migraine%20headache
MIGRAINE HEADACHE
Migraine headache without aura has at least 5 attacks of any 2 symptoms of unilateral headache that is throbbing or pulsating in nature, moderate to severe in pain and activity aggravates pain. It is accompanied with either nausea and vomiting or photophobia &/or phonophobia. The symptoms last for 4-72 hours without signs of secondary headache.
Migraine headache with aura has at least 2 attacks with any of the fully reversible symptoms of flickering lights, spots or lines &/or vision loss, sensory symptoms of pins & needles &/or numbness and dysphasic speech disturbance but without motor weakness. Accompanied by at least 2 of the following symptoms of homonymous visual symptoms &/or unilateral sensory symptoms or at least 1 aura symptoms develop gradually over ≥5 minutes &/or different aura symptoms that occur in succession over ≥5 minutes.

Principles of Therapy

Principles of Treatment - Acute Treatment

  • Therapy should be guided according to frequency, duration and severity of attacks, associated symptoms, degree of disability, history of treatment and patient’s preference
  • Coexisting medical conditions should also be considered in migraine therapy
    • Myocardial infarction, stroke, epilepsy, affective and anxiety disorders are common in patients with migraine
  • Effective therapy should be established and promptly used to decrease pain and disability
  • Non-oral route of administration should be used in patients who suffer migraines associated with severe nausea and vomiting
  • Antiemetics should be used if nausea and vomiting are likely to occur
  • Educate patient about avoiding medication overuse
    • Administer preventive therapy if necessary
  • To avoid headache from drug overuse, simple analgesics should be taken for a maximum duration of 15 days per month while combined analgesics should be taken up to 10 days per month

Goals of Treatment - Acute Treatment

  • Abort migraine attack
  • Treat migraine attack rapidly and consistently without recurrence
  • Restore patient’s ability to function
  • Minimize need for back-up and rescue medications
  • Self-care should be optimized
  • Avoid adverse effects

Criteria for a Successful Treatment

  • Pain-free after 2 hours
  • Improvement of migraine from moderate or severe to mild or none after 2 hours
  • Consistent efficacy in 2 of 3 migraine attacks
  • Sustained pain relief defined as absence of headache recurrence and no further intake of drugs within 24 hours

Management Strategy - Acute Treatment
Stratified Care Strategy

  • Acute treatment is based on headache severity
  • Promotes the use of migraine-specific agents for moderate to severe headache regardless of the previous response to other agents

Stepped Approach

  • Use of drugs is based on a progressive predetermined way
  • Safe, effective and inexpensive medications are used as 1st-line agents
  • If initial agent fails, migraine-specific medication is then used
  • Eg commence treatment with an analgesic with or without antiemetic, then escalating to triptan or 5HT1 receptor agonist

Principles of Therapy - Prophylactic Treatment 

  • Agent used should be started at a low dose and slowly titrated to higher doses
    • Increase dose until benefit is seen or until limited by adverse events
  • Choice of drug agent depends on the following: Adverse effects, presence of comorbidities, drug interactions, evidence-based efficacy, patient preference
  • Migraine prophylaxis is considered successful if there is at least 50% decrease in the frequency of migraine attacks per month within 3 months
  • Prophylactic drugs that are effective should be continued for 4-6 months followed by withdrawal by tapering the dose over 2-3 weeks 

Goals of Treatment - Prophylactic Treatment 

  • Reduce severity, duration and frequency of migraine headache
  • Improve patient’s quality of life and decrease disability
  • Improve response to acute therapy 
  • Prevent progression to chronic migraine & occurrence of medication overuse headache

Pharmacotherapy

PHARMACOLOGICAL THERAPY - ACUTE TREATMENT

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) including Analgesics

  • Analgesics are the 1st-line agents for moderate migraine attacks
  • Efficacy and tolerability of nonsteroidal anti-inflammatory drugs have been shown in a number of clinical trials
  • Paracetamol is recommended as acute treatment for moderate migraine
  • Aspirin is recommended for acute treatment in patients with all severities of migraine
  • Intravenous Aspirin with or without Metoclopromide is the 1st choice in patients with severe migraine in an emergency situation
  • For resistant attacks, nonsteroidal anti-inflammatory drugs (oral, rectal or IM) can be given following, or added to, a triptan
  • The use of selective COX-2 inhibitors in acute migraine treatment has been investigated in clinical trials

 

Triptans (Serotonin 5HT1 Receptor Agonists)

