TOMORROW is the day! Migraine expert @rashmihalker will take you on an accredited #tweetorial tour through the latest on acute treatment of #migraine. FOLLOW US now so you don't miss a tweet! @headacheMD @EricaSchuyler @maryannmays11 @DrJeffRatliff @EhrlichNP @NinaRiggins pic.twitter.com/R7v5XZ2a7u
— @migraine_ce (@migraine_ce) September 13, 2021
2) This series is supported by an educational grant from AbbVie and is intended for #healthcare providers. Faculty disclosures are listed at https://t.co/WqtnjZHgh0. And with that, let’s start talking about #migraine & its acute treatment!
— @migraine_ce (@migraine_ce) September 14, 2021
4) The burden of #migraine is not only due to the pain & associated symptoms during an attack, but many people also experience interictal burden between attacks, due to the unpredictable nature of the disease. This is heightened in those who don't have good acute treatment.
— @migraine_ce (@migraine_ce) September 14, 2021
6) Additionally, per data, stratified care is the best approach to acute #migraine therapy, esp if an individual can assess at onset if the attack will respond best to a nonspecific med (eg, an NSAID) or not, & choose to start with the med they perceive will be most effective.
— @migraine_ce (@migraine_ce) September 14, 2021
8) While #triptans are 1st line for acute #migraine treatment, a recent meta-analysis found that NSAIDs, acetaminophen, DHE, #CGRP antagonists, lasmiditan, & some nonpharm tx are also associated w improved pain & function (VanderPluym JH et al JAMA. 2021 Jun 15;325(23):2357-2369)
— @migraine_ce (@migraine_ce) September 14, 2021
10) As to the quiz: The answer is B. Only 26.3% of people with episodic #migraine (& < 5% with #chronicmigraine per CaMEO data) receive appropriate acute migraine treatment. We can do better! (Lipton RB et al Headache. 2013;53:81-92; Dodick DW et al Headache. 2016;56(5):821-834)
— @migraine_ce (@migraine_ce) September 14, 2021
12) … and more women, compared to men, received an accurate diagnosis once they sought out care, revealing gender bias. Additionally, economic factors played a role in whether a pt was given appropriate prescriptions for acute #migraine treatment, revealing further inequities.
— @migraine_ce (@migraine_ce) September 14, 2021
14) Increasing community education of #migraine may help improve consultation rates, & both clinicians & the public need to be more aware of the diagnosis of men with migraine. (https://t.co/OmGXnUv3ok)
— @migraine_ce (@migraine_ce) September 14, 2021
16) … He has been using OTC ibuprofen 600-800mg with minimal relief. The attacks occur 2-3 days per month, and he is otherwise headache free. He denies aura. He’s otherwise healthy, w/ no other meds. He’s never tried anything else for migraine.
— @migraine_ce (@migraine_ce) September 14, 2021
18) Mark your choice and return tomorrow for the answer and for more education! We're glad you are on board! @obegassededhaem @ihs_official @headachedoc @AMastersMD @thedizzydoc @drpearcekorb @tcascino1 @MarkMilsteinMD @WHMayoClinic @bidmcheadache @SerenaLOrr @medinmanhattan
— @migraine_ce (@migraine_ce) September 14, 2021
20) Now back to the quiz: any of these could be the right answer, as triptans are 1st line acute #migraine treatment, as long as you know how to troubleshoot if your first choice isn’t a home run! Let’s take a closer look…
— @migraine_ce (@migraine_ce) September 15, 2021
22) …When a person wakes with a #migraine, the attack is often already full blown, and a non-oral triptan can have a faster mode of onset. So if oral triptans (i.e. – rizatritaptan 10mg PO) doesn’t help, consider SQ sumatriptan or nasal spray sumatriptan/zolmitriptan.
— @migraine_ce (@migraine_ce) September 15, 2021
24) … Both SQ sumatriptan and NS zolmitriptan are good options in this case. If he tries one for a few attacks & it doesn’t help, he can switch! A person’s response to 1 triptan isn’t predictive of how they’ll do with other triptans.
