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 The leading web portal for pharmacy resources, news, education and careers March 21, 2018
Pharmacy Choice - Migraines Disease State Management - March 21, 2018

Migraines Disease State Management

Headaches: Focus on Migraines
by Darrell Hulisz, RPh, PharmD
Associate Professor, Department of Family Medicine, Case Western Reserve University, School of Medicine

Migraine disorder is considered the most disabling and burdensome of all the headache disorders. Migraine headaches affect over 28 million Americans. It is disabling and burdensome to individuals and their families. It also has a negative impact on society primarily due to high economic costs and lost productivity. The prevalence of migraine disorder is approximately 18.2% in females, and 6.5% in males. The median frequency is 1.5 attacks per month, with 10% of migraine sufferers experiencing weekly attacks. The median attack duration is about 24 hours, but episodes may last as long as 2-3 days in 20% of patients. The annual indirect costs associated with missed workdays and reduced productivity due to migraines is estimated at over $13 billion.

A migraine attack is an episodic headache lasting between 4 and 72 hours when untreated. The pain is frequently unilateral or throbbing, and of moderate or severe intensity. Migraine attacks are usually associated with nausea, vomiting, or sensitivity to light, sound, or movement. Each patient who experiences a migraine attack will have some combination of these characteristics, but not all features are present in every migraine attack. A minority of migraine attacks are preceded or accompanied by an aura. An aura consists of transient and focal neurologic symptoms. The symptoms may be visual, sensory, or motor phenomenon and may involve language or brain stem disturbances. It is important to correctly differentiate migraine from other types of headache before determining the optimal treatment. Cluster headache is the most painful of the primary headaches. It comes on without warning, is unilateral, and is characterized by a rapid increase in pain intensity. Cluster headaches lasts 45-90 minutes on average, compared with 4-72 hours for migraine, and unlike migraine, is not usually associated with aura, nausea, and vomiting. In contrast to migraine, cluster headache is four times more common in men. Tension headache and analgesic overuse headache are rarely accompanied by nausea, vomiting, photophobia, and phonophobia. These are often frontal, bilateral headaches, accompanied by tightness around the neck and shoulder muscles.

The pathophysiology of migraine is complex and poorly understood, but most likely has a neurovascular basis. The main neurotransmitter that has been targeted for treatment is serotonin. However, acute treatment of migraine is best accomplished with a combination of pharmacologic and nonpharmacologic modalities. Maintaining usual patterns of activity, adequate sleep, regular meals, and physical exercise are all beneficial to migraine sufferers. However, during an attack, patients should be advised to rest and refrain from noise, light, temperature extremes and other stressors. Patient identification of migraine triggers and learning how to avoid them are also a necessary part of treatment. Triggers may be dietary (chocolate, alcohol, cheese, other foods), chronobiological (too much or too little sleep, schedule changes), hormonal changes, environmental factors (light, odors, weather change, or altitude change), physical exertion, stress or anxiety, or head trauma. Biofeedback and relaxation therapy may help, especially when stress is a trigger. Pharmacologic therapy includes prophylactic drugs, such as beta-blockers, tricyclic antidepressants, valproic acid, topiramate and other anticonvulsants.

Acute migraine treatments include nonspecific drugs (e.g. simple analgesics, such as acetaminophen) and migraine-specific drugs, such as triptans. Most of the nonspecific agents are used for a range of pain disorders. Many patients respond to simple analgesics and NSAIDs (with or without caffeine) if the headache is recognized early and the drug dose is adequate (e.g. 1000 mg acetaminophen, and 500-1000 mg naproxen). However, overuse of these agents should be avoided, with intake limited to no more than 2 to 3 days per week. In extreme cases where patients do not respond to conventional treatment, opiates may be used cautiously in selected patients. Drugs, such as ergotamine and DHE have long been used for migraines, but have several drawbacks. These include erratic pharmacokinetics, lack of evidence for effective doses, potent and sustained vasoconstrictor effects, and high risk of overuse syndromes and rebound headaches.

Although more costly, triptans have advantages over other agents. Triptans have a good track record of safety and efficacy based on a numerous, well-controlled clinical trials. They are generally well tolerated, but should not be used in patients with cardiovascular disease. These drugs can cause angina-like symptoms as a side effect; patients should be cautioned to expect some chest paresthesias after an initial dose. drug interactions, cost and individual response rate. Pharmacists can be consulted to assist in providers in optimal selection of agents and dosing. Pharmacists are also ideally suited to provide feedback to prescribers whenever patients are regularly requesting early refills or additional quantities of triptans. This may signal the need for the physician to consider adding a drug for migraine prophylaxis.
A variety of helpful internet resources are available for patients with migraines and their caregivers.
American Migraine Foundation

American Academy of Neurology

American Headache Society

National Headache Foundation

National Institute of Neurological Disorders & Stroke

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