A recording of this presentation is available HERE.
Many thanks to Dr. Mike Dacre for a presentation this week on Migraines.
My notes:
Migraine syndrome is super common (~10% of all people), 1 billion people globally, 2nd cause of disability worldwide, 50% underdiagnosed and undertreated. 2:1 female to male ratio
- Migraine headaches 4-72 hours
- Note Pediatric usually max 2-4 hours (often not unilateral)
- Classic pattern of prodrome>> aura>> headache>> postdrome
What causes migraine? Has long been thought of as a blood vessel problem (spasm vs dilation)>> pain often pulsatile, worse with movement/position changes, vasoconstrictors (caffeine, ergo alkaloids) then migraines get better, vasodilators (Viagra) make migraines worse.
BUT this understanding is now known to not be true. In actuality, the blood vessel changes are SECONDARY. Now belief is that migraine is primarily a disease of neuronal activity: large ion shifts (potassium, glutamate, ATP across cell membranes)>> two receptors particularly notable now, include CGRP receptor and PACAP
- CGRP is potent vasodilator, but is a side effect of activation of this cascade>> mast cell degranulation, inflammation and sensitization
- get irritation and inflammation around the blood vessels, causing painful vasodilation
Migraines tend to start in the brainstem (where trigeminal nerve originates), direction impacts the type of migraine a person experiences. Where it moves, impacts the symptoms/manifestations
I love this simple diagram of how genetic set point+ cumulative burden push people toward migraine thresholds and lead to migraine syndromes:
Migraine headaches can move from being episodic to being chronic/intractable. Once you get migraines frequently enough, you can get medication overuse headaches, which then push you to central sensitization, which makes you more likely to get migraines. Similar to chronic pain syndrome progression>> it is not uncommon for people with headache syndromes to not seek care, overtake meds, and then have their disease progress to central sensitization and "chronification".
Abortive Treatments
Medications
- NSAIDs are very effective (shouldn't be taken more than QOD due to risk of medication overuse headache)
- acetaminophen and caffeine can potentiate/help (care with overuse)
- Excedrin is "worse" for medication overuse (no more than 5 times/month)
- Corticosteroids + PPI
- short course of prednisone has good evidence (NNT 9)
- Triptans (actually inhibit CGRP release)
- should be used in episodic migraine, more effective when done before pain starts (aura phase), not useful after 1 hour after onset of pain
- NNT 4-5
- Sumatriptan and Rizatriptan are most commonly used (familiarity)> no head to head trials
- Care with vasoconstriction effect (e.g. contraindicated in CAD, uncontrolled Htn)
- Opioids don't work well, high risk for misuse/dependence
- Caffeine is very effective in some people for aborting migraine, but people with > 2 cups coffee/day have more frequent and worse migraines
- Ditans: not available in US (schedule 5) but do see them in Middle East and Latin America
Nerve Blocks
Greater occipital nerve block>> safe and effective even in people who don't have predominant occipital pain, helps to abort migraine.
- can be done with or without ultrasound
- Can do block + anti-emetic + steroid
- lidocaine+ bupivacaine
- very safe (low vascular, infection risk)
Medications
- Beta blockers all work (propranolol, metoprolol)
- TCA: Amitriptyline
- SNRIs
- ARBs
- Anti-seizure meds (e.g. valproate, topiramate)>> best responders are people who failed other classes
- Anti-CGRPs: American Headache Society released guidelines in 2024 that these meds are first line for anyone with migraine >15 days/month ($600-700/month)
- safe and effective
- can be prescribed by PCPs
- can get covered by PHP (prior auth)
- one comparison study vs. topiramate, better tolerated
- Gepants
- remigapant, ubrogopant (can be used for ppx and abortive)
- Supplements
- Magnesium 400mg/day (moderate evidence)
- Riboflavin 400mg/day (good evidence)
- Coq10 (not great evidence) 100 TID
- Botox NNT 9 (50% reduction in HA days)
- Acupuncture NNT 11 (weekly acupuncture, 50% reduction in HA days)
- OMT/PT/massage are all also very effective, studies to support their use in reducing HA days
Summary:
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