Migraine Diagnosis and Treatment
Transcript of Migraine Diagnosis and Treatment
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Lehigh Valley Health NetworkLVHN Scholarly Works
Neurology Update for the Non-Neurologist 2013 Neurology Update for the Non-Neurologist
Feb 20th, 6:30 PM - 7:00 PM
Migraine Diagnosis and TreatmentVitaliy Koss MDLehigh Valley Health Network, [email protected]
Follow this and additional works at: http://scholarlyworks.lvhn.org/neurology_update_non_neurologist
Part of the Diagnosis Commons, Nervous System Diseases Commons, Neurology Commons,and the Neurosciences Commons
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Koss, V. (2013). Migraine Diagnosis and Treatment. Neurology Update for the Non-Neurologist, .Retrieved from http://scholarlyworks.lvhn.org/neurology_update_non_neurologist/2013/february_20/9
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Migraine Diagnosis and
Treatment
Dr. Vitaliy Koss, MD
Neurologist
© Lehigh Valley Health Network
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Diagnostic Criteria
A. At least 5 attacks fulfilling criteria B through D B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (ie. walking or climbing stairs) D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and/or Phonophobia E. Not attributed to another disorder
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Pillars of Acute Migraine Treatment
• NSAIDs (IV Ketorolac, Ibuprofen,
Diclofenac)
• Neuroleptics (Reglan, Compazine,
Droperidol, Thorazine, Haldol)
• Migraine specific (DHE, Triptans)
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Additional Considerations
• Steroids (Methylprednisolone,
Dexamethasone)
• Anticonvulsants (Valproic Acid,
Levitiracetam)
• Magnesium Sulfate
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Opioids
▪ In almost all cases of primary headache,
Opioids must be avoided!
▪ Most primary headache disorders are
made worse by Opioid exposure
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New Treatments??
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Population-Based Study
▪ Acute Migraine Medications and Evolution
From Episodic to Chronic Migraine: A
Longitudinal Population-Based Study
▪ Marcelo E. Bigal, MD, PhD; Daniel
Serrano, MA; Dawn Buse, PhD; Ann
Scher, PhD; Walter F. Stewart, PhD;
Richard B. Lipton, MD
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Population-Based Study Cont’d
▪ Compounds containing barbiturates and
opiates were associated with a twofold
increased risk of TM in 2006 vs.
maintaining an episodic migraine status
(barbiturates OR = 2.06, 95% CI = 1.3-3.1;
opiates OR = 1.98, 95% CI = 1.4-2.8)
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Admission
▪ Avoid PRN medications during admission
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Abortive and Preventative
Treatments
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Abortive Medications
▪ Triptans
•Almotriptan (Axert)
•Eletriptan (Relpax)
•Frovatriptan (Frova)
•Naratriptan (Amerge)
•Rizatriptan (Maxalt)
•Sumatriptan (Imitrex)
•Zolmitriptan (Zomig)
•Sumatriptan/Naproxen (Treximet)
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Preventative Treatments
▪ Antihypertensives
▪ Antidepressants
▪ Antiepileptics
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Evidence-based guideline update:
Treatment for episodic migraine
prevention
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Level A: Established Efficacy
▪ Antiepileptic drugs: Divalproex sodium,
Topiramate
▪ Beta-blockers: Metoprolol, Propranolol,
Timolol
▪ Triptans (MRM): Frovatriptan
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Level B: Probably Effective
▪ Antidepressants: Amitriptyline, Venlafaxine
▪ Beta- blockers: Atenolol, Nadolol
▪ Triptans (MRM): Naratriptan, Zolmitriptan
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Level C: Possibly Effective
▪ ACE inhibitors: Lisinopril
▪ Angiotensin receptor blockers:
Candesartan
▪ Alpha- Agonists: Clonidine, Guanfacine
▪ Antiepileptic drugs: Carbamazepine
▪ Beta-blockers: Nebivolol, Pindolol
▪ Antihistamines: Cyproheptadine
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Level U: Inadequate or Conflicting
Data
▪ Carbonic anhydrase inhibitor: Acetazolamide
▪ Antithrombotics: Acenocoumarol, Coumadin, Picotamide
▪ Antidepressants: Fluvoxamine, Fluoxetine, Protriptyline
▪ Antiepileptic: Gabapentin
▪ Beta-blockers: Bisoprolol
▪ Ca blockers: Nicardipine, Nifedipine, Nimodipine, Verapamil
▪ Direct vascular smooth muscle relaxants: Cyclandelate
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Other Medications Possibly or
Probably Ineffective
▪ Lamotrigine (Level A negative)
▪ Clomipramine (level B negative)
▪ Acebutolol (level C negative)
▪ Clonazepam (level C negative)
▪ Nabumetone (level C negative)
▪ Oxcarbazepine (Level C negative)
▪ Telmisartan (level C negative)
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Evidence- based guideline
update:
NSAIDs and other complimentary
treatments for episodic migraine
prevention
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Level A: Established Efficacy
▪ Herbal: Butterbur
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Level B: Probably Effective
▪ NSAIDs: Fenoprofen, Ibuprofen,
Ketoprofen, Naproxen
▪ Herbal/ minerals: Magnesium, feverfew,
Riboflavin
▪ Histamines: Histamine SC
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Level C: Possibly Effective
▪ NSAIDs: Flurbiprofen, Mefenamic Acid
▪ Herbal/ minerals: CoQ10, Estrogen
▪ Antihistamines: Cyproheptadine
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Level U: Inadequate or Conflicting
Data
▪ NSAIDs: Aspirin, Indomethacin
▪ Herbal/ minerals: Omega-3
▪ Other: Hyperbaric Oxygen
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Other: Established Possibly or
Probably Ineffective
▪ Leukotriene receptor antagonist:
Montelukast (level B negative)
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Chronic Migraine
▪ Treatment
•Botox
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In Summary:
▪ Acute treatment of intractable headache
should include NSAIDs, Neuroleptics, and
Migraine specific medications.
▪ Opioids and Barbiturates make primary
headache disorders worse.
▪ Preventive medications should be
considered.