1. “Say Something About Migraine” (Freelove 2012) Anne Walling MB, ChB

2. “Say Something About Migraine” It Hurts!! “Under-diagnosed” in primary care “Under-treated” in primary care especially Low use of prophylaxis

3. Objectives participants will be able to Describe diagnostic criteria and tools Discuss new recommendations for preventive therapy Select and manage preventive therapy in migraine patients

4. Under-diagnosis? FPs very good at positive diagnosis (95% accurate) Alleged to mis- diagnose 25% of migraine mainly as tension or sinus

5. Definition (International Headache Society) 1.Recurrent headache lasting 4-72 hours 2.Nausea/vomiting and/or photo-phonophobia 3.At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion 4. No alternative explanation for symptoms Several subtypes based on symptoms

6. Office Diagnostic Tools: When you have a headache do you have ……. PIN Photophobia, Incapacity, Nausea (PPV 2 symptoms 93%, 3=98%) or POUND Pulsating, One day, Unilateral, Nausea, Pounding (PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

7. On treating acute attacks: Stratified Therapy based on severity/disability Mild – analgesics & symptomatic therapy Moderate – consider triptans or ergots Treat early in attack Monitor for transformed migraine New US Headache Consortium guidelines due this year

8. Preventive Therapy: indications Significant disability (impact on quality of life) Medication overuse or contraindication High risk of serious migraine complication (rare) Estimate 39% “need” 3-13% use Basically a PATIENT decision

9. Preventive Therapy for Migraine Potential 50% reduction in attacks May reduce attack severity Multiple agents & mechanisms ( esp anti-hypertensives, -depressants,-convulsants, NSAIDs, herbs ) - Can’t predict response by migraine/patient type - Quality problems in studies New guidelines (AAN 2012)

10. Patient Mrs. Smith 24 yr old teacher. Married G0P0 No significant PMH, FH, SH, RoS c/o recurrent headaches used to be every 4-6 weeks for 2-3 hours, now nearly every 10-14 days and lasting longer (entire day or longer) Temple/eye area mostly right side, sometimes left Nausea, some vomiting, can’t stand smell of food Noise & light make worse Feels exhausted & can’t concentrate during episode Feels headache coming on but no clear warning signs Takes tylenol & goes to bed. Recently taking excedrin <6/day Stress over time off work, student loans/mortgage, husband’s job, decisions about starting a family – feeling miserable several days/week Physical - normal except vitals 130/90, 70, 210lbs, 63”

11. Exercise: Does she have migraine? What is your evidence? How confident can you be in the diagnosis (PPV)? What acute treatment do you recommend? Would you advise preventive therapy? What class of preventive treatment would you advise?

12. Definition (International Headache Society) 1.Recurrent headache lasting 4-72 hours 2.Nausea/vomiting and/or photo-phonophobia 3.At least 2 of following - Unilateral - Pulsating - Severe - Aggravated by exertion 4. No alternative explanation for symptoms Several subtypes based on symptoms

13. Office Diagnostic Tools: When you have a headache do you have ……. PIN Photophobia, Incapacity, Nausea (PPV 2 symptoms 93%, 3=98%) or POUND Pulsating, One day, Unilateral, Nausea, Pounding (PPV 4 symptoms 92%,3=64%,0-2 =17%) PLUS negative neuro exam + no “red flags”

14. Ideas for acute treatment? Patient information Address triggers/exacerbators Stress reduction (esp exercise) Analgesic plan – provide effective relief - minimize adverse effects - prevent conversion to chronic daily headache

15. What medication would you advise? 1.None 2.Propranolol 3.Amytriptyline 4.Sodium valproate 5.Topiramate 6.Verapamil 7.Fluoxetine 8.Butterbur extract 9.Feverfew 10.Riboflavin VOTE!!!

16. Selecting a Preventive Medication Efficacy (new AAN guidelines) Potential adverse effects Potential added benefits ( eg HBP, seizure) Compliance Willingness to collaborate in management PATIENT beliefs and expectations

17. AAN Guidelines for Migraine Prevention B-blockersAntiepilepticsAntidepressantsOthers Level A established efficacy Metoprolol (Lopressor) 1 1 (100-200 mg/day) Propranolol (Inderal) (40-320 mg/day) Timolol (Blocadren) (10-15 mg bid) Divalproex sodium (Depakote ER) (750-1500 mg/day) Sodium valproate (Depakene) 1 1 (800-1500 mg/day) Topiramate (Topamax) (50-200 mg/day) Frovatript an (Frova) 1 1 (2.5 mg daily or bid short term only) Petasits (Butterbur) (50-75mg bid)

18. AAN Guidelines for Migraine Prevention B-blockersAltern atives Antidepres sants Others Level B Probably effective Atenolol (Tenormin) 1 1 (50-200 mg/day) Nadolol (Corgard) 1 1 (20-160 mg/day) MIG99 (feverfe w 6.25 tid) Magne sium (400- 600mg) Ribofl avin (400 mg) Amitriptyline (Elavil) 1 1 (30-150 mg/day) Venlafaxine (Effexor) 1 1 (150 mg XR/day) Fenoprofen (Nalfon) 1 1 (1800 mg/day) Ibuprofen ( Motrin) 1 1 (dosage not established) Ketoprofen (Orudis) 1 1 (150 mg/d) Naproxen (Naprosyn) 1 1 (dosage not established) Naproxen sodium (Anaprox) 1 1 (1100 mg/day) Naratriptan (Amerge) 1 1 (1 mg bid x 5 days premenses) Zolmitriptan (Zomig) 1 1 (2.5 mg bid or tid short term only)

19. AAN Guidelines for Migraine Prevention B-blockersAnti epileptic s Anti Depres s ants Others Level C Possibly effective Nebivolol (Bystolic) 1 1 (5 mg/day) Pindolol (Visken) 1 1 (dosage not established) Carbama zepine (Tegretol) 1 1 (600 mg/day) Mefenamic acid (Ponstel) 1 1 (1500 mg/day) Flurbiprofen (Ansaid) 1 1 (200 mg/day) Cyproheptadine (Periactin) 1 1 (dosage not established) Lisinopril (Prinivil) 1 1 (dosage not established) Candesartan (Atacand) 1 1 (dosage not established) Clonidine (Catapress) 1 1 (0.075-0.15 mg/day) Guanfacine 1 1 (1 mg/day)

20. What medication would you advise now? 1.None 2.Propranolol 3.Amytriptyline 4.Sodium valproate 5.Topiramate 6.Verapamil 7.Fluoxetine 8.Butterbur extract 9.Feverfew 10.Riboflavin VOTE!!!

21. Final Thoughts Migraine is not cured but can be managed Address beliefs, lifestyle etc Specific individual strategies, adjusted over time Update acute therapy (new guidelines 2012) Consider preventive therapy Recognize/avoid/manage comorbidities Physician is the “coach”