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Migraine Headaches
By Dr. Shafiq Qaadri, MD

What are the latest theories about “migraine headache”?
Migraines are a neurovascular condition, a primary brain disorder. It is characterized by severe headache, occurring with or without aura, which can be sensory, visual, or motor. Four million Canadians have migraines.

Women are three times more likely to experience these than men. The Pathophysiology of migraines still isn’t clearly understood….Migraines involve a very sensitive, hyperactive brain; the blood vessels of the brain become dilated. These send painful impulses which intensifies the pain and prolongs the existence of the headache.

Are these the vessels going through the dura to the brain, or the brain parenchyma?
It is usually the extradural vessels that are involved. Basically, vasodilatation of the blood vessels. There is a neural peptide released, a release of transmitters, augmented signal transmission. Then you get sensitization of the brain itself, so there are really multiple mechanisms.

These neurotransmitters cause inflammatory changes within the blood vessels themselves. Transmitters that are involved are serotonin, CJRT; these transmitters cause further swelling of the blood vessels themselves, inflammatory changes, and so on.

What are the key signs and symptoms that a family physician should look for to actually diagnosis a patient with migraine?
I think the big problem with migraine, of course, is that it continues to be under recognized and not treated. But it is a clinical diagnosis; you do not make a migraine diagnosis based on a CT scan or even based on the physical exam.

Your migraine diagnosis should be based on the clinical history and according to the International Headache Society. The diagnostic criteria usually include the following: the attacks last anywhere to one to 72 hours. They are unusually unilateral, but they can be bilateral; they can be frontal in location, some can be posterior; they are described as pulsatile or throbbing pains; the intensity is moderate to severe; and the pain is usually aggravated by exertion.

There are a number of associated features that would tend to look for: nausea, vomiting, sensitivity tolight, sensitivity to noise, sensitivity to smells. These are the symptoms that we all tend to try and ask patients about on and history to elicit a diagnosis of migraine.

How exclusive are those criteria from the features of, say, tension headaches, sinus headaches, TMJ headaches and so on?
The criteria is quite exclusive actually. We like to have at least two of the associated symptoms such as nausea, vomiting, sensitivity to light, sound, smell.

The duration of the migraine, an hour to 72 hours usually has to fall within those criteria. The location does not really matter, or whether it is unilateral or bilateral. The severity varies, as there is patient variability, even within the same patient during different migraine episodes: you can have some patients that have mild migraines that will respond to an Advil sometimes, and that same patient will have a migraine that is very intense, very severe, that is quite disabling, with all those features.

Is the headache that patients experience with, for example, calcium channel blockers--is that also considered an iatrogenic migraine?
By description it may sound very much like migraine. It may have a pulsatile quality, it may be unilateral. There is usually lots of photophobia, but they usually do not have the nausea and they do not have the sensitivity to the noise, and not often aggravated by exertion. So there may not be the associated features with that kind of headache.

Also, there are other things that we look for with migraines, for example, some of the things that may give you a clue, for example is the family history, triggers that bring on migraine such as the menstrual cycle, food triggers it, barometric pressure changes. We want to know if there is a pattern to a headache that makes you think migraine.

What are the medication protocols for mild, moderate and severe migraine?
Migraine pain relief depends greatly on the patient, their needs, and their pain threshold. Your decision of that treatment really should be dictated based on the patients’ disability and that is really an important point to bring across.

Family physicians should really be looking at patients’ disability when they are trying to make a decision about what medication they choose. For example, if a patient can get by when their headaches are occurring, if they are not disabled, if they can manage to work through their headache, or if the patient is at home, or in bed, not able to function, or not able to work? That really should help to dictate what their treatment strategy is.

If the headache is mild, then over-the-counter analgesics, ibuprofen, other anti-inflammatories, may be sufficient. If their headaches are severe, disabling, then their treatment may be more migraine specific, for example, ergotamines or triptan therapy.

So that really is the first step--the question about the severity. Mild headaches, education, analgesics, over the counter drugs. Moderate severity, education again, triptans, combination preparation such as Tylenol #2 or Fiorinal preparations. Very severe, triptans and/or preventative therapies.

What exactly do triptans do, and how does the family doctor evaluate their effectiveness?
Triptans are what we classify as migraine specific medications, and these have been around now since about 1990. Triptan therapies are medications that work on the blood vessels. They work at constricting blood vessels, and preventing the inflammatory response.

There are six triptans available in Canada: Maxalt (rizatriptan), Zomig (zolmitriptan), Imitrex (sumatriptan), Relpax (eletriptan), Amerge (naratriptan) and Axert (almotriptan)….Patients have to take the triptan early in the course of their headache, which is the most important message to get across.

