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 
Editor's Recommendations
Most Read Articles
01 Jan 2015
Ginkgo biloba has been shown to improve cognitive as well as neuropsychiatric symptoms (NPS) in patients with Alzheimer’s disease (AD) and mixed dementia. During a Schwabe-sponsored symposium last 20 October 2014 held at the University of Malaya in Malaysia, Professor Serge Gauthier of the McGill Centre for Studies in Aging in Quebec, Canada, and Dr Robert Hoerr of the Dr Willmar Schwabe GmbH & Co. KG in Germany, discussed studies that support the safety and efficacy of Ginkgo biloba extract (EGb 761®) in patients with AD and dementia.
26 Aug 2017
Elderly individuals with high levels of serum uric acid may be at an increased risk of dementia, particularly vascular or mixed dementia, a study suggests.
Elvira Manzano, 01 Feb 2014

There is no benefit to using ibuprofen over paracetamol in most patients with upper respiratory tract infections (URTIs). Steam inhalation therapy also does not offer any advantage, research has shown.

Dr. Joseph Delano Fule Robles, 01 Mar 2017

The tau and Aβ amyloid pathways have emerged as possible novel targets in treating Alzheimer’s disease (AD), according to studies discussed at the recently concluded Hong Kong Pharmacy Conference.