MIGRAINE

Alfansuri Kadri

HEADACHE
 Definition: pain / unpleasant sensation of the head as long as chin until cervicooccipital

Epidemiology
 Prevalence life time of headache are
90% male 96% female

Epidemiology in Indonesia (hospital based)

 Prevalence life time TTH 78%  Episodic TTH 63%

male 56% ,female 71%  TTH chronic 3% male 2 % ,female 5% ETTH(Indonesia 31%) CTTH (Indonesia 24%)  Migraine = 10% (Indonesia)

Prevalence in Indonesia outpatient clinic

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Sefalgia Osteo arthritis Stroke LBP + OA Insomnia Epilepsy Vertigo Bell s palsy LBP+HNP Neuropathy

42 % 9.5% 7.7% 7.3% 4.0% 3.8% 3.6% 3.2% 2.5% 2.3%

1. Migraine wthout aura 2. Migraine with aura 3. ETTH 4. CTTH 5. Cluster Headache 6. Mixed Hx 7. Post trauma cap syndr 8. Secondary Headache 9. Chronic Daily Headache 10.CPH

6-10% 1.8% 31% 24% 0.5% 14% 14% 3% 9% 1%

HEADACHE CLASSIFICATION


PRIMARY HEADACHE
1. Migraine 2. Tension Type Headache 3. Cluster Headache & other trigeminal autonomic cephalalgias 4. Other primary headache

SECONDARY HEADACHE
Other headache, cranial neuralgia, central or primary facial pain.
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MIGRAINE
 Definition :

Migraine is a condition of paroxysmal or occasionally constant headaches that are the product of primary brain dysfunction resulting in a neurovascular reaction in genetically predisposed individuals.

International Headache Classification (IHS) 2004 Migraine

1.1 Migraine without aura 1.2 Migraine with aura 1.3 Childhood periodic syndromes that are commonly precursors of migraine 1.4 Retinal migraine 1.5 Complications of migraine 1.6 Probable migraine

1.2 Migraine with aura

x 1.2.1 Typical aura with migraine headache x 1.2.2 Typical aura with non-migraine headache x 1.2.3 Typical aura without headache x 1.2.4 Familial hemiplegic migraine(FHM) x 1.2.5 Sporadic hemiplegic migraine x 1.2.6 Basilar type migraine

1.3 Childhood periodic syndromes that are commonly precursors of migraine

1.3.1 Cyclical vomiting
x 2.5% schoolchildren x Recurrent unexplained nausea & vomiting 4x /hours 5 days x No sign of gastrointestinal disease

1.3.2 Abdominal migraine

x 12% of schoolchildren x Abdominal pain, anorexia, nausea, vomiting

1.3.3 Benign paroxysmal vertigo of childhood

x x x x x At least 5 attacks severe vertigo Resolve within few minutes-hour no neurological deficit Normal vestibular function EEG normal
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1.4. Retinal migraine

 Rare  At least 2 attacks scintillating, scotoma, blindness  Unilateral (only one eye)  Follows with migraine with aura  No attributed to another disorders

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1.5 Complications of migraine

1.5.1 Chronic migraine
x x x x x Migraine without aura > 15 days > 3 months No attributed to another disorders without Medication over used

1.5.2 Status migrainosus

x Severe headache migraine > 72 jam x No attributed to another disorders

1.5.3 Persistent aura without infarction 1.5.4 Migrainous infarction 1.5.5 Migraine-triggered seizures
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EPIDEMIOLOGY
Worldwide > 10% of people. In the United States 6% of men and 18% of women get a migraine in a given year lifetime risk of about 18% and 43% respectively. In Europe 12 28% of people at some point in their lives migraine Based on the results of a number of studies, one year prevalence of migraine ranges from 6 15% in adult men and from 14 35% in adult women.
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EPIDEMIOLOGY
Approximately 4 5% of children aged < 12 suffer from migraine

Young adult age >>

After menopause, attacks in women tend to decline dramatically > 70s equal numbers of male and female sufferers prevalence returning to around 5%.  Genetic factor

