Women and MigraineWomen and MigraineThe Hormonal LinkThe Hormonal Link

Womens Health in Primary CareWomens Health in Primary CareOrlando Florida March 2011Orlando Florida March 2011

Norma Jo Waxman MDNorma Jo Waxman MD

Associate Professor of Family and Community MedicineAssociate Professor of Family and Community MedicineFaculty in the Bixby Center for Global Reproductive HealthFaculty in the Bixby Center for Global Reproductive HealthUniversity of California San FranciscoUniversity of California San Francisconjwaxmanfcmucsfedunjwaxmanfcmucsfedu

Learning ObjectivesLearning ObjectivesAt the end of this talk participants will be able to At the end of this talk participants will be able to

Define migraine with and without aura menstrually Define migraine with and without aura menstrually related migraine and true menstrual migrainerelated migraine and true menstrual migraine

Utilize pharmacologic and behavioral options for acute Utilize pharmacologic and behavioral options for acute and prophylactic management of migraineand prophylactic management of migraine

Understand when hormonal medication is helpful and Understand when hormonal medication is helpful and safe for women with migrainesafe for women with migraine

Recognize and decrease incidence of chronic daily Recognize and decrease incidence of chronic daily headache in your practiceheadache in your practice

No pharmaceutical No pharmaceutical support or commercial support or commercial disclosuresdisclosures

Member of ARHP Member of ARHP expert advisory expert advisory committee on committee on Hormonal Migraines Hormonal Migraines and developed slide and developed slide set Many used in this set Many used in this presentationpresentation

Faculty DisclosureFaculty Disclosure

ldquoDespite the fact that it is so common and has so much impact on society migraine is one of the most misunderstood misdiagnosed and undertreated diseases on earthrdquo

Carolyn Bernstein MD The Migraine Brain

Why Care About MigraineWhy Care About Migraine Very Common neurologic Very Common neurologic

disorderdisorderbull UnderrecognizedUnderrecognizedbull UndertreatedUndertreated

Produces severe disability Produces severe disability 1212

Overuse of any drug may lead Overuse of any drug may lead

to chronic daily HAsto chronic daily HAs3434

IHS Headache Classification Subcommittee of the International Headache Society (IHS) The International Classification of Headache Disorders 2nd ed Cephalalgia 200424(Suppl1)139-41 1 Lipton RB et al Headache 200141646ndash657 2 Bigal ME et al Cephalalgia 2006 2643ndash49 3 Scher AI et al Pain 20031681ndash89 4 Bigal ME Lipton RB Headache 2006461334ndash1343 5 Kruit MC et al JAMA 2004291427ndash434 6 Kurth T et al JAMA 2006296283ndash291

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Learning ObjectivesLearning ObjectivesAt the end of this talk participants will be able to At the end of this talk participants will be able to

Define migraine with and without aura menstrually Define migraine with and without aura menstrually related migraine and true menstrual migrainerelated migraine and true menstrual migraine

Utilize pharmacologic and behavioral options for acute Utilize pharmacologic and behavioral options for acute and prophylactic management of migraineand prophylactic management of migraine

Understand when hormonal medication is helpful and Understand when hormonal medication is helpful and safe for women with migrainesafe for women with migraine

Recognize and decrease incidence of chronic daily Recognize and decrease incidence of chronic daily headache in your practiceheadache in your practice

No pharmaceutical No pharmaceutical support or commercial support or commercial disclosuresdisclosures

Member of ARHP Member of ARHP expert advisory expert advisory committee on committee on Hormonal Migraines Hormonal Migraines and developed slide and developed slide set Many used in this set Many used in this presentationpresentation

Faculty DisclosureFaculty Disclosure

ldquoDespite the fact that it is so common and has so much impact on society migraine is one of the most misunderstood misdiagnosed and undertreated diseases on earthrdquo