  • Efficacy of triptans ranges in comparative efficacy as shown in clinical trials; however, there are unpredictable individual variations in response to different triptans
  • They have better efficacy when given at the very onset of the headache or while the migraine pain is at mild level
    • Not safe and effective when administered during the aura
  • Oral triptans are recommended for acute treatment of migraine with all severities if previous attacks are not controlled by simple analgesics
  • Use is limited to maximum of 9 days/month
  • Sumatriptan is available in nasal, subcutaneous (SC) and rectal formulations
    • Subcutaneous Sumatriptan has the fastest onset of efficacy, yet also has the highest recurrence rate; may also be considered in treatment of severe migraine
    • Nasal formulation is not recommended if vomiting precludes oral therapy since its bioavailability depends largely on ingestion
    • Suppositories should be given in patients with vomiting
  • Use of Zolmitriptan nasal formulation is considered in patients with severe migraine; may also be used even ifvomiting is already occurring since up to 30% is absorbed through the mucosa
  • It is confirmed on several trials that patients who fail to obtain adequate relief with 1 triptan can benefit from another in subsequent attacks
    • Each triptan should be tried in 3 attacks before it is rejected
    • Change in dosage and route of administration should be considered

 

Ergot Alkaloids

  • Used in patients with very long migraine attacks or with regular recurrence due to its lower recurrence rate
  • Use has been limited by their high potential to cause medication overuse headache and rebound headache
    • Intake should be limited to 10 days/month

Ergotamine

  • Combinations with Caffeine, Butalbital and/or Belladonna are available
  • Historically has been used to treat moderate-severe migraine headache
  • Restricted in patients with very long migraine attacks or with regular recurrence due to its longer half-life and lower recurrence rate
    • Use has been limited by high potential to cause medication overuse headache and rebound headache
    • Suppository formulation is available
    • Should not be taken concomitantly with any triptan

Dihydroergotamine (DHE)

  • Available in rectal, parenteral and nasal formulations
    • Nasal formulation is effective and safe as monotherapy
  • More appropriately used in severe migraines
  • Recommended as treatment for status migrainosus

Antiemetics

  • Antiemetics have been used in conjunction with migraine medications to control nausea and vomiting
  • Fair evidence has shown that Metoclopramide may be effective as monotherapy for acute attacks
    • It has mild analgesic efficacy in migraine when given orally and higher efficacy when given IV
  • Domperidone is less sedating than Metoclopramide; has also less risk of extrapyramidal effects
  • Available in different forms (eg oral, parenteral, rectal)

Other Drugs

  • Opioid Analgesics
    • Opiates and tranquilizers are not recommended in the treatment of acute migraine
    • There are no studies that support the effectiveness of opiates

Combination Therapy

  • There is some evidence that combination of Sumatriptan and Naproxen is superior to either drug alone
    • Combination reduces the development of headache recurrence
  • Fixed combinations containing Paracetamol, Aspirin and caffeine have been shown to be effective
    • They are better than single substances or combinations without caffeine
  • Caffeine should be added as 1st choice in treating intermittent, infrequent headache
  • Other combinations:
    • Oral analgesic or nonsteroidal anti-inflammatory drug with or without antiemetic plus specific anti-migraine drugs, followed by
    • Rectal analgesic with or without antiemetic plus specific anti-migraine drugs

Menstrual Migraine

  • Acute treatment is same as that of non-menstrual headache
    • May be necessary to repeat the treatment since menstrual attacks may have longer duration

Migraine in Pregnancy

  • Paracetamol may be used if migraine occurs anytime during pregnancy
  • In the 2nd trimester of pregnancy, nonsteroidal anti-inflammatory drug can be given
  • Non-pharmacological management is preferred
    • Biofeedback, relaxation and physical therapy may be tried
  • Ergotamine and dihydroergotamine are contraindicated during pregnancy

PHARMACOLOGICAL THERAPY - PROPHYLAXIS

Antiepileptic Drugs

  • Valproic acid, Divalproex sodium and Topiramate have been shown to be effective in preventing migraines
    • Efficacy is comparable with Metoprolol, Propranolol and Flunarizine
    • Topiramate has been considered as one of the drugs of 1st choice for migraine prophylaxis

Antidepressants

  • Useful in patients with coexisting depression or insomnia
  • Not all antidepressants are effective
  • Amitriptyline has been studied more than any other antidepressant
    • Has been shown statistically to be effective in preventing migraines
  • Fluoxetine has been studied w/ inconclusive evidence of efficacy
  • Venlafaxine may also be recommended for migraine prophylaxis