70 %
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PREVALENCE MIGRAINE

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HISTORY
 An early written description Ebers papyrus, written

around 1200 BC in ancient Egypt.  Aretaeus of Cappadocia "discoverer" of migraines second century description unilateral headache associated with vomiting, with headache-free intervals in between attacks.  Galenus of Pergamon used the term "hemicrania" (half-head), from which the word "migraine" was derived

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HISTORY
 Ibnu Sina described migraine in his textbook "El Qanoon fel teb" as "... small movements, drinking and eating, and sounds provoke the pain... the patient cannot tolerate the sound of speaking and light.  The term "Classic migraine" is no longer used, and has been replaced by the term "Migraine with aura"

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CLINICAL SYMPTOMS
 4 phases :
Prodrome Aura Headache postdrome

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PRODROME PHASE
 Occurs in 25

50 % of migraineurs  Gradual onset & evolution over up to 24 hours  Lightheadedness, dulled perception, irritability, withdrawal, cravings for particular food, frequent yawning, elation, and speech difficulties.

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AURA PHASE
 15 25 % of migraine attacks associated with aura.  Visual symptoms  Somatosensory  Dysphasia  Gradual onset build up over 5 10 minutes subside within 5 60 minutes.

most commonly

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HEADACHE PHASE
 Site : unilateral, frontotemporal occipital  Quality : throbbing / pulsatile, moderate to severe  Aggravating factors : physical activity, bright light, loud noise  Duration : 4 72 hours  Associated factors : nausea (90 %), vomitting (60 %), scalp tenderness.

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POSTDROME PHASE
 Tired  Drained  Aching muscles  Euphoric

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PATOPHYSIOLOGY
 Neuronal hyperexcitability in inter-iktal and pre-headache phase.  Cortical spreading depression (CSD)  Peripheral and central activation of trigeminal nerve  Periaquaductal gray matter (PAG) lesion  Genetic

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DIAGNOSIS
A. At least 5 attacks B. Attacks lasting 4-72 hrs C. Has 2 following characteristics:
A. B. C. D. Unilateral Pulsating Moderate or severe pain Aggravation by physical activity

D. During attacks

1 of the following

A. Nausea and/or vomiting B. Phonophobia and photophobia

E. Not attributed to another disorder

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DIAGNOSIS
 The mnemonic POUNDing (Pulsating, duration of 4 72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine.  If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.

Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM (September 2006). "Does this patient with headache have a migraine or need neuroimaging?". JAMA 296 (10): 127483
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AURA
Migraine headache. Frank visual field loss can also occur associated with migraine. This example shows loss of the entire right visual field as described by a person who experiences migraines.

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AURA
Migraine headache. Example of a central scotoma as described by a person who experiences migraine headaches. Again note the visual loss in the center of vision.

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AURA
Migraine headache. Example of visual changes during migraine. Multiple spotty scotomata are described by a person who experiences migraine

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AURA
Migraine headache. Example of a visual migraine aura as described by a person who experiences migraines. This patient reported that these visual auras preceded her headache by 20-30 minutes

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The triggers or precipitants of the acute migraine attack.

1207 pts migraine of whom 75.9% reported triggers.

Stress hormones in women not eating weather sleep disturbance perfume or odour neck pain

(79.7%), (65.1%), (57.3%), (53.2%), (49.8%), (43.7%), (38.4%),

light(s) alcohol smoke sleeping late heat Food exercise sexual activity

(38.1%), (37.8%), (35.7%), (32.0%), (30.3%), (26.9%), (22.1%) (5.2%).

Kelman L. Cephalalgia 2007; 27:394 402.