Carolyn Bernstein MD The Migraine Brain

Why Care About MigraineWhy Care About Migraine Very Common neurologic Very Common neurologic

disorderdisorderbull UnderrecognizedUnderrecognizedbull UndertreatedUndertreated

Produces severe disability Produces severe disability 1212

Overuse of any drug may lead Overuse of any drug may lead

to chronic daily HAsto chronic daily HAs3434

IHS Headache Classification Subcommittee of the International Headache Society (IHS) The International Classification of Headache Disorders 2nd ed Cephalalgia 200424(Suppl1)139-41 1 Lipton RB et al Headache 200141646ndash657 2 Bigal ME et al Cephalalgia 2006 2643ndash49 3 Scher AI et al Pain 20031681ndash89 4 Bigal ME Lipton RB Headache 2006461334ndash1343 5 Kruit MC et al JAMA 2004291427ndash434 6 Kurth T et al JAMA 2006296283ndash291

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

No pharmaceutical No pharmaceutical support or commercial support or commercial disclosuresdisclosures

Member of ARHP Member of ARHP expert advisory expert advisory committee on committee on Hormonal Migraines Hormonal Migraines and developed slide and developed slide set Many used in this set Many used in this presentationpresentation

Faculty DisclosureFaculty Disclosure

ldquoDespite the fact that it is so common and has so much impact on society migraine is one of the most misunderstood misdiagnosed and undertreated diseases on earthrdquo

Carolyn Bernstein MD The Migraine Brain

Why Care About MigraineWhy Care About Migraine Very Common neurologic Very Common neurologic

disorderdisorderbull UnderrecognizedUnderrecognizedbull UndertreatedUndertreated

Produces severe disability Produces severe disability 1212

Overuse of any drug may lead Overuse of any drug may lead

to chronic daily HAsto chronic daily HAs3434

IHS Headache Classification Subcommittee of the International Headache Society (IHS) The International Classification of Headache Disorders 2nd ed Cephalalgia 200424(Suppl1)139-41 1 Lipton RB et al Headache 200141646ndash657 2 Bigal ME et al Cephalalgia 2006 2643ndash49 3 Scher AI et al Pain 20031681ndash89 4 Bigal ME Lipton RB Headache 2006461334ndash1343 5 Kruit MC et al JAMA 2004291427ndash434 6 Kurth T et al JAMA 2006296283ndash291

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

ldquoDespite the fact that it is so common and has so much impact on society migraine is one of the most misunderstood misdiagnosed and undertreated diseases on earthrdquo

Carolyn Bernstein MD The Migraine Brain

Why Care About MigraineWhy Care About Migraine Very Common neurologic Very Common neurologic

disorderdisorderbull UnderrecognizedUnderrecognizedbull UndertreatedUndertreated

Produces severe disability Produces severe disability 1212

Overuse of any drug may lead Overuse of any drug may lead

to chronic daily HAsto chronic daily HAs3434

IHS Headache Classification Subcommittee of the International Headache Society (IHS) The International Classification of Headache Disorders 2nd ed Cephalalgia 200424(Suppl1)139-41 1 Lipton RB et al Headache 200141646ndash657 2 Bigal ME et al Cephalalgia 2006 2643ndash49 3 Scher AI et al Pain 20031681ndash89 4 Bigal ME Lipton RB Headache 2006461334ndash1343 5 Kruit MC et al JAMA 2004291427ndash434 6 Kurth T et al JAMA 2006296283ndash291

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Why Care About MigraineWhy Care About Migraine Very Common neurologic Very Common neurologic

disorderdisorderbull UnderrecognizedUnderrecognizedbull UndertreatedUndertreated

Produces severe disability Produces severe disability 1212

Overuse of any drug may lead Overuse of any drug may lead

to chronic daily HAsto chronic daily HAs3434

IHS Headache Classification Subcommittee of the International Headache Society (IHS) The International Classification of Headache Disorders 2nd ed Cephalalgia 200424(Suppl1)139-41 1 Lipton RB et al Headache 200141646ndash657 2 Bigal ME et al Cephalalgia 2006 2643ndash49 3 Scher AI et al Pain 20031681ndash89 4 Bigal ME Lipton RB Headache 2006461334ndash1343 5 Kruit MC et al JAMA 2004291427ndash434 6 Kurth T et al JAMA 2006296283ndash291

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Migraine in USAMigraine in USA

30 million migraine sufferers30 million migraine sufferers 1 in 10 persons a migraineur1 in 10 persons a migraineur 1 of 4 households include a migraineur1 of 4 households include a migraineur 99thth leading disability more common than diabetes leading disability more common than diabetes

or asthmaor asthmabull 30 of migraineurs have 3+ attacksmo30 of migraineurs have 3+ attacksmobull 75 have reduced ability to function75 have reduced ability to functionbull 50 are severely impaired50 are severely impaired

