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Migraine: Practical Treatment

Richard C. Peatfield

Curr Med Res Opin 17(1s):s94-s97, 2002. © 2002 Librapharm Limited

Introduction

This volume has, so far, been devoted first to a description of the epidemiological problem of headache, and then to the pharmacological basis of the many treatments that have been used, both older and more modern. In this brief chapter I will attempt to translate all the science into practical guidance in the clinic, both in neurology clinics (specialist or otherwise), and indeed in general practice.

Assessment

It remains essential to take an adequate history - the attached table1 lists the important ones; clearly any one of these may need to be followed by supplementary questions.

Ten questions for headache patients

  1. Age, occupation, etc. General past history.
  2. How old was the patient when the headaches began? Are the headaches in attacks?
  3. How frequent?
  4. How long do they last untreated?
  5. Where in the head is the pain?
  6. Is it throbbing? Is it worse on exercise?
  7. Is there nausea or vomiting?
  8. Any focal symptoms, such as visual, sensory or speech disturbances related to attacks?
  9. What acute treatments have been tried?
  10. What long-term treatments have been tried? Pill or other hormones?

The examination is seldom revealing, but often reassuring for the patient, particularly if no investigations are to be undertaken. There are few essentials within the examination, though most would feel, even in the most hurried of general practice settings, that an examination of the fundi, of the visual fields for asymptomatic defects, for impairments of balance and focal weakness should not be overlooked. Few investigations are ever justified[2] unless the history or examination provide clues though, once again, many CT or even MRI brain scans are undertaken purely to provide reassurance for an anxious patient.

The differential diagnosis of headache is covered extensively in other texts[1,3]. It will usually be possible to identify patients with subarachnoid haemorrhage, meningitis, trigeminal neuralgia, temporal arteritis, neck disease and benign intracranial hypertension on clinical grounds alone, supplemented by appropriate investigations. The clinical characteristics of cluster headache and episodic tension headache are also considered in detail elsewhere[1,3]. It should not, of course, be overlooked that patients with increasing, and particularly, chronic headache may be abusing medication (ergotamine, codeine or even triptans), depressed, or taking the contraceptive pill or hormone replacement therapy, and attention to these factors will often improve the patients enormously. The whole of this text, of course, has been devoted to patients whose headaches, after appropriate diagnostic assessment, are attributed to migraine.

Management Strategy in Migraine

Management strategy is largely based on the frequency, as well as the severity, of the attacks. Infrequent attacks (certainly less than twice monthly, but sometimes also for patients with 2-4 attacks monthly) are best managed with appropriate analgesia. Most will have already tried aspirin, codeine and ibuprofen, but the new compound analgesic and anti-emetic preparations (which include Migramax and Domperamol) are worth considering, as are more potent prescription anti-inflammatory drugs such as naproxen or diclofenac, if necessary combined with an anti-emetic. Codeine containing analgesics may be of value, so long as the hazards of taking these too frequently are recognized. Many patients have already taken a triptan, but it will be clear to readers of the preceding chapters that each triptan has slightly different pharmacological properties, and it is sometimes possible to exploit these to the benefit of the patients (Table 1). For example, patients with relatively prolonged attacks and/or a tendency for pain to recur on the following day may benefit from longer-acting agents such as naratriptan or perhaps frovatriptan, whereas patients seeking early relief for relatively short attacks may benefit from rizatriptan. If early vomiting is a problem, intranasal or even subcutaneous sumatriptan may even be an appropriate drug of first choice. Recent clinical studies[8] have emphasized the importance of 'stratified care' - the physician should attempt to select an appropriate treatment to be taken at the beginning of the attack, and the patient should be discouraged from trying a series of analgesics in a single attack, as it may then be 2 or even 4 hours before they even take the drug they should have taken as soon as they were confident the attack was going to become disabling.

More Frequent Attacks

The analgesic management of more frequent attacks should be same, but such patients should be considered for prophylaxis as is discussed by Silberstein in Chapter 16 (see also Table 2 this chapter). At present the treatment of first choice is a b-blocker such as propranolol or atenolol, and perhaps pizotifen, although this is only marketed in Europe. Second-line agents include valproate, methysergide, amitriptyline and perhaps flunarizine in the countries where it is available. Gabapentin, Topiramate and Lisinopril (see Table 2) may also be worth trying.

Status Migrainosus

Patients with severe and continuous migrainous headaches ('status migrainosus') often require admission to hospital[10]. As has already been mentioned, exacerbating factors such as analgesic abuse, hormone treatment and depression may need to be addressed. These patients are relatively uncommon and there have been no adequate double-blind treatment trials, but most authorities would ensure that the patient was not dehydrated and that inappropriate medication was not worsening their headaches, although some treatments (notably narcotics) may need to be withdrawn slowly under close clinical supervision. Many authorities, particularly in the United States, recommend a combination of prochlorperazine, metoclopramide, and even dihydroergotamine, though other neuroleptics such as haloperidol or even diazepam have been used. Other authorities use parenteral corticosteroids, though this management remains anecdotal. Subcutaneous sumatriptan may be of value so long as the patient has not previously been abusing this or a related drug, and has not taken ergotamine in the previous 24 hours.

It should always be born in mind that there are occasional patients with intractable headache as a result of major psychopathology, which may involve 'secondary gain'. These patients often lose confidence in each individual practitioner and move to another, but some may benefit from more extensive psychological assessment.

