PatientCentered Strategies for Effective Management of Migraine PatientCentered

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Patient-Centered Strategies for Effective Management of Migraine

Patient-Centered Strategies for Effective Management of Migraine

Patient-Centered Strategies Background u Best clinical practice combines the evidence with clinical experience u

Patient-Centered Strategies Background u Best clinical practice combines the evidence with clinical experience u PCS is a practical set of strategies specifically designed to fit the context of the current practice of medicine in the primary care environment u Developed by a panel of specialists and primary care practitioners interested in headache

Patient-Centered Strategies Method of Development u Utilizes principles put forward by the NHF Standards

Patient-Centered Strategies Method of Development u Utilizes principles put forward by the NHF Standards of Care n USHC Evidence-Based Guidelines n Canadian Guidelines for Headache Management n u Incorporates experience consensus and clinical

Patient-Centered Strategies Table of Contents u Clinical Recognition u Acute Treatment Strategies for Migraine

Patient-Centered Strategies Table of Contents u Clinical Recognition u Acute Treatment Strategies for Migraine u Phase Specific Acute Therapy u Preventative Treatment for Migraine u Non-Pharmacological Treatment u Special Considerations u System Management u Resources

Clinical Recognition of Migraine

Clinical Recognition of Migraine

Migraine Diagnosis u International Criteria n n n Headache Society (IHS) Diagnostic Established in

Migraine Diagnosis u International Criteria n n n Headache Society (IHS) Diagnostic Established in 1988 Consensus criteria Symptom and attack based Widely utilized in worldwide clinical trials Minimal utilization in clinical practice u Require diagnosis for each clinical presentation of headache

Migraine Variability u Migraineurs experience variability in clinical presentations of headache Migraine with aura

Migraine Variability u Migraineurs experience variability in clinical presentations of headache Migraine with aura n Migraine without aura n Migrainous n Menstrual Migraine n Tension-type Headache n “Sinus” headache n

Migraine Transformation Episodic Migraine Tension-Type Headache Mixed Headache Time Chronic Daily Headache

Migraine Transformation Episodic Migraine Tension-Type Headache Mixed Headache Time Chronic Daily Headache

Migraine Recognition u Most recurrent disabling headaches seen in clinical practice are migraine u

Migraine Recognition u Most recurrent disabling headaches seen in clinical practice are migraine u Clinicians need to prioritize headaches that are medically relevant u Recognition tools need to be efficient, facilitate communication, and relate to treatment need

The Headache Recognition Questionnaire

The Headache Recognition Questionnaire

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently do you experience headache of any type? u Has there been any change in your headache pattern over the last 6 months? u How often and how effectively do you use medications to treat headaches?

Impact-Based Migraine Recognition u How life? do headaches interfere with your u How frequently

Impact-Based Migraine Recognition u How life? do headaches interfere with your u How frequently do you experience headache of any type? u Has there been any change in your headache pattern over the last 6 months? u How often and how effectively do you use medications to treat headaches?

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently do you experience headache of any type? u Has there been any change in your headache pattern over the last 6 months? u How often and how effectively do you use medications to treat headaches?

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently do you experience headache of any type? u Has there been any change in your headache pattern over the last 6 months? u How often and how effectively do you use medications to treat headaches?

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently

Impact-Based Migraine Recognition u How do headaches interfere with your life? u How frequently do you experience headache of any type? u Has there been any change in your headache pattern over the last 6 months? u How often and how effectively do you use medications to treat headaches?

Comfort Features of Migraine u Onset of headache under the age of 40 u

Comfort Features of Migraine u Onset of headache under the age of 40 u Positive family history u Menstrual association u Variability of headache location u Fulfillment u Response of IHS criteria to a treatment plan over time

Worrisome Features u Onset after age 40 u New or different headache u Progressively

Worrisome Features u Onset after age 40 u New or different headache u Progressively worsening headache pattern u Abnormal physical or neurological findings u Fever u Hypertension u “Red Eye”

Impact-Based Recognition of Migraine -Conclusions u Impact-based recognition is a practical approach to the

Impact-Based Recognition of Migraine -Conclusions u Impact-based recognition is a practical approach to the evaluating the complain of headache. It is time efficient n It builds rapport n It is provider friendly n

Acute Treatment Strategies in Migraine

Acute Treatment Strategies in Migraine

The Attack of Migraine u Migraine is a neurological “process” u By the time

The Attack of Migraine u Migraine is a neurological “process” u By the time headache emerges the “process of migraine has been going on for hours or even days u Therapeutic efficacy is significantly influenced by when in the migraine ”process” treatment is initiated

Phases of Migraine Pre-Headache Prodrome Headache Aura Post-Headache Postdrome Migraine phase slide Mild ©

Phases of Migraine Pre-Headache Prodrome Headache Aura Post-Headache Postdrome Migraine phase slide Mild © 2000 Primary Care Network Moderate Severe Rescue

Phase-Specific Acute Therapy

Phase-Specific Acute Therapy

Phase-Specific Migraine Therapy u Timing of pharmacological intervention relative to the phase of migraine

Phase-Specific Migraine Therapy u Timing of pharmacological intervention relative to the phase of migraine influences treatment outcome. n n n Efficacy rates differ Recurrence rate differ Tolerability of therapy may differ u Understanding phase-specific differences allows patient to optimize treatment

