Diagnosis prophylaxis and treatment of migraine in men women and children
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DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN. BASIL AL-SAIGH, FMR-2 JANUARY 2007 REGINA GENERAL HOSPITAL. BACKGROUND READING :. Diagnosis and Treatment of Migraine

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Diagnosis prophylaxis and treatment of migraine in men women and children

DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN

BASIL AL-SAIGH, FMR-2

JANUARY 2007

REGINA GENERAL HOSPITAL


Background reading

BACKGROUND READING :

  • Diagnosis and Treatment of Migraine

    ROGER CADY, MD;DAVID W. DODICK, MDFrom the Headache Care Center, Primary Care Network, Springfield, Mo (R.C.); and Department of Neurology, Mayo Clinic, Scottsdale, Ariz (D.W.D.).

  • Answers to Frequently Asked Questions About Migraine

    IVAN GARZA, MD;JERRY W. SWANSON, MD From the Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minn.

    Dr Garza’s headache fellowship was partially supported by GlaxoSmithKline.

  • Prevention of Migraine in Women Throughout the Life Span

    BEVERLY S. TOZER, MD;ELIZABETH A. BOATWRIGHT, MD;PARU S. DAVID, MD;DEEPA P. VERMA, MD;JANIS E. BLAIR, MD;ANITA P. MAYER, MD;JULIA A. FILES, MD From the Division of Women’s Health Internal Medicine (B.S.T., E.A.B., P.S.D., D.P.V., J.A.F.), Mayo Clinic College of Medicine, Scottsdale, Ariz.

Migraine in Men, Women and Children RGH, January 2007


Background reading1

BACKGROUND READING :

  • Triptans. Are they all the same?

    Lead author: William A. Kehoe, Pharm.D., MA, FCCP, BCPS

    Prescriber's Letter U.S. 2002; 9(1):180105

  • Supplements for Migraine

    Lead author: Gayle Nicholas Scott, Pharm.D., BCPS, ELS, Assistant Editor

    Canadian Prescriber's Letter 2005; 12(4):210414

  • Drug Therapy for Children and Adolescents with Migraine Headaches

    Lead author: Neeta Bahal O'Mara, Pharm.D., BCPS

    Canadian Prescriber's Letter 2005; 12(3):210307

  • Canadian Family Physician

    June 2005, pgs 838-843

Migraine in Men, Women and Children RGH, January 2007


Migraine in primary care

MIGRAINE IN PRIMARY CARE :

  • Overall prevalence – 1 migraineur / 4 households

  • Prevalence > asthma / diabetes combined

  • Most initially seek tx for HA in a primary care setting

  • Majority of patients who seek help for a HA have migraine

  • Median pain intensity 8/10

  • Median attack duration 24 hours

Migraine in Men, Women and Children RGH, January 2007


Migraine in primary care cont d

MIGRAINE IN PRIMARY CARE Cont’d :

  • 1/3 of migraineurs miss 1 day of work in a 3 month period

  • Most patients seek care from a primary care physician

  • 3 : 1 Female : Male prevalence

Migraine in Men, Women and Children RGH, January 2007


Spectrum of ha

SPECTRUM OF HA :

  • Pt.’s with clinically relevant migraine experience spectrum of HA presentations – Migraine / Migrainous / Tension-Type HA

  • All respond equally well to migraine-specific medications

  • Similar underlying biology?

  • HA expereinced by migraine sufferers differs more in degree vs type

Migraine in Men, Women and Children RGH, January 2007


Categories of the international headache society classification system

CATEGORIES OF THE INTERNATIONAL HEADACHE SOCIETY CLASSIFICATION SYSTEM :

1.Migraine

2.Tension-type headache

3.Cluster headache and chronic paroxysmal hemicrania

4.Miscellaneous headache not associated with structural lesions

5.Headache associated with head trauma

6.Headache associated with vascular disorders

7.Headache associated with nonvascular intracranial disorder

8.Headache associated with substance use or withdrawal

9.Headache associated with noncephalic infection

10.Headache associated with metabolic disorders

11.Headache or facial pain associated with disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structure

12.Cranial neuralgias, nerve trunk pain, and deafferentation pain

13.Headache not classifiable

Migraine in Men, Women and Children RGH, January 2007


Spectrum of ha cont d

SPECTRUM OF HA Cont’d :

  • “Thus, the academic headache community no longer supports the concepts or use of the terms mixed headache disorder, tension-vascular headaches, vascular headaches, or muscle-contraction headaches. These terms imply different headache types with a different pathophysiological basis, and they are incompatible with the current construct of migraine as a paroxysmal neurologic disorder that is initiated within the central nervous system rather than a disorder of cerebral blood vessels.”

