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Dr Mueller is an associate professor of family medicine and director of the University Headache Center at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford. Dr Mueller has been principal investigator in clinical trials for Merck & Co, Inc; GlaxoSmith Kline, Vernalis, Ortho-McNeil, and AstraZeneca. She is a national consultant for Merck & Co, Inc, and on speakers bureaus for Merck & Co, Inc, and GlaxoSmithKline.
Address correspondence to Loretta L. Mueller, DO, University Headache Center, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354. E-mail: SOMPhysicians{at}umdnj.edu
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated.
A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscularautonomic regulatory mechanisms to reduce discomfort from headache.
Migraine typically begins affecting individuals when they are in their teens or twenties, with peak prevalence occurring at approximately age 40 years.2 First onset of migraine after age 50 years should raise suspicion of secondary headache causes. One quarter of adults with migraine will experience four or more severe attacks per month, each with a mean duration of about 24 hours.2
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Diagnosis of Migraine |
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It is important to note that no isolated characteristic is necessary to make the diagnosis of migraine. The three most predictive characteristics for a migraine diagnosis are disability, nausea, and photophobia.5 An abbreviated set of diagnostic criteria for migraine is available in a validated screening instrument called ID Migraine.5
Less than a third of patients with migraine have focal neurologic signs, termed auras, just before or during some headaches.4 The diagnosis for these patients is migraine with aura (formerly called "classic migraine"), in contrast to migraine without aura (formerly called "common migraine").4 Auras are most commonly visual and less commonly sensory or motor in nature. Migraines associated with motor auras are called hemiplegic migraines and may occur on a hereditary basis within families and a sporadic basis among individuals.4 Triptans are contraindicated for patients with hemiplegic migraine because of a lack of adequate testing of these medications in this small population.
Migraine is often mistaken for sinus or tension headache. Migraine is confused with sinus headaches because the autonomic symptoms of migraine include nasal stuffiness or discharge, occurring in 87% of patients with migraine.6 In addition, the headache in these patients may be located above the sinuses.6 Migraine often is confused with tension headache because 75% of patients with migraine have neck pain during or immediately before or after a migraine.7
The diagnosis of migraine is based on criteria developed by the International Headache Society in 1988 and revised by the society in 2004—the International Classification of Headache Disorders II (ICHD II).4 Similar to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) used in psychiatric evaluations, the ICHD II requires that patients' headaches must have certain characteristics for each kind of diagnosis (Figures 1 and 2). Headaches are categorized by primary or secondary headaches, with four broad groups of primary headaches, including migraine, tension, cluster, and miscellaneous headaches, and 10 broad groups of secondary headaches (Figure 2).4
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Any abnormalities in a patient's medical history or physical examination suggesting secondary headache must be carefully evaluated before making a primary headache diagnosis. However, recommendations by the US Headache Consortium8 state that neuroimaging is generally not necessary in adult patients presenting with typical migraine, normal findings on neurologic examination, and no recent change in headache characteristics.9 These recommendations are based on data indicating that only 0.18% of this patient group show a clinically significant intracranial pathologic lesion on neuroimaging.9
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Triggers of Migraine |
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Approximately a quarter of patients with migraine recognize certain food as migraine triggers.12 Such triggers include monosodium glutamate (also known as hydrolyzed yeast extract, natural flavoring, hydrolyzed vegetable protein), often found in soups and Chinese food.12 Nitrites (a preservative found in lunch meats and hot dogs), tyramines (found in wines and such aged foods as cheeses), and phenylethylamine (found in chocolate, garlic, nuts, raw onions, and seeds) are other potential migraine triggers.12 Alcohol of any kind, artificial sweeteners, citrus fruits, pickled products, and vinegars are additional likely triggers.12 It should be noted that not all patients have these food triggers, so a diet totally eliminating these items is not warranted in all migraineurs.
