Identifying, Diagnosing, and Managing Patients with Chronic Migraine in Primary Care Everett Schlam, MD Assistant Director Mountainside Hospital Family

Identifying, Diagnosing, and Managing Patients with

Chronic Migraine in Primary Care

Everett Schlam, MDAssistant Director

Mountainside Hospital FamilyMedicine Residency Program

Verona, NJ

Best Practices Pearls

Communication is the only diagnostic tool available for migraine and successful communication requires participation of the healthcare provider and patient

Open-ended questions that allow the patients to “tell their story” provides better alignment and understanding

Warning signs and comfort features can help separate primary and secondary headache disorders

Chronic migraine is a diagnosis defined by 15 or more days per month of headache for at least 3 months in an individual with migraine

Making a Diagnosis

Primary vs. secondary headacheWarning signs

Comfort signs

Migraine vs. non-migraineSymptoms

Duration of attacks

Changes over time

Disability

Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008.

Evaluating the Patient with the Complaint of Headache

Warning signsAge - <5 or > 50 yrs

New onset or recent change

Neurological symptoms or signs

Underlying diseases

Systemic symptomsFever, hypertension, weight loss

Comfort featuresEstablished pattern of HA 6 months

Menstrual association

Variable locations of HA

Complete resolution between attacks

Positive family history

HA, headache

Worrisome Headache “Red Flags”‘SNOOP4’ – When in doubt, investigate the atypical! Systemic

symptoms (fever, weight loss); or

Secondary risk factors – underlying disease (HIV,

systemic cancer)

Neurologic symptoms or abnormal signs (confusion, impaired

alertness, or consciousness)

Onset: Sudden, abrupt, or split-second (first, worst)

Older: New onset and progressive headache, especially

in middle age >50 (giant cell arteritis)

Pattern change: First headache or different, change in

type of headache

Postural aggravation

PapilledemaDodick D. Semin Neurol. 2010;30:74-81.Sadovsky D, et al. Am J Med. 2005:118(Suppl 1):11S-17S.

Secondary Headaches

Vascular

Infectious

Inflammatory/Neoplastic

PrimaryHeadaches

What to Listen For: Patterns

Minutes Hours/Days Weeks/Months Months/Years

Cady RK, et al. Headache. 2002;42:204-216.

Profiling HeadachePattern Recognition

Primary Headaches

Migraine

Tension-type

Cluster

Miscellaneous

headaches

unassociated with

structural lesions

Secondary Headaches

Post-traumatic

Vascular disorders

Stroke, hemorrhage

Nonvascular intracranial

disorder

Neoplasm, meningitis, low

or high CSF pressures

Substances/withdrawal

Systemic infection or metabolic

disorder

Cranial, extracerebral lesions

Intl Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004;24(Suppl 1):7.

CSF, cerebral spinal fluid

Migraine – The Most Common Headache Seen in Clinical Practice

Patients seen in primary care IHS diagnosis based on diary review

94%

3%3%

Migraine-typeEpisodic Tension-typeUnclassifiable

Tepper SJ, et al. Headache. 2004;44:856-864.

N = 377

IHS, International Headache Society

Pre-testARS Questions

Pre-test ARS Question

Diagnostic Criteria for Chronic Migraine includes

which of the following

1. Headache ≥10 days per month for greater

than 6 months

2. Headache ≥ 15 days per month for greater

than 6 months


than 3 months


than 3 months

5. Unsure


Collaborative Care in the Management of Migraine is characterized by all of the following except

1. Effective communication between the provider and patient

2. Patient responsibility including keeping a headache diary

3. Patient reporting all headaches to the provider to get advice on how to treat each attack

4. Development of a “migraine tool box”

5. Unsure

Migraine in Primary Care

A harbinger of a patient population at high risk of decades medical needChronic migraine (>15 HA days/mo) has annual prevalence of 3% (1.1%-5.1%) but a lifetime prevalence is much higher

14% transform to chronic annually

26% resolve; 40% transition; 34% persistMost remain with very frequent episodic or chronic migraine

Katsarava Z, et al. Neurology. 2004;62:788-790.Manack A, et al. Neurology. 2011;76:711-718 .