Lipton RB et al Headache 200141646ndash657

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Migraine Co-morbiditiesMigraine Co-morbiditiesbull PMSPMSbull DepressionDepressionbull Anxiety disorders (generalized panic Anxiety disorders (generalized panic

bipolar OCD)bipolar OCD)bull AbusePTSDAbusePTSDbull StrokeStrokebull Irritable bowel syndromeIrritable bowel syndromebull EpilepsyEpilepsybull FibromyalgiaFibromyalgia

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Epidemiology of Migraine in Epidemiology of Migraine in WomenWomen

Women are affected 3x more than menWomen are affected 3x more than men 20 million women in USA 20 million women in USA 40 of women in their lifetime40 of women in their lifetime

bull Before puberty equally prevalent in both sexes Before puberty equally prevalent in both sexes bull After puberty 3x more women than menAfter puberty 3x more women than menbull Peaks in midlifePeaks in midlifebull darrdarr after menopauseafter menopause

Lipton RB Headache 2001 Lipton RB Neurology 2007 Stewart Cephalalgia 2008

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine Without AuraMigraine Without Aura

At least 5 attacks with At least 5 attacks with Headache lasts 4ndash72 hours wo treatment or Headache lasts 4ndash72 hours wo treatment or

without successful treatmentwithout successful treatmentAt least 2 of the following four symptomsAt least 2 of the following four symptoms

bull Unilateral pain (60)Unilateral pain (60)bull Throbbing (70)Throbbing (70)bull Aggravation by movement Aggravation by movement bull Moderate to severe painModerate to severe pain

ICHD = International Classification of Hreadache DisordersAdapted from Cephalalgia 20048(suppl 1)S24-26

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine Without AuraMigraine Without Aura (contrsquod) (contrsquod)

And at least 1 of the following 2 symptomsAnd at least 1 of the following 2 symptoms

bull Nausea andor vomitingNausea andor vomitingbull Photophobia andor phonophobiaPhotophobia andor phonophobia

Not attributed to organic diseaseNot attributed to organic disease

Adapted from IHS Cephalalgia 2004

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

ICHD Diagnostic Criteria for ICHD Diagnostic Criteria for Migraine with AuraMigraine with Aura

At least 2 attacks withAt least 1 fully reversible symptom wo motor

Visual (flickering lights zigzags spots or lines andor loss of vision) + andor

Sensory (ldquopins and needlesrdquo andor numbness) + andor Dysphasic speech

Adapted from IHS Cephalalgia 2004

morehellip

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

IHS Diagnostic Criteria for IHS Diagnostic Criteria for Migraine with AuraMigraine with Aura (contrsquod)(contrsquod)

bull Symptoms of aura develop gradually over Symptoms of aura develop gradually over gt5min or gt5min or different symptoms occur in different symptoms occur in succession over gt5 min succession over gt5 min

bull Each symptom last gt5 and lt60 min Each symptom last gt5 and lt60 min

bull Migraine begins with aura or within lt60 min Migraine begins with aura or within lt60 min

bull Symptoms are fully reversibleSymptoms are fully reversible

bull No organic diseaseNo organic disease

Adapted from IHS Cephalalgia 2004

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Prevalence of MigrainePrevalence of Migraineby Age and Sexby Age and Sex

FemalesMales

Age (years)

20 30 40 50 60 70 80 1000

5

10

15

20

25

30

Migraine Prevalence

()

Lipton RB et al Headache 2001

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Headaches and the Menstrual Headaches and the Menstrual CycleCycle

Adapted from Stewart WF et al Neurology 2000

12

10

8

6

4

2

0

Day of Menstrual Cycle

Pa

tie

nts

wit

h H

A (

)

Migraine without aura

Tension type

Migraine with aura

minus16 minus14 minus12 minus10 12 14 161086420minus8 minus6 minus4 minus2

HA = headache

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Menstrual Migraines SubtypesMenstrual Migraines Subtypes(ICHD-2)(ICHD-2)

