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Chronic Migraine Chronic Migraine ICHD-I ICHD-II Headache Group, UCSF Migraine Disclosure- by proportion* 2014 • Sandler Family Trust Recent Advances in Neurology • Department of Defence University of California, San Francisco • Governments: California, China, Germany, Australia, th 12 February 2012 Portugal, NINDS Professor Peter J. Goadsby • Industry : Amgen/Allergan/eNeura • Consulting : Allergan, Ajinomoto, Alder, Amgen, Arteaus, Avanir, Colucid, Gore, eNeura, Ethicon, Heptares, Nupathe, Pfizer, DrReddy and Zosano • Reviewing : Belgian Research Council, European Space Agency, Italian Telethon, Medical Research Council UK, Migraine Research Foundation, Migraine Trust, Netherlands Research Council, National Health and Medical Research Council, Australia, Organisation for Understanding Cluster Headache- UK. *Font scale for direct contributions in proportion to contribution Q1-13 to Q4-13 Department of Neurology (Font ~ {Contribution/Total Group Income} * 100) International Classification of Headache Disorders-III β Cases I- Primary European II Secondary 1. Migraine 2. Tension-type headache – infection 3. Trigeminal autonomic cephalalgias – hemorrhage 3.1 Cluster headache 3.2 Paroxsymal hemicrania – trauma 3.3 SUNCT/SUNA – tumour 3.4 Hemicrania continua 4. Other Primary Headaches – CSF pressure change 4.1 Cough headache 4.2 Exercise Headache III Cranial neuralgias/facial pain 4.3 Sexual activity headache - trigeminal neuralgia 4.4 Thunderclap headache 4.5 Cold stimulus: external/ingestion - glossopharngeal neuralgia 4.6 External pressure: compression/traction - occipital neuralgia 4.7 Stabbing Headache 4.8 Nummular headache 4.9 Hypnic headache 4.10 New Daily Persistent Headache Cephalalgia 2013;33:629 1 Cases Nummular Headache European 4.8 Pain in a small area without a lesion A. Continuous pain fulfilling B-C B. Felt in a round or elliptical shape 1-6 cm in diameter C. Lasting hours or days D. Not better accounted for by another ICHD-III diagnosis United States • Case series (Grosberg et al ., 2009) - Nine patients - PHx- Migraine (6) - Three had moderate to severe pain - Five continuous, three episodic, one evolved - Rx- amitriptyline Migraine - Update Migraine The Attacks & the Disorder • Clinical Aspects Attacks Disorder • Repeated attacks • Premonitory symptoms – < 15 days/month: Episodic • Pain • Disorder mechanisms – ≥ 15 days/month: Chronic – unilateral • Family history • Treatment – throbbing – movement worse • Triggers (biology) – Sleep: missing/excess • Nausea – Food: skipping meals • Sensory sensitivity – Chemical: alcohol or nitroglycerin – photophobia – Weather – phonophobia – Sensory: light, smells – osmophobia – Hormonal • Aura – Stress- relaxation “The simple headaches have the same characters, and occur under the same causal conditions of heredity &c, as those in which there are additional other sensory symptoms” Gowers 1893 2 Chronic Migraine Chronic Migraine ICHD-I ICHD-II A. Headache frequency ≥15 days for ≥ 3 months B. Attacks fulfill criteria for migraine without aura C. Not attributed to another disorder Cephalalgia 1988;8 (suppl 7):1-96 Cephalalgia 2004;24 (suppl 1):1-160 Chronic Migraine Chronic Migraine ICHD-II-R ICHD-III β A. Headache frequency ≥15 days for ≥3 months A. Headache frequency ≥15 days for ≥3 months B. Patient with at ≥5 attacks of migraine with aura B. Patient with at ≥5 attacks of migraine without (MwA) or without aura (MwoA) in the past aura (MWoA) in the past C. On ≥8 days per month for three months one of: C. On ≥8 days per month for three months has 1. MwoA: C. pain characteristics AND D. nausea/sensitivity 1. typical MWoA 2. MwA: typical aura (B & C) 2. attacks treated and relieved by triptans/ergots 3. Attacks considered migraine by patient and relieved by D. Not attributed to another disorder, particularly triptans/ergots no medication overuse D. Not better accounted for by another ICHD-III diagnosis (Olesen et al ., Cephalalgia 2006;26:742) ICHD-III β Cephalalgia 2013;33:629-808 3 Botulinum Toxin A (Botox-A) in the preventive Botulinum Toxin A (Botox-A) in the preventive management of chronic migraine… in context management of chronic migraine 50% & 75% responder rates • 18-65 yrs, baseline one month/ 50% days migraine/probable migraine • Primary endpoint : headache episodes baseline vs last four weeks (20-24) • Result : I- NS , II- significant ; I/II Headache days/migraine days- significant Baseline, n = 12.7 11.5 19 19 17 17 0 n = 338 341 358 347 153 153 -2 * -4 patients % * -4.7 -6 + -6.1 -6.3 -6.4 * n = 696 688 358 347 153 153 -8 -7.6 ** -8.7 -10 Placebo Botox-A Topiramate Headache 2010;50:921 Cephalalgia 2011;31:87 Headache 2006;46:838 Reduction migraine/probablein migrainedays Aurora et al Diener et al Silberstein et al. Cephalalgia 2010;40:793 2010;40:804 Headache 2007;47:170 50% 