A Model of Migraine Progression

Severe Impairment


Normal Neurological Function

Mild Impairment

Moderate Impairment

Stage 4Chronic

Migraine

Stage 3Transforming

Migraine

Stage 1&2EpisodicMigraine

Migraine

Creating a Clinical Model for Successful Management of Chronic

Migraine Patients

IHS Criteria for Episodic Migraine (without Aura)

At least 5 attacksHeadache attacks lasting 4-72 hoursHeadache with at least 2 of the following:

Unilateral locationPulsating qualityModerate to severe painAggravation or avoidance of physical activity

During headache at least one of the following:Nausea and/or vomitingPhotophobia and phonophobia

Not attributed to another disorder

The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24(suppl 1):24-25.

Classification of Migraine

Episodic Migraine

<15 headache days per month X 3 months = EM

Without aura

With aura

Chronic Migraine

≥15 headache days per month X 3 months = CM

HA day = 4 or more hours of moderate-to-severe HA or response to

migraine-specific medications

EM, episodic migraineCM, chronic migraine

Intl Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004;24(Suppl 1):1-160.Olesen J, et al. Cephalalgia. 2006;26:742-746.

Chronic Migraine

Headache (tension-type, probable migraine, and/or migraine) on ≥15 days per month for ≥3 monthsOccurring in a patient who has had at least 5 lifetime IHS 1.1 migraine attacksOn ≥8 or more days per month headache has fulfilled

IHS criteria for migraineTreated and relieved by triptan/ergot before the expected development of symptoms fulfilling IHS migraine criteria

No MOH as defined by IHS 8.2Describes patient not headache attack

Olesen J, et al. Cephalalgia. 2006;26:742-746.

MOH, medication overuse headache

Criteria Accepted by FDA: Chronic Migraine

A. Headache ≥15 days per month for greater than 3 months

B. Headache duration, if untreated, of ≥4 hours

C. (Established History of Migraine)

Olesen J, et al. Cephalalgia. 2006;26:742-746.Dodick DW, et al. Headache. 2010;50:921-936.Botox product information: http://www.allergan.com/products/eye_care/botox.htm

The Migraine Process

Headache

Post -headache

Pre-headache Mild Moderate Severe

Time

© 2012 Primary Care Network

Aura

54321

Headache Days in Chronic Migraine

Pre-headache phase

Headache phase

Migraine Evolution Time (hours)

Premonitory Aura w/oHeadache

Mild Headache(tension-type)

MigrainousHeadache

MigraineHeadache Diagnosis if Process Terminates at Different Stages

54321


NeurochemicalDisruption

ElectricalDisinhibition

PhysiologicalPhases of Migraine

TrigeminalDisinhibition

NeurovascularActivation

CentralSensitization

Understanding the Journey from Episodic to Chronic Migraine

Relationship of Episodic to Chronic Migraine

Episodic migraine precedes chronic migraine

Chronic migraine can be considered a complication of episodic migraine

Chronic Migraine Risk Factors

Modifiable

Attack frequency

Obesity

Snoring/obstructive sleep apnea

Stressful life events

Medication overuse

Caffeine overuse

Not modifiable

Age

Female gender

Low education or socioeconomic status

Genetic factors

Head injury

Ashina S, et al. Curr Treat Options Neurol. 2008;10:36-43.

Stage 1: Infrequent Episodic Migraine

Impact During Attack

Frequency

Sev

erit

y

Infrequent Episodic Migraine

Headache

Complete Recovery between attacks

Incapacity

Normal

Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:25.

Stage 2: Frequent Episodic Migraine

Impact During Attack

Frequency

Sev

erit

y

Frequent Episodic Migraine

Headache

Time to Recover

Incapacity

Normal


Stage 2 Migraine

3 or less migraine attacks per month or 8 HA days

Full recovery between migraine episodes

MIDAS generally 10 or less


MIDAS, The Migraine Disability Assessment

Stage 3: Transforming Migraine

Functional Status

Frequency

Sev

erit

y

Transforming Migraine

MigrainePoor Recovery Time

Incapacity

Normal


Transforming Migraine

Attacks less distinct: 8-14 days of HA per month

Return to baseline function does not always occur between migraine attacks

Evidence of physiological and/or psychological dysfunction often present

MIDAS 11-20Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:26.