Migraine in Men, Women and Children RGH, January 2007


Primary vs secondary ha

PRIMARY VS SECONDARY HA :

  • HA + Onset in adolescence or early adulthood – Primary HA

  • HA + Stable pattern of similar HA over 6 months or more – Primary HA

  • HA + FHx of HA – Primary HA

  • HA + Association with mensturation – Primary HA

  • HA + Variable site of HA from attack to attack – Primary HA

Migraine in Men, Women and Children RGH, January 2007


Primary vs secondary ha cont d

PRIMARY VS SECONDARY HA Cont’d :

  • HA + Sudden onset – Secondary HA

  • HA + Onset > age 40 – Secondary HA

  • HA + New type – Secondary HA

  • HA + New Level of Pain “Worst HA ever” – Secondary HA

  • HA + Exertion / Valsalva – Secondary HA

  • HA + Neurological changes – Secondary HA

  • HA + HIV/malignancy – Secondary HA

  • HA + Interrupts sleep – Secondary HA

Migraine in Men, Women and Children RGH, January 2007


Imaging

IMAGING :

  • Recent significant change

    • pattern, frequency, or severity

  • Progressive worsening

    • in spite of appropriate treatment

  • Focal neurologic signs or symptoms

  • Onset of headache with exertion/cough

  • Onset of headache after age 40

  • Orbital bruit

Migraine in Men, Women and Children RGH, January 2007


Criteria for dx of migraine

CRITERIA FOR DX OF MIGRAINE :

  • At least 5 attacks fulfilling criteria B-D

  • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

  • Headache has at least 2 of the following characteristics:

    • Unilateral location

    • Pulsating quality

    • Moderate or severe pain intensity

    • Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

Migraine in Men, Women and Children RGH, January 2007


Criteria for dx of migraine1

CRITERIA FOR DX OF MIGRAINE :

  • During headache at least 1 of the following

    • Nausea and/or vomiting

    • Photophobia and phonophobia

  • Not attributed to another disorder

Migraine in Men, Women and Children RGH, January 2007


Screeners for dx of migraine

SCREENERS FOR DX OF MIGRAINE :

  • Aura is not present in 2/3 of patients

  • Identification of Migraine Screener :

    • Are you nauseated or sick to your stomach when you have a headache?

    • Have your HA limited your activity for a day or more in the last 3 months?

    • Does light bother you when you have a HA?

    • If 2/3 positive : PPV 93 percent for migraine

    • If 3/3 positive : PPV 98 percent for migraine

Migraine in Men, Women and Children RGH, January 2007


Screeners for dx of migraine cont d

SCREENERS FOR DX OF MIGRAINE Cont’d :

  • INFOPOEM CMA Criteria for Dx Migraine HA

    • POUNDing

      • P – Pulsatile Quality

      • O – 4-72 hOurs duration

      • U – Unilateral location

      • N – Nausea and Vomiting

      • D – Disability and intensity

Migraine in Men, Women and Children RGH, January 2007


Common migraine triggers

COMMON MIGRAINE TRIGGERS :

  • Sleep (too much or too little) **

  • Schedule Change

  • Alcohol **  

  • Caffeine ** 

  • Certain foods  

  • Odors  

  • Weather change

  • Head or neck pain  

  • Trauma 

Migraine in Men, Women and Children RGH, January 2007


Common migraine triggers1

COMMON MIGRAINE TRIGGERS :

  • Fasting or skipping meals **  

  • Hunger

  • Environmental factors  

  • Altitude  

  • Light glare or visual stimuli

  • Medications  

  • Physical exertion  

Migraine in Men, Women and Children RGH, January 2007


Common migraine triggers2

COMMON MIGRAINE TRIGGERS :

  • Hormonal changes  

  • Menopausal fluctuations  

  • Menstruation **

  • Exercise  

  • Sexual activity

  • Stress and anxiety **

Migraine in Men, Women and Children RGH, January 2007


Acute medications for the tx of migraine

ACUTE MEDICATIONS FOR THE TX OF MIGRAINE :

  • NON-SPECIFIC ANALGESICS

    • Acetaminophen

    • ASA

    • NSAID

    • Opiates

    • Combination Analgesics (ASA/Acetaminophen/Caffeine/Codeine/Butalbital)

    • Antiemetics

  • SPECIFIC ANALGESICS

    • Dihydroergotamine (DHE)

    • Triptans

Migraine in Men, Women and Children RGH, January 2007


Approaches to treatment

APPROACHES TO TREATMENT :

  • STEP CARE

    • Initiate acute HA therapy with inexpensive low-end medications and establishing failure before using more specific medications

    • Start with OTC products, then try NSAID’s, then combination analgesics, and so forth

  • STRATIFIED CARE

    • Medications based on headache characteristics

    • High-end therapy for patents with severe HA, and so forth

    • If failure is established on low-end therapy, move up to higher-end therapy

Migraine in Men, Women and Children RGH, January 2007


Approaches to treatment1

APPROACHES TO TREATMENT :

  • STEP CARE WITHIN ATTACK CARE

    • Low end medications at beginning of migraine attack and then advance to a stronger compound if not effective.

