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Migraine- treatment

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Migraine- treatment

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Migraine is a 
Chronic , complex , genetically determined 
neurological disorder

It is a Primary episodic headache disorder- ie not associated with an underlying pathology other examples include migraine , tension-type and cluster headache
Often ( but not always ) unilateral throbbing pulsating headache with associated symptoms 
○ photophobia
○ phonophobia ( sensitivity to sound )
○ nausea and vomiting
lasting 4-72 hrs

Subdivided into migraine with and without aura , defined as episodic or chronic
Headache classification system – most commonly used is the system published by the International Headache Society
Migraine is the most common severe form of primary headache – one of 5 leading cause of long term disability
High socioeconomic cost ( UK- around £ 3 billion / Y)
Three times more common in women
Prevalence declines with age in both sexes
BASH guidance -Metoclopramide 10 mg ( not more than 5 days )
Domperidone 10 mg tds ( less sedating than metoclopramide and less risks of extra-pyramidal SEs , upto a week
If vomiting restricts use consider 
○ zolmitriptan nasal spray
○ diclofenac suppository
○ buccal preparation such as Buccastem® 3-6 mg up to twice in 24 