Beta-Blockers

  • Useful in patients with coexisting essential tremors, anxiety and/or panic attacks
  • Propranolol and Metoprolol have both been shown to be consistently effective in preventing migraines
  • Atenolol, Bisoprolol, Nadolol and Timolol have shown limited effectiveness

Botulinum toxin A

  • Currently approved for prophylaxis of chronic migraine headaches
  • Given approximately every 12 weeks as multiple injections around the head and neck to dull future symptoms of headache

Calcium Channel Blockers

  • Flunarizine has shown efficacy in migraine prophylaxis in several studies
  • Flunarizine has been recommended as one of the drugs of 1st choice for prophylaxis

Nonsteroidal Anti-inflammatory Drugs

  • May be considered in patients in need of migraine prophylaxis
  • Should be used w/ caution as prolonged use (≥15 days/month) may cause medication overuse headache

Serotonergic Antagonists

  • Use of Methysergide is limited to short-term prophylaxis (maximum of 6 months) because of adverse effects;also associated with severe rebound headache
  • Pizotifen is not recommended because of its poor efficacy and severe side effects

Herbal/Vitamin/Mineral

  • Although the level of evidence is low, the following have been recommended for migraine prophylaxis due to fewer side effects and modest efficacy:
  • Co-enzyme Q10
    • One randomized placebo-controlled trial has shown that co-enzyme Q10 has decreased migraine attack frequency and with good tolerability
  • Magnesium
  • Riboflavin

Hormone-Related Migraine

  • Prophylaxis should be tried for a minimum of 3 cycles at maximum dose before it is deemed ineffective
  • Mefenamic acid is recommended as 1st-line agent in migraine occurring with menorrhagia and/or dysmenorrhea
    • May be given at the onset of menstruation until the last day of bleeding
  • Triptans (eg Frovatriptan, Naratriptan, Zolmitriptan) have been studied in clinical trials of short-term prophylaxis of menstrual migraine
  • There are limited studies available on the use of ergot alkaloids as cyclic prophylaxis
  • Hormones are considered supplements in patients with menstrual migraine
    • In a patient with intact uterus and menstruating regularly, progestogens are not necessary
    • Patients suffering from menstrual migraine can benefit from the following drugs: combined hormonal contraceptives (CHC), progestogen-only oral Desogestrel, subdermally-implanted Etonogestrel and injectable depot Progestogen
    • The following are contraindications to contraceptive use of combined hormonal contraceptives: Migraine with aura and migraine treated with ergot derivatives

Migraine in Pregnancy

  • Most women with migraine improve during pregnancy, hence prophylaxis is not usually needed
  • If prophylaxis is necessary, Magnesium and Metoprolol are recommended
    • Propranolol has the best safety profile
    • Amitriptyline in the lowest effective dose can also be us

Non-Pharmacological Therapy

Behavioral and Physical Methods For Migraine Prophylaxis

  • Appropriate for patients who:
    • Prefer non-pharmacological methods
    • Do not respond to prophylactic medication
    • Cannot tolerate or in whom pharmacologic agents are contraindicated
    • Have significant stress or deficient stress-coping skills
  • May combine behavioral or physical treatments with pharmacotherapy if necessary

Relaxation Training, Stress Reduction and Coping Strategies

  • Considered 1st-line treatments where a specific indication exists (eg stress, anxiety)
  • Yoga and meditation are said to enhance stress management
  • Train patients to control muscle tension, use mental relaxation and/or visual imagery
  • Has been found to be somewhat effective in preventing migraines

Biofeedback Therapy

  • Standard thermal and electromyographic (EMG) biofeedback training are usually the techniques of choice
  • Thermal biofeedback combined with relaxation training may be somewhat effective
  • Should be conducted by a trained healthcare provider
  • It is time-consuming and requires patient commitment

Cognitive-Behavioral Therapy (CBT)

  • Psychotherapeutic intervention
  • The goal is to teach skills to identify and control stress, and minimize its effects
  • Hypnotherapy has also been used
  • Cognitive-behavioral therapy may be considered somewhat effective

Physical Therapy

  • May be useful where a specific condition exists (eg migraine due to neck dysfunction)
  • Improving physical fitness may decrease susceptibility to migraine

Acupuncture

  • Fine needles pierce skin at specific “pressure points” to relieve pain
  • It is believed that endorphins are released into patient’s system which relieve pain
  • Controlled studies have produced mixed findings for the effectiveness of acupuncture
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