Transcript Myaesthenia gravis - London Headache Centre

Acute treatment of
migraine
Dr Mark Weatherall
London Headache Centre
2010
The intangibles
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Doctor-patient relationship
Realistic expectations
Education
Triggers
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Hormonal
Dietary
Psychological
Environmental
Sleep
Drugs
10 steps to success
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Make the diagnosis
Use the right drugs
Use effective doses
Treat early when the pains mild
Treat associated symptoms
10 steps to success
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Choose appropriate route of delivery
Observe contraindications
Use prior experience to select/reject drugs
Avoid drugs with high potential for MOH
Combine medications if necessary
Where to start?
paracetamol 1 g
 or, aspirin 900 mg
 or, ibuprofen 600-800 mg
 +/- domperidone 10-20 mg
 taken as soon as possible*ª
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* 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
Variations on a theme
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if early nausea, you can use:
soluble aspirin
suppositories*:
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diclofenac 75 mg
domperidone 30 mg
*be French!
Headache response at 2 hr
Problems, problems…
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Not effective
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Contraindications
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dose? timing? route? combination?
asthma, upper GI problems, renal impairment
Side effects
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GI, CNS
Codeine…?
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… is NOT a treatment for headache
the WHO analgesic ladder should NOT be
applied to headache management
Triptans
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5-HT1B/1D receptor agonists
seven different formulations
options for route of delivery
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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
Which triptan?
Headache response at 2 hr
Pain freedom at 2 hr
Problems, problems…
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Ineffective
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Headache recurrence
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switch? combination with NSAID?
Contraindications
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dose? timing? route? switch?
HT, IHD
SE
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nausea, GI, CNS, ‘triptan chest’
Is the future ‘pants’?
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CGRP antagonists
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two with data recently published
proof-of-concept trial of intravenous BIBN4096BS
(now called olcagepant) was published in NEJM
in 2004
phase II study of oral CGRP antagonist MK-0974
(now called telcagepant) presented at IHS 2007
and published in Neurology in 2008
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multicentre phase III R-PT-PC-DB-T of oral
telcagepant 150 or 300 mg vs zolmitriptan 5
mg and placebo published in The Lancet in
last four weeks