Protocols

Many 'guidelines' for the management of migraine have now been published, sometimes by national headache associations, and sometimes sponsored by the drug industry. If these are complex enough to be of value in most clinical circumstances, they are often relatively large, and may be considered small textbooks, comparable indeed to this one! Most authorities would agree that there are so many variables in the management of patients complaining of headache that a wholly regimented restrictive protocol is of little value.

Tables

Clinical stratification of acute specific migraine treatments

Clinical situation Treatment options
Failed analgesics/NSAIDS First tier
Sumatriptan 50 mg p.o.
Rizatriptan 10 mg p.o.
Zolmitriptan 2.5 mg p.o.
Almotriptan 12.5 mg p.o.
Eletriptan 40 mg p.o.

Slower effect/better tolerability
Naratriptan 2.5 mg
Frovatriptan 2.5 mg

Infrequent headache
Ergotamine 1-2 mg p.o.
Dihydroergotamine nasal spray 2mg
Early nausea or difficulties taking tablets Sumatriptan 20 mg nasal spray
Rizatriptan 10 mg MLT wafer
Zolmitriptan 5 mg nasal spray*
Headache recurrence Ergotamine 1-2 mg
(perhaps most effective pr/usually with caffeine)
Naratriptan 2.5 mg p.o.
Almotriptan 12.5 mg p.o.
Eletriptan 80 mg p.o.
Dihydroergotamine 1 mg i.m.i.
Tolerating acute treatments poorly Naratriptan 2.5 mg
Almotriptan 12.5 mg p.o.
Eletriptan 20 mg p.o.
Early vomiting Zolmitriptan 5 mg nasal spray*
Sumatriptan 6 mg s.c.
Dihydroergotamine 1 mg i.m.i.
Menstrually-related headache Short-term prevention
Ergotamine p.o. nocte
Oestrogen patches
Short-term NSAIDs
Acute treatment
Triptans
Dihydroergotamine nasal spray/i.m.
Very rapidly developing symptoms Zolmitriptan 5 mg nasal spray*
Sumatriptan 6 mg s.c.
Dihydroergotamine 1 mg i.m.i.
*Likely to be available in 2001 and positioning based on clinical trials9; compounds in italics were not marketed at the time of writing.

Preventive treatments in migraine

Drug Dose Selected side-effects
Proven or very well accepted treatments[4]
b-blockers
   Propranolol 40-120 mg b.d. Reduced energy
Tiredness
   Metoprolol 100-200 mg daily Postural symptoms
Contraindicated in asthma
Tricyclics
   Amitriptyline
   Dothiepin
   Imipramine		 25-75 mg nocte Drowsiness
Note: some patients are very sensitive and may only need a total dose of 10 mg, although generally 1-1.5 mg/kg body weight is required for a response
Pizotifen 0.5-3 mg daily Drowsiness
Weight gain
Flunarizine 5-15 mg daily Tiredness
Weight gain
Depression
Parkinsonism
Sodium valproate 400-600 mg b.d. Drowsiness
Weight gain
Tremor
Hair loss
Foetal abnormalities
Haematological and liver abnormalities
Methysergide 1-6 mg daily Drowsiness
Leg cramps
Hair loss
Retroperitoneal fibrosis (a 1-month drug holiday is required every 6 months)
Widely used with poor evidence
SSRIs, e.g. fluoxetine
Verapamil		 20 mg daily
Promising but more evidence needed
Gabapentin[5] 900-2400 mg daily Tiredness
Dizziness
Topiramate[6] 25-200 mg daily Confusion
Parasthesiae
Weight loss
Lisinopril[7] 20 mg daily Cough

References

  1. Peatfield R. Headache and facial pain. Medicine 2000;28: 5-10
  2. Frishberg BM. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations. Neurology 1994;44:1191-7
  3. Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical Practice. Oxford: Isis Medical Media, 1998
  4. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache. Neurology 2000;55:754-63
  5. Mathew NT, Rapoport A, Saper J. et al. Efficacy of gabapentin in migraine prophylaxis. Headache 2001;41: 119-28
  6. Potter DL, Hart DE, Calder CS, Storey JR. A double-blind, randomized, placebo-controlled study of Topiramate in the prophylactic treatment of migraine with and without aura. Cephalalgia 2000;20:305
  7. Schrader H, Stovner LJ, Helde G, et al. Prophylactic treatment of migraine with angiotensin converting enzyme inhibitor Lisinopril; randomized, placebo-controlled, crossover study. Br Med J 2001;322:19-22.
  8. Lipton RB, Stewart WF, Stone AM, et al. Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: a randomized trial. JAMA 2000; 284:2599-605
  9. Dowson, AJ, Boes-Hansen, S, Farkkila, AM. Zolmitriptan nasal spray is fast-acting and highly effective in the acute treatment of migraine. Eur J Neurol 2000;7:82
  10. Campbell JK, Zagami AS. Status migrainosus. In Olesen J, Tfelt-Hansen P, Welch KMA, eds. The Headaches, 2nd edn. Philadelphia: Lippincott Williams & Wilkins, 2000: 525-7

Reprint Address
Address for correspondence: Richard C. Peatfield MD, FRCP, Princess Margaret Migraine Clinic, Charing Cross Hospital, London W6 8RF, UK. Tel: +44 020 8846 1303; email: r.peatfield@ic.ac.uk

Richard C. Peatfield, Princess Margaret Migraine Clinic, Charing Cross Hospital, London, UK


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