Transcript Management of Migraine

Management of Migraine
MIGRAINE - Pattern of recurrent episodes of severe
disabling headache associated with nausea and sensitivity
to light and who have a normal neurological examination.
ACUTE TREATMENT
Avoid opiates due to potential for developing medication overuse headache.
Step one: simple oral analgesia (aspirin 900mg [adults only], paracetamol
1000mg, ibuprofen 400-600mg in soluble or mouth-dispersible formulation
taken early in the attack. And if necessary, metoclopramide 10mg or
domperidone 20mg as antiemetics and to promote gastric emptying.
Step two: parenteral administration to bypass the stomach such as diclofenac
suppositories 100mg for pain plus domperidone suppositories 30mg (if
needed) for nausea/vomiting.
Step three: triptans should be offered, unless contra-indicated, to all patients
failing steps 1 and 2. They are associated with return of symptoms within 48
hours (relapse) in up to 40% of patients who have initially responded.
Different triptans work for different individuals and include:
Sumatriptan tablets (50mg and 100mg), nasal spray (10mg [licensed for adolescents] and
20mg) or self-administered subcutaneous injection (6mg). The last is appropriate when a rapid
response is important above all, or if vomiting precludes oral therapy.
Zolmitriptan tablets (2.5mg), mouth-dispersible tablets (2.5mg) (two of either may be taken if
needed) or nasal spray (5mg). The last may be useful despite vomiting since absorption is
through the nasal mucosa.
Rizatriptan tablets (5mg [to be used when propranolol is being taken] and 10mg) or mouthdispersible wafers (10mg).
Naratriptan tablets (2.5mg). It has slower onset of effect but may be appropriate when other
triptans cause undue side-effects.
Almotriptan tablets (12.5mg).
Eletriptan tablets (20mg and 40mg: 2 x 40 mg may be taken if needed).
Treatment of relapse: a second dose of a triptan is usually effective for
relapse. The second dose may lead to further relapse in which case diclofenac
may be an effective alternative. Ergotamine tartrate, with prolonged duration of
action, may be useful for this purpose; it should not be used within 12 hours
after any triptan.
In Menstrually related migraine:
Mefanamic acid 500mg tds-qds or
Naproxen 500mg bd during
menstruation. Or COCP or
transdermal oestrogen as long as
there is no aura.
CI to Triptans:
- Uncontrolled HTN
- CHD
- CVD
- PVD
- RF for the above
PROPHYLAXIS
Prophylactic therapy is added when best acute therapy gives
inadequate symptom control. Once-daily dosing is preferable and
each should be tried for a minimum of 3-4 weeks. Otherwise, there
are no criteria for choice of prophylactic drug except those of
comorbidity and contraindications. The dose of each should, start
low in the suggested range and be increased in the absence of sideeffects.
Beta-adrenergic blockers without partial agonism - atenolol 25-100mg bd,
propranolol LA 80mg od-160mg bd. Avoid in asthma, heart failure,
peripheral vascular disease and depression.
Sodium valproate 0.6-2.5g daily. Avoid during pregnancy and when
pregnancy may occur, and use with care in children.
Topiramate 50-200mg per day
Gabapentin 1200-2400mg per day
Pizotifen 1.5mg at bedtime. Avoid when weight gain is undesirable.
Amitriptyline 10-150mg at bedtime (or 2-4 hours before). Use when
migraine coexists with TTH, depression or sleep disturbance. It may be
used concomitantly with a beta-blocker. Explain the choice of this drug to
patients who do not consider themselves depressed or they may reject it.
In children: beta-blockers or pizotifen (available as an elixir) may be
tried. Some paediatricians use sodium valproate or amitriptyline.
Dosage is adjusted according to age.
Also stress management and Acupuncture.
If effective it should be continued for 4-6 months, then withdrawn (abruptly
or tapered) to establish continued need.
Management of Common Headaches seen in GP
RED FLAGS - Need specialist referral
Tension-type headache
Bilateral headache that is non-disabling where there is a normal
neurological examination.
Drug therapy has limited scope but is effective in some patients:
• Symptomatic treatment with over-the-counter analgesics is appropriate for
episodic TTH occurring on <2 days per week: aspirin 600-900mg,
ibuprofen 400mg or paracetamol 1000mg
• Codeine and dihydrocodeine should be avoided.
Assessment requires a
detailed history.
Exam should include BP,
Neuro exam, fundoscopy
and neck muscles. If over
50 consider ESR
New onset or change in headache in patients over 50
Thunderclap headache
Focal neurological symptoms
Non-focal neurological disturbance eg, cognition
Abnormal Neurological exam
Headache which changes with posture
Headache waking up form sleep
Headache ppt by valsava maneouvre or exercise
Cluster headache
Patients with RF for venous sinus thrombosis
SHOULD BE MANAGED
BY A SPECIALIST
Neck stiffness
• A 3-week course of naproxen 250-500mg bd may interrupt frequently
recurring or unremitting headaches
Jaw claudication or visual disturbance
Fever
Headache in patient with cancer
Headache in patient with HIV infection
PROPHYLAXIS
Frequent, brief, unilateral headaches with autonomic features.
Amitriptyline is the prophylactic treatment of choice for frequent episodic or
chronic TTH; intolerance is reduced by starting at 10mg at night and
incrementing by 10-25mg each 1-2 weeks usually into the range 50-150mg
at night. Sodium valproate 0.6-2.5g daily is an alternative; avoid during
pregnancy and use with care in children.
The objective in both episodic and chronic CH, not always achievable, is total
attack suppression. In most cases, preventive drugs are the mainstay of
treatment. Analgesics have no place in treating CH.
If there is evidence of musculoskeletal problems – physio may be of benefit.
If the patient admits to feeling stressed encourage lifestyle changes,
relaxation and possibly CBT.
Acute therapies
- Sumatriptan 6 mg subcutaneously is the only proven highly-effective acute
treatment
- Oxygen 100% at 7 l/min (requires a special mask and regulator) helps some
people
PROPHYLAXIS
Medication-overuse headache
Prevention is ideal, with education the key factor.
This type of headache must be excluded in all patients with chronic daily headache.
Treatment is withdrawal of the suspected medication(s). Although this will lead initially to
worsening headache, with forewarning and explanation it is probably most successfully done
abruptly. Within 2-3 weeks, usually, the headache shows signs of improvement. Patients
should be reviewed at this time to ensure withdrawal has been achieved. Improvement may be
slow but continues for weeks to months. 50-75% of patients revert to their original headache
type which may be migraine (usually) or TTH. This headache should be reviewed after 2-3
months and managed appropriately. Most patients require extended support: the relapse rate is
around 40% within five years.
Prophylaxis of episodic CH should begin early after the start of a new cluster
bout.The following are used by specialists.
- Verapamil 240-960 mg/day (Do not take with beta blocker and need ECG to
exclude AV block)
Prednisolone 60-80 mg/day for 2-4 days, discontinued by gradual dose reduction
- Lithium carbonate 600-1600 mg/day
Ergotamine 2-4 mg/day per rectum, usually omitted every 7th day
- Methysergide 1-2mg tds
Duration of use of prophylaxis: apart from prednisolone, treatment should be
discontinued 2 weeks after full remission.