Pre-Headache Therapy u Minimal research available in this phase of migraine u Behavioral therapy

Pre-Headache Therapy u Minimal research available in this phase of migraine u Behavioral therapy is encouraged u Simple pharmacological intervention reported anecdotally to be effective u Single small open label study on naratriptan suggests efficacy

Mild Headache Interventions u Successful intervention during this phase avoids much of the pain

Mild Headache Interventions u Successful intervention during this phase avoids much of the pain and disability traditionally associated with migraine. Triptan efficacy of over 80% pain free by four hours n Recurrence rates ~ 15% n u No first line therapies have been evaluated prospectively

Intervention During Moderate to Severe Migraine u Moderate to severe pain generally signals the

Intervention During Moderate to Severe Migraine u Moderate to severe pain generally signals the trigeminovasclar system has been activated Pain characteristics become vascular in nature n Trigeminally innervated vessels become inflamed n u This phase of migraine is where almost all clinical trials were conducted

Preventative Therapy for Migraine

Preventative Therapy for Migraine

Indications for Preventative Treatment for Migraine u Headache frequency greater than 2 X/week u

Indications for Preventative Treatment for Migraine u Headache frequency greater than 2 X/week u Failure of control with acute therapy u Consistent use of acute therapy greater than 2 days/week u Use of rescue medication more than 1 X/month u Contraindications to, failure or adverse events with acute therapy u Patient preference

General Principals of Prophylactic Care u Educate the patient about compliance, expectations, and the

General Principals of Prophylactic Care u Educate the patient about compliance, expectations, and the medication to be used u If successful therapy is maintained, consider a taper of prophylactic medication in 6 - 12 months u Consider co-morbid conditions in selecting prophylactic medications. u Headache diaries or calendars are an essential component of prophylactic programs

Medications for Prophylaxis u. Beta adrenergic blocking agents n Propranolol u. Tricyclic 20 -160

Medications for Prophylaxis u. Beta adrenergic blocking agents n Propranolol u. Tricyclic 20 -160 mg / day Antidepressants n Amitriptyline 10 - 100 mg / day u. Anticonvulsants n Divalproex sodium 125 -1000 mg / day

Behavioral Therapy

Behavioral Therapy

Behavioral Therapy u Behavioral therapy in the form of education and reassurance should begin

Behavioral Therapy u Behavioral therapy in the form of education and reassurance should begin before medication is prescribed u Cognitive restructuring, biofeedback, and relaxation techniques can be effective in reducing headache activity and medication usage u Behavioral therapy for children is highly effective and a gift for coping through adulthood

Special Considerations

Special Considerations

Chronic Headache Disorders u. Prevention is the goal u. Chronic headache disorders are often

Chronic Headache Disorders u. Prevention is the goal u. Chronic headache disorders are often difficult to treat and may require consultation u. Screen for medication overuse

Pregnancy u Discuss behavioral therapy before pregnancy whenever possible u Educate and partner with

Pregnancy u Discuss behavioral therapy before pregnancy whenever possible u Educate and partner with pregnant women regarding the risks and benefits of pharmacological therapy u Enroll pregnancy exposures into a pregnancy registry n n suma/naratriptan 1 -800 -336 -2176 zolmitriptan 1 -800 -236 -9933 rizatriptan 1 -800 -986 -8999 Depakote. TM 1 -888 -2334

Children and Adolescents u Harbinger of migraine include: n family history n motion sickness

Children and Adolescents u Harbinger of migraine include: n family history n motion sickness n episodic abdominal pain n episodic vertigo u Migraine attacks are generally shorter than in adults u Acute treatment: OTC’s, NSAIDs, & triptans (not FDA approved) u Prophylactic therapy: biofeedback recommended

Hormonally Associated Headache u Migraines associated or not have approximately the same response rate

Hormonally Associated Headache u Migraines associated or not have approximately the same response rate to acute therapy u Consider the same principles for acute therapy especially intervention before moderate to severe headache u Avoid abrupt withdrawal of estrogen u Withdraw birth control pills every 3 rd cycle u Utilize an estrogen patch on days 21 -28

Neuroimaging u MRI preferred for non acute headache u CT preferred for acute bleed

Neuroimaging u MRI preferred for non acute headache u CT preferred for acute bleed u Recommended if: study will lead to change in management n patient is more likely than general population to have a significant abnormality n Indicated on an individual basis n

Consultation/Referral u Neurological n e. g. Atypical or prolonged aura, basilar or hemiplegic migraine

Consultation/Referral u Neurological n e. g. Atypical or prolonged aura, basilar or hemiplegic migraine u Headache n referral for diagnostic needs Specialist for management needs e. g. Failure at 2 attempts with prophylactics or medication overuse u Psychologist therapy or psychiatrist for behavioral

Patient Education Resources u National n Headache Foundation 1 -888 -643 -5552 or www.

Patient Education Resources u National n Headache Foundation 1 -888 -643 -5552 or www. headaches. org u American n 1 -856 -423 -0258 or www. achenet. org u Primary n Council for Headache Education Care Network www. headachecare. com

Thank You!

Thank You!