Diagnosis and Treatment of Migraine

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Introduction

Migraine is the most common neurological condition in the world, affecting about 12-15% of people. This means that approximately 500,000 people suffer from migraine in Ireland.¹

It starts in childhood and adolescence and is most prevalent in young adults and middle-aged people.² Three times more women than men suffer mainly due to hormonal changes. It is hereditary in approximately 60% of cases.¹

Migraine exerts a significant burden on the sufferer in terms of pain, suffering and impaired quality of life. It is one of the top 20 causes of disability expressed as years of healthy life lost to disability, and severe migraine attacks are classified by the World Health Organisation as among the most disabling illnesses, comparable to dementia, quadriplegia and active psychosis.³

It is a heterogeneous condition, with headache attacks varying in frequency, duration, symptoms and associated disability, both between patients and between attacks in the individual patient.² Some people experience only one or two attacks per year while others suffer on a weekly basis.

Migraine generally features a one-sided, moderate to severe pulsating headache which is episodic and lasts from 4 hours to 3 days with total freedom from symptoms between attacks. The headache is normally worsened by movement or routine physical activity.¹

Migraine is often associated with nausea, vomiting, and extreme sensitivity to light and noise.

Many patients claim that at its height, migraine is the worst pain they have ever experienced.¹

Despite the severity of pain and the huge personal impact involved, about 50% of patients do not seek treatment, in the mistaken belief that headaches are untreatable or not recognised as serious medical conditions.²

Migraine is often misdiagnosed in primary care and many patients are provided with inappropriate and ineffective treatment.²

Chronic daily headache, which can be a consequence of poor migraine management, is a significant cause of morbidity.²

Migraine can be effectively managed through primary care in the majority of cases.¹

Headache Disorders

In primary care, the headache disorders which account for almost all headaches are:

• Migraine
• Tension-type headache
• Cluster headache
• Chronic daily headache

A tiny proportion of headache is due to a more serious underlying pathology, and should be eliminated during the patient’s first consultation.^1,2

Migraine has two major subtypes, migraine without aura and migraine with aura.

Migraine without aura is suffered by the majority of patients. It is characterised by headache with specific features and associated symptoms. Migraine with aura is characterised by the fully reversible neurological symptoms that usually precede or sometimes accompany the headache, and is experienced by about 20% of suffers. These symptoms can last about 5 to 60 minutes.^1,3,4

Migraine Triggers

Certain trigger factors can bring about a migraine attack. Patients should be encouraged to keep a migraine diary to help identify their personal trigger factors. This may assist patients in avoiding their triggers and reducing the frequency of attacks. While some patients may be very sensitive to specific triggers, others may be susceptible only when several triggers occur together.

Certain foods, drinks, situations or environmental conditions may precipitate a migraine, e.g. cheese, chocolate, products containing MSG, alcohol (especially red wine), caffeine products or caffeine withdrawal, irregular eating patterns, irregular sleeping patterns, stress, meteorological triggers (change of seasons, high atmospheric pressure, heat or cold), environmental triggers (smoke, strong smells, loud noise, bright or flickering lights).

In women, hormonal changes such as puberty, menstruation, pregnancy, oral contraceptives, hormone replacement therapy and menopause, may trigger an attack. Women are also more susceptible to other triggers at these times.^1,2,3

Diagnosis

The criteria below (see table 1), which incorporate key features of the International Headache Society (IHS) classification guidelines, can be used to confirm diagnosis of migraine (see IHS guidelines for further information).⁴

Table 1. Diagnosis of Migraine (with or without aura) in Adults^4,6

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Some patients also experience a premonitory phase, occurring hours or days before the headache, and a headache resolution phase. Premonitory and resolution symptoms include hyper/hypo-activity, depression, cravings for particular foods, repetitive yawning, fatigue and neck stiffness and/or pain.^1,4

Depending on their severity, migraine attacks should be divided into mild-to-moderate and moderate-to-severe in intensity.^2,5

Management in Primary Care¹

The aims of migraine management in primary care are:

• Successful treatment of acute attacks
• Prevention and limitation of future attacks
• Encourage patients to be committed to the management of their condition
• Identification and referral of the minority of patients who need specialist care

The Stratified Care Approach^1,5

The stratified care approach is the approach of choice when treating headache disorders. Recent best practice guidelines on the management of migraine (e.g. MIPCA guidelines) are based on the stratified care model:

• Each patient should have an individual treatment plan, based on factors such as headache frequency, duration and severity, non-headache symptoms, the impact it has on the patient’s life and the patient’s own history and preference.
• Migraine-specific treatments should be provided from the start if necessary. Rescue medication is recommended in case the initial therapy fails.