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Food as Trigger factor of migraine

MAYOR  MSG  wine /vodka/bier  Cheese  Chocolate  Yogurt/yeast  citrus fruits  Buttermilk, milk MINOR  nuts  Fried foods  Popcorn  Chile peppers  Seafoods  Pork / livers  Salty food/sweet
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INVESTIGATION
Should only be necessary if suspected to be secondary to another disorder Alarm symptoms include :
Onset > 50 years Aura w/ out headache Aura symptoms that are very brief or very long Sudden increase in migraine frequency or change in migraine characteristics y High fever y Abnormal neurologic examination
y y y y
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INVESTIGATION
 The role of imaging in patients with suspected migraine exclude structural cause for the headache such as AVMs or tumors.  Contrast enhanced CT

satisfactory

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DIFFERENTIAL DIAGNOSIS
 Other primary headaches  Subarachnoid hemmorhage  Drug induced headache  Head injury  Acute obstruction of the CSF pathways  Glaucoma  Raised ICP  Structural intracranial lesion
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MIGRAINE TREATMENT
Pharmacological treatment y Acute abortive treatment
Spesific Non-spesific

y Preventive (profilaxis) treatment

Non-pharmacological treatment
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ABORTIVE TREATMENT : NON SPESIFIK

DRUG PARASETEMOL ASPIRIN IBUPROFEN NAPROXEN SODIUM DICLOFENAC POTASSIUM KETOROLAC BUTORPHANOL SPRAY DOSAGE 500 1000 mg / 6 8 hour 500 1000 mg / 4 6 hour 400 800 mg / 6 hour 275 550 mg/2-6 hour 50 100 mg / day single dose 60 mg / i.m / 15 30 mnt max : 120 mg / day, < 5 days 1 mg / hour max : 4 spray / day

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ABORTIVE TREATMENT : NON SPESIFIK

DRUG PROCHLORPERAZINE STEROID (DEXAMETHASONE, METIL PREDNISON) DOSAGE 25 mg oral or suppositoria DRUG OF CHOICE STATUS MIGRENOSUS

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ABORTIVE TREATMENT : SPESIFIK

SITUASI KLINIK Gagal dengan analgetik / NSAID PILIHAN OBAT PILIHAN PERTAMA MENURUT URUTAN Sumatriptan 50 mg p.o Rizatriptan 10 mg p.o Zolmitriptan 2,5 mg p.o Almotriptan 12,5 mg p.o Eletriptan 40 mg p.o EFEK LAMBAt TAPI TOLERABILITAS LBH BAIK : Naratriptan 2,5 mg Frovatriptan 2,5 mg NYERI KEPALA YG TIDAK TERLALU SERING Ergotamine 1 2 mg p.o Dihydroergotamine nasal spray 2 mg
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ABORTIVE TREATMENT SPESIFIC

 Triptans  Dihydroergotamine  Ergotamine

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ABORTIVE TREATMENT : SPESIFIK

SITUASI KLINIK Gejala awal mual muntah atau sulit menelan obat Nyeri kepala yang sering berulang PILIHAN OBAT Sumatriptan 20 mg nasal spray Zolmitriptan 5 mg nasal spray Ergotamine 1 2 mg (usually with caffeine) Naratriptan 2,5 mg p.o Almotriptan 12,5 mg p.o Eletriptan 80 mg p.o Dihydroergotamine 1 mg / i.m Zolmitriptan 5 mg nasal spray Sumatriptan 6 mg / s.c Dihydroergotamine 1 mg / i.m

Muntah awal yang terus menerus

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ABORTIVE TREATMENT : SPESIFIK

SITUASI KLINIK Menstrually related headache PILIHAN OBAT SHORT TERM PREVENTION Ergotamine p.o Oestrogen patches Short term NSAID ACUTE TREATMENT Triptans Dihydroergotamine nasal spray / i.m

Gejala timbul sangat cepat Zolmitriptan 5 mg nasal spray dan berkembang cepat Sumatriptan 6 mg / s.c Dihydroergotamine 1 mg / i.m Muntah awal yang terus menerus Zolmitriptan 5 mg nasal spray Sumatriptan 6 mg / s.c Dihydroergotamine 1 mg / i.m
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Indication for Prophylaxis Migraine

1. Migraine duration is greater than 48 hours 2. Acute medications are ineffective/failure, contraindicated,

have side effect of drug or likely to be overused medications 3. Attacks produce profound disability (occurs > 2 days per month) prolonged aura, or true migrainous infarction 4. Attacks occur > 2 more times per week, even with adequate acute care treatment with the risk of developing rebound headache 5. Patient preference for preventive therapy
US Headache Consortium Guidelines, Bigal, 2006, Loder, 2005
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PREVENTIVE / PROFILAXIS TREATMENT

