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/ev60HiX8pv.
Now let's start with some basic facts about migraine!— @migraine_ce (@migraine_ce) August 17, 2021
4) According to data from the American Migraine Prevalence and Prevention study, only 25% of persons with migraine in need of medical care (MIDAS Grade II or greater), traversed the 3 steps . . .
— @migraine_ce (@migraine_ce) August 17, 2021
6) Special considerations when choosing migraine prevention are based on subtype (chronic migraine vs migraine) and the presence of comorbidities such as anxiety, depression, obesity, insomnia, chronic pain, and medication overuse headache (Headache 2021 doi: 10.1111/head.14153)
— @migraine_ce (@migraine_ce) August 17, 2021
8) Limitations of oral preventive treatments include slow titrations, need for dose escalations, drug-drug interactions, and at least daily dosing which may contribute to non-adherence.https://t.co/o2ITH9UtJG
— @migraine_ce (@migraine_ce) August 17, 2021
10) . . . and some procedures like acupuncture or OnabotulinumtoxinA for chronic migraine. https://t.co/etS7q184WS
— @migraine_ce (@migraine_ce) August 17, 2021
12) Please answer the quiz and join us tomorrow for more discussion and a case! @schwedtt @nmspare @HeadacheNP @kathleen_digre @n8bennett @MariusLBirlea @wvheadachedoc @TRobert @NinaRiggins @EhrlichNP @rashmihalker
— @migraine_ce (@migraine_ce) August 17, 2021
14) As to yesterday's quiz: the answer is D.
According to the AHS Consensus Statement, migraine prevention should be considered if:
• attacks significantly interfere with patients’ daily routines despite acute treatment.— @migraine_ce (@migraine_ce) August 18, 2021
16) . . . her ability to participate in virtual meetings. She also reports difficulty with conversations due to slow thinking and “fogginess”. She has had more stress due to financial worries and also has insomnia. Paroxetine was started for anxiety 2 months ago.
— @migraine_ce (@migraine_ce) August 18, 2021
18) It is important to take a history and screen for red flags or concerning signs of a secondary progress, to determine if further diagnostic testing is needed.
Indications for imaging for headache include: new or change in headache above 50, head trauma, cancer . . .— @migraine_ce (@migraine_ce) August 18, 2021
(See the AMA guidance for Overuse of Imaging https://t.co/rQSosk5M1e)
— @migraine_ce (@migraine_ce) August 18, 2021
21) Linda has migraine without aura. Risk factors include recent stress, anxiety, and caffeine overuse which may be contributing to poor sleep. We discussed her therapeutic options and I provided her with resources from the AMF such as https://t.co/peQQ1eGioQ.
— @migraine_ce (@migraine_ce) August 18, 2021
23) POLL: What would you try next?
a) beta blockers
b) venlafaxine
c) valproate
d) anti-CGRP monoclonal antibodies— @migraine_ce (@migraine_ce) August 18, 2021
• Inability to tolerate (due to side effects)
• At least moderate disability
• Inadequate response to at least 2, 8-week trials, with an appropriate dose of evidence-based treatments:
a) Topiramate, Divalproex sodium/valproate sodium— @migraine_ce (@migraine_ce) August 18, 2021
26) . . . so that the 15d threshold of chronic migraine may not capture the full spectrum of disease burden of higher frequency migraine episodic patterns (Headache 2021 https://t.co/Z84foIR3Oz).
— @migraine_ce (@migraine_ce) August 18, 2021
28) Linda has a high frequency episodic migraine pattern. She should be followed closely and both acute and preventive treatments should be optimized to reduce disability and improve quality of life.
— @migraine_ce (@migraine_ce) August 18, 2021
30) Modification of risk factors has not been prospectively shown to prevent chronification but promoting lifestyle interventions such as adequate sleep (about 8 h/night), regular exercise, a high quality and regular diet . . .
— @migraine_ce (@migraine_ce) August 18, 2021
32) Linda was concerned about beta blockers because of a history of hypotension. Valproate is a concern in childbearing age because of the potential for fetal complications. SNRI is contraindicated with SSRIs. I started her on a CGRP monoclonal antibody.
