Migraine Management for Internists — 22Jan2020Prepared by Dr. A. Ford M.D.

Migraine headache criteria (ICHD-3):Diagnostic criteria:A. At least five attacks fulfilling criteria B-DB. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)

C. Headache has at least two of the following four characteristics:

1. unilateral location2. pulsating quality3. moderate or severe pain intensity

4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

D. During headache at least one of the following:

1. nausea and/or vomiting2. photophobia and phonophobia

E. Not better accounted for by another ICHD-3 diagnosis.

Red flag features:SNOOP

o Systemic symptoms

o Neurologic symptoms

o Onset (either new onset over the age of 40 or thunderclap onset)

o Other associated conditions (trauma, drug use, awakens from sleep, worse with valsalva, triggered by cough,

exertion, or sexual activity)

o Previous headache history: headache progression with change in attack frequency, severity, or clinical features.

Red flag features require prompt evaluation with imaging.

o MRI brain with and without contrast is the preferred modality.

Standard lab evaluation (per the Fords):

CBC, CMP, TSH, vitamin D (treat using daily D3 to goal level of 40-60), vitamin B12 (treat if < 400 to goal of >400), Ferritin

(treat if less than 25 in anyone and if < 50 if fatigue or RLS), and Magnesium RBC (treat if less than 5).

Acute/abortive headache treatment:

General recs:o Do not use any abortive agents more than 2 days per week. May cause medication over use headache.

o Use triptans for severe/refractory headaches.

o Do not use fioricet:

• Not FDA approved for migraine.

Can cause medication overuse headache with as little as 4-5 uses per month.

o Do not use opiates• More effective options available with less risk.

Tylenol tends to be ineffective

NSAlDs may be effective

Combination analgesics (Excedrin, Goody's Powder, BC Powder) can be very effective. Tend to be overused due to easy

availability.

Triptans:o Maxalt (5mg/10mg) is best tolerated

• Need to use low dose if patient also on Propranolol

Can take every 2 hours.

• Max 3 in a day with low dose, 2 with high dose.

• Max 2 days per week

o Zomig (2.5mg/5mg)

Relpax (20mg/40mg)

o Imitrex:• Use injections for patients with severe nausea from onset or headaches that are severe quickly.

Can use triptans with NSAlDs — typically naproxen

If patient has concurrent nausea treat with Reglan, Phenergan, or Zofran

Preventive headache treatment:If patient has headaches that require frequent use of triptans or other abortives (more than 5 times per month) or

headaches require the patient to miss work/important life events, would consider treatment with a prophylactic agent.

General recommendations:o Start at low doses and increase every 1-2 weeks

o Counsel patients to push through mild initial side effects

o Continue at a therapeutic dose for at least 6-12 weeks prior to considering a medication a failure.

o Have patient track headache frequency:• What day they had a headache• Did they take an abortive?

Did it work?

Firstline preventive agents to consider:

o Nortriptyline (Pamelor)

Start low dose 10mg in the evening and titrate up weekly to effective dose ranges from 10-150mg daily.• Common or serious side effects: drowsy, dry mouth, lightheaded, and erectile dysfunction. 10% of

patients get insomnia and can take in the morning. Can cause heart block, would check EKG in patientswith heart history or if high doses are needed for long times.

• Could also choose amitriptyline or an SNRI.o Topiramate (Topamax)

• Start 25mg at bedtime and titrate by 25mg weekly to dose of 50-100mg nightly, but can be increased

further if needed. Effective dose is usually 100-200 mg daily. If higher than 100mg, would split 2x a day.

May be better tolerated at 2x a day.• Side effects: paresthesias, weight loss, taste changes, cognitive complaints, kidney stones, and glaucoma.

High risk for neural tube defects — would avoid in patients that could become pregnant. Doses > 100mg

may decrease effectiveness of oral contraceptive pills.Propranolol (Inderal)

Short acting use twice a day, LA use daily• Start at 60mg LA and titrate up to effective dose, can be as high as 120-240 mg daily.

Side effects: fatigue, hypotension, lightheaded, depression, exercise intolerance, and erectile dysfunction.o Magnesium supplementation

Especially effective for menstrual migraine, migraine with aura, and migraine associated with low

magnesium.

Mag oxide 400mg (1-2 per day)• MagDelay (2-4 per day)

Common side effect: loose stools = max absorption. Decrease dose.Preventive agents should be continued for 2-3 months at effective doses before they are considered failure. Nortriptylinemay work in as quickly as a week when the right dose is reached. Topiramate may take 8-10 weeks to work at effectivedoses. Inderal typically takes 6-8 weeks to work at effective doses.Second-line treatments:

o CGRP antagonists3 available monoclonal abs to either CGRP or the receptor. 1 more nearing approval.Injected subQ monthly or every 3 months.Common side effects include injection site reactions and constipation (3%)

o Botox:Only FDA approved for chronic migraine (Headache on 15 days per month with at least 8 fulfillingcriteria for migraine)155-195 units of Botox injected in 31-39 sites in the face, head, neck, and shouldersEffect lasts 2-3 months, at which point injections are repeated (every 12 weeks).