migraine and medication overused
TRANSCRIPT
NNC CMUThe Northern Neuroscience
Centre Chiang Mai University
Primary headache: You don’t want to missed
Migraine Medication overused issues
24 March 2016
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Outline• Issue 1 : Concept• Issue 2 : Diagnosis criteria• Issue 3 : Prevention• Issue 4 : Emergency and inpatient
management
Head
ache
Unilatateral
Secondary: side-lock Intracranial *
Primaryside- shift
Localized small area primary
Secondary Paracranial
Diffuse
Primary
Secondary Sysetemic, Meningeal,IICP
Practical approach
Reference: Prof.Kummant Punthumjinda
Plus
oth
er t
ools
1.Re
d fla
gs2.
Hea
dach
e sy
ndro
mes
3. H
isto
rica
l det
ails
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Concept :ClassificationICHD 3 beta
Primary: Pain modulating
system
1. Migraine 2.Tension type 3.Trigeminal Autonomic Cephalgia4. Others
Secondary:Pain sensitive
structureHeadache attribute to…1.Injury2.Vascular3.Non vascular4. Substance/withdraw 5. Infection6. Homeostasis7. Paracranial structure8.Psychiatric disorder
Cranial Neuralgia : Nerve fiber
Cortex hyperexitability• Cortical spreading
depression (-> aura)• Subcortical wave (no
aura)
Modulating factorsGene
Gender/hormoneDrug/metabolic
Environment
Brain stem Dorsolateral ponsHypothalamus (->premonitory)
Peripheral sensitizationTrigeminovascular5-HT,CGRPNeurogenic inflamation
AEDBetablockerErgot
TriptanNSAIDs
Central sensitazaio
n-> allodyniaChronic pain
Maassenvandenbrink A. Eur J Pharmacol. 2008;585(2-3):313-9
12-24 hrs 0.5-1
hrs
4-72 hrs 12-24 hrs
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Cortical spreading : Aura
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Visual aura : Scintillating (spark) scotoma (dark)
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Sensory aura: Cheiro-oral numbness
1.M
igra
ine
1.4 Complication of migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.5 Probable migraine
1.6 Episodic syndrome that may associatie with migraiine
1.3 Chronic migraine
• Status migranosus• Persistent aura without infarction• Migranous infarction• Migralepsy
• Migraine with typical aura• Migraine with brain stem aura• Hemiplegic migraine (sporadic,
FHM)• Retinal migraine
Medication overused
Episodic migraine• Migraine without
aura• Migraine with aura
Chronic migraineStatus migranosus
High frequency episodic migraine
Migranous infarction?
Probable migraine
5 attacks
4 hrs to 72 hrs without treatment
Severe
Throbbling
Unilateral
Disabling *
Intestinal symptoms: Nausea or Vomiting
Oto&Oph symptoms: Phonophobia & Photophobia
Migraine without aura
54 STUDIO
60%
90%70%
1
1
2/4
1/2
2 attacks
Type of aura - Typical : Visual , Sensory, speech - Hemiplegic - Brainstem - Retinal
Character of aura - spread gradually >5 min - unilateral - last 5-60 min - accompanie or ‘follow by’ headache within 60 min
Exclude Seizure, TIA
Migraine with aura
1
1/6
2/4
1/1
Note: No need ‘headache’< 5 min suspect seizure> 60 min suspect TIA
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Chronic migraine• Headache may be migraine-like
or tension-type like ( Transformed migraine)
• >= 15 days / month of headachewith 8 days/month = migraine-like (aura / without aura / response to migraine specific medication)
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Medication overused• Triptans, Ergots, Opioids > 10 days/mo
• Simple analgesic > 15 days/mo
• Regular used of above medication >3months
Medication overused headache
• Headache resolved or reverts to previous patternwithin 2 mo after cessation
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
MOH common presentation• Using combination of acute medication
• Morning headache – nocturnal withdraw
• Predominant neck pain
• Autonomic and vasomotor symptom
• Comorbidity depression and anxiety
• Sleep disturbance
• Reduced effectiveness of alltreatments
1. >= 4 times/ month or >= 8 days of headache
2. Overuse of acute medication
3. Troublesome side effect of acute medication
4. Types of Migraine- Hemiplegic , Brain stem- Frequent prolong uncomfortable aura- Migraine with complication ie. Migranous infarction
5. Patient’s preference
When to use migraine prevention
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Preventive medication (AAN’s Level A)
• Propranolol 40-120 mg twice daily• Metoprolol 25-100 mg twice daily• Valporate 400-600 mg twice daily• Topiramate 50-200 mg daily
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Approach MOHOverused
agentTapering Bridging order
TriptanErgot
Abrupt orGradual
Long acting NSAIDsStearoid taper
Naproxen 500 twice dailyPrednisolone60 mg day 1-2 taper over week
Opioid Gradual taper
Add triptan or long acting NSAIDs
NSAIDs Abrup or gradual
Add triptan
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Approach status migranousus• IV hydration
• Dopaminergic antagonist
• Metoclopramide 20 mg IV
• Chlorpromazine 12.5 -37.5mg IV
• Haloperidol 5 mgIV in 500 mg NSSover20-30 min
• Valorate 300 -500 mg IV
• Dexamethasone 10-24 mg IV
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Take home messageConcept : Primary headache : pain modulating abnormal Migraine = Hyperexitabitatory trigeminovascular
Prevention : Avoid acute medication overused is important
Diagnosis : Follow ICHD 3 beta criteria
Emergency : AED, Dopamine antagonist, Steroid Not opioid appropriate for status migranosus
NNC CMUThe Northern Neuroscience Centre Chiang Mai University
Reference• ตำ�ร�ประส�ทวทิย�คลินิก . สม�คมประส�ท
วทิย�แหง่ประเทศไทย 2557 • Continuum 2012;18(4)• Continuum 2015;21(4)