— @migraine_ce (@migraine_ce) August 18, 2021
34) Linda has migraine and several migraine comorbidities. She may need a headache specialist after trying 2-3 migraine preventive agents. It is worthwhile to first consider a 3rd preventive option as we have done here.
— @migraine_ce (@migraine_ce) August 18, 2021
36) Mark your answer and be sure to COME BACK TOMORROW to wrap up this case and earn your CE/#CME credit! @DrMauskop @AbbyMetzlerMD @ThomasBerkMD @SHSHeadache pic.twitter.com/fZrgoiDCFE
— @migraine_ce (@migraine_ce) August 18, 2021
40) She reports about 20 headache days per month for 4 months. Half of them are severe and are associated with photophobia and nausea.
— @migraine_ce (@migraine_ce) August 19, 2021
38) The answer to yesterday's poll is C. Clinical trials with CGRP monoclonal antibodies show fast onset of action w/in 1 wk, no need for dose escalation or titrations (monthly or quarterly dosing). Injection site reactions are quite common, but rarely result in discontinuation.
— @migraine_ce (@migraine_ce) August 19, 2021
44) A second consideration is to first start preventive therapy to treat medication overuse headache, and to follow the patient closely. How do YOU manage pts with chronic migraine + MOH?
— @migraine_ce (@migraine_ce) August 19, 2021
45) In a recent small randomized control trial, all strategies improved MOH. However, treatment of medication overuse with both acute withdrawal and the initiation of early preventive therapy was associated with the best outcomes (Headache 2021 https://t.co/lmV0xzK7Uf).
— @migraine_ce (@migraine_ce) August 19, 2021
47) In a new study of 42 women with chronic migraine, the use of digital cognitive behavioral therapy for insomnia was associated with a reversion from chronic migraine to episodic migraine and improved sleep parameters (Headache 2020;60(5):902-15).
— @migraine_ce (@migraine_ce) August 19, 2021
49) . . . but she did not tolerate this. All four CGRP monoclonal antibodies have positive RCTs for chronic migraine in the setting of medication overuse although specific randomized controlled studies are lacking for MOH. OnabotulinumtoxinA may also be effective: pic.twitter.com/t4KURUm2AK
— @migraine_ce (@migraine_ce) August 19, 2021
51) After educating Linda about her best evidenced-based choices, she chose to try OnabotulinumtoxinA injections this time around. Her goal was to have as little migraine attacks as possible. Supportive data come from the PREEPT studies (Headache 2010;50(6):921-36).
— @migraine_ce (@migraine_ce) August 19, 2021
53) Head-to-head chronic migraine studies evaluating the efficacy of CGRP monoclonal antibodies vs OnabotulinumtoxinA are lacking, and sometimes the decision is dictated by insurance! Single center retrospective studies show some benefit combining the 2 treatments.
— @migraine_ce (@migraine_ce) August 19, 2021
55) . . . calcitonin gene related peptide receptor antagonists may be considered for acute therapy.
— @migraine_ce (@migraine_ce) August 19, 2021
57) We discussed the approach to the management of migraine a high frequency of attacks. For ideal outcomes, the important things to reminder are developing a therapeutic relationship, getting a good headache history with the help of a diary and objective measures . . . pic.twitter.com/wU7HI24ph3
— @migraine_ce (@migraine_ce) August 19, 2021
59) The goals of preventive care, to reduce disability, improve function, reduce medication overuse, and possibility comorbidities can be accomplished with a personalized treatment plan.
— @migraine_ce (@migraine_ce) August 19, 2021
60) That's it! You made it! Now go to https://t.co/3MOSl2PGTw and claim your CE/#CME credit! I am @headacheMD and I am so happy you joined us. FOLLOW US for more accredited @tweetorials from #migraine experts! pic.twitter.com/mb94L80bBH
— @migraine_ce (@migraine_ce) August 19, 2021
