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NNC CMU
Effective Migraine
Management
Surat Tanprawate, MD, MSc(Lond), FRCPT
Headache specialist, Division of Neurology
Chiang Mai University
https://www.wfneurology.org/world-brain-day-2019
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Migraine Subtypes
Migraine
Co-morbidities
MOH
• 5-HT1D: presynaptically
inhibits trigeminal peptide
release and interfere with
central trigeminal nucleus
caudalis
Karsan N, Goadsby PJ Nature Review (2018)
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Functional change
Central sensitization
Sensitization: altered
perception of stimuli by
peripheral or central Dorsolateral pontine activity features prominently
in the pathophysiology of episodic migraine
considered as adaptive Weiller C, May A, Limmroth V, et al Nat Med. 1995;1:658-660
• Mild น้อย
• 1-4 วัน/เดือน ไมเกรนเป็นครั้งคราว
Episodic Migraine Low Frequency • Moderate ปานกลาง
ความถี่และความรุนแรง
Migraine Level
Tr Layer I r
ig i o
ge a v
rs e h
B
สิ่งกระตุ้น พฤติกรรม
3 Pillars of Migraine Management
The Northern Neuroscience Centre
NNC CMU
Chiang Mai University
Acute Medication
management
Co Layer II /
-m ci ry
or n
o to
b h r c
id C fr a
ity e
โรคร่วม R
ไมเกรนเรื้อรังและ
ดื้อยา
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
7 migraine types: Classified Headache
Depend on Complexity of Therapy
1. Migraine - Low frequency, Low impact
• anti-CGRP?
Tools
Headache Impact
Test (HIT-6)
Headache diary
Headache
follow up form
Headache day
HIT-6 scale
Treatment response
Headache Education is Still Important
Acute therapy
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Rationale to use acute migraine medication
• what, when, to start initial treatment, back up
treatment and rescue treatment
• corticosteroids
• DA antagonists
Acute migraine pharmacotherapy
The Northern Neuroscience Centre
NNC CMU
Chiang Mai University
• Dihydroergotamine
• Ergotamine
• Triptan
Evers, S et al. European Journal of Neurology 2009, 16: 968–981 Eletriptan Zolmitriptan Sumatriptan
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Risk of Progress to CM Based on Acute Treatment
Efficacy
n t
Progressed
re ve
Treatment N from EM to OR
n p 95% CI
CM,%(n)
c a
n t
m e
Very poor 369 6.8(25)
a t i o n 1.42,4.61
re
t res s
s
k og
Poor 1007 4.4(44)
t a c r
1.02,2.81
a t e p
u t e a i n
Moderate 2657
a c
2.7(73)
i g r 0.81,1.97
s s m
c e
u c
S
Maximum 1648 1.9(32) 0.81,1.97
0 1 2 3 4 5
Second order
neuron
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
53.5
45
46
37.5
30
30
24
15
6
0
%2-h pain free %24-h sustain pain free %24-h headache recurrence
PJ Goadsby Cephalalgia 2008,26(Suppl):36-41
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
• 6 migraine attacks
• first 3 attacks with aspirin if not satisfy -> step up to zolmitriptan next 3 attacks
Non-specific
NNC CMU
migraine
medication:
Analgesics with
evidence of efficacy
EFNS migraine
treatment guideline
2009 Evers, S et al. European Journal
of Neurology 2009, 16: 968–981
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Options
• Fixed combination ASA + Paracetamol + caffeine
more effective than single substance
• Valdecoxib 20-40 mg
• Celecoxib 400 mg
• Rofecoxib 25-50 mg
Migraine specific medication
Migraine- specific
medication
Ever S, Afra J. Eur J Neurol 2009, 16:968-981
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Side effect of triptan
• Triptan sensations – paraesthesias, sensations of
warmth, heaviness, pressure or tightness in
different parts of the body including the throat,
neck and chest.
Abstinence vs
Non-abstinence
(Caffeine < 200 mg/
d or > 200 mg/d)
n=798
4.33 / month
Estimated 1-year incidence rate of: (a) chronic daily headache (180+ HA day/
year); or (b) increased HA (105-179) in an episodic headache population
• Serotonin antagonists
65
61.5
58.89 59.11
58.86
58
0 1 3 6
Month Poster presentation, Annual Thai
Neurology Meeting(2018)
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
NNC CMU
PJ Goadsby, UCL, UK
• Do not cause
vasoconstriction
• Modulate sensory
signaling within
trigeminal pathway
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
2013-
Galcanezumab, eptinezumab, fremanezumab, erenumab - shown
2016 efficacy for migraine prevention
Ubrogepant, an orally active gepant, shown to be effective in acute
2016
migraine attack without adverse side effect
Review with guideline of antibody migraine therapy by FDA, and
2018
release in the Market
Edvinsson L et al. Nature 2018;14: 338-350
-mab -gepant
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Trigeminal ganglion and
CGRP target therapy
NNC
Chiang Mai University
CMU
CGRP-target therapies for Migraine
Dosing and
CGRP target Rx Company Target Indication
administration
Eptinezumab
1 IV dose every 3
Alder peptide or ligand Prevention (EM, CM)
(humanized) mo
Erenumab
AEs leading to
7 (2.2%) 7 (2.2%) 8 (2.5%)
discontinuation
AEs leading to
7 (2%) 5 (1%) 8 (2%)
discontinuation