Transcript Myaesthenia gravis - British Association for the Study of Headache

Acute treatments for migraine
Fayyaz Ahmed
Chester Migraine Education Day
8 September 2012
YOUNG OR OLD
To set the scene...

“[Migraine] is a malady of which the student gains little
practical knowledge in the course of his hospital work,
unless he is so unhappy as to learn from the most
effective of all instructors, personal suffering... It is
common enough, but seems, to most of its subjects, by
long experience so much an inevitable part of life that
few seek relief.”
William Gowers (1906)

“A doctor who cannot take a good history and a
patient who cannot give one are danger of giving and
receiving bad treatment”
Anonymous
10 steps to success
Get the diagnosis right
 Set realistic expectations
 Consider non-pharmacological measures
 Use the right drugs
 Use effective doses
 Treat early when the pains mild
 Treat associated symptoms
 Choose appropriate route of delivery
 Avoid medication overuse
 Use prophylactic treatments appropriately

1. Making the Right Diagnosis

‘migraine’ - a disorder and an attack
◦ the disorder is characterised by:
 the tendency to repeated attacks
 triggers
 sleep, food, weather, chemical (EtOH/GTN), hormonal, sensory, stressrelaxation
 family history
◦ the attack
 premonitory symptoms (20%+)
 headaches typically unilateral, throbbing
 associated with nausea +/- vomiting
 sensitivity to light, sound, smells, movement
 auras, usually visual, occur ~15-20% of patients
Migraine or TTH?


phenotype the worst type of attack
patients with headaches that met criteria for
migraine, probable migraine, and TTH, all
headache types responded to triptans
(Spectrum Study)
◦ this was not true for patients with purely TTH

recurrent severe headaches are migraine,
until proven otherwise
2. Set realistic expectations
there is no ‘cure’
 recognising the disorder
 goal setting

◦
◦
◦
◦

trigger management
effective acute treatment
reducing attack frequency
appraisal of best available options
explaining the natural history
3. Non-pharmacological measures

lifestyle issues
◦ Hectic lifestyle
◦ No time for timely sleep or meals
◦ Too much on your plate

trigger management
◦ hormonal
◦ dietary
◦ psychological
 CBT, relaxation
◦ environmental
◦ sleep
◦ neck...
4. Use the right drug
 START WITH
Simple Painkillers
 Aspirin, Paracetamol, Ibuprofen
 ESCALATE TO TRIPTANS
 AVOID
CODEINE, CAFFEINE,
BARBITURATE BASED
COMBINATIONS
Why simple painkillers first?

50% Headache sufferers do not consult1
◦ ‘it is too inconvenient to see a doctor’ (53%)
◦ ‘there is nothing a doctor could do’ (22%)

70-80% would respond to first line and are self limiting1

OTC availability – less use of healthcare resources
1. Steiner and Fontebasso 2002
Why Ibuprofen than other NSAID?
Availability OTC
 Less side effects and better tolerability1-2,10,11
 More evidence based3-4
 Recommended by guidelines5-9

1. Langman et al, Lancet 1994
2. Rainsford, 2009
3. Rabbie et al, 2010 Cochrane Collaboration
4. Haag et al, 2007
5. SIGN guidelines, 2010
6. British Association for the Study of Headache, 2010
7.Bendtsen et al EFNS guidelines 2010
8. EHF guidelines, 2009 Steiner, Marteletti
9. American Academy of Neurology, April 2012
10. Henry D et al, BMJ 1996
11.Doyle, 1999
5. Use effective doses
 paracetamol
1g
 or, aspirin 900 mg
 or, ibuprofen 600-800 mg
◦ If early nausea
soluble aspirin
 suppositories*:

◦ diclofenac 75 mg
*be French!
6. Treat early when mild

Benefit
◦ Avoiding a disabling
attack
◦ Better response

Risk
◦ Treating a wrong
attack
◦ Risking medication
overuse
7. Rx associated symptoms
Avoid physical activity
 Avoid bright lights
 Avoid disturbing noises
 Domperidone 10-20 mg

8. Choose appropriate route of delivery
Problems, problems…

not effective
◦ dose? timing? route? combination? diagnosis?

contraindications
◦ asthma, upper GI problems, renal impairment

side effects
◦ GI, CNS
This is what patients do next
Codeine…?

… is NOT a treatment for headache
◦ the WHO analgesic ladder should NOT be
applied to headache management
Triptans



5-HT1B/1D receptor agonists
seven different formulations
options for route of delivery
◦ oral tablets or melts
◦ nasal spray
◦ subcutaneous injection

taken as soon as possible*ª¹
* i.e. as soon as the patient knows that this is a migraine
ª if there is aura, take at the start of the headache phase
¹ this is a race against the development of allodynia
Headache response at 2 hr
Pain freedom at 2 hr
advantages
disadvantages
Sumatriptan
well-established
available OTC
now the cheapest
s/c, nasal spray
expensive
poorly absorbed
Zolmitriptan
cheaper
long acting
nasal spray, melt
occasional confusion
Naratriptan
cheaper
long acting
slow onset
Rizatriptan
rapid onset
melt
high recurrence
Almotriptan
cheaper
low SE incidence
Eletriptan
cheaper
long acting
pumped out of CNS
Frovatriptan
longest half-life
slow onset
9. Avoid medication overuse
Restrict to two
doses per week
 Use long acting
triptans
 Avoid combination
analgesics
 Can use triptan and
NSAID such as
sumatriptan and
naproxen

Problems, problems…

ineffective
◦ dose? timing? route? switch?

headache recurrence
◦ switch? combination with NSAID?

contraindications
◦ HT, IHD

SE
◦ nausea, GI, CNS, ‘triptan chest’
10. Use preventive treatment

Should be offered to patients with 6 or more
headache days per month; 4 or more days with some
impairment; or 3 or more days with severe functional
impairment

Should be considered with 4–5 days per month with
normal functioning; 3 days with some impairment
and 2 days with severe impairment

Should not be given to patients with <4 days of
headache per month with normal functioning; or no
more than 1 day per month regardless of impairment
The future

new drugs with novel targets
◦ serotonin subtypes; CGRP; glutamate; TRPV1; nitric
oxide; prostanoids; cortical spreading depression

new delivery mechanisms for existing drugs
◦ inhaled DHE
◦ inhaled, transdermal, needle-free triptans
Neurostimulation

Transcranial Magnetic Stimulation

Vagal nerve stimulation (Gammacore)