Identifying and Managing Migraine :

Barriers and Opportunities

Widodo Mardi Santoso

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OUT LINE
01 Introduction

02 Epidemiology

03 Clinical Features

04 Diagnosis

05 Treatment

06 Conclussion
INTRODUCTION

• Migraine is often underdiagnosed and undertreated, with more than two-thirds of patients either
having never consulted a physician or having stopped doing so.
• The American Migraine Studies I and II conducted a decade apart, have confirmed that
approximately 18% of women and 6% of men have migraine. Many migraine sufferers remain
undiagnosed or misdiagnosed.
• Many of these patients resort to the overuse of painkillers, which leads to the development of a
new type of headache or worsening of the pre-existing headache described as medication
overuse headache.

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• About one-third thought the
criteria were too complex for use
in clinical practice.
• As the Guidelines recommend the
use of the IHS criteria, this is a
potential barrier to Guidelines-
based care.
• Some neurologists (18%) felt that
the neurologic exam was not
obligatory.
• The majority reported using MRI
or CT when evaluating severe
migraine, even in those with a
normal neurologic exam.

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EPIDEMIOLOGY

• Migraine is common worldwide and is more frequent in women. The one-year prevalence
figures for migraine are around 12% (6% males, 15% females) with a lifetime prevalence of 15-
18%. Chronic migraine affects around 2% of the general population and accounts for 8% of all
migraine cases.
• Many epidemiological studies have documented its high prevalence and socio-economic and
personal impacts. In the Global Burden of Disease Study 2010 (GBD 2010), it was ranked as
the third most prevalent disorder in the world.
• In GBD 2015, it was ranked the third-highest cause of disability worldwide in both males and
females under the age of 50 years.

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CLINICAL FEATURES

• Migraine is a common neurovascular disorder characterised by episodes of, often severe,

headache occurring in association with nausea and sensitivity to sensory input, i.e. light, sound,
etc.
• Migraine can occur with or without aura. In a large population-based study 64% of migraineurs
had pure migraine without aura, 18% had pure migraine with aura, and 13% had both. Thus up
to 31% of migraineurs have aura on some occasions.
• Therefore, relying on the presence of aura to diagnose migraine will miss most cases.
• Aura symptoms are usually visual (99%), together with sensory (31%), speech (18%) or motor
(6%).
• The phenotype of the headache may change with time, especially with co-existent overuse of
migraine abortive agents. With an increasing intake of painkillers, patients often complain of an
escalation of migraine attacks or a transformation to a chronic daily background pain with
exacerbations

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 DIAGNOSIS
There is no diagnostic test for
migraine and therefore a good
clinical history is vital.

Flowchart shows the stepwise

diagnosis and management of
headaches.

Singapore Med J 2018; 59(8): 399-406

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 The SNOOP4 mnemonic for excluding red
flags (secondary causes of headache).

Singapore Med J 2018; 59(8): 399-406

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Migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.3 Chronic migraine
1.4 Complications of migraine
1.5 Probable migraine
1.6 Episodic syndromes that may be
associated with migraine
• Individuals who otherwise meet criteria for Migraine
without aura but have had fewer than five attacks
should be coded Probable migraine without aura.
• When the patient falls a sleep during a migraine
attack and wakes up without it, duration of the
attack is reckoned until the time of awakening.
• Migraine headache in children and adolescents
(aged under 18 years) is more often bilateral than is
the case in adults.
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Conclusions:
The ID-Migraine questionnaire has a
sensitivity of 0.81, a specificity of 0.75 and a
positive predictive value of 0.93 when
compared with ICHD-based diagnosis by a
headache specialist.
The three-item ID Migraine™ migraine
screener was found to be a valid and reliable
screening instrument for migraine
headaches. Its ease of use and operating
characteristics suggest that it could
significantly improve migraine recognition in
primary care. 11
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TREATMENT Develop
Pharmacologic
01 Management Plan
Acute treatment
Preventive Strategies

