Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.


Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

Phases of a Migraine Attack


Treatment Phase

Pre-HA

Migraine Intensity

Premonito
ry/
Prodrome
Migraine
symptoms
occurring
hours/days prior
to headache

Headach
e

PostHA

Aura
Focal
neurological
symptoms
preceding
headache
(<1 hour)

Symptoms:
Flashing lights
Symptoms :
or wavy lines
Food cravings Numbness
Mood changes Tingling in face
Yawning
Disturbed
Fatigue
senses

Moderate
to Severe

Mild

Migraine when
headache is mild

Symptoms:
Sensitivity to light
Sensitivity to sound
Nausea
Pain in the back of
the head and neck

Migraine when
headache is moderate
to severe

Symptoms:
Same as mild but
more intense

Postdrom
e

Migraine
symptoms
occurring
hours/days
after headache
resolution

Symptoms:
Tiredness
Confusion
Lowered appetite
Stiff or sore
muscles

Time
Adapted from Cady RK. Headache. 2008;48(9):1415-1416.
Headache Classification Subcommittee of the International Headache
Society. Cephalalgia. 2004;24(suppl 1):117-118.
Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone.
1999;1(6):21-32.

National Institutes of Health. National Institute of Neurological


Disorders and Stroke.
http://www.ninds.nih.gov/disorders/headache/detail_headache.htm.
Accessed December 7, 2009.

Medication Options Available


for
Migraine
Acute Medications
Preventative Medications

May work quickly to relieve


migraine pain and other symptoms
Usually taken during a migraine
attack
Triptans
NSAIDs
Opioids
Analgesics (Rx and OTC)
Ergotamine/DHE
Antiemetics
Neuroleptics
Corticosteroids

Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.


Silberstein SD. Neurol Clin. 2009;27(2):429-443.

May prevent or reduce the number


of migraine attacks
Typically taken on a daily basis
Antiepileptics
Antidepressants
Beta blockers
Calcium channel blockers

Identifying Candidates
for Preventive Therapy
Guidelines for Initiating Preventive Therapy
Frequency of headache 2 per month with disability
3 days per month
Recurring migraines that, in the patients opinion, significantly
interfere with routine daily activity.
Use of acute (over-the-counter or prescription) medication
more than 2 times a week
Acute medications are contraindicated, not tolerated, or
ineffective
Even patients with <2 attacks per month may experience
disability severe enough to require preventive treatment.

NHF Migraine Prevention


Summit Consensus
Statement
Migraine is a chronic disorder, rather than an
episodic disorder. Healthcare professionals treating
patients with migraine must be educated about recent
advances in the understanding of migraine and current
treatment options.

Data on file. Titusville, NJ: Ortho-McNeil Neurologics, Inc.; June 2006; September 2006; December 2006; February
2007.

Proper use of acute medications is


essential to maximize their efficacy. Acute
medications should be taken at the first sign
of migraine (or during the aura, if present).

Acute medication is not always adequate


to control migraine attacks. Preventive
therapy should be considered in patients
requiring acute medication more than 2 days
per week and in those experiencing frequent
disability during and between migraine attacks

Healthcare professionals need to determine


patient disability and the total level of
impairment migraine has on a patients life,
both during and between attacks, to
better assess when patients may be
appropriate candidates for preventive therapy.
In addition, it is important to recognize how
migraine affects other aspects of the
patients life, such as family and work .

Preventive
therapies
include
both
medications and behavioral modifications.
Patients need realistic expectations about
treatment outcome, specifically time to
response. Preventive therapies may take 6
weeks or longer to reach clinical effect. In
addition, patients should be counseled on
what side effects to expect and should be
titrated slowly to the target dose.

Patients are important partners in the


management
of
migraine.
Open
communication about treatment options and
healthcare professional-patient support
is essential to ensure treatment plans are
followed. Adherence to treatment regimens,
including both lifestyle changes and
medications, is necessary to achieve
optimal effect.

Migraine Is Often Overlooked

Sinus headache is the most common


misdiagnosis

Sinus pain caused by


inflammation induced
allergens or by infection
occurs when exudate in
inflamed, blocked sinuses
exerts pressure that
stimulates local trigeminal
nerve fibers
Chronic sinusitis is not
validated as a cause of
headache unless it
relapses into an acute

Migraine Is Often Overlooked


(contd)
Tension headache is another common
misdiagnosis
Symptoms include
Dull steady ache
Physical activity does not worsen pain
Nausea, photo/phonophobia
are not usually present
Vomiting never present
Patients have likely tried OTCs and failed

Cady et al. Headache Free. 1993;36-38.

Migraine Pain Can Be Felt in Peripheral


Locations Such as the Neck
In Kanieckis study of 144 patients with
migraine
75% reported neck
pain with their
migraine
43% described neck
pain as bilateral and
57% as unilateral

75%
reported neck pain
with their migraine

Migraine Is Often Overlooked


(contd)
Tension headache is another common
misdiagnosis
Symptoms include
Dull steady ache
Physical activity does not worsen pain
Nausea, photo/phonophobia
are not usually present
Vomiting never present
Patients have likely tried OTCs and failed

Cady et al. Headache Free. 1993;36-38.

Thank You