Menstrually Related Migraine (MRM)Menstrually Related Migraine (MRM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 2 out of 3 menstrual cycles and menstruation in at least 2 out of 3 menstrual cycles and additionally at other times of the cycleadditionally at other times of the cycle

~46 of women with migraine~46 of women with migraine

Pure Menstrual Migraine (MM)Pure Menstrual Migraine (MM)Attacks fulfill criteria for Attacks fulfill criteria for 11 Migraine without aura11 Migraine without auraAttacks occur days 1 Attacks occur days 1 plusmn 2 (ie days -2 to +3) of plusmn 2 (ie days -2 to +3) of

menstruation in at least 23 cycles and at no other time of menstruation in at least 23 cycles and at no other time of the cyclethe cycle

~14 of women with migraine ~14 of women with migraine

IHS Cephalalgia 2004

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Distribution of Migraine Types in Distribution of Migraine Types in WomenWomen

bull 40 non-menstrual migraine

bull 60 menstrual migraine ndash MRM comprises the

majority of MM (46 of 60)

Female MigraineursMRM = menstrually related migraine MM = menstrual migraine

MRM 46

Non-menstrual Migraine

40

Pure MM 14

Mannix LK Calhoun AH Curr Treat Options Neurol 2004

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Menstrual MigrainesMenstrual Migraines

Compared with attacks at other times of Compared with attacks at other times of the cycle menstrual attacks arethe cycle menstrual attacks are

bull More disablingMore disablingbull Longer in durationLonger in durationbull Less responsive to acute treatmentLess responsive to acute treatmentbull More likely to relapseMore likely to relapse

MacGregor EA Hackshaw A Neurology 2004 Dowson AJ et al Headache 2005

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Non-HormonalNon-HormonalMigraine Triggers Migraine Triggers

bull HungerHungerbull Certain FoodsCertain Foodsbull DehydrationDehydrationbull SleepSleepbull Head and neck Head and neck

painspains

bull EmotionalEmotionalbull Environmental smoke Environmental smoke

bright lights change in bright lights change in weather weather

bull Concomitant diseaseConcomitant diseasebull SexSex

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Hormonal Migraine Triggers Hormonal Migraine Triggers

bull Estrogen withdrawal or change in level Estrogen withdrawal or change in level MenstruationMenstruationPlacebo days with combined hormonal Placebo days with combined hormonal

contraceptivescontraceptivesPregnancyPregnancyPeri-menopausePeri-menopauseHormone replacement therapyHormone replacement therapy

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 SarahNew Patient VisitNew Patient Visit

24-year-old non-smoker 24-year-old non-smoker Sexually activeSexually activeOn intake checks off On intake checks off

ldquoheadachesrdquo which she ldquoheadachesrdquo which she says are worse with her says are worse with her periodsperiods

Presents for Presents for contraceptioncontraception

Does Sarah have migraine

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Use ldquoPINrdquo for Diagnosis of Use ldquoPINrdquo for Diagnosis of MigraineMigraine

Impairment Do your headaches limit you

Nausea Do you feel nauseated

Photophobia Does light bother you

Based on Lipton RB et al Neurology 2003

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 Sarah

Accurate diagnosis of migraine aura is Accurate diagnosis of migraine aura is essential for the safe prescribing of essential for the safe prescribing of estrogen-containing contraceptionestrogen-containing contraception

Sarah has migraine Sarah has migraine without without aura She has no aura She has no other risk factors for strokeother risk factors for stroke

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 Sarah Is Sarah eligible for estrogen-Is Sarah eligible for estrogen-

containing contraceptioncontaining contraception

A) A) YesYes

B) B) NoNo

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 Sarah

bull Is Sarah eligible for estrogen-containing contraceptives Might she opt for a patch or ring

A) Yes Low-dose estrogen contraception can be used in women under age 35 who have migraine without aura and no other risk factors for stroke

B) No OCPs should never be used in women who have migraine

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

MEC Headaches and CHCMEC Headaches and CHC

InitiateInitiate ContinueContinueNon-migrainous (mild or severe)Non-migrainous (mild or severe) 11 2 2MigraineMigraine

(i) without focal neurologic symptoms(i) without focal neurologic symptomsAge lt 35Age lt 35 22 3 3