Two simple questionnaire-based tests that may assist when assessing the impact of migraine on a patient:

• Headache Impact Test (HIT)
• Migraine Disability Assessment Score (MIDAS)^1,2,5

Acute Treatment

The goal of acute treatment is to relieve or stop the progression of an attack. Acute treatment should be taken as early as possible in the headache phase of an attack to prevent its escalation. All patients should have access to acute medications to treat attacks of differing severities, and for use as rescue medications if the initial therapy fails.

Acute treatment for mild-to-moderate migraine

Products containing aspirin, paracetamol or ibuprofen will be effective in many cases. Products containing diclofenac (e.g. Cataflam, Kyflam) may also be useful. Several combination products are available, containing aspirin and/or paracetamol combined with codeine, caffeine, and/or an antiemetic (e.g. Excedrin, Migraleve, Paramax). Antiemetics containing domperidone (e.g. Domerid, Motilium), metoclopramide (e.g. Maxolon) or prochlorperazine (e.g Stemetil) may be effective in the treatment of nausea. Regular, long-term use of painkillers may lead to mediation-overuse headache.

Acute treatment for moderate-to-severe migraine

Triptans are migraine-specific, prescription-only drugs and are considered to be the first-line treatment of choice for patients with moderate-to-severe migraine (with or without aura). Triptans will resolve the pain within two hours in up to 80% of cases, but only if the drug is taken early after the onset of migraine headache when the pain is milder. If the headache recurs, a second dose of the triptan may be taken (see table 2).^1-5

 Table 2. Acute Treatments Available in Ireland for Moderate-to-Severe Migraine

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Prophylactic Treatment^2,5

The goal of preventative treatment is to reduce the frequency and severity of migraine attacks. Prophylactic medications should be provided for patients who:

• Have frequent high-impact migraine attacks (≥ 4 per month)
• Do not achieve satisfactory treatment with acute medications
• Have concomitant conditions that preclude the use of acute medications
• Overuse headache medications and/or have chronic daily headache

The need for continuing migraine prophylaxis should be reviewed 6 months after the start of prophylactic treatment.^1,6

Table 3. Prophylactic Treatments Available in Ireland for Migraine

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Botox for Migraine

Botox (Allergan) is now indicated as preventative treatment for chronic migraine (i.e. headaches on at least fifteen days per month of which at least eight days are with migraine) in patients unresponsive or intolerant of prophylactic migraine medications. Must only be administered under specialist supervision.

Follow-up^2,5

Long-term follow-up should be arranged for all migraine patients.

• A migraine diary should be used to record the pattern of attacks over time.
• Impact questionnaires (HIT, MIDAS) can gauge the impact of migraine over time and may also be useful in assessing the response to therapy.

Patients who do not respond to repeated courses of acute and prophylactic medications should be referred to a specialist for care.

References:

1. Migraine Association of Ireland. Last accessed online 17^th August 2015 at http://www.migraine.ie

2. Dowson AJ et al. New Guidelines for the Management of Migraine in Primary Care. Curr Med Res Opin. 2002;18(7)

3. Migraine Trust. Last accessed online 18^th August 2015 at http://www.migrainetrust.org

4. International Headache Society. Last accessed online 17^th August 2015 at http://www.ihs-headache.org

5. Migraine in Primary Care Advisors. Last accessed online 18^th August 2015 at http://www.mipca.org.uk

6. NICE Guidance. Headaches: Diagnosis and management of headaches in young people and adults. Last accessed online 18^th August at http://www.nice.org.uk/guidance/cg150/chapter/1-recommendations

Caroline McDermott