ACUTE MIGRAINE
Medication needed not more than twice a week
MILD
- NSAIDs or combination NSAIDs/Paracetamol (+/- caffeine)
MODERATE / SEVERE
Triptans (Serotonin 1B/1D receptor agonists)
Sumatriptan (Imigran)
- Oral: 25 mg, 50 mg, 100 mg
- Nasal: 5 mg, 20 mg
- Auto-injector (SCI): 4 mg, 6 mg (works as quickly as 15 min)
- Transdermal: 0.5 mg?
Zolmitriptan (Zomig)
- Oral: 2.5 mg, 5 mg
- ODT: 2.5 mg, 5 mg
- Nasal: 5 mg
Rizatriptan (Maxalt)
- ODT (wafers): 10 mg
Ergotamines
Dihydroergotamine (DHE)
- 0.5 – 1.0 mg IV/SC x days @ risk
- Nasal [4 mg/mL]: 1 spray each nostril, repeat 15 min x days @ risk
Note: a good combination is Naproxen + a Triptan !
Who to treat?
All patients. Arm them with different therapies depending on the profile of the attack (i.e. stratifying the attack within a patient) according to:
Timing
Menstrual (tend to be more severe)
- Triptans + NSAIDs
- Dihydroergotamine
Prolonged attack (especially > 72 hours)
- IV DHE
- Triptans (especially non-orals)
Associated symptoms (N/V)
- Non-oral Triptans
Patient preference
Delivery of drug
Profession/work
Avoid opiates
CHRONIC MIGRAINE
“You’re still going to get headaches, but …”
By definition, when there is headache for 15 or more days a month, and that refractory pattern has been going on for over 3 months, then focus on prevention with the aim of reducing headache frequency by 50% and headache severity by 50% (i.e. not cure but rather to revert to infrequent episodic migraine pattern) — importantly, will still need acute medications (which may work better than previously). This usually takes 1-2 months.
At the outset, it is important to find out what medications they have tried in the past (for prevention) and what doses did they get up to and why?
Management requires a combination of:
Preventive medications (have a bout a 50% response rate) — start low and advise the patient to increase the dose every week to get to a therapeutic dose:
Antihypertensives
BBs
- Propranolol 80-240 mg PO
- Metoprolol 100-200 mg PO
CCBs
Antidepressants
TCAs
- Amitriptyline (start at 10 mg)
- Nortriptyline
SNRIs
- Venlafaxine
SSRIs
- Fluoxetine
Anticonvulsants (AED)
- Topiramate —start at 25 mg (oral 50 – 200 mg)
- Divalproex
Procedures
- Onabotulinumtoxin A
- Addressing medication overuse
- Use of acute medications > 2 x/week and increasing
- Attention to comorbid conditions
- Hypertension
- Anxiety
- Bipolar
- Counselling —CBT, Biofeedback, Physical therapy
Follow-up is monthly and needs to also address:
- Lifestyle — Sleep; Diet —caffeine, alcohol; Exercise
- Medications
- Herbal preventives — Butterbur 75 mg bd, Vitamin B2, Magnesium, Feverfew, CoQ10
- Prescription drugs (as above)
Who to treat?
By definition, those who have two migraine attacks per month with significant disability (e.g. significant vomiting, miss work) or complicated migraine with aura, then think prophylaxis.
Medication Overuse Headache (MOH) 1-2%
ICHD-II
- Headache: 15 days/month
- Medicate: 10 days/month for 3 months
- Develop/worsen during overuse
- Resolve/revert 2 months after discontinue medication
Because of the inherent time lag in effecting a diagnosis, the last criterion has since been removed.
Note: MOH accompanies a Primary chronic daily headache (CDH), that is not due to secondary causes.
[CDH = HC, NDPH, CM, CTTH]
Risk Factors for MOH
Modifiable v non-modifiable
Provide patient education
Management strategies — medicated withdrawal, whether outpatient or inpatient, and education
- Fluids
- Limited quantity of acute abortive agents
Treatment
- NSAIDs
- Triptans
- Ergotamines
- Diphenhydramine
- Magnesium
- Neuroleptics
After withdrawal, limit acute analgesics to less than 10 days per month.
Treatment
- Onabotulinumtoxin A
- Topiramate
- Behavioural/psychological support (refer to psychologist with chance pain?/MOH)
70% success rate but 40-60% relapse (usually first 6-12 months)
Comorbidity
A variety of different medical and psychological disorders that are associated with greater disability in migraineurs and require unique management/treatment considerations but offer areas for education/validation for the patient — e.g. mood disorders, pain disorders, CVS disorders, others (e.g. allergies, asthma, epilepsy, sleep disorders).
Summary
Avoid opioids in your everyday migraine management. Of the opioids, pethidine (neurotoxicity), codeine (erratic pharmacokinetics) and tramadol (strange pharmacodynamics) are probably the least predictable and should be overlooked. If opioids are necessary, consider judicious but adequate use of oxycodone, hydromorphone, or morphine.
References:
https://education.redmeded.com/wf/wf.do
http://www.myvmc.com/drugs/dihydergot/
A comprehensive review of Migraine Treatment From A to Z: 2014, can be found at http://www.practicalpainmanagement.com/pain/headache/migraine/migraine-treatment-z-2014 as at June 26, 2016.