Migraine and Treatment: Magnitude of Migraine Dr. Michael Sermersheim JWM Neurology

The following is a presentation outline by Dr. Michael Sermersheim from the Current Concepts in Neurology Seminar on April 20, 1999.

• 17.6% prevalence in women
• 5.7% prevalence in men
• 40% of women use prescription medication
• 30% of men use prescription medication

Societal Cost

• Average cost per patient
• $2187 in medical claims
• $371 in pharmacy claims
• Medical resource use
• 70% more medical claims
• 73% more physician visits
• 288% more ER visits
• 76% more hospital visits

IHS Classification Scheme

• Primary Headache
  • Migraine, with and without aura
  • Tension type
  • Cluster
  • Transformed migraine (chronic daily)
• Secondary Headache (symptom of another process)
  • Much less frequent in practice

Migraine Criteria

• Two of the following:
  • Unilateral pain
  • Pulsatile quality
  • Nausea
  • Photophobia and phonophobia
• Aura
  • Visual
  • Sensory
  • Hemiparesis
  • Aphasia

Tension-type Headache Criteria

• Two of the following:
  • Pressing or tightening quality
  • Mild to moderate intensity
  • Bilateral
  • Not aggravated by exertion/activity
• No evidence of:
  • Nausea/vomiting
  • Both photophobia and phonophobia

Organic Disease Clues

• Meningeal irritation (stiff neck)
• Sudden onset (thunderclap)
• Altered consciousness or cognition
• Papilledema or fundoscopic hemorrhages
• Pupils unequal or sluggish
• Visual loss
• Abnormal vital signs
• Tender, poorly pulsatile temporal arteries
• Weakness or sensory loss in face or limbs
• Clumsiness or impaired gait
• Reflex asymmetry
• Babinski signs

General Treatment Guidelines

• Nonpharmacological
• Abortive
• Symptomatic
• Prophylactic

Nonpharmacological Therapy

• Education
• Relaxation Training
• Sleep Hygiene
• Biofeedback
• Trigger Management

Triggers

• Hormones
• Sleep disruption
• Stress level change
• Weather change
• Sensory stimuli
• Drugs
• Foods

Symptomatic Treatment

• OTC analgesics
• Butalbital and codeine combinations
• NSAIDS
• Antiemetics
• Anxiolytics
• Narcotics

Symptomatic Medication Overuse

• Use of multiple pain pills
• Persistant calls for refills
• Escalating frequency of refills
• Creative excuses
• Multiple physicians
• Signs of impending REBOUND HEADACHE

Abortive Therapy
Old Drugs

• Ergotamine Cafergot , Wigraine , Ercaf
• Dihydroergotamine
• NSAIDS, especially naproxen
• Imitrex 25 and 50 mg tablets, nasal spray, and subcutaneous injection

Abortive Therapy
New Agents

• Amerge, 1 mg, 2.5 mg
  Slower onset, longer duration of action
• Zomig 2.5 and 5 mg
• Migranal
• nasal Dihydroergotamine, soon to be in a redesigned dispenser
• Maxalt 10 mg tablet and MLT
  10 mg tablet and MLT, 5 mg dose for concurrent use with Inderal

Prophylactic Therapy
General

• Choose first based on concurrent symptoms
• Monotherapy first
• Education regarding expectations and potential side effects
• Low starting dose, Slow increases to effect or toxicity

Prophylactic Therapy
Medications (including usual starting doses)

• Beta Blockers
  • Inderal start at 20 mg bid or LA60
  • Corgard 20 mg
    Not for asthmatics
    Can cause depression, sluggishness, dizziness
    
• Tricyclics
  • Elavil 10 to 25 mg qhs
  • Pamelor 10 mg start
    Can cause dry mouth, weight gain, orthostasis
    
• NSAIDs
  • Ansaid
  • Anaprox
    Can cause ulcers
• Ca Channel Blockers
  • Verapamil , 40 mg bid
    May cause constipation, edema, weight gain
• Anticonvulsants
  • Depakote 250 bid
    Birth defects, edema, weight gain, hair loss, liver abnormalities
  • Gabitril 4 mg bid
• SSRIs
  • Prozac, Zoloft, Paxil-
• Novel antidepressants
  • Welbutrin 100mg bid
  • Serzone 100mg qhs
• Antiseritonin Drugs
  • Sansert
    May cause pulmonary fibrosis Requires drug holiday every six months
  • Periactin 2mg bid
    May cause daytime sedation, weight gain
• MAO Inhibitors
  • Nardil
    - Parnate
  • Tyramine crisis, requires very strict diet and med restrictions