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© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
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© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
in the clinic
Migraine
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Who is at risk for migraine headache?
 Family History
 One parent with migraine: 40% children
 Both parents with migraine: 75% children
 Age
 Usual onset - late childhood or early adolescence
 Remission after few years or recurrence in variable cycles
 Peaks in fifth decade
 Decreases significantly in sixth and seventh decades
 Gender
 More common in preadolescent boys than girls
 But 3 times more common in adult women than men
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Can migraine in patients at increased risk
be prevented?
 Impossible to change the natural history of migraine
 Early diagnosis, early management improve prognosis
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What clinical features are required for
diagnosis?
 Criteria most predictive of migraine: “POUND”
 Pounding headache: pulsatile quality, throbbing
 One-day duration (headache lasts 4h to 72h if untreated)
 Unilateral location
 Nausea or vomiting
 Disabling intensity (usual activities altered during episode)
 Headache often unilateral + photophobia, phonophobia
 May be preceded by focal neurologic symptoms (“aura”)
 Visual, hemisensory, or language abnormalities
 Each symptom develops over ≥5 minutes, lasts ≤60 minutes
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What clinical features help distinguish
migraine from tension headache?
 Tension headache lacks characteristic symptoms
 Typically bilateral, lasting 30 minutes to 7 days
 Nonpulsating pressing or tightening quality
 Intensity mild to moderate, doesn’t prohibit activity
 Routine physical activity doesn’t aggravate headache
 No association with nausea or vomiting
 Photophobia or phonophobia may be present
 Migraine variability may = tension headache misdiagnosis
 In presence of bilateral pain or sinus headache
 When discomfort is a frontal or facial pressure
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What clinical features suggest the cause of
headache may be more serious than migraine?
 Focal abnormality on neurologic exam
 Diastolic blood pressure >120 mm Hg
 Diminished or absent temporal artery pulsations
 Fever
 Necrotic lesions of scalp or tongue
 Nuchal rigidity or limitation of anterior neck flexion
 Papilledema
 Decreased visual acuity, elevated intraocular pressure
 Reddened, tender scalp nodules
 Tender or nodular temporal arteries
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What is the role of physical examination in
patients who present with migraine?
 To assure no underlying pathology
 Pay attention to cranial nerves, tendon reflexes, optic discs
 Measure pulse and BP
 Listen for cardiac abnormalities and bruits (particularly if
vasoconstrictor drugs considered for Rx)
 Examine jaw for TMJ dysfunction
 Examine neck and cervical spine for muscle contraction,
cervical spondylosis, or even meningismus
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What is the role of diagnostic testing in
patients with suspected migraine?
 Neuroimaging
 Usually not warranted if neurologic exam normal
 Consider for unexplained abnormal findings on neurologic
exam or atypical features
 Electroencephalography
 Not useful for routine evaluation of headache
 Consider if symptoms suggest seizure disorder
 ESR
 Measure if patient >50y with new-onset headache
 >30 mm/h: highly sensitive for giant cell arteritis
 Lacks specificity; temporal artery Bx confirms Dx
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
When should a neurologist be consulted
for diagnosis?
 Uncertain diagnosis or suspicion of serious secondary cause
 Any new or unexpected headache
 HIV infection or immunodeficiency
 Unusual migraine aura or aura w/o headache in absence of
migraine history with aura
 Progressively worsening headache over weeks or longer
 Postural change suggesting high or low intracranial pressure
 Headache with unexplained fever or physical signs
 Persistent management failure
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Are there special considerations for
pregnant women with migraine symptoms?
 Consult OB for headache with peripheral edema or HTN
 Risk factor for pregnancy hypertensive disorders
 Imaging studies
 Defer if migraine typical and neurologic exam normal
 MRI: for abnormal neurologic exam, worsening headache,
unexplained change in headache pattern
 Head CT: head trauma, suspected intracranial hemorrhage
 Reduce voltage and limit z-axis: more effective than shields
 No contrast agents unless absolutely necessary
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Migraine without aura if:
 ≥5 episodes of headache lasting 4–72 hours
 Associated photophobia, phonophobia, nausea, disability
 Patient otherwise well between attacks
 Migraine with aura:
 Reversible visual, sensory, motor, language abnormalities
 Develops over ≥5 mins, lasts <60 mins
 Tension headache
 Bilateral “featureless” headache lasts 30 mins to 7 days
 Exclude secondary headache if focal neurologic signs present
 Neuroimaging unwarranted if neurologic exam normal and
headache typical
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What is the role of diet in management
of migraine?