Stage 4: Chronic Migraine

Incapacity

Normal

Frequency

Sev

erit

y

Chronic Migraine

Headache

DiseaseImpact

Incomplete Recovery


Chronic Migraine

Greater than 15 days of HA/month for greater than 3 months (HA>4h)Little or no return to normal baseline function

Low-grade HA or feeling as if on the edge of next migraine

Comorbidity frequentMIDAS 21-270

Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81:428-432.Cady R, et al. Curr Pain Headache Rep. 2005;9:47-52.Blumenfeld AM, et al. Cephalalgia. 2011;31:301-315.

Chronic Migraine

CM is not just “more” episodic migraineGreater severity of headache and associated symptoms

Greater impact and healthcare cost

It can be reversed

Delayed diagnosis and management may result in end organ damage

Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81:428-432.Welch KMA, et al. Headache. 2001;41:629-637.

End Organ Damage Possibly Associated With Chronic Migraine

Welch KMA, et al. Headache. 2001;41:629-637; Kurth T, et al. BMJ. 2011;342:c7357; McWilliams L, et al. Pain. 2004; 111:77-83; O’Bryant SE, et al. Headache. 2006;46:1364-1376; Bigal ME, et al. Headache. 2006;46:1334-1343; Breslau N, et al. Neurology. 2003;60:1308-1312.

Comorbidities of CM and EM

Comorbidity Chronic migraine Episodic migrainePsychiatric disorders

• Depression• Anxiety

46.3%n=231

28.5%n=2347

Non-headache pain• Fibromyalgia• Chronic fatigue

syndrome

41.7%n=208

33.3%n=2739

Vascular disease events• Hypertension• Stroke

8.2n=41

3.3%n=275

Survey of 8726 migraine sufferersCM (N=499) EM (N=8227)

Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81:428-432.Bagley CL, et al. Headache. 2012;52:409-421.

Evolution of Chronic Migraine

Episodic MigraineEpisodic Migraine Chronic MigraineChronic Migraine

Medication overuse

Medication overuse

Mood and anxiety

disorders

Mood and anxiety

disorders

Sleep disorders and IBS

Sleep disorders and IBS

Normal

Mild Impairment

Moderate Impairment

Severe Impairment

Cady R, et al. Curr Pain Headache Rep. 2005;9:47-52.

Migraine “Plus”

As migraine chronifies it becomesMore debilitating

Associated with greater comorbidity

More difficult to manage

Possible for end-organ damage

It becomes Migraine “Plus”

Welch KMA, et al. Headache. 2001;41:629-637.Kurth T, et al. BMJ. 2011;342:c7357.Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA, eds. The Headaches. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;2006.

How is Staging Useful?

Acute and preventive care can be based on stage of migraine

Documentation of treatment benefit

Assessment of change over time

Increase awareness to comorbidities, consultations, and referrals

Cady RK, et al. Headache 2004;44:426-435.

Establishing the Diagnosis of Chronic Migraine

Early Diagnosis

The most important tool to prevent chronic migraine is effective control of episodic migraine

Early diagnosis

Meaningful education

Effective acute treatment

Regularly scheduled follow-up visits


Migraine Can and Often Will be a Medical Problem That Last Decades

Healthcare interventions

span decades

Scores of visits to PCP

Numerous diagnostic studies

Multiple medications

Comorbidities

It’s best to get it “right”

sooner rather than later

Diamond ML, et al. Practicing Physician's Approach to Headache. 6th ed. Phila;PA: WB Saunders;1999:243-255.

Patient-centered/HCP-monitored Management of Acute Migraine: Developing, Not Discovering, Patients

Collaborative care dynamic2 experts in the room

Why is collaborative care important?Migraine is a chronic disease

Treatment needs change and evolve over time

Patient will ultimately determine treatment decisions

Consequences: Stitch in time saves nine

Primary care specialists will be left managing poorly treated patients


Collaborative Care Model

Patient Expertise

Self-observation/HA diary

Treatment need

Awareness of what works

Awareness of lifestyle

Awareness of triggers

Clinician Expert

Knowledge of evidence

Knowledge of the disease

Effective communication

Tools for migraine tool box

Pharmacology


The 5 “Ps” for Effective Migraine Communication

Pattern

P P P P P

Phenotype Person Pharmacology Precipitants

Pattern over time

Phenotype of dominant headache(s)

Person between orat baseline headache

Pharmacology

WeatherLifestyle

Diet

1 2 3 4 5

Reproduced with permission © 2011 Primary Care Education

Patterns of Headache“Can you explain to me the pattern of your headaches?”