    • Beneficial in patients with slow to develop migraines, of mild-moderate severity

  • PATIENT-CENTERED STRATIFIED CARE

    • Educating migraineurs so that they determine treatment need based on the individual HA characteristic

Migraine in Men, Women and Children RGH, January 2007


Acute tx of migraine ha

ACUTE TX OF MIGRAINE HA :

  • Ambulatory :

    • High dose NSAID +/- antiemetic

    • DHE (Nausea)

    • Triptan (expensive, but effective)

  • In the ER :

    • Triptan?

    • IV proclorperazine 10 mg

    • IV DHE 1mg + metoclopramide 10 mg

Migraine in Men, Women and Children RGH, January 2007


Acute migraine tx in child adolescents

ACUTE MIGRAINE TX IN CHILD/ADOLESCENTS :

  • Ibuprofen

    • Most studied medication

    • Safe and effective

  • Acetaminophen

    • Probably effective and well tolerated

  • Sumatriptan

    • Nasal spray effective

    • Inadequate data for SC or PO use

    • Other triptans have inadequate data to support their use

Migraine in Men, Women and Children RGH, January 2007


Triptans for acute tx of migraine

TRIPTANS FOR ACUTE TX OF MIGRAINE :

  • ALMOtriptan – ELEtriptan – FROVAtriptan – NARAtriptan – RIZAtriptan – SUMAtriptan – ZOLMItriptan

  • All are 5-HT 1B/D agonists

    • Induce vasoconstriction of cranial blood vessels

    • Help decrease release of neuropeptides responsible for vasodilation and pain pathways involved in the Trigeminal Nerve

    • Vs Ergots : also bind to dopamine and adrenergic receptors – thus worse side effect profile

  • Compared on basis of response 2 hour after medication

Migraine in Men, Women and Children RGH, January 2007


Triptans for acute tx of migraine cont d

TRIPTANS FOR ACUTE TX OF MIGRAINE Cont’d :

  • Frovatriptan / Naratriptan less effective orally

  • Rest have 2-hour response rates b/w 57 – 77 percent

  • Great interindividual variation in patient preference and response rate

  • Poor response to one does not mean ALL will be ineffective

  • Initial choice of triptan often driven by patient’s health plan formulary

Migraine in Men, Women and Children RGH, January 2007


Triptans for acute tx of migraine cont d1

TRIPTANS FOR ACUTE TX OF MIGRAINE Cont’d :

  • If N and V early in attack, nasal spray (sumatriptan / zolmitriptan) or SC injection (sumatriptan) preferred

  • Most S/E include facial flushing, tingling, chest discomfort

Migraine in Men, Women and Children RGH, January 2007


Triptan contraindications

TRIPTAN CONTRAINDICATIONS :

(Due to minor peripheral vasoconstrictive properties on coronary vessels)

  • IHD

  • CVD

  • PVD

  • Uncontrolled HTN

  • Avoid if patient used Seratonin Agonist/Ergot in past 24 hours

Migraine in Men, Women and Children RGH, January 2007


Triptan failure

TRIPTAN FAILURE :

  • Troubleshooting a treatment failure with Triptans

    • May not be taking it early in attack, when they are most effective

    • Consider higher dose

    • Consider SC or Nasal Spray route if N and V

    • Consider anti-emetic

    • Consider adding NSAID

    • Flexible approach is necessary

Migraine in Men, Women and Children RGH, January 2007


Frequency of use of acute medications

FREQUENCY OF USE OF ACUTE MEDICATIONS :

  • Can cause Medication-Overuse HA

  • Highest risk – Opioids / butalbital-containing combination analgesics / ASA-Acetominophen/Caffeine combinations

    • 3 or fewer days / month

  • Moderate risk – Triptans

    • 9 or fewer days / month

  • Low risk – NSAID

    • 15 or fewer days / month

Migraine in Men, Women and Children RGH, January 2007


Prophylactic medications in the tx of migraine

PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE :

  • Recurring migraine that interferes with activities of DL despite acute tx

  • > 2 such HA / week

  • Failure / overuse / CI to acute tx

  • ADE of acute tx

  • Presence of Hemiplegic Migraine / Basilar Migraine / Migraine with prolonged aura

Migraine in Men, Women and Children RGH, January 2007


Prophylactic medications in the tx of migraine cont d

PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d :

  • Goal of prophylaxis

    • Reduce attack frequency, severity, duration

    • Improve response to acute medications

    • Improve function / reduce disability

    • Decrease cost of migraine management

  • Define an “Effective Agent” to the patient such that realistic goals are set

    • Patient should expect 50 percent reduction in frequency of attacks

Migraine in Men, Women and Children RGH, January 2007


Prophylactic medications in the tx of migraine cont d1

PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d :

  • Should be used one at a time

  • Efficacy of combination treatment is limited

  • Start low, go slow

  • Maximum clinical benefit can take as long as 3 months

  • HA diary helps document response to prophylactic tx

Migraine in Men, Women and Children RGH, January 2007


Prophylactic medications in the tx of migraine cont d2

PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d :

  • Can attempt to taper prophylactic medications in 6-12 months if HA have been under good control

  • Patients may choose to continue tx for longer periods : acceptable option

Migraine in Men, Women and Children RGH, January 2007


Prophylactic medications in the tx of migraine cont d3

PROPHYLACTIC MEDICATIONS IN THE TX OF MIGRAINE Cont’d :

  • B Blockers – Propranolol

  • TCA – Amitryptaline

  • Non-DHP CCB – Verapamil

  • SSRI

  • Anticonvulsants – Valproic Acid

  • AED – Gabapentin, Topiramate

  • Choice can be driven by therapeutic opportunities

  • Patient preference is paramount

Migraine in Men, Women and Children RGH, January 2007


Role of combined acute and prophylactic treatment of migraine

ROLE OF COMBINED ACUTE AND PROPHYLACTIC TREATMENT OF MIGRAINE :

  • Imperative !

Migraine in Men, Women and Children RGH, January 2007


Supplements for migraine

SUPPLEMENTS FOR MIGRAINE :

  • “But, if a patient tells you about a product that works for him and it's not potentially toxic, it's probably best not to refute his claim by explaining that the product hasn't been clinically proven. An explanation of evidence-based medicine to a patient who is not getting relief from conventional treatment may be perceived as arrogance. For some patients, migraine remedies that are unproven, but not toxic nor unreasonably expensive, may fall into the "worth a try" category”

Migraine in Men, Women and Children RGH, January 2007


Supplements for migraine cont d

SUPPLEMENTS FOR MIGRAINE Cont’d :

  • 40 percent of patients with migraine respond to placebo

  • Study to compare effectiveness of fish oil for migraine, olive oil (the placebo) was similar in efficacy to the first

  • American Academy of Neurology recognizes Feverfew, Riboflavin and Mg as preventative tx of migraine

  • Some conventional tx of migraine also lack proof as the other supplemental treatments

  • Many natural products fit the description of inexpensive, and possibly effective with minimal risk of toxicity for prophylaxis

Migraine in Men, Women and Children RGH, January 2007


Supplements for migraine cont d1

SUPPLEMENTS FOR MIGRAINE Cont’d :

  • Feverfew [A]

    • 50 to 100 mg capsules daily

  • Riboflavin [A]

    • Reduces frequency but not severity or duration

    • 400 mg per day

    • Precursors of nucleotides needed for activity of enzymes in the ETC

  • Ginger

    • Anecdotal reports suggest that ginger, ginko and valerian might help

    • No reliable research thus far

Migraine in Men, Women and Children RGH, January 2007


Supplements for migraine cont d2

SUPPLEMENTS FOR MIGRAINE Cont’d :

  • Mg [A]

    • Helpful especially in those with low levels

    • GI S/E

  • Butterbur [A]

    • Reduces frequency, duration and intensity of attacks

    • Potential cause of allergy in pt’s allergic to ragweed/related plants

  • Caffeine/ASA or Acetaminophen [A]

  • Melatonin not yet recommended b/c it is too early

Migraine in Men, Women and Children RGH, January 2007


Supplements for migraine cont d3

SUPPLEMENTS FOR MIGRAINE Cont’d :

  • L-Arginine

    • Has been used in combination with Ibuprofen

    • Contribution of Arginine unclear as Ibuprofen alone relives migraine

  • CoQ10 [A]

    • Favorable

    • Impaired O2 metabolism and low energy states implicated in pathogenesis of Migraine

