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Migraines Dr. Md. Samiul Huda

A Short presentation on Migraines for Junior Doctors with Guideline Recommendations and Tips for treatment and approach.

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Migraines Dr. Md. Samiul Huda

  1. 1. Dept. of Medicine, AKMMCH MIGRAINES 1
  2. 2. HEADACHES
  3. 3. “ *Global Burden of Disease Study 2013, Collaborators (22 August 2015), The Lancet Headache is one of the most commonly experienced of all physical discomforts. Tension headaches are the most common, affecting about 1.6 billion* people followed by Migraines which affect about 848 million* 3
  4. 4. 4 CLASSIFICATION OF HEADACHES* *International Classification of Headache Disorders- 3rd Edition
  5. 5. 5 CLASSIFICATION OF HEADACHES* *International Classification of Headache Disorders- 3rd Edition
  6. 6. 6 6 RED FLAG SIGNS REQUIRING FURTHER INVESTIGATIONS • New Onset of Headache Particularly in >50 year olds • Headaches lasting ≥72hrs Visual, Sensory or Language symptoms lasting >1hr • Escalation of headache frequency/intensity in the absence of medication overuse headache • Very Sudden onset Headache/ Neurological symptoms • Abnormal Neurologic Examination • Associated fever, systemic Illness or epilepsy • Posterior Located Headaches
  7. 7. MIGRAINES
  8. 8. “ *Peter J. Goadsby, Annals of Indian Academy of Neurology 2012 Aug **Charles Andrew, Migraine: NEJM, 2017 Migraine is in essence a Familial, Episodic disorder whose Key Marker is Headache, with certain Associated Features.* It is also associated with increased risks of several other disorders, including asthma, stroke, anxiety and depression, and other pain disorders** 8
  9. 9. 9 *PATHOPHYSIOLOGY OF MIGRAINE 1 2 3 4 5
  10. 10. • Unilateral (70%) But may also be Bilateral • Throbbing (Pulsating/ Banging in <18yrs) in Character, Gradual Onset • Headache lasts 4-72hrs (2- 72hrs<18yrs) • Moderate-Severe Intensity • May or may not be associated with visual or sensory Auras • Nausea/ Vomiting • Allodynia and avoidance of routine activities HISTORY 10
  11. 11. • Females are usually more affected • Episodes may occur during Menstrution • Peak Age: 35-39 years • Skipped Meals • Irregular Caffeine Intake • Stress • Lack of Sleep • OCP • SSRIs • Nasal Decongestants • PPIs • Opioids • Barbiturates HISTORY 11
  12. 12. Premonitory Phase Mood Changes, Fatigue, Unusual Thirst (Lasts 1-24 Hrs) 12 Aura Visual, Sensory or Speech Disturbances (Present in 70% of Migraine cases) Headache Gradual Onset with Crescendo Pattern (Lasts 4-72 hours in adults, 2-72 hours in children) Resolution Headache gradually/ suddenly wears off Postdrome Consists of similar symptoms as the Premonitory Phase *PHASES OF MIGRAINE 1 2 3 4 5
  13. 13. 13 CLASSIFICATION OF MIGRAINES* *International Classification of Headache Disorders- 3rd Edition
  14. 14. AURA A Reversible, Perceptual Disturbance that is experienced by SOME individuals with Migraines or a Seizures BEFORE the Headache or Seizure begins AURANICE, 2015 AURAS INCLUDE • VISUAL SYMPTOMS that may be positive (eg. flickering lights, spots or lines) and/or negative (eg. Partial vision loss) • SENSORY SYMPTOMS that may be positive (eg. Tingling) and/or negative (eg. Numbness) • SPEECH DISTURBANCES
  15. 15. Dx CRITERIA *International Classification of Headache Disorders- 3rd Edition
  16. 16. 3. Headache has at least TWO of the following four characteristics: a. Unilateral location b. Pulsating quality c. Moderate or severe pain intensity d. Aggravation/causing avoidance of routine physical activity 4. During headache at least ONE of the following: a. Nausea and/or Vomiting b. Photophobia and/or Phonophobia 5. Not Better Accounted for by any other ICHD-3 Diagnosis FIVE FULFILLING ‘2’ ‘4’ LASTING 4-72 HOURS 16*International Classification of Headache Disorders- 3rd Edition