Age gt 35Age gt 35 33 4 4(ii) with focal neurologic symptoms(ii) with focal neurologic symptoms 44 4 4 (at any age)(at any age)

photophonophobia NV are not focal symptomsphotophonophobia NV are not focal symptoms

Focal symptoms = vision changes numbness parasthesiasFocal symptoms = vision changes numbness parasthesiashttpwwwwhointreproductive-healthpublicationsRHR_00_2_medical_eligibility_criteria_3rd

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Treatment of MigrainesTreatment of Migraines Education and behavior modificationEducation and behavior modification

Identify and avoid or modify triggersIdentify and avoid or modify triggers

Acute treatmentAcute treatment

Prophylactic treatment Prophylactic treatment bull Short-termShort-termbull Long-termLong-term

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Treatment of MigrainesTreatment of Migraines TriptansTriptans more effective than NSAIDs and more effective than NSAIDs and

combination analgesics- warn about SEscombination analgesics- warn about SEs

NSAIDS can act synergistically with TriptansNSAIDS can act synergistically with Triptans

Phenothiazines PO or PR great for nausea amp Phenothiazines PO or PR great for nausea amp painpain

Think non-oral meds with nausea amp vomiting Think non-oral meds with nausea amp vomiting

Sleep can abolishes headache Sleep can abolishes headache

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Options for Acute TherapyOptions for Acute Therapy AspirinAspirin IbuprofenIbuprofen Naproxen sodiumNaproxen sodium

Combination AnalgesicsCombination Analgesics Acetaminophen aspirin and caffeineAcetaminophen aspirin and caffeine

TriptansTriptans PhenothiazinesPhenothiazines

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Rescue or Emergency Rescue or Emergency Treatment of MigraineTreatment of Migraine

When acute tx failsWhen acute tx fails

When HA returns in lt24 hrs or continues When HA returns in lt24 hrs or continues for daysfor days

IVIM phenothiazines in addition to DHE or IVIM phenothiazines in addition to DHE or a triptan work better than narcotics- a triptan work better than narcotics-

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Prophylaxis of MigrainesProphylaxis of Migraines Consider prophylaxis if acute meds used Consider prophylaxis if acute meds used

gt 4xmo rescue meds gt 1xmo or gt 4xmo rescue meds gt 1xmo or headaches are functionally limitingheadaches are functionally limiting

Start prophylaxis at low dose and titrate Start prophylaxis at low dose and titrate up over 2-3 monthsup over 2-3 months

TCAs are effective independent of their TCAs are effective independent of their antidepressant effectantidepressant effect

Limited studies show biofeedback relaxation Limited studies show biofeedback relaxation training spinal manipulation and physical training spinal manipulation and physical therapy may be helpful therapy may be helpful

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Medications for ProphylaxisMedications for ProphylaxisConsider hx co-morbidities and hormonal stateConsider hx co-morbidities and hormonal state TCAs- Amitrip best studied but most side effectsTCAs- Amitrip best studied but most side effects SNRIs (more effective then SSRIs)SNRIs (more effective then SSRIs) Beta- blockers- Beta- blockers-

Propranolol most studied and successful- Nadolol and Propranolol most studied and successful- Nadolol and Timolol tooTimolol too

Valproate Topiramate Gabapentin and other ldquoanti-Valproate Topiramate Gabapentin and other ldquoanti-convulsantsrdquo and ldquomood stabilizersrdquoconvulsantsrdquo and ldquomood stabilizersrdquo

BotoxBotox Verapamil and CCB- less effectiveVerapamil and CCB- less effective Hormonal Tx Hormonal Tx

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

SupplementsMagnesiumVitamin B2- riboflavinFeverfewButterbur (Petadolex)Coenzyme Q10 Omega-3 Fatty Acids Isoflavones

chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best chelated magnesium at 400-600 mgd for 3-4 months works as prophylaxis (best in pt w aura or perimenstrual migraine and those not responding to triptans) in pt w aura or perimenstrual migraine and those not responding to triptans) Riboflavin 400mgd for 3 months decrease migraine frequencyRiboflavin 400mgd for 3 months decrease migraine frequency

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Preventive Options with Preventive Options with Non-pharmacologic ModalitiesNon-pharmacologic Modalities