KRITERIA : Jangka waktu migren berlangsung > 48 jam Pengobatan akut gagal atau tidak efektif, ada kontraindikasi, mempunyai efek samping, dan ada kecenderungan over used medication Serangan menyebabkan disabilitas parah (terjadi > 2 hari per bulan) Aura yg memanjang, atau menjadi infark migrenosus Serangan terjadi > 2 kali per minggu, meskipun telah diberikan pengobatan akut yg adekuat Permintaan pasien
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PREVENTIVE / PROFILAXIS TREATMENT

JENIS OBAT PROPANOLOL PIZOTIFEN METHYSERGIDE VERAPAMIL FLUNARIZINE AMITRIPTILIN DIVALPROATE GABAPENTINE TOPIRAMATE DOSIS 40 320 mg 2 x sehari 0,5 1,5 mg / hari 1- 6 mg / hari 160 320 mg / hari 5 10 mg / hari 25 150 mg malam hari 400 1500 mg 2 x sehari 900 2400 mg / hari 25 200 mg / hari REAKSI OBAT 2+ 2+ 4+ 1+ 2+ 2+ 2+ 2+ 2+
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MEKANISME OBAT MIGREN

JENIS OBAT MEKANISME KERJA ACETAMINOPHEN Inhibisi sintesa PG di CNS, inhibisi aktifitas nosisept ASPIRIN NSAID CAFFEINE ERGOTS OPIOIDS STEROID Inhibisi sintesa PG dan leukotriene Inhibisi sintesa COX, PG, lipoxygenase & leukotriene, PG reseptor antagonis Stimulasi reseptor adenosine Selective arterial constrictor yg kuat Stimulasi reseptor opioid endogen Anti inflamasi terhadap inflamasi neurogenik steril, mengurangi edema vasogenik.
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MEKANISME OBAT MIGREN

JENIS OBAT TRIPTANS MEKANISME KERJA Berikatan dengan reseptor 5HT1B, 5HT1D, 5 HT1F, menginhibisi neuronal dengan cara blokade aferen sensoris pada n. trigeminal, memblokade pelepasan vasoaktive peptide & juga proses inflamasi neurovaskuler di meningens. Juga efek vasokonstriksi pembuluh darah serebral & dural. 5HT2 antagonis Selective serotonin reuptake inhibitor Potent 5HT1, & 5HT2 antagonist Antagonis reseptor 5HT2

PIZOTIFEN SSRI ANTIDEPRESSAN CYPROHEPTADINE BETABLOCKER

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PROGNOSIS
The risk of stroke increased two- to threefold in

migraine sufferers. Young adult sufferers and women using hormonal contraception particular risk. Women who experience auras twice the risk of strokes and heart attacks Migraine sufferers at risk for both thrombotic and hemorrhagic stroke as well as transient ischemic attacks. Death from cardiovascular causes higher in people with migraine with aura
Etminan M, Takkouche B, Isorna FC, Samii A (2005). "Risk of ischaemic stroke in people with migraine: Systematic review and meta-analysis of observational studies". BMJ 330 (7482): 63. Becker C, Brobert GP, Almqvist PM, Johansson S, Jick SS, Meier CR (2007). "Migraine and the risk of stroke, TIA, or death in the UK (CME).". Headache 47 (10): 137484. Kurth, T; Kurth T, Gaziano JM, Cook NR, Logroscino G, Diener HC, Buring JE (2006). "Migraine and risk of cardiovascular disease in women". JAMA 296 (3): 28391.

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TAKE HOME MESSAGE

 Migrain is one of the primary headache  The mnemonic POUNDing (Pulsating, duration of 4 72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine.  Has several triggers with stress being the most.  Can be treated with pharamacological therapy (abortive and preventive) and non-pharmacological therapy.  Must be aware of CVD events in the future.

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THANK YOU

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