Migraine: Approach for prevention Ehab Ahmed HashishAssistant lecturer of NeurologyFaculty of medicine Suez canal university

Migraine EpidemiologyGo Back to Main Menu

Lipton RB, et al. Neurology. 2007; 68(5):343-349.National Headache Foundation. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine. Accessed December 1, 2009.Migraine Prevalence

One in 4 households has at least 1 with migraine

Migraine Prevalence:Age and GenderLipton RB, et al. Neurology. 2007;68(5):343-349.

Migraine prevalence peaks in the 25-55 age range

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Migraine Diagnosis and TreatmentGo Back to Main Menu

Migraine Is an Episodic Recurrent Headache Lasting 4-72 Hours with:International Headache Society Criteria for MigraineFeatures such as osmophobia and posterior head and neck pain can also be present in a headache that meets IHS criteria for migraine.Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24(suppl1):117-118,138.

Many Migraine Sufferers Remain UndiagnosedDiagnosed Migraine56%Undiagnosed Migraine44% Diamond S et al. Headache. 2007;47(3):355-363.

Patients with Recurrent Headache May Meet Criteria for Migraine87% of patients presenting to OPD with recurrent headache met IHS criteria for migraineMigraine (n=237)Other (n=3) 1%Probable Migraine (n=31)Episodic Tension-type Headache (n=1) 0.4%Tepper SJ et al. Headache. 2004;44(9):856-864. 11%87%

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Focusing on Migraine DiagnosisOpportunities for accurate diagnosis of migraine patients still exist:

80% of sinus headache patients met IHS criteria for migraine

85% of tension/stress headache patients met IHS criteria for migraine

Schreiber CP et al. Arch Intern Med. 2004;164(16):1769-1772.Kaniecki R et al. CMRO. 2006;22(8):1535-1544.

Adapted from Cady RK. Headache. 2008;48(9):1415-1416.Headache Classification Subcommittee of the International Headache Society. Cephalalgia. 2004;24(suppl 1):117-118. Cady RK. Diagnosis and treatment of migraine. Clinical Cornerstone. 1999;1(6):21-32.

Premonitory/ProdromeAuraMildModerate to Severe PostdromeTimeMigraine IntensityPhases of a Migraine AttackMigraine symptoms occurring hours/days prior to headacheMigraine when headache is mildMigraine when headache is moderate to severeMigraine symptoms occurring hours/days after headache resolutionFocal neurological symptoms preceding headache (

Medication Options Available for MigrainePreventative MedicationsMay prevent or reduce the number of migraine attacksTypically taken on a daily basisAntiepilepticsAntidepressantsBeta blockersCalcium channel blockers

Acute MedicationsMay work quickly to relieve migraine pain and other symptomsUsually taken during a migraine attackTriptansNSAIDsOpioidsAnalgesics (Rx and OTC)Ergotamine/DHEAntiemeticsNeurolepticsCorticosteroids

Tepper SJ and Spears RC. Neurol Clin. 2009;27(2):417-427.Silberstein SD. Neurol Clin. 2009;27(2):429-443.

Identifying Candidates for Preventive TherapyGuidelines for Initiating Preventive Therapy Frequency of headache 2 per month with disability 3 days per month Recurring migraines that, in the patients opinion, significantly interfere with routine daily activity. Use of acute (over-the-counter or prescription) medication more than 2 times a week Acute medications are contraindicated, not tolerated, or ineffective Even patients with

NHF Migraine Prevention Summit Consensus Statement

Migraine is a chronic disorder, rather than an episodic disorder. Healthcare professionals treating patients with migraine must be educated about recent advances in the understanding of migraine and current treatment options.

Data on file. Titusville, NJ: Ortho-McNeil Neurologics, Inc.; June 2006; September 2006; December 2006; February 2007.

Proper use of acute medications is essential to maximize their efficacy. Acute medications should be taken at the first sign of migraine (or during the aura, if present).

Acute medication is not always adequate to control migraine attacks. Preventive therapy should be considered in patients requiring acute medication more than 2 days per week and in those experiencing frequent disability during and between migraine attacks

Healthcare professionals need to determine patient disability and the total level of impairment migraine has on a patients life, both during and between attacks, to better assess when patients may be appropriate candidates for preventive therapy. In addition, it is important to recognize how migraine affects other aspects of the patients life, such as family and work .

Preventive therapies include both medications and behavioral modifications. Patients need realistic expectations about treatment outcome, specifically time to response. Preventive therapies may take 6 weeks or longer to reach clinical effect. In addition, patients should be counseled on what side effects to expect and should be titrated slowly to the target dose.

Patients are important partners in the management of migraine. Open communication about treatment options and healthcare professional-patient support is essential to ensure treatment plans are followed. Adherence to treatment regimens, including both lifestyle changes and medications, is necessary to achieveoptimal effect.

Sinus headache is the most common misdiagnosis Migraine Is Often OverlookedSinus pain caused by inflammation induced allergens or by infection occurs when exudate in inflamed, blocked sinuses exerts pressure that stimulates local trigeminal nerve fibersChronic sinusitis is not validated as a cause of headache unless it relapses into an acute stage

Cady et al. Headache Free. 1993;36-38.Migraine Is Often Overlooked (contd)Tension headache is another common misdiagnosisSymptoms includeDull steady ache Physical activity does not worsen painNausea, photo/phonophobia are not usually presentVomiting never presentPatients have likely tried OTCs and failed

Migraine Pain Can Be Felt in Peripheral Locations Such as the NeckIn Kanieckis study of 144 patients with migraineKaniecki et al. Poster presented at: 10th IHC; June 29-July 2, 2001; New York, NY.75%reported neck pain with their migraine75% reported neck pain with their migraine43% described neck pain as bilateral and 57% as unilateral

Cady et al. Headache Free. 1993;36-38.Migraine Is Often Overlooked (contd)Tension headache is another common misdiagnosisSymptoms includeDull steady ache Physical activity does not worsen painNausea, photo/phonophobia are not usually presentVomiting never presentPatients have likely tried OTCs and failed

Thank You

*************Added cerebrovascular disease - OK*Added cerebrovascular disease - OK*Added cerebrovascular disease - OK*Added cerebrovascular disease - OK*Added cerebrovascular disease - OK**Consider adding the opposites of this list to the migraine slide to reenforce assoced sxs of migraine -NOT sure what we are wanting here??*In this study, 75% of patients reported neck pain during their migraines. The neck pain was unilateral among 57% of patients98% of whom reported pain ipsilateral to headacheand bilateral among 43%. Approximately two thirds of patients (69%) described their neck pain as tightness; 17% and 9% described it as stiffness and throbbing, respectively; and the remaining 5% described it in other (miscellaneous) terms. These data show that the presence of neck pain should not automatically trigger a diagnosis of tension-type headache. Migraine should be considered among the possible diagnoses for headaches accompanied by neck pain. *Consider adding the opposites of this list to the migraine slide to reenforce assoced sxs of migraine -NOT sure what we are wanting here??