Cognitivebehavioral ModalitiesCognitivebehavioral Modalities 1048707 1048707 MeditationMeditation Recognize and Avoid TriggersRecognize and Avoid Triggers Headache DiaryHeadache Diary

Physical ModalitiesPhysical Modalities Massage Massage Yoga Yoga AcupunctureAcupuncture 1048707 1048707 Osteopathic manipulationOsteopathic manipulation Peppermint oil ( Helpful for acute)Peppermint oil ( Helpful for acute)

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Evaluating MigraineEvaluating Migraine Lab testsLab tests

Hormone Hormone TestsTests

Cat ScanCat Scan

Headache Headache DiaryDiary

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Red FlagsRed Flags Headaches begin after age 50Headaches begin after age 50 Very sudden onset of HeadacheVery sudden onset of Headache First or worstFirst or worst Change in frequency or severityChange in frequency or severity ImmunosuppressionImmunosuppression Fever stiff neck rash traumaFever stiff neck rash trauma Focal neurologic symptoms or signsFocal neurologic symptoms or signs PapilledemaPapilledema

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 SarahRecommended ApproachRecommended Approach

Migraine diaryMigraine diary

Counseling about migraine triggers and Counseling about migraine triggers and non-pharmacologic treatment optionsnon-pharmacologic treatment options

Her choice of hormonal non-hormonal Her choice of hormonal non-hormonal contraceptioncontraception

Acute treatment with triptanAcute treatment with triptan

Schedule 2-3 mo fu to review diarySchedule 2-3 mo fu to review diary

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 SarahReturn VisitReturn Visit

Headache diary confirms menstrual related migraine 2ndash3 attacksmo without aura Severe attack during pill-free week

What do you do next

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Options for Pharmacologic Options for Pharmacologic Treatment for MRMTreatment for MRM

RescueEmergency treatmentsIMIV phenothiazines or DHE

Prophylactic perimenstrual treatmentsNSAIDsSupplemental estrogenTriptansExtended cycle combined hormonal

contraceptives

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Prophylactic Treatments for MM and Prophylactic Treatments for MM and MRM with Continuous hormonal therapyMRM with Continuous hormonal therapy

Continuous combined contraceptives Dedicated product Monophasic product throw away placebo Continuous cycling with ring

Estrogen back in hormone-free interval Mircette Yaz Supplemental estrogen

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Migraine OCPs and StrokeMigraine OCPs and Stroke 6 per 100000 6 per 100000 year ndash healthy year ndash healthy 12 per 100000 12 per 100000 year ndash migraine year ndash migraine 18 per 100000 18 per 100000 year ndash migraine with aura year ndash migraine with aura

12 per 100000 12 per 100000 year ndash healthy and COC year ndash healthy and COC 19 per 100000 19 per 100000 year ndash migraine and COC year ndash migraine and COC 30 per 100000 30 per 100000 year ndash migraine with aura and COC year ndash migraine with aura and COC

34 per 100000 34 per 100000 year ndash stroke in pregnancy year ndash stroke in pregnancy

Attributable risk 7-19 per 100000 women per yearAttributable risk 7-19 per 100000 women per year ~ ~ 4000 year4000 year

So What about estrogen containing contraception in women with MigraineSo What about estrogen containing contraception in women with Migrainebull IHS low-dose estrogen in women with simple visual auraIHS low-dose estrogen in women with simple visual aura

bull ACOG progestin only intrauterine or barrier contraceptionACOG progestin only intrauterine or barrier contraception

bull WHO absolute contraindication in all women with auraWHO absolute contraindication in all women with aura

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Prescribing Contraception in Prescribing Contraception in Women with MigrainesWomen with Migraines

Use a Progesterone Only method with auraUse a Progesterone Only method with aura

Lowest estrogen levels with ring Lowest estrogen levels with ring

Consider 20 or 25 mcg pillsConsider 20 or 25 mcg pills

Consider eliminating the placebo week Consider eliminating the placebo week

Follow-up in 1-3 months after initial RxFollow-up in 1-3 months after initial Rx

Stress need to discontinue method if Stress need to discontinue method if Migraines worsenMigraines worsen

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 1 SarahCase 1 SarahTreatment and OutcomeTreatment and Outcome