Daily consumption of caffeine can lead to caffeine withdrawal headaches or rebound headaches interfering with or negating the effects of migraine preventive medications. Daily caffeine consumption is much greater than many people expect, with a typical cup (8 oz) of drip coffee containing about 135 mg of caffeine.13 Patients should be advised that caffeine is used in combination with many over-the-counter (OTC) pain medications because it enhances analgesia.14,15 Caffeine has a half-life of up to 9.5 hours; and the body transforms it into more than 25 metabolites.14
Overuse of caffeine is a risk factor for progression of occasional migraine to a chronic daily pattern. Additional considerations for such a progression include acute medication overuse, depression, obesity, sleep disorders, and stressful life events.16
Head trauma may cause or exacerbate headaches. Based on ICHD II criteria,4 new onset of headaches within 7 days of head trauma is diagnosed as posttraumatic headache, while continued headache after 3 months is termed chronic posttraumatic headache. Even mild head trauma without loss of consciousness or objective findings can cause new onset or exacerbation of headaches, necessitating long-term management.4
The proposed neurophysiologic basis for cervicogenic headache is nocioceptive input from trigeminal and cervical (C1-C3) afferent neurons converging on second-order neurons in the trigeminocervical nucleus.17 In addition, several recent anatomic discoveries identify direct neuronal connections between extracranial structures and the dura mater.18 Hack et al19 found a neuronal connection between the rectus capitis posterior minor muscle and dorsal spinal dura mater at the atlanto-occipital junction, which appears to restrict dural movement toward the spinal cord. Abnormalities in the cervical spine, such as muscular spasm, may transmit forces to the pain-sensitive dura mater.
Theoretically, alleviating accessible causes of pain through such modalities as osteopathic manipulative treatment (OMT) should increase a patient's headache thresholds. However, because of a lack of controlled studies on OMT and other modalities, biofeedback is the only nonpharmacologic therapy for migraine that is considered to be "evidence-based" by the US Headache Consortium.8
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Pharmacologic Management of Migraine |
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Patients are usually not adept at initiating accurate descriptions of disability experienced during migraine attacks, and physicians may not accurately assess migraine-related disability of their patients, many of whom may be healthy young individuals between headache attacks. In light of these problems, a clinically useful, validated instrument for disability assessment is the Migraine Disability Assessment (MIDAS) tool,21 which can be used to assess the number of work or school days lost during a 3-month period due to migraine. Studies show that healthcare providers are more likely to treat patients with effective, migraine-specific therapeutic modalities if they are aware of the patients' migraine disabilities.22,23 The Disability in Strategies of Care (DISC) trial22 confirmed that patients with moderate to severe migraine-caused disability are more likely to respond to high-end modes of therapy. In the DISC trial, 75% of patients had a failed response to high-dose aspirin (800-1000 mg/d) and metoclopramide (10 mg/d) therapy, requiring zolmitriptan (2.5 mg/d) as effective high-end therapy.
The US Headache Consortium recommends serotonin 5HT1B/D agonists (ie, triptans) as first-line therapy in a stratified-care approach for patients with migraine who experience moderate to severe disability (Figure 3).23 Seven triptans are available for migraine, all in tablet formulation.23 Two of these triptans (rizatriptan, zolmitriptan) are available as oral wafers that may be taken without water; two (sumatriptan, zolmitriptan) are available as nasal sprays; and one (sumatriptan) is available in a subcutaneous formulation.23 Headache relief with triptans is not pathognomonic to migraine; migraine, tension-type, and secondary headaches may all respond to these drugs.24 Conversely, not all migraines respond to triptans.24
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Labels on all triptans carry a cautionary statement noting that these drugs may cause the "serotonin syndrome" when used in combination with other serotonergic drugs such as serotonin reuptake inhibitors (SSRIs, including the antidepressant fluoxetine hydrochloride).26 Symptoms of serotonin syndrome may include autonomic hyperactivity such as tremor, diarrhea, hypertension and tachycardia. Neuromuscular abnormalities or mental status changes such as rigidity, hyperreflexia, hyperthermia, anxiety, or akathisia are additional symptoms. Although all triptans have documented efficacy for migraine with and without aura (including menstrual migraine), naratriptan and frovatriptan generally have slower onset of action as demonstrated by 2 hours' pain relief data.
Interpatient variability also exists for triptan efficacy, with different patients responding differently to particular triptans, and some patients requiring transition from one triptan to another to maintain efficacy.23 Assessment of efficacy of triptans and other abortive medications should be repeated at each patient visit, with several questions asked of patients and various target endpoints addressed (Figure 4).
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"Rescue" treatment options when first-line agents fail in an outpatient or emergency department setting include the following: dihydroergotamine, divalproex sodium,29 droperidol,30 intranasal lidocaine,31 ketorolac, magnesium sulfate,32 opioids, parenteral sumatriptan, prochlorperazine, propofol,33 and steroids. All of these medications except sumatriptan and dihydroergotamine are used off-label for migraine.
