Migraine

GENERAL

Migraine without aura occurs in about one third of patients suffering from headache and is relatively easy to diagnose. Migraine patients typically have a number of relapsing episodes of moderate to severe headache, which may be unilateral or/and pulsating and may last for part of the day up to 3 days long. The episode is usually accompanied with gastrointestinal symptoms. Patients limit their activities and prefer to be confined in quiet and dark places. Between episodes the patients are free of symptoms.

DIAGNOSTIC CRITERIA FOR MIGRAINE WITHOUT AURA (ACCORDING TO THE INTERNATIONAL HEADACHE SOCIETY)

The symptoms of migraine with aura are of gradual onset, lasting 5-60 minutes before the starting headache. They are visual in quality with a transient hemianoptic defect  or a diffuse scotoma. Sometimes visual symptoms occur simultaneously or succesively with reversible neurologic disturbances, such as unilateral paraesthesia in the arm, forearm or face (the lower limb is rarely affected) and/or dysphagia, all being manifestations of cortical dysfunction from one cerebral hemisphere.

The patients may have some migraine attacks without aura and others with aura.  There may be long periods during which the one or the other type of migraine prevail alternately. The migraine that occurs on a daily basis constitutes the chronic type of migraine which is a complication of the classical migraine and needsa special management.

TREATMENT

THERAPEUTIC TARGET

It is very important for the patient to understand what s/he suffers from and have realistic expectations. On the other hand, many patients are very pessimistic with regard to how to handle their condition. In general, there has to be very good cooperation between the therapist physician and the patient and a lot of patience is needed from the part of the therapist until both effective preventive treatment and  acute attack treatment are found.

ACUTE MIGRAINE ATTACK TREATMENT

There is a pain scale, which is used, starting from the first degree and moving up level as long as there are three attacks ineffectively treated. The general rule that should be followed is that, besides taking their drugs, patients should rest and sleep in all episodes.

STEP 1

Simple analgesics with or without antiemetic drugs

1a) Over-the-counter analgesics (non-prescribed) with or without antiemetic drugs

For the pain

• Aspirin 600-900 mg or
• ibuprofen  400-600 mg

Analgesics should be taken in time at the onset of the migraine, when absorption has not yet been inhibited to a great extent by gastric stasis. Up to 4 doses can be taken during 24 hours. These drugs should not be combined with codeine (lonarid N). There is little evidence for the efficacy of paracetamol as monotherapy.

For nausea and vomiting (if needed)

• Domperidone  10 mg up to 4 times daily

2b) Prescribed non steroid anti-inflammatory drugs and a prekinetic antiemetic drug

For the pain

• Aspirin 600-900 mg or
• Ibuprofen  400-600 mg or
• Tolfenamic acid of rapid release 200mg with another repetition after 1-2 hours, if necessary
• Naproxen 750-825mg with additional 250-275 mg up to 2 times daily
• Diclofenac-potassium 50-100mg with repeated dose, maximum daily dose 200mg

Prekinetic antiemetic drugs for accelerating the action of anti-inflammatory drugs

• Metoclopramide 10 mg or
• Domperidone 20 mg

Domperidone is less suppressive than metoclopramide and is less likely to provoke extrapyramidal symptoms

3c) Triptanes

They should be taken at the onset of the headache, when symptoms are still mild, because in this way they become more effective. They seem to be ineffective when administered in the aura phase. When triptanes are administered, symptoms recur within 48 hours in 20-50% of the patients who responded to the first administration. When taken orally, the co-administration of prekinetic antiemetic, metoclopromide or domperidon is recommended.

• Sumatriptan per os, initial does 50mg and in case of no relief 100 mg. Maximum daily dose per os 300 mg. There are two nasal spray forms, one for adults (20 mg per spray) and one for children 12-17 years old (10 mg per spray). Maximum nasal dose 40 mg. If fast action is needed, the most effective scheme is 6 mg subcutaneously with maximum daily dose 12 mg.
• Zolmitriptan 2,5 mg tablet or nasal spray and repetition after 2 hours if needed. Sometimes the starting dose is directly 5 mg. Maximum daily dose 10 mg. The spray is useful when there is vomiting because 30% is absorbed by the nasal mucosa.
• Rizatriptan tablet 5, 10 mg. Starting dose 10 mg and maximum daily dose 20 mg. Patients already receiving propranolol, should start wigh 5 mg and maximum daily dose 10 mg.
• Naratriptan tablet 2,5 mg. Starting dose 2,5 mg and maximum daily dose 5 mg
• Almotriptan tablet 12,5 mg. Studies have shown efficacy similar to sumatriptan 100 mg.  It is well tolerated and is the drug of choice from the category of triptanes. Maximum daily dose 25 mg.
• Eletriptan tablet 20, 40 mg. Dose-dependent efficacy, starting dose 20 or 40 mg. Maximum daily dose 80 mg.

Contraindications for triptanes (3c above)

• Uncontrolled hypertension
• Risk factors for coronary disease or cerebrovascular event
• Children under 12 years old

4d) Combinations of drugs

There is evidence that the combination of sumatriptan 50mg and naproxen 500mg is superior to monotherpay.

GENERAL LIMITATIONS

• Avoiding taking opioids (codeine, tramadole etc)
• Avoiding taking triptanes for 10 or more days or/and anti-inflammatory, analgesics for 15 or more days due to the risk of having headache induced by oversuse of analgesics

MIGRAINE PREVENTIVE THERAPY

INDICATION FOR STARTING PREVENTIVE THERAPY

The migraine preventive therapy is implemented for reducing the number of episodes when the treatment of acute attacks is not sufficient, as evaluated by the patient. In children, the evaluation criterion is the frequency of the need for being absent from school due to migraine. Another criterion is the overuse of analgesics. The preventive therapy does not replace the acute phase therapy but is combined with it.

DOSAGE ΤITRATION

The drug dosage should be increased until there is effective result or no non-tolerable side effects occur. If the drug, after its initial titration, does not bring a satisfactory result having been used for 6-8 weeks, it is dicscontinued and switched to another one. The preventive therapy with an effective drug should be continued for 4-6 months and gradually cut down and discontinued within 2-3 weeks.

FIRST LINE PREVENTIVE DRUGS

• B-adrenergic blockers, cardioselectivity and hydrophylia reduce the risk of side-effects
• Amitryptiline*, 10-150mg daily 1-2 hours before bedtime, is a first line drug when migraine coexists with:

–           tension headache

–          other chronic pain condition

–          sleep disorder

–          depression

SECOND LINE PREVENTIVE DRUGS

• Topiramate 25-50 mg twice daily
• SodiumValproate 300-1000mg twice daily

MEDICAL INFORMATION SOURCES

BRITISH ASSOCIATION FOR THE STUDY OF HEADACHE