KEY TO SUCCESSFUL
MIGRAINE MANAGEMENT Establish a Partnership
With the Patient

Establish a Treatment Plan :

• Nature and mechanism of
disorder
• Strategi for identifying and
avoiding triggers
• Behavioral management
strategies
Promote Patient  Reguler sleep, exercise, meals
Education  Stress management

02 03
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TREATMENT

EDUCATION Explanation, reassurance and objectives

• Patient centricity and education have important roles in the management of migraine.
• Patient satisfaction is a key management outcome and treatment success depends on it but
most people with migraine report at least one perceived unmet treatment need.
• A realistic objective is a return of control from the disease to the patient with treatment that
mitigates attack related disability (by reducing attack frequency, attack duration and/or pain
intensity) to an extent that the patient can continue with life with as little hindrance as possible.
• Explain to the patient both the disease and the principles of managing it effectively, including
instruction on the correct use of medication, potential adverse effects and what to do about
them, and the importance of avoiding medication overuse.

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 TYPICAL TRIGGERS FOR MIGRAINE
• Hunger/missing a meal
• Dehydration
• Sleep disruption – too much or too little sleep
• Hormonal changes in women – certain
stages of the menstrual cycle, certain
contraceptive pills, pregnancy and the
menopause
• Periods of high stress
• Relaxation after stress
• Overexertion – physical and mental
• Environmental changes – bright lights, hot or
humid weather, loud noises
• Alcohol – severe headache develops the next
day
• Caffeine – excessive consumption of
caffeinated drinks, which can be as little as
two drinks daily, can lead to escalation of
migraine attacks
• Dietary factors – cheese, citrus fruits. Often
food cravings (part of a migraine attack) are
confused with food triggers so diets of
exclusion often unnecessary
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Objective : the Migraine-Treatment Optimization Questionnaire

No Item Yes No
1. Are you able to quickly return to your
normal activities after taking your
migraine medication?
2. Can you count on your migraine
medication to relieve your pain within 2
hours for most attacks?
3. Dose one dose of your migraine
medication usually relieve your headache
and keep it away for at least 24 hours ?
4. Is your migraine medication well
tolerated?
5. Are you comfortable enough with your
migraine medication to be able to plan
your daily activities?
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Suggested treatment in patients with a “no” answer to individual M-TOQ-5 questions

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 STRATEGI FOR MIGRAINE TREATMENT

To S t op pain and P r ev ent

P r ogr es s ion
A c ut e • is initiated during an attack to relieve
Tr eat m ent pain and disability and to stop
Progression of the attack

M igr aine Tr igger Tim e -

Lim it ed and P r edic t able
• is used when a known headache trigger P r eem pt iv e Dec r eas e in M igr aine
exists, such as exercise or sexual Tr eat m en F r equenc y W ar r ant ed
activity, and for patients experiencing a
P r ev ent iv e
Tr eat m ent • is maintained for months or even years
time-limited exposure to a trigger, such to reduce attack frequency, severity, and
as ascent to a high altitude or duration.
menstruation.

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Non Spesifik Abortif Migrain Treatment

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 Onset analgesik K-
Diklofenak sachet
terjadi pada menit ke-15

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 K-Diklofenak superior
dibandingkan Sumatriptan
dalam mengurangi gejala
penyerta.

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K-Diklofenak lebih efektif
dari sumatriptan untuk
menurunkan nyeri

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 CONCLUSION
• Migraine is a condition that is frequently encountered in
primary and secondary care.
• Physicians need the tool was found to be a valid and reliable
screening instrument for migraine headaches. Its ease of use
and operating characteristics suggest that it could significantly
improve migraine recognition in primary care.
• Physicians need to optimize treatment on an individual basis; a
simple decision tool, based on treatment guidelines, might
facilitate treatment optimization.

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THANK YOU