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

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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)