MigraineEpisodic

Transforming

Chronic

NonmigraineNew onset persistent daily headache

Short duration

P1 P1


Headache Phenotype:Critical Question to Ask

Tell me what you experience when your headache is at its worstOften need to evaluate more than one headache phenotypeMigraine can have many different phenotypes

2 2PP2 2

Headache Phenotypes “Tell me what your worst headaches feel like.”

Migraine

Probable Migraine(Migrainous)

Tension-type

Other

Wheeler SD. Neurologist. 2009;15:59-70.

P2 P2

PPatient“What do you feel like between episodes of severe headache?”

A look between headaches

Normal

Episodic physiological disruptions

Comorbid diseases

Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81:428-432.Cady R, et al. Curr Pain Headache Rep. 2005;9:47-52.

P3 P3

Pharmacology“How do you treat your headaches?”

Assessment for excessive or inappropriate medication usage

Silberstein SD, Lipton RB. Chronic daily headache, including transformed migraine, chronic tension-type headache, and medication overuse. In: Silberstein SD, et al, eds. Wolff’s Headache and Other Head Pain. 7th ed. New York: Oxford University Press; 2001:247-282.

I take hydrocodone… it’s the only thing that works,

but… I only take it when I need it

Well…I take my triptan…

…but only as a last resort!

P4 P4

Medication overuse (MO)

Consensus defined limits on specific drugs associated with medication overuse headache

10 days a month X 3 monthsOpioids

Butalbital

Caffeine combinations

Triptans/Ergotamines

15 days per month X 3 monthsNSAIDs

Other OTCs

Medication Overuse Headache

Clinic diagnosis based on escalating or worsening of headache pattern with increasing use of acute treatment medicationGenerally considered over 3 month period of time

Lifestyle Recommendations“Natural” measures of brain restoration

Schedule regulationSleep

Meals

Exercise

Hydration

School/work attendance

Keep a DiaryEliminate or restrict stimulantsAvoid “triggers”

I can’t sleep…I have no energy…

I just don’t understand why doctors can’t help me

"Are you aware of events or other things that put you at risk of having a migraine?"

P5 P5


Pre-testARS Question


Evidence-based efficacious acute migraine treatment strategies include all of the following except

1. Oral triptan taken early in the attack

2. DHE (Dihydroergotamine) non-oral delivery

3. Injectable sumatriptan

4. Opioids such as hydrocodone

5. Unsure

Management of Chronic Migraine

Building a Unique Migraine Tool Box

Migraine Tool Box

Preventive Strategies

Education

Lifestyle/behavior

Pharmacologic

Nonpharmacologic

Nonpharmacologic

BiofeedbackCognitive behavioral therapy

Useful at all stages of migraine!

Never too young to start

Nicholson RA, et al. Curr Treat Options Neurol. 2011;13:28-40.

Preventive Drugs for Frequent Episodic Migraine

Level ADivalproex sodium*

Oral 125 – 1000 mg

Sodium valproate*Oral 125 – 1000 mg

Topiramate*Oral 50 – 200 mg

MetoprololOral 100 – 200 mg

Propranolol*Oral 80 – 240 mg

Timolol*Oral 20 – 60 mg

Frovatriptan (MRM)Oral 2.5 mg

ButterburOral 75 mg bid

Level BAmitriptyline

Oral 30 – 150 mg

VenlafaxineOral 12.5 – 75 mg

AtenololOral 50 – 100 mg

NadololOral 40 – 320 mg

Naratriptan (MRM)Oral 1, 2.5 mg

Zolmitriptan (MRM)Oral 2.5, 5 mg

ODT 2.5, 5 mg

Nasal 5 mg

Silberstein SD, et al. Neurology. 2012;78;1337-1345.