After the patients have been given triptans, and they return to the family doctor’s office, the important questions to ask are: how did the medication work? How quickly did it work? How quickly were they able to return to function? When were they pain free--in an hour, four hours? Did they have to take a second dose of medication? Or a different medication before they were pain free, and were there any side-effects with the medication?

If they asked those questions, the family doctor will be able to assess whether the medication was effective, or do they need to consider a different kind of medication, or a different triptan.

They might use another Triptan which might be faster acting of faster onset perhaps a different formulation of the Triptan or perhaps another Triptan which may have a different side-effect profile. So for example, if they gave a patient an oral Triptan without naming one, an oral Triptan that was a slower acting Triptan or the patient comes back and said “me headache went away, but it took about four hours before it worked and I had a lot of nausea with it”. The family physician may say “well may be this time we will try this Triptan which has a faster onset of action and because you had a lot of nausea perhaps we will give you a non-oral preparation like a Nasal Spray” and that may be the route that they take the next time. Because unless they ask the question of how fast did it work? Do you have side-effects? Where you returning to function after within two hours? The Triptan should really work within two hours of taking it; otherwise it is not working fast enough for the patient.

What are some of the side effects of triptans?
Overall, the triptans are essentially the same, as a general rule. We have common side effects--tingling, parasthesia of the extremities, chest tightness, jaw stiffness, occasional dizziness, some flushing. Side-effects are generally benign for the most part and short-lived. Many patients will have them for perhaps 20 minutes, half an hour, and then they subside.

Would you elaborate on the research paper by Dr. Dodick concerning “SNAE,” Sustained Pain-Free plus No Adverse Events?
Yes. Sustained pain-free is the gold standard; what we look regarding triptan efficacy. It means freedom from pain within two hours, with no recurrence of pain, no need for rescue medication, and no recurrence of headache within 24 to 48 hours….We want to add to that no adverse events… good tolerability. So that is “SNAE.”

Is there anything to distinguish one group or type of triptans versus the others, and versus other migraine therapies, or are there class-effects?
You have to be careful how you interpret things. Triptans are similar in many ways, but there are slight differences. In this particular paper, the meta-analysis that was used has to be interpreted with caution. These are basically very, very large reviews of data; so we just have to interpret them carefully….Basically, within this paper he did find there were differences, particularly with almotriptan, better in terms of the efficacy and tolerability.

Are there particular triptans you recommend for particular patient profiles?
I think there is a triptan for every migraine patient. There are patients that will respond to every type of triptan; other patients who respond to particular ones. There are triptans that are milder, and have a lower side effect profile that I will use for a particular patient. There are triptans that are slightly faster-acting. There are triptans that I consider a little stronger, and so I do not know that I can say that there is a better triptan than another one.

Do you anticipate Dr. Dodick’s contribution to be very impactful?
I think the concept of Sustained Pain-Free and No Adverse Event is an important one. When you look attributes of migraine medication, and you survey patients, what is the most important thing? What do they want? Patients want complete pain relief with rapid onset. They want no recurrence. They want to good tolerability.

The referrals that you get from your family physicians—are they to figure out if the patient has a migraine or not, or is it more to finesse the migraine therapy?
I think most family doctors do zero in on the diagnosis most of the time; I do not think that is the problem. I think the problem many times is getting the right treatment. The diagnosis of migraine is not difficult.

Would you advise family physicians to decrease the use of codeine medications, and use more migraine specific therapy?
I think that is an important point. Getting migraine specific, number one. The second point is to recognize the disability with migraines--I really ask patients about disability.

Also, follow-up. Find out if the prescribed therapy is not working, find out why, because what I find when patients come to my office is they will say, “Oh, I have tried this, I’ve tried that,” and when you ask them did it work, you find they had not been followed up.

We need to know how quickly did the therapy work? Did it have side-effects? Was there headache recurrence? If those questions are followed-up, then that is the first step.

Other than triptans, are there any other important groups of migraine therapies?
Migraine prophylaxis is another issue, a whole subject in itself. The problem with prophylaxis that I see in the patients in my office is that they come to me and say, “I have been tried on amitriptyline, and I have been tried on beta-blockers, and I have been tried on this and that.” They may have tried different prophylactic medications, but the biggest problem is that they have not been given a therapeutic dosage, and they have not been tried on them for a long enough period of time. So one word of advice would be, treat for a longer period of time--a therapeutic trial at least six weeks and a therapeutic dosage.

What is your final message?
Get the migraine treatment right the first time, and get the patient satisfied, because once you get them in your office, that is the biggest first step.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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