Handout for “Fighting Through The Pain”
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Fighting Through Pain: Treating Migraines
Anne H. Calhoun, MD
Clinical Associate Professor, Department of Neurology
University of North Carolina
Identifying Migraine
Prevalence, Pitfalls, and Diagnostic Criteria
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Objectives
Identifying Migraine
Prevalence, Pitfalls, and Diagnostic Criteria
Identifying Migraine: Prevalence
Age and Gender Prevalence of Migraine in Adults
Migraine Prevalence (%)
30
Females
Males
25
20
15
10
5
0
0 20
30
40
50
60
70
80
100
Age (y)
Age and Gender Prevalence of
Migraine in Adults
Lipton et al. Headache. 2001;41:646-657.
Identifying Migraine: Prevalence
Referred Pain / Autonomic Sxs
IHS Criteria: Migraine without Aura




≥5 attacks lasting 4-72 hours
Any two:
– Moderate-to-severe intensity
– Pulsatile
– Unilateral
– Exacerbated by activity
Either:
– Nausea
– Photophobia & phonophobia
Not attributed to other disorder
IHS Criteria: Migraine without Aura
International Headache Society. Cephalalgia. 2004;24(suppl 1):24-36;139-151.
IHS Criteria: Migraine with Aura
When to Refer
Identifying the patient whose headaches need further evaluation
Pharmacists & Headache Care
Pharmacists are asked to recommend treatment for headache 53,000 times a day
“Excuse Me, Can You Recommend
Something for My Headache?”
1. How often do your headaches prevent normal function?
2. How many days per month are you completely headache-free?
Q#1: How Often Do Headaches Prevent Normal Function?
Q#1: How Often Do Headaches Prevent
Normal Function?
>50% disabling &/or
>20% with vomiting:
Refer to physician
“Disabling” means:
• Cannot perform daily tasks
• Missed work/school/family activities
• ≥50% reduction in ability to perform chores
• Vomiting
• Sleep required for improvement
>50% disabling &/or >20% with vomiting:
Refer to physician
<15 days/month?
◦Patient has a chronic daily headache subtype
◦There is a high probability of medication overuse headache
(Do not recommend more analgesics)
Refer to physician
Treat at least 3 attacks
◦With inadequate relief in ≥2 out of 3 attacks, try a distinctly different OTC product
Acute Therapy for Migraine
Non-specific and Migraine Specific Medications
Acute Migraine Medications:
The Available Options
Nonspecific treatments
◦NSAIDs
◦Combination analgesics
◦Opioids
◦Neuroleptics/antiemetics
◦Isometheptene
Specific treatments
◦Triptans
◦Ergotamine/dihydroergotamine (DHE)
Acute Migraine Management:
Evidence-Based Guidelines
NSAIDs as first-line therapy
Triptans (or DHE) indicated for those
who fail to tolerate or respond to NSAIDs
No evidence to support the use of IV corticosteroids or intranasal lidocaine
Little evidence to support the use of isometheptene combinations in migraine
Opioids should be “reserved for use when other medications cannot be used”
The Triptans—Specifically Indicated for Migraine
Triptans Are Highly Selective
Triptan Effects are Minimal
Triptan Binding Shows Craniovascular Selectivity
5-HT1B receptors are
denser in meningeal arteries
than in coronary arteries
Triptans stimulate meningeal 5-HT1B receptors more potently than those in the heart
Triptans are unlikely to cause serious cardiovascular (CV) events in healthy patients
Available Triptan Formulations
Almotriptan
◦Oral 6.25, 12.5 mg
Eletriptan
◦Oral 20, 40 mg
Frovatriptan
◦Oral 2.5 mg
Naratriptan
◦Oral 1, 2.5 mg
Achieving optimal results
What your clients can do to improve outcome with their medications
4 Reasons for Sub-optimal Response to a Triptan
1. Chronic Daily Headache
Analgesic Overuse Can Complicate Patient Profile
2. Hormonally Mediated Migraine
Hormonal Treatment of MRM
Naratriptan Mini Prophylaxis
Randomized, double-blind, parallel-group, placebo-controlled, 3-arm study
◦Naratriptan 1 mg bid for 5 days
◦Naratriptan 2.5 mg bid for 5 days
◦Placebo bid for 5 days
Naratriptan 2.5 mg bid was not effective
Naratriptan 1 mg bid reduced the median number of MRM attacks in 4 months from 4
to 2 (p=0.01)
Frovatriptan Mini Prophylaxis
Randomized, double-blind, placebo-controlled, three-way crossover study
◦Frovatriptan 2.5 mg QD for 6 days
◦Frovatriptan 2.5 mg BID for 6 days
◦Placebo for 6 days
Incidence of MRM during the 6-day PMP was
◦67% for placebo
◦52% for frovatriptan 2.5 mg QD
◦41% for frovatriptan 2.5 mg BID
Both frovatriptan regimens reduced
◦Severity of MRM
◦Duration of MRM
◦Use of rescue medication
Impact of MRM
3. Patient Delayed Treatment
Central Sensitization
Central Sensitization
Central Sensitization
4. Headache Awakened Patient
•
Sleep complaints were common in
a sample of 1283 migraineurs
• >50% reported insomnia
• 71% were regularly awakened by
headaches
• 50% reported that sleep disturbances
triggered migraine
• 38% were “short sleepers” (≤6 hrs per night)
• Compared to those who slept longer, short sleepers
experienced:
• More frequent and more severe headaches
• More headaches on awakening
4. Headache Awakened Patient
Kelman L, Rains JC. Headache and sleep: examination of sleep patterns and complaints in a large
clinical sample of migraineurs. Headache. Jul 2005;45(7):904-910.
4. Headache Awakened Patient
Study Design
In Summary . . .
Questions & Answers