* FDA approved

Risks of Preventive MedicationsAEDs

DivalproateWeight gain

Hair loss

Tremor

Pancreatitis (rare)

TopiramateParesthesias

Cognitive changes

Kidney stones

Decrease effectiveness of oral contraceptives

Beta BlockersLethargy/fatigue

Heart block

Asthma

Cold hands and feet

See Package Insert on specific drugs for completedescriptions of adverse events

Risks of Preventative MedicationsTricyclic Antidepressants

Weight gain

Cardiac arrhythmias

Anticholinergic symptoms

Sedation

Seizures

SNRI - Venlafaxine

Dry mouth

Nausea

Nervousness

Insomnia

Somnolence

Abnormal ejaculation

Withdrawal syndrome

See Package Insert on specific drugs for complete descriptions of adverse events

Looking to the Patient to Define Preventive Prophylactic Needs (Not really trial and error)

Obese topiramate

Depressed tricyclic or venlafaxine

Bipolar divalproex sodium

Performance anxiety propranolol

Hypertension propranolol

Menstrual migraine frovatriptan

Preventative Medications in Chronic Migraine

OnabotulinumtoxinA

Only FDA approved interventionPreempt studies: Large placebo controlled (saline injection) studies of subject with CM.Efficacy at 24 weeks minus 8.4 – 9.0 days per month vs. placebo of 6.7 days per monthVery low drop out rates (3.8%) and excellent tolerability with only neck pain (9%) and headache (5%) being reported greater than 5%Significant improvement in QOL

Dodick DW, et al. Headache 2010;50:921-936.Diener HC, et al. Cephalalgia. 30 804–814.

Adverse Reactions Reported by 2% of Patients Treated With BOTOX (More Frequent Than Placebo) in Two Chronic Migraine Double-Blind, Placebo-Controlled Clinical Trials

Adverse Reactions by Body Systems

BOTOX® 155 Units-195 Units

(n=687)Placebo (n=692)

Nervous system disorders• Headache• Migraine• Facial paresis

32 (5%)26 (4%)15 (2%)

22 (3%)18 (3%)0 (0%)

Eye disorders• Eyelid ptosis 25 (4%) 2 (<1%)

Musculoskeletal and connective tissue disorders• Neck pain• Musculoskeletal stiffness• Muscular weakness*• Myalgia• Musculoskeletal pain• Muscle spasms

60 (9%)25 (4%)24 (4%)21 (3%)18 (3%)13 (2%)

19 (3%)6 (1%)

2 (<1%)6 (1%)

10 (1%)6 (1%)

General disorders and administration site conditions• Injection site pain 23 (3%) 14 (2%)

Vascular disorders• Hypertension 11 (2%) 7 (1%)

*Dodick et al 2010 reported n=39 (5.5%);15 of the 39 incidences of muscular weakness were facial paresis. BOTOX® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., 2010. Dodick DW et al. Headache. 2010;50:921-936.

Severe worsening of migraine requiring hospitalization occurred in approximately 1% of patients treated with BOTOX ®

in Study 1 and Study 2, usually within the first week after treatment, compared to 0.3% of placebo-treated patients.

Topiramate in Chronic Migraine

Double-blind, placebo-controlled, randomized study of 306 patients with CMReduction of HA days

Topiramate 5.8 days

Placebo 4.7 days

Statistically significant improvement in QOL and symptom severity

Silberstein S, et al. Headache. 2009,49:1153-1162.

Acute Treatment in Chronic Migraine

(no acute treatment has been studied or approved in chronic migraine)

Factors That Influence Acute Therapy Outcomes

Choice of acute medication

Delivery method

Treatment times

Patient adherence

Different presentations of migraine

Medication limits

Bigal M, et al. Headache. 2009;49:1028-1041.

Triptans

Sumatriptan Oral – 25, 50, 100 mg

Nasal – 5, 20 mg

Auto-injector – 4 or 6 mg

Needle-free injector – 6 mg

Zolmitriptan Oral – 2.5, 5 mg

ODT – 2.5, 5 mg

Nasal – 5 mg

Naratriptan Oral – 1, 2.5 mg

Rizatriptan Oral – 5, 10 mg

ODT – 5, 10 mg

AlmotriptanOral – 6.25, 12.5 mg

FrovatriptanOral – 2.5 mg

EletriptanOral – 20, 40 mg

Sumatriptan/NaproxenOral – 85 mg/500 mg

ODT, orally disintegrating tablet

Physicians' Desk Reference, 2011. 65th ed. Montvale, NJ: PDR Network, LLC; 2010.