Abortive polytherapy is an option when single agents do not provide adequate relief for patients with migraine. An NSAID and/or a gastrokinetic drug (eg, metoclopramide) may be used in addition to a triptan.34
Researchers have found that cutaneous allodynia (a condition in which such nonnoxious stimuli as mechanical pressure and thermal changes cause skin pain) develops in nearly 80% of patients with migraine.35 Studies indicate that cutaneous allodynia is a marker for central sensitization and abortive medications are less likely to produce complete pain relief after this phenomenon develops.35
Providing abortive treatment during the early mild phase of migraine results in higher pain-free rates among patients.35 However, for patients with frequent headaches who consistently require treatment more than 2 days per week, prophylactic medication may be needed to reduce headache frequency. The potential for headache rebound exists with frequent use of most abortive medications, including butalbital-combination products, caffeine-containing products, and triptans.23
Prophylactic Medications
Generally, prophylactic medications
(Figure 3) are taken
daily to reduce headache frequency, decrease headache intensity, and/or allow
for improved abortive management of migraine. However, more subtle
improvements in quality of life may warrant continuation of prophylactic
therapy, even if a high level of headache reduction is not achieved. Serial
MIDAS tests can monitor improvements for such measures as lost work or school
days and loss of productivity related to home chores or social
functions.21 More
than one prophylactic medication may be used in combination when only a
partial response is achieved with one drug and when that drug's dosage cannot
be increased because of maximal dose or drug intolerance. Prophylactic modes
of therapy may be used intermittently for headaches occurring at predictable
times, such as during menses, exercise, or sexual
activity.23
Physicians should keep in mind that prophylactic medications are not a cure for headache, and abortive therapy will remain necessary for breakthrough attacks. In addition, patient education about medication use is important for compliance.
No prophylactic medication was originally developed to treat patients with migraine, and only four medications have US Food and Drug Administration (FDA) indication for migraine: divalproex sodium, propranolol, timolol maleate, and topiramate. Major classes of prophylactic medications for migraine include antiepileptics, ß-blockers, calcium-channel blockers, and tricyclic antidepressants (Figure 3).23 The exact physiologic mechanisms of these varied drugs are not known, but the mechanisms are believed to involve suppression of central hyperexcitability and/or enhancement of antinociceptive pathways.10
Comorbidities (eg, angina, depression, epilepsy) generally will influence prescribing considerations for prophylactic medications (Figure 3). The US Headache Consortium has published evidence-based guidelines for selecting a prophylactic medication for patients with migraine.23 There are conflicting reports regarding the efficacy of botulinum toxin A for migraine or chronic daily headache prophylaxis, with most studies not achieving primary endpoint efficacy.36
For patients with infrequent migraines and those who are reluctant or unable to use prescription prophylactic medications, alternative agents may be considered. Dietary supplements that may be effective for migraine prevention, based on results of placebo-controlled trials, include butterbur root (Petasites hybridus), coenzyme Q10, feverfew, magnesium, melatonin, and riboflavin (vitamin B2).37,38 Many combination products are available, such as MigreLief (feverfew, magnesium, riboflavin) and Migravent (butterbur root, feverfew, magnesium, riboflavin; Vita Sciences, Airmont, NY).
The following anecdotal case presentation describes a typical patient whose case illustrates the diagnosis and management of migraine.
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Case Presentation |
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Cheryl's headaches started at age 14 years, typically occurring only during her menses and persisting for 1 day. She now complains of a gradual increase in headache frequency and duration during the previous 2 years, with her typical "bad" headaches (ie, migraine without aura) occurring both during menses (lasting 4 days) and outside of menses (two attacks lasting 1 day each). Sumatriptan succinate tablets (100 mg/d) no longer provide her with adequate relief.
On further questioning, Cheryl admits to milder headaches occurring on a daily basis for at least the entire previous year. She says she manages those headaches daily with six OTC combination analgesics containing caffeine, accounting for 390 mg of caffeine (65 mg/tablet) per day. She had not initially noted this analgesic use on her medication list because she believed she could control these milder headaches on her own. She also admits to drinking two cups of coffee daily (20 oz each), accounting for approximately 675 mg of additional caffeine (135 mg/8 oz)13 per day.
Cheryl reports that all previous preventive treatments had failed, including divalproex sodium (1000 mg/d for 3 wk), topiramate (25 mg/d for 2 mo), and verapamil (240 mg/d for 1 mo). She notes that she could not tolerate propranolol hydrochloride (60 mg/d) because it made her too tired.
Management of Cheryl's Headaches
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Comment |
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Successful management of migraine requires intensive patient education and thorough physician knowledge about available treatment options and strategies. These treatment options and strategies include stratified care with a migraine-specific abortive medication for patients with moderate to severe disability; early intervention with an abortive medication before central sensitization occurs; and the use of a prophylactic medication to reduce headache frequency, severity, and risk for rebound.
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References |
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TopDiagnosis of MigraineTriggers of MigrainePharmacologic Management of...Case PresentationCommentReferences |
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2. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache.2001; 41:646 -657.[Medline]
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