75% Headache episode- Four hours headache bounded by no pain; * P = 0.002; ** P = 0.001; +P = 0.01 (* P < 0.05) Levetiracetam in Chronic Daily Headache Lacosamide is ineffective in Episodic Migraine Prevention • Double-blind randomised placebo-controlled crossover trial • Double-blind randomized placebo-controlled, parallel group • CDH: migraine (74%) and tension-type headache (37%) • Migraine: 2-8 attacks/month AND ≤ 15 days headache/month • Issues : drop-out and ordering effects • Stable acute treatment 50 • Primary endpoint - reduction in migraine rates in days Placebo Levetiracetam 3g Placebo: -1.4, Lacosamide 100mg: -1.4, 300mg: -1.6 40 30 •Adverse event : 19 18 (% patients) (% 20 15.5 - fatigue % patients % 10 8 N = 83 82 0 n = 71 70 74 Headache free rate Loss of CDH criteria Beran & Spira Cephalalgia 2011;41:530 (NCT00440518) 4 Case 1 Landmark Study Migraine in Primary Care Offices • Prospective, open-label study • Patients tracked for three months or six attacks • Assigned ICHD diagnoses by experts 100 Migraine Migrainous 80 76 60 % Patients 40 18 20 0 (Tepper et al ., Headache 2004;44:856-864) Tension-Type Headache Relationship of (appendix) Migraine and Tension-type headache • Episodic • Chronic Attacks • throbbing • Non-throbbing – lasts 30 mins to 7 days – ≥15 days/month • movement worse • no effect of movement – Two of – Two of • associations • associations • pressing/tight pain • pressing/tight pain – nausea – No nausea • mild/moderate severity • mild/moderate severity – photophobia – No photophobia – phonophobia – No phonophobia • bilateral • bilateral • Aura • ? aura • no aggravation by • no aggravation by activity activity Patient • Family history – Both of – Both of • Triggers • No nausea • No vomiting – Sleep: missing/excess • Photophobia or • Only one of mild – Eating: including alcohol phonophobia, not both nausea, photophobia or – Weather phonophobia – Hormonal ICHD-III-beta Cephalalgia 2013;33:629 – Stress- relaxation 5 Infantile Colic Migraine - Update A1.6.1.3 Infantile Colic • Clinical Aspects Description: Recurrent infantile attacks of irritability that are not predictable in duration or time occurring between birth and 4 months consistent with Wessel’s criteria. • Disease mechanisms Premonitory symptoms Diagnostic Criteria: A. Recurrent episodes of irritability, fussing or crying from birth to 4 months • Treatment of age fulfilling criteria B and C B. Episodes lasting 3 or more hours per day C. Episodes occurring at least 3 days per week for at least 3 week. D. Not better accounted for by another ICHD-III diagnosis Gelfand et al ., Neurology 2012;79:1392 Dose-dependent dopaminergic modulation of Migraine: The Premonitory Phase trigeminocervical complex neurons 100 Giffin et al . MMA: middle meningeal artery Bergerot et al . Ann Neurol 2007;61:251 100 premonitory Neurology 2003;60:935 80 80 headache postdrome 60 60 premonitory 40 40 20 VAS of health ratingstate of VAS 20 headache 0 0 -100 -50 0 50 100 * l ck wn ria rst a Time (hours) e n ness n ya thi io d t e polyu hunger tir stiff mo • Double-blind placebo controlled crossover e • Four period ( n = 19 subjects; n = 76 attacks) * Premonitory- somnolence- Gowers, 1883 • Symptoms reported 7-48 hrs prior to attack • Migraine with aura 120 100 80 30 mg 60 Firing (%Firing baseline) 40 % attacks %attacks aborted 20 saline dopamine 20 µg/kg 0 baseline 5 10 15 20 25 30 Waelkens BMJ 1982;289:944 Time (min) 6 Charbit et al. A11 Modulation of J Neurosci 2009 Premonitory Phase of Migraine Trigeminocervical Neurons 15 H2 O PET • Patients with premonitory symptoms, such as yawning and thirst, and no Stimulation Lesion headache 20 20 20 20 • First premonitory scan vs baseline MMA MMA + A11 MMA MMA + A11 15 15 15 15 Hypothalamus PAG Dorsal pons 10 10 10 10 Total cells fired Total Total cells fired cells Total Total cells fired cellsfired Total 5 5 5 5 0 0 0.00 0.02 0.04 0.06 0.08 0.10 0.00 0.02 0.04 0.06 0.08 0.10 0 0 Time (sec) 0.00 0.02 0.04 0.06 0.08 0.10 0.00 0.02 0.04 0.06 0.08 0.10 Time (sec) Time (sec) Time (sec) MMA Noxious pinch 160 M MA noxious pinch Innocuous brush 120 * innocuous brush 140 * Baseline 100 response 120 * Baseline response 80 * 100 B aseline * response * * * 80 60 60 40 = 8) n = 8) = 8) n 40 n Percentage of baseline firing ofPercentage baseline = 5) = 5) n = 5) n Percentage of baseline firing of baseline Percentage 20 n 20 =5 =6 =5 =5 =5 = = 12 =13 =5 =6 =6 =5 = = 14 n n n n n n n n Sham Sham( Lesion A11 Lesion( A11 n n n n n n n n n n n Sham Sham ( Sham Sham ( Lesion A11 Lesion ( Lesion A11 Lesion ( 0 0 A11 A11 5-40 mins 5-40 mins post i.v. post iv 5-40mins D2 antagonist D2 antagonist post lesion A11 Maniyar et al ., Brain 2014;137:232 or control Migraine - Update Trigeminovascular System & Migraine • Clinical Aspects • Disease mechanisms – Premonitory
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