Thread by @migraine_ce

Be sure to join us RIGHT HERE on Monday for the launch of a new accredited #tweetorial on continuity of care in the mgt of #migraine, by expert author Annika Ehrlich, MS, FNP-C, AQH, CNRN (@EhrlichNP). Follow us so you don't miss a tweet on your way to 0.75h CE/#CME credit!

1) Welcome to an accredited #tweetorial on #migraine, focusing on continuity of care, education, communication & resources for you & your patients. I am Annika Ehrlich, MS, FNP-C, AQH, CNRN (@EhrlichNP). Follow this thread & earn 0.75h CE/#CME credit! @academiccme @UCSFHospitals

2) This series is supported by an educational grant from AbbVie and is intended for healthcare providers. Faculty disclosures are listed at academiccme.com//migrainetweet…. Program chair Dr. Tesha Monteith (@headacheMD) and I welcome your participation! #FOAMed #neurotwitter

3) As reviewed in our previous @migraine_ce tweetorials (you can still earn credit! just go to academiccme.com/migraine-tweet…), #migraine is one of the most common neurologic conditions, affecting over 1 billion people worldwide.

4) It is the leading cause of disability for people during prime years of life when they are most productive. See Lancet, 390 (10100):1211–1259. @AANPublic @amfmigraine @MigraineDisordr

5) Given that migraine is a genetic neurologic disorder, pts may experience periods of worsened and/or improved symptoms throughout their lifespan. Providing education about migraine, possible progression, and non-pharmacologic management strategies ...

6) ... can help improve symptoms, self-efficacy and give the patient a sense of control over their condition. So with that in mind, let’s discuss a patient case.

7) Robert, 25M with no sig PMH, presents to your office for eval of #headaches that occur several times/mo & are quite disabling. Headache is located over his left temple but can move location and is “pounding”. He prefers to lie down in a dark room when he gets these headaches.

8) He sometimes has nausea with them. Headaches can start slowly, last several hours and sometimes improve if he takes ibuprofen early enough with a lot of water. No other associated symptoms, sometimes being dehydrated or not sleeping well can be triggers.

9) He does remember getting occasional headaches starting in childhood, but not as severe, & frequency has been ⬆️ing over the past few years. Family history is positive for headaches in his mother. History, Review of Systems and the physical exam, including fundoscopy, are WNL.

10) He asks what types of tests are needed to help make sure “nothing serious” is going on and to find out what is causing his headaches. How would you respond? Well, per International Classification of Headache Disorders, 3rd Edition, ichd-3.org, his headache ...

11) ... meets ICHD3 criteria for migraine without aura (episodic, as he is getting 2-5 headache attacks/mo).
ICHD3 Criteria for Migraine:
Number of attacks: At least 5
Duration: 4-72 hours (untreated or unsuccessfully treated)

12) Pain characteristics (at least 2 of 4): Unilat location, pulsating quality, moderate-severe pain intensity, aggravation by or causing avoidance of routine activity
Accompanying feature (at least 1 of the following during headache): Nausea &/or vomiting, photo & phonophobia

13) @ahsheadache joined the Choosing Wisely initiative of @ABIMFoundation in 2013 to help make recs regarding tests & procedures in headache medicine. 1 rec: “don’t do neuroimaging studies in pts w/stable headaches that meet criteria for migraine”, given low yield in this group.

14) That ref is Headache 2013;53:1651–1659. You explain to Robert that he has migraine, which is a clinical diagnosis and there are no current available blood or imaging tests to diagnose the problem. Imaging may help to look for other causes when atypical symptoms occur, ...

15) ... & genetic testing at this time does not provide any useful info due to the complex nature of migraine. You focus communication on teaching that migraine is an inherited neurologic disorder, & ask if he would like to review some things that he can do ...

16) ... to help improve his symptoms & frequency of attacks, in addition to talking about medications that may be helpful. See doi: 10.1016/j.mcna.2018.10.003. Lifestyle modification benefits pts by modifying triggers for migraine, mitigating frequency & severity of symptoms.

17) It is important to partner with patients and educate that lifestyle factors can be triggers but are not the cause of their underlying migraine disorder.
Some of the most important lifestyle factors to consider when evaluating a patient with migraine include:

18) It's ALL of the above! A great mnemonic to help remember the important lifestyle factors in migraine is “SEEDS” – Sleep, Exercise, Eat, Diary, Stress.
americanmigrainefoundation.org/resource-libra… and doi: 10.3949/ccjm.86a.19009

19) SLEEP: How much sleep is the patient getting per night? Do they snore, or wake up with headache (consider #OSA)? Do they go to sleep & wake up at the same time? Are they napping during the day? Obstructive sleep apnea & insomnia are associated with migraine.

20) Addressing these issues is important for overall health and may improve migraine symptoms. Headache 2018;58:1030–1039.

EXERCISE: The recommended goal is 30-60min of aerobic exercise, 3-5x/wk. There have been several studies comparing exercise to prophylactic meds ...

21) ... or in addition to other pharmacologic treatments.
One study randomized participants to an exercise group (40min 3x/wk) or a med group w/topiramate. Both groups demonstrated reduction in migraine attacks. Cephalalgia 2011;31:1428–1438.

22) For some patients, vigorous exercise can be a trigger. Discussing data regarding links between exercise & migraine reduction & working with them on a feasible exercise plan is advised. Swimming, yoga, tai chi, are other gentler ways of movement that may provide benefit.

23) See americanmigrainefoundation.org/resource-libra… as a resource. If a patient asks which diet is best for someone w/migraine, the best answer is EAT: consistency is key with migraine. Keeping well-hydrated and blood sugar levels stable is important.

24) There are certain common food triggers for migraine, however triggers can vary widely and there is little data on benefits of avoiding certain triggers or to support specific diets. Keeping a food diary or consulting with a nutritionist may be helpful for patients ...

25) ... particularly interested in identifying triggers, pursuing specific diets, or those having trouble maintaining a healthy diet. See Headache 2020;60:1300–1316. Patients should be counseled on sticking to a healthy diet full of fresh fruit &vegetables, lean proteins & ...

26) ... whole grains, and avoiding simple carbohydrates. Hydration with water throughout the day is equally important, as dehydration can be a trigger. See Headache 2005;45:757–759. So, a poll: All patients with migraine should eliminate caffeine from their diet:

27) Mark your answer and return TOMORROW for more education! @MigraineDisordr @CSWhiteMD @stephanieJnahas @MiaMinenMD @ThomasBerkMD @ahsheadache @diamondheadache @AMastersMD @DrMeganDonnelly @AEPaceMD @ffiorito27 @AmaalStarlingMD @daviddodick @mrobbinsmd @aligha1981 @ASunejaMD