— @migraine_ce (@migraine_ce) September 15, 2021
26) #medicationoveruse can occur with most acute analgesics, opiates & barbiturates have 2x higher risk compared w simple analgesics & triptans. Important to consider #migraine prevention if need for acute therapy increases. (Katsarava Z et al Neurology 2003 27;60(10):1682-3)
— @migraine_ce (@migraine_ce) September 15, 2021
28) What do we offer next?
— @migraine_ce (@migraine_ce) September 15, 2021
30) Thank you for returning! I am @rashmihalker and we are about to wrap up an accredited #tweetorial on acute management of #migraines. #neurotwitter #FOAMed @MedTweetorials #medtwitter @jkiarashiMD @BobkerMd @OrlyA @CalliCookNP @AbbyMetzlerMD @SaitAshina @ThomasBerkMD
— @migraine_ce (@migraine_ce) September 16, 2021
32) Generally, a pt's response to 1 triptan doesn’t predict that with another, & it’s reasonable to try a different triptan as next option. So, switching to zolmitriptan 5 mg NS can be an appropriate next step. (Ailani J. Continuum 2021, DOI: 10.1212/CON.0000000000000956)
— @migraine_ce (@migraine_ce) September 16, 2021
34) Taking time to discuss a patient’s experience with an acute #migraine treatment allows a clinician to better understand patient preferences, try to increase adherence, encourage treatment continuation, & improve their ability to match treatment with patient needs…
— @migraine_ce (@migraine_ce) September 16, 2021
36) These short, easy to use surveys include Migraine Treatment Optimization Questionnaire (mTOQ), Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire, Patient Perception of Migraine Questionnaire (PPMQ-R), & Functional Impairment Scale (FIS).
— @migraine_ce (@migraine_ce) September 16, 2021
38) Per the consensus statement #gepants & #ditans can also be considered if patients have contraindications to or inability to tolerate #triptans. So, having a discussion regarding triptan AEs to determine if the problem is with a specific drug or the class is important.
— @migraine_ce (@migraine_ce) September 16, 2021
40) If a patient has contraindications to triptans or finds them ineffective, the #gepants #ubrogepant or #rimegepant are good options. Like triptans, these #CGRP small molecule receptor antagonists work best if taken early.
— @migraine_ce (@migraine_ce) September 16, 2021
— @migraine_ce (@migraine_ce) September 16, 2021
— @migraine_ce (@migraine_ce) September 16, 2021
45) Troubleshooting #gepants: as #rimegepant is ODT, it offers convenience. It’s also the 1st #migraine acute tx to be FDA approved for migraine prevention & can be transitioned to preventive tx. These are practical things to discuss w your patient when choosing between gepants.
— @migraine_ce (@migraine_ce) September 16, 2021
48) #lasmiditan carries an 8 h driving restriction to potential AEs. Consequently, it’s a great choice as rescue tx for #migraine, for people with nighttime attacks, & perhaps teleworkers & those who don’t need to drive. (Pearlman EM et al Hum Psychopharmacol 2020;35(5):e2732)
— @migraine_ce (@migraine_ce) September 16, 2021
50) A US claims-based study found 1/2 of new #triptan users didn’t refill initial triptan Rx within 1 year, & half of these users filled an opioid Rx – these results demonstrate we must do a better job meeting patient needs w acute #migraine care. (Marcus SC et al Neurology 2019)
— @migraine_ce (@migraine_ce) September 16, 2021
52) Remember – common reasons triptans fail patients are waiting too long to treat an attack, using too low of a dose at onset, or using an oral triptan in attacks w early nausea & significant vomiting. Triptans work best if taken early; combining w NSAID or antiemetic may help.
— @migraine_ce (@migraine_ce) September 16, 2021
54) Noninvasive #neuromodulation devices also provide non-drug options for acute #migraine treatment & can be used as initial monotherapy or adjunctive therapy. Several are FDA cleared; cost & ins coverage can be barriers. (Halker Singh RB et al Headache 2019;59 Suppl 2:33-49)
— @migraine_ce (@migraine_ce) September 16, 2021
56) That's it! You made it! Free CE/#CME! Now go to https://t.co/seDtFe4yC2 and claim your 0.75h credit from @academiccme! I am @rashmihalker. Program chair @headacheMD and I are so happy you joined us! Follow @migraine_ce for more tweetorials! Always free! Always expert authors!
— @migraine_ce (@migraine_ce) September 16, 2021