Migraine through cases

Mrs Smith Age 33, headaches for some time “on and off” for which she has to take regular painkillers. Someone has told her it could be migraine so she has come to you for advice. She is not on any other medication. What are the common causes of headache?

Headache Types Tension type headache Migraine Cluster headache Chronic Daily headache Medication misuse headache

Mrs Smith You think she has migraine. How do you classify migraine?

Migraine Classification In 1988 The International Headache Society published its classification and operational diagnostic criteria for all headache disorders. This remains the gold standard and is due to be revised in 2002. Its section on migraine covers: Migraine without aura Migraine with aura Ophthalmoplegic migraine Retinal migraine Childhood periodic syndromes

Migraine without aura (common migraine) This is an idiopathic, recurring disorder involving attacks that last 4-72 hours. The headache is typically unilateral, pulsating, of moderate or severe intensity, and is aggravated by normal physical activity. It is associated with nausea, vomiting, photophobia, and phonophobia. Five or more attacks are required to make the diagnosis. Seventy-five per cent of sufferers have this form.

Migraine with aura (classical migraine) This is an idiopathic, recurring disorder with attacks of neurological symptoms that arise in the cerebral cortex or the brain stem, creating the aura. The aura usually develops gradually over 5-20 minutes, lasts less than 60 minutes, and is completely reversible. Typical examples of an aura are: Homonymous visual disturbance (the most common type), usually a fortification spectrum - a spreading, scintillating scotoma in the shape of a jagged crescent Unilateral paraesthesia or numbness Unilateral weakness Dysphasia A combination of the above

Migraine with aura (classical migraine) The headache usually starts within 60 minutes of resolution of the aura, and lasts 4-72 hours. However, it may begin before the aura, or at the same time as the aura, or it may even be absent. The headache is typically unilateral, pulsating, of moderate or severe intensity, and is aggravated by normal physical activity. It is associated with nausea, vomiting, photophobia, phonophobia and osmophobia Two or more attacks are required to make the diagnosis. Twenty-five per cent of sufferers have this form.

The Economic Cost of Migraine Approximately 1 in 10 members of the UK population suffer from migraine, resulting in the loss of 18 million working days each year. The cost of lost production, replacement staff and the times when migraine sufferers are working below par is estimated at £750 million per annum

Incidence The prevalence of migraine is 16%; it is higher in women (25%) than in men (8%) [Rasmussen et al, 1991]. Only a minority of sufferers consult their GP. In a practice of 2000 people there are likely to be 5 newly diagnosed cases of migraine each year, and 40 consultations for existing migraine [MeReC, 1997].

Mrs Smith So why do I get migraine?

Migraine Triggers Migraine is believed to be triggered by a fall in the levels of Serotonin (5HT) but what actually causes this fall is still unknown. For most sufferers there is not just one trigger but a combination or accumulation of factors which individually can be tolerated but, when several occur together, a personal threshold is passed.

Migraine Triggers (continued) Stress – emotional or physical Relief of stress Insufficient food or long gaps between food Certain foods Environmental factors: loud noise, bright, flickering or flashing lights/glare, strong smells Changes in routine – weekend lie-ins, shift work etc. Hormonal factors – menstruation, menopause, the pill, HRT

‘THRESHOLD’ THEORY Raised or lowered by internal and external factors ? by medication threshold MENSTRUAL PERIOD MISSED LUNCH STRESS OF OVERWORK LONG JOURNEY TO WORK LATE NIGHT 1

Warning signs Yawning Unusual hunger/craving for certain foods Heightening of the senses Irritability Exhilaration/excitability Confusion Speech difficulties

Mrs Smith How do I treat my migraine? What self help treatments are available? What can she buy over the counter and what is prescribable

Self-help Measures Keep a diary Avoid triggers to which you know you are sensitive Eat regularly, avoid sugary snacks and include slow release carbohydrate foods in your diet Drink plenty of water Limit your intake of drinks containing caffeine and alcohol Take regular exercise Get plenty of fresh air and practise deep breathing Ensure that ventilation indoors is good and try to keep rooms at a constant temperature Avoid strong perfumes etc Avoid bright, flashing or flickering lights (e.g. fluorescent) Avoid large reflective surfaces (e.g. plain white walls) Wear sunglasses and/or a hat in bright sunlight Ensure that computer screens are properly adjusted and fitted with anti-glare filters Take regular breaks, especially if you are working at a VDU or if your work is repetitive Take care with your posture Ensure that your working environment is as ergonomically designed as possible Learn relaxation techniques

Treatment - Acute In the UK a stepwise approach to migraine care is generally recommended: A first-line analgesic with or without an anti-emetic is used initially. If this consistently fails to relieve migraine, treatment with a 5-hydroxytryptamine (5-HT1)-receptor agonist (a triptan) is the next step.