Change 21-day OCPs to continuous hormonal therapy

For symptomatic treatment of migraine continue therapy with nsaids and triptans

Lifestyle modificationsMore regular mealsMore sleep and exerciseStress-reduction techniques

Follow up in 1-3 months

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 2 PamCase 2 Pam

35-year-old woman6th week of pregnancyMenstrual migraine diagnosed 10 years agoMigraine more frequent and severe since

she became pregnant

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Migraine and MRM in PregnancyMigraine and MRM in Pregnancy60 ndash 70 of migraineurs improve 60 ndash 70 of migraineurs improve

during pregnancy during pregnancy

Non-pharmacologic treatment is Non-pharmacologic treatment is preferredpreferred

BiofeedbackBiofeedbackRelaxation therapyRelaxation therapyCognitive-behavioral therapyCognitive-behavioral therapyMagnesiumMagnesium

MacGregor EA MacGregor EA J Fam Plann Reprod Health Care J Fam Plann Reprod Health Care 20072007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AcetaminophenAcetaminophen YY YY YY YY

CodeineCodeine (Y)(Y) (Y)(Y) (Y)(Y) YY

AspirinAspirin (Y)(Y) (Y)(Y) AvoidAvoid AvoidAvoid

DiclofenacDiclofenacIbuprofenIbuprofenNaproxenNaproxen

(Y)(Y) (Y)(Y) AvoidAvoid YY

DihydroergotamineDihydroergotamineErgotamineErgotamine

CICI CICI CICI CICI

Migraine Drug Use During Pregnancy and Lactation (Analgesics and Ergots)

YY = no evidence of harm = no evidence of harm(Y) (Y) == data suggest unlikely to cause harmdata suggest unlikely to cause harm(Y) (Y) = limited data but probably safe= limited data but probably safeCICI = contraindicated = contraindicated IDID = insufficient data = insufficient data = for emergency treatment of migraine = for emergency treatment of migraine not responding to standard measuresnot responding to standard measures

MacGregor EA J Fam Reprod Health Care 2007

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

DrugDrug 1st Trimester1st Trimester 2nd Trimester2nd Trimester 3rd Trimester3rd Trimester LactationLactation

AlmotriptanAlmotriptanFrovatriptanFrovatriptan

IDID IDID IDID IDID

EletriptanEletriptan IDID IDID IDID YY

NaratriptanNaratriptanRizatriptanRizatriptan

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

SumatriptanSumatriptan (Y)(Y) (Y)(Y) (Y) (Y) YY

ZolmatriptanZolmatriptan IDID IDID IDID (Y)(Y)

Magnesium Magnesium sulphatesulphate

(Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

PrednisolonePrednisolone (Y)(Y) (Y)(Y) (Y)(Y) (Y)(Y)

Drug use during pregnancy and lactation (Triptans magnesium prednisolone)

MacGregor EA J Fam Reprod Health Care 2007

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 2 PamTreatment and Outcome ReassuranceReassurance

bull Migraine may improve by the 2Migraine may improve by the 2ndnd trimester trimester particularly in women w history of menstrual particularly in women w history of menstrual migraine migraine

bull No evidence migraine will affect pregnancy outcomeNo evidence migraine will affect pregnancy outcome

AcuteAcutebull Acetaminophen NSAIDS Acetaminophen NSAIDS

bull Triptans (1-2nd trimester- may be safe- need Triptans (1-2nd trimester- may be safe- need more studies)more studies)

ProphylacticProphylacticbull If possible delay treatment until 2If possible delay treatment until 2ndnd trimester trimester

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 2 Pam Case 2 Pam Treatment and OutcomeTreatment and Outcome (contrsquod) (contrsquod)

Propranolol Propranolol safe and effective and can be used safe and effective and can be used postpartum and during lactation (FDA C)postpartum and during lactation (FDA C)

bull Use lowest effective dose Use lowest effective dose bull Stop 2 to 3 days before deliveryStop 2 to 3 days before deliverybull Manage with neurologist or headacheManage with neurologist or headache

specialistspecialist

AmitriptylineAmitriptyline is another option is another option (FDA C)(FDA C)

