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
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