Treatment - Acute Starting acute treatment early in the attack is beneficial because gastric stasis during the migraine reduces drug absorption Aspirin 900 mg, paracetamol 1000 mg, or ibuprofen 400 mg are suitable first choices for the acute treatment of migraine with or withour anti-emetic Domperidone, Metoclopramide (not in young) Aspirin 900 mg plus metoclopramide was found to give relief similar to sumatriptan 100 mg. The combination was superior for the first attack studied, but sumatriptan was superior for the second and third attacks [Thompson, 1992]. Soluble forms are preferred as these are absorbed faster. 5HT Agonists (triptans) Ergotamine

5-Hydroxytryptamine receptor agonists (triptans) 5-Hydroxytryptamine(5-HT1)-receptor agonists, or triptans, should be taken as soon as possible after the onset of headache. People who do not respond to a particular triptan are likely to respond to another [Stark et al, 2000; Mathew et al, 2000]. Efficacy Triptans provide headache relief for about 30% more people than placebo at 2 hours (placebo response about 30%) [Ferrari et al, 2001]. Headache relief is defined as reduction in headache pain from moderate or severe to mild or none. Headache recurrence is an issue with all triptans. About 20-40% of people who experience pain relief by 2 hours experience headache recurrence within 24 hours [Ferrari et al, 2001]. A pain-free response is sustained for 24 hours in about 20% of responders. A recent meta-analysis of placebo-controlled studies found that rizatriptan 10 mg and almotriptan 2.5 mg had higher sustained pain-free rates than other triptans [Ferrari et al, 2001]. Similar results were found in a meta-analysis of studies comparing rizatriptan 10 mg to other triptans [Adelman et al, 2001].

5-Hydroxytryptamine receptor agonists (triptans) Adverse effects are generally mild and self-limiting for all triptans. They include nausea, dizziness, somnolence, and dry mouth. Asthenia, dizziness, drowsiness, and somnolence may be more common with rizatriptan 10 mg and zolmitriptan 5 mg [Fox, 2000]. 'Triptan sensations' include a warm-hot sensation, tightness, tingling, flushing, and feelings of heaviness or pressure in areas such as the face and limbs, and occasionally the chest. They occurr in less than 3% of people in clinical studies. People with ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, or uncontrolled hypertension should not use triptans. People with risk factors for ischaemic heart disease should be evaluated carefully before starting a triptan [Welch et al, 2000; Evans and Martin, 2000].

Mrs Smith She comes back to see you having tried hard to reduce her triggers but is still getting migraines almost once a week. What else can you do?

Migraine prophylaxis Prophylaxis should be considered for people with: More than two attacks per month Less frequent but severe or prolonged attacks Frequent use of acute treatment (to prevent development of medication-overuse headache)

Migraine prophylaxis Acute treatments are still required; the severity and frequency of attacks is only reduced by prophylaxis. Prophylactic drugs may need to be tried for 1-3 months before the full effect is seen. Prophylactic drugs that are effective should be used for 4-6 months and then withdrawn gradually to establish whether they are still required. It is difficult to make firm suggestions for one prophylactic drug over another because there is a lack of robust clinical studies

Treatment - Chronic Beta-blockers (e.g. propanolol, atenolol) Anti-depressants (e.g. amitriptyline start low dose and maintain at 50-75mg) Feverfew (Bandolier) 5HT Antagonists (e.g. pizotifen but poor) Others - Calcium channel blockers, Clonidine, Lisinopril, SSRI

Mrs Smith Her migraines are well controlled on prophylaxis and she now wants to be started on the pill for contraception. Discuss the issues that you will need to consider with regard to this request and her migraine.

Complications Migraine is associated with increased risk of ischaemic (but not haemorrhagic) stroke. Migraine with aura poses a higher risk than migraine without aura [MacGregor, 2001]. A recent case-control study confirmed that a personal history of migraine was associated with a more than three-fold risk of ischaemic stroke. Coexistence of risk factors for stroke (e.g. use of combined oral contraceptives, high blood pressure, or smoking) had more than multiplicative effects on the odds ratio for ischaemic stroke associated with migraine [Chang et al, 1999].

Migraine and COC Contraindications to the use of combined oral contraceptives (COCs) in women with migraine are based on expert opinion because there is limited evidence in this area. These recommendations are intended to enable most women with migraine to use COCs safely, with minimal risk of ischaemic stroke, while protecting those at risk [MacGregor, 2000]. The contraindications apply whether the conditions are present before starting COCs, or arise during the use of COCs: Migraine with aura Migraine without aura when there is a history of more than one additional risk factor for stroke (e.g. age 35 years or over, diabetes mellitus, close family history of arterial disease in those under 45 years of age, hyperlipidaemia, hypertension, obesity, or smoking) Status migrainosus (headache phase lasting more than 72 hours) Migraine treated with ergot derivatives