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 3 HannahCase 3 Hannah52-year-old womanPresents with headache5-year history of menstrual

migraine and occasional attacks of migraine with aura

Hot flashes mood swingsAsks about hormone therapy

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Menstrual Migraine and Menstrual Migraine and Hormone Therapy (HT)Hormone Therapy (HT)

Lowest and Non oral routes are best

Evaluate risk factors for stroke and CAD

Migraine with aura is not a contraindication to HT in low risk women (no RCTs expert opinion)

If aura 1st appears after start of HT reduce estrogen and consider work up for TIA

Macgregor EA Migraine the menopause and hormone replacement therapy a clinical review J Fam Plann Reprod Health Care 200733(4)245-9 Macgregor EA Estrogen replacement and Migraine Maturitas Volume 63 Issue 1 20 May 2009 Pages 51-55

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Case 3 HannahCase 3 HannahTreatment and OutcomeTreatment and Outcome

Acute treatment with NSAIDS amp triptansAcute treatment with NSAIDS amp triptans

Low-dose non-oral estradiol AND continuous progestin (if Low-dose non-oral estradiol AND continuous progestin (if needed)needed)

Hannahrsquos migraine attacks increase when HT is initiated Hannahrsquos migraine attacks increase when HT is initiated but improve with continued usebut improve with continued use

Fluoxetine amp venlafaxime useful migraine prophylaxis and Fluoxetine amp venlafaxime useful migraine prophylaxis and treat hot flashestreat hot flashes

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Diagnostic CriteriaDiagnostic Criteria Headache 15 or Headache 15 or more daysmonth for at least 6 monthsmore daysmonth for at least 6 months

Preventable with accurate medication Preventable with accurate medication history history

Speaks to early use of prophylaxisSpeaks to early use of prophylaxis

Depression anxiety and drug abuse may Depression anxiety and drug abuse may complicate presentationcomplicate presentation1 Cephalalgia 20048 (suppl 1)S24ndash26 2 Bigal ME et al Cephalalgia 200727568

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH) AKA rebound headacheAKA rebound headache chronic tension- chronic tension-

type medication induced transformed type medication induced transformed migrainemigraine

CDH caused by CDH caused by overuse of acuteoveruse of acute meds meds

Unrecognized epidemicUnrecognized epidemic majority of majority of referrals to headache clinicsreferrals to headache clinics

Disabling and expensive Disabling and expensive

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Chronic Daily Headache (CDH)Chronic Daily Headache (CDH)

Taper off acute medications Taper off acute medications Overuse of NSAIDs tylenol narcotics Overuse of NSAIDs tylenol narcotics

typicaltypical May require hospitalization May require hospitalization 6 RCTs showed sig improvement w 6 RCTs showed sig improvement w

AmitriptylineAmitriptyline The longer one has CDH the harder it is The longer one has CDH the harder it is

to treatto treat Steroids may be helpful during taper Steroids may be helpful during taper

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Creating a Supportive Office Creating a Supportive Office EnvironmentEnvironment

Educate patients Educate patients and entire and entire healthcare teamhealthcare team

Make adjustments Make adjustments in your officein your office

bull LightLightbull OdorsmellsOdorsmellsbull NoiseNoisebull ChemicalChemical

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Summary Behavioral and Summary Behavioral and Lifestyle Modifications Lifestyle Modifications

Avoid dietary emotional and Avoid dietary emotional and environmental triggersenvironmental triggers

Eat regular healthful mealsEat regular healthful mealsGet the right amount of sleepGet the right amount of sleepGet regular exerciseGet regular exerciseLearn stress management techniquesLearn stress management techniques

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

Summary Pharmacologic TxSummary Pharmacologic TxAcute treatment (NSAIDs triptans) Rescue Tx- DHE phenothiazinesProphylactic treatmentPerimenstrual (NSAIDs estrogen triptan) if

Response to acute tx inadequateRegular predictable periods

Continuous (extended cycle contraception) ifPatient needs contraceptionPatient has irregular periodsOther strategies fail

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses

A range of behavioral and drug options exist for the management of severe migraine

Take-Home PointsTake-Home PointsMigraine is a neurological illness caused by abnormality in

brain chemistry

A substantial proportion of women with migraine experience increased incidence around onset of menses

Short-term prevention is the best approach for these women if they have regular menses