 Avoiding dietary triggers can prevent migraine
 Regular meal times necessary
 Reduce caffeine, artificial sweeteners, additives (MSG)
 Avoid possible triggers at least 4 weeks
 If migraine improves, reintroduce slowly to identify triggers
 Bear in mind: migraine starts 24-48h before headache onset
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Is behavioral therapy effective in
management of migraine?
 Provides relief without risk for adverse drug effects
 Indications for behavioral therapy for migraine
 Preference for nondrug interventions
 Poor tolerance for specific drug treatments
 Medical contraindications for specific drug treatments
 Insufficient or no response to drug treatment
 Pregnancy, planned pregnancy, or nursing
 History of long-term, frequent, or excessive use of
analgesic or acute medications
 Significant stress or deficient stress-coping skills
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Which drugs are indicated for patients with
mild-to-moderate migraine?
 Mild analgesics
 Acetaminophen, aspirin, or combined analgesics
 Effective in adequate doses
 Less costly
 Less likely to cause AEs than migraine-specific drugs
 Antiemetics
 Symptomatic relief of nausea
 Facilitate use of oral analgesics for pain relief
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Which drugs are indicated for severe migraine?
 Migraine-specific
 Use initially for better outcome than stepped-care approach
 Triptans: more effective than ergots, cause less nausea
 Ergotamine: effectiveness less certain
 Butalbital: No evidence for efficacy despite widespread use
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What is the appropriate treatment strategy
when first-line drugs fail?
 Opiate analgesics
 Use if no relief within 1h from initial, nonopiate treatment
 Don’t exceed 2 doses/wk on regular basis
 Don’t use in >50% of migraine attacks
 Provide guidance on how and when to use
 Hospitalization
 If there’s no effective clinical response
 For parenteral treatment
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
When should clinicians consider
preventive therapy?
 Recurrent headaches (≥2/mo) interfere with daily routine
 Contraindication to acute therapy
 Failure or overuse of acute therapy
 Adverse effects from acute therapy
 Patient preference
 Uncommon migraine (e.g., basilar-type, hemiplegic)
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Which drugs are useful in prevention?
 Select drug based on efficacy
 Medications with established efficacy
 Propranolol (60–240 mg/d) or timolol (5–30 mg/d)
 Divalproex sodium (500–2000 mg/d)
 Topiramate (100–200 mg/d)
 If menstrually-related: perimenstrual frovatriptan
 Consider patient preference and patient adherence
 Consider comorbid conditions and drug side effects
 Consider adding behavioral therapy
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What is medication-overuse headache?
 Medication-overuse headache (MOH)
 When overuse of medications causes headaches rather
than relieving them
 Suspect if headache occurs on ≥15d/mo for >3 months
 Tension daily headache and/or migraine-like attacks
 Associated symptoms
 Nausea and GI symptoms
 Irritability, anxiety, depression
 Problems with concentration and memory
 Usually resolves after overuse is stopped
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
How can MOH be prevented and treated?
 Dose frequency more important than drug quantity
 Restrict commonly responsible meds + caffeine, codeine
 Consider early prophylaxis (medical or behavioral)
 Educate patients about MOH
 Have patients monitor headache frequency, drug use
 Most patients revert to original headache type in 2mos
 Onabotulinumtoxin A or topiramate: reduce withdrawal
 Reintroduce overused medications after 2 months
 Follow up with patients regularly to prevent relapse
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Are there special considerations for
treating migraine in the pregnant patient?
 In 1st trimester, migraine can develop or worsen
 In 2nd and 3rd trimesters, many experience improvement
 Due to sustained estrogen levels of 2nd and 3rd trimesters
 Migraine in pregnancy is usually benign
 But associated with pregnancy-induced HTN, preeclampsia
 Risk highest in women >30y of age or who are obese
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
 Nonpharmacologic therapies preferred
 Magnesium supplementation
 Simple remedies (rest, ice)
 Physical therapy, relaxation training, biofeedback
 If pharmacologic therapies needed
 Use acetaminophen, NSAIDs, and codeine or other
narcotics (in that order), with or without metoclopramide
 Stop NSAIDs before week 32 (risk of premature closure of
ductus arteriosis)
 Avoid opioids in the late 3rd trimester
 Use sumatriptan and other triptans with caution
 Don’t use ergots
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
When should clinicians consider
hospitalization for a patient with migraine?
 Severe intractable migraine lasting >72h
 Migraine associated with MOH
 For administration of therapies
 Parenteral dihydroergotamine: if no triptans or ergots w/in 24h
 IV dopamine antagonists + IV diphenhydramine + hydration
 IV ketorolac + sodium valproic acid preparation
 Adding single dose of dexamethasone may reduce recurrence
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Treatment…
 Identify and avoid diet-related factors
 Behavioral therapies can provide relief without drug AEs
 Use simple or compound analgesics if migraine mild-moderate
 Use triptans and ergots for severe migraine
 Reserve opiate analgesics for rescue medications
 Use antiemetics to relieve nausea, facilitate oral analgesic use
 Prevent episodic migraine with propranolol, timolol, divalproex
sodium, topiramate
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What are the components of good
follow-up care?
 Reevaluate patients after treatment of ≥3 attacks
 Have patients keep headache diary and bring in to review
 Review the need for preventive therapy and consider if:
 Poor response to treatment
 Frequent need for rescue medication
 Consider increasing dose or changing agents if:
 Headache frequency hasn’t improved after 3 months of
preventive treatment
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
Is it appropriate to taper or discontinue
preventive treatment for migraine?
 Maintenance phase
 Maintain treatment for 6- to 12-mo after response achieved
 Response = 50% reduction in headache frequency
 Taper phase
 Taper with the aim to discontinue if no relapse occurs
 Over time migraine symptoms may change and preventive
treatment may no longer be needed
 This may avoid the risks, costs of unnecessary drug Rx
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
When should clinicians consider subspecialty
referral for patients with migraine headache?
 Neurologist or headache specialist
 Possible ophthalmic, basilar, atypical, complicated migraine
 Status migrainosus or MOH
 Neuro-ophthalmologist or ophthalmologist
 Headache with visual changes other than typical aura
 If >50yo with visual symptoms: possible giant cell arteritis
 Obstetrician
 Headaches with peripheral edema or HTN in pregnancy
 Evaluate for possible preeclampsia
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
What should patients be taught about
managing their migraines?
 Goals, use, and expectations of treatment
 Reduce frequency / severity of attacks, improve efficacy of
acute medications, assist in managing comorbidities
 Therapies rarely completely eradicate headaches
 Develop a plan for self-management
 ≈ 50% of recurrent headache sufferers don’t adhere
properly to drug treatment regimens
 ≈ 66% don’t make optimal use of rescue medications
 Identify all treatment modalities used and dosing limits
 Include how and when to contact health care provider
 Encourage patients to identify, avoid lifestyle factors
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.
CLINICAL BOTTOM LINE: Follow-up…
 Reevaluate patients after treatment of ≥3 attacks
 Review need for preventive therapy
 Consider if poor response to treatment or frequent need for
rescue medication
 Increase dose or change agents if no improvement in
headache frequency after 3 months preventive treatment
 After maintenance phase, taper preventive care and
discontinue if no relapse occurs
 Refer to subspecialist for possible ophthalmic, basilar,
atypical, complicated migraine, status migrainosus, or MOH
 Teach patient about goals, use, and expectations of
treatment
 Develop a plan for patient self-management
© Copyright Annals of Internal Medicine, 2013
Ann Int Med. 159 (9): ITC5-1.