  17. 17. TWO FULFILLING ‘2’ ‘3’ 2. ONE OR MORE 17 3. At least TWO of the following Four characteristics: a. At least one aura symptom spreads gradually over ≥5 min, and/or two or more symptoms occur in succession b. Each individual aura symptom lasts 5-60 min c. At least one aura symptom is unilateral d. The aura is accompanied, or followed within 60 minutes, by headache 4. Not Better Accounted for by any other ICHD-3 Diagnosis *International Classification of Headache Disorders- 3rd Edition
  18. 18. BASED ON FREQUENCY OF HEADACHES • EPISODIC MIGRAINES: • CHRONIC MIGRAINES: 18*International Classification of Headache Disorders- 3rd Edition
  19. 19. PLAN OF Mx !
  20. 20. 20 TREATMENT OPTIONS ACUTE ATTACK 1 2 3 4 5
  21. 21. 21 ACUTE ATTACK: TREATMENT FACTS NICE, 2015 • Offer combination therapy with an oral TRIPTANS AND AN NSAID/ PARACETAMOL • For people who prefer to take only one drug, consider Monotherapy with oral: a. Triptan Zolmitriptan(2.5mg) Stat; repeat dose after 1hr if attack does not subside b. NSAIDs/Aspirin (900 mg)/Paracetamol • Consider an Anti-emetic (Metoclopramide, Chlorpromazine) EVEN IN the absence of nausea and vomiting
  22. 22. 22 ACUTE ATTACK: TREATMENT FACTS NICE, 2015 • Never give Ergots or Opioids • For people in whom oral preparations are ineffective or not tolerated, Offer: a. Non-oral preparation of Metoclopramide/ Prochlorperazine AND b. A non-oral NSAID or Triptan
  23. 23. ≥2 OR 1 INDICATION OF PROPHYLAXIS
  24. 24. 24 TREATMENT OPTIONS PROPHYLAXIS 1 2 3 4 5
  25. 25. 25 TREATMENT PROPHYLAXIS NICE, 2015 • Offer TOPIRAMATE (25-100mg-Twice Daily) OR Propranolol according to the person's comorbidities and risk of adverse events (Advise women and girls of childbearing potential that Topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception if needed) • Consider AMITRIPTYLINE (10-150mg-Daily) according to the person's comorbidities and risk of adverse events. • Do not Give Gabapentin for the prophylaxis
  26. 26. 26 TREATMENT PROPHYLAXIS NICE, 2015 • If BOTH Topiramate and Propranolol[12] are UNSUITABLE OR INEFFECTIVE, consider a course of up to 10 sessions of Acupuncture over 5–8 weeks according to the person's comorbidities and risk of adverse events • RIBOFLAVIN (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people • REVIEW at 6 months after the start of prophylactic treatment.
  27. 27. 27 CGRP: THE NEXT FRONTIER FOR ACUTE MIGRAINE Andrew D. Hershey, NEJM 2017 ANTIBODIES DIRECTLY ACTING ON CGRP • Eptinezumab • Fremanezumab • Galcanezumab ANTIBODIES TARGETTING CGRP RECEPTOR • Erenumab
  28. 28. 28 FREMANEZUMAB FOR THE PREVENTIVE TREATMENT OF CHRONIC MIGRAINE Stephen D. Silverstein, NEJM 2017
  29. 29. 29 SELECTED PREVENTIVE THERAPIES *Charles Andrew, Migraine: NEJM, 2017
  30. 30. 30 MENSTRUATION RELATED MIGRAINE *NICE, 2015
  31. 31. 31 MIGRAINE WITH COMBINED HORMONAL CONTRACEPTIVE USE *NICE, 2015
  32. 32. 32 MIGRAINE IN PREGNANCY ACUTE Rx: *NICE, 2015
  33. 33. 33 MIGRAINE IN PREGNANCY PROPHYLAXIS: *NICE, 2015
  34. 34. 34 FEATURES TTH MIGRAINE CLUSTER HEADACHE Pain Location Bilateral Unilateral/ Bilateral Unilateral around eye Pain Quality Tightening (Non-Pulsating) Pulsating (Throbbing in 12-17 year olds) Variable Intensity Mild-Moderate Moderate-Severe Severe-Excruciating Effect on Activities Not Aggravated by routine activity Aggravated or causes avoidance of routine activities Restlessness or Agitation Other Symptoms None Unusual sensitivity to light and/or sound or nausea and/or vomiting Aura Symptoms can occur with or without headache • Fully Reversible • Developing over at least 5mins • Lasts 5-60 mins On the SAME side as the headache: • Red and/or watery eye • Nasal congestion and/or runny nose • Swollen eyelid forehead and facial sweating • Constricted pupil and/or drooping eyelid Headache Duration 30 Mins- Continuous 4-72 hours (1-72hrs in <17yrs) 15-180 mins Treatment (NICE,2015) Acute Attack Aspirin or NSAIDs for Acute Phase Oral Triptans with NSAIDS/ Paracetamol+ Anti emetics Oxygen AND Nasal Triptans Prophylaxis 10 sessions of Accupuncture over 5-8 wks Topiramate or Propranolol; Amitryptyline; Riboflavin Verapamil*
  35. 35. TAKE HOME MESSAGE
  36. 36. TAKE HOME MESSAGE
  37. 37. TAKE HOME MESSAGE
  38. 38. THANK 38

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