Oral Therapies

Non-triptan

NSAIDS

Diclofenac potassium solution*

Combinations

Acetaminophen/aspirin/caffeine

Analgesics

Antiemetics

Triptans

ErgotaminesMatchar DB, et al. Evidence-based guidelines for migraine headache. AAN. US Headache Consortium. 2000:1-58.

* FDA approved

Parenteral Therapies

TriptansSubcutaneousNasal

Ergotamines/DHE1

IM/SCIN

Phenothiazines2

RectalIM

KetorolacIV, IM, IN

DHE, dihydroergotamineIM, intramuscularIN, intranasalIV, intravenous

1 Physicians' Desk Reference, 2011. 65th ed. Montvale, NJ: PDR Network, LLC; 2010. 2 Kelly AM, et al. Headache. 2009;49:1324-1332.

Rescue Therapies

TriptansSubcutaneous

DHENSAIDs

IM/IV

Rectal

AntihistaminesSteroidsOther

Kelley NE, et al. Headache. 2012;52:114-128.Kelley NE, et al. Headache. 2012;52:292-306.Kelley NE, et al. Headache. 2012;52:467-482.

Dihydroergotamine

Used by headache specialist for chronic or intractable migraine for decadesCan be delivered IV, IM, SC, or oral inhalationAnti-emetics often used with IV and IM but not necessarily with oral inhalationWorks anytime during attackLow risk for MOH

Medication Overuse and Medication Overuse Headache

Risks of Acute Medications

TriptansMOH

Triptan sensations

Rare cardiac events

Rare serotonin syndrome?

DihydroergotamineNausea

Muscle pain

Vasoconstriction

Non-Steroidal MedicationsGI events including bleeding

Liver and renal toxicity

Rare CV events

See Package Insert on specific drugs for complete descriptions of adverse events

Therapeutic Hierarchyin Management of CM

Management of CM

Accurate diagnosisEmphasis of collaborative management Preventive therapyAcute therapyFrequent follow upQOL and reduction in overuse of medical resources

Points to Consider

Don’t repeat failuresThink of synergy

Triptan and NSAID

DHE and antiemetic

Pharmacology

Initiate preventives, including behavioral therapies, early

Blumenfeld A, et al. Headache. 2012;52:636-647.

Pre-testARS Question


Treatment options for chronic migraine include all of the following, except1. ß-blockers2. OnabotulinumtoxinA3. Long-acting Oxycodone4. Topiramate5. Unsure

Best Practices Pearls

Communication is the only diagnostic tool available for migraine and successful communication requires participation of the healthcare provider and patient

Open-ended questions that allow the patients to “tell their story” provides better alignment and understanding

Warning signs and comfort features can help separate primary and secondary headache disorders

Chronic migraine is a diagnosis defined by 15 or more days per month of headache for at least 3 months in an individual with migraine

Thank you for attending!

Post-testARS Questions

Post-test ARS Question

Diagnostic Criteria for Chronic Migraine includes

which of the following:

1. Headache ≥10 days per month for greater

than 6 months


than 6 months


than 3 months


than 3 months

5. Unsure


Collaborative Care in the Management of Migraine is characterized by all of the following except:

1. Effective communication between the provider and patient

2. Patient responsibility including keeping a headache diary

3. Patient reporting all headaches to the provider to get advice on how to treat each attack

4. Development of a “migraine tool box”

5. Unsure


Evidence-based efficacious acute migraine treatment strategies include all of the following except:

1. Oral triptan taken early in the attack

2. DHE (Dihydroergotamine) non-oral delivery

3. Injectable sumatriptan

4. Opioids such as hydrocodone

5. Unsure


Treatment options for chronic migraine include all of the following, except:

1. ß-blockers

2. OnabotulinumtoxinA

3. Long-acting Oxycodone

4. Topiramate

5. Unsure

Q & AEverett Schlam, MD

Documents

Identifying, Diagnosing, and Managing Patients with Chronic Migraine in Primary Care Everett Schlam, MD Assistant Director Mountainside Hospital Family