    • Improves mitochondrial oxidative phosphorylation

    • Watch for patients on Warfarin as might reduce anticoagulant effect

Migraine in Men, Women and Children RGH, January 2007


Botulinum toxin for prophylaxis of migraine

BOTULINUM TOXIN FOR PROPHYLAXIS OF MIGRAINE :

  • RCT thus far have yielded mixed results

  • “Many HA specialists believe that it is effective in a subset of patients”

  • Currently it is routinely part of a HA specialist’s armamentarium for migraine prevention

  • Injected pericranially, and tx repeated Q3 months if beneficial

  • Ptosis, frontal m. weakness, and local injection site pain are mild and temporary

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • MC in women than men, by a ratio of 3 : 1

  • MC than DM, OA or asthma

  • MC occurs in reproductive years

  • Menstruation, pregnancy, OCP use, menopause, HRT influence incidence of migraine and subsequent management

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span1

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • CHILDHOOD

    • In 4-7 y/o, boys get migraine > girls

    • By puberty, girls get migraine > boys by 3 : 1

    • Shorter in duration (1-48 vs. 4-72), peak to intensity more quickly (w/in 1 hour), bilateral rather than unilateral

    • More common to see migraine variants – hemiplegic migraine, basilar migraine, cyclic vomiting

    • Stress is a more common trigger in children

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span2

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • CHILDHOOD

    • More on weekdays than on weekends

    • Ibuprofen is proffered over Tylenol or triptans due to lack of evidence

    • 1/3 require prophylactic tx

    • Topiramate preferred for obese patients for weight reducing side effects

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span3

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • MENSTURAL MIGRAINE

    • 60 percent have migraines associated with menstrual cycles

    • Migraine without aura MC than with aura

    • ? Related to decline in Estrogen in late luteal phase of cycle

    • Miniproprophylaxis with NSAID’s, ergots and triptans

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span4

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • USE OF OCP

    • Unpredictably induce, alter or alleviate migraines

    • If OCP’s exacerbate symptoms, lower OCP to an EE of less than 20 mgm

    • Persistent HA despite above might necessitate OCP’s in these patients

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span5

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • USE OF OCP

    • Both migraine and OCP’s increase stroke risk

    • Migraineurs with aura or other RF for stroke should be assessed individually for appropriate OCP use

    • OCP’s should not be used in migraineurs who smoke

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span6

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • PREGNANCY

    • 50-80 percent of 1st trimester pregnancies in ladies with migraine cause a decrease in migraine frequencies

    • Secondary causes should be considered in pregnant patients who experience migraine for the first time during a pregnancy

    • Avoid preventative medications b/c of potential for teratogenecity

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span7

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • PREGNANCY

    • Topiramate or propranolol are a last measure

    • Definitely avoid valproic acid or ergot derivative-medications

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span8

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • MENOPAUSAL TRANSITION

    • Fluctuations in hormone levels can exacerbate migraines

    • Continuous use low-dose OCP can provide necessary contraception and migraine control

    • Migraine improves after menopause as hormone levels stabilize

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span9

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • MENOPAUSAL TRANSITION

    • Migraines worsen in 2/3 of females with surgically induced menopause

    • Preventative medications in this context should focus on therapeutic opportunities

    • New onset HA after age 45 should be investigated more thoroughly for secondary causes

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span10

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • ELDERLY WOMEN

    • Migraine beginning after age 65 very uncommon

    • > 1/3 of all HA in elderly women has a secondary cause

    • Avoid triptans in patients with PVD, CVD, ACS or uncontrolled HTN

    • B blockers good for prevention in patients with CAD or HTN

Migraine in Men, Women and Children RGH, January 2007


Prevention of migraine in women throughout the life span11

PREVENTION OF MIGRAINE IN WOMEN THROUGHOUT THE LIFE SPAN :

  • ELDERLY WOMEN

    • Avoid TCA in patients with urinary retention or arrhythmias

    • Aura w/out HA – easily confused with TIA

      • Positive (scotoma) vs. Negative symptoms (loss of vision)

      • Gradual buildup vs. abrupt

      • Sequential in modality vs. simultaneous appearance

      • 20-30 mins vs < 15 mins

      • Flurry of mid-life attacks vs. not as common

Migraine in Men, Women and Children RGH, January 2007


Diagnosis prophylaxis and treatment of migraine in men women and children1

DIAGNOSIS, PROPHYLAXIS AND TREATMENT OF MIGRAINE IN MEN, WOMEN AND CHILDREN

BASIL AL-SAIGH, FMR-2

JANUARY 2007

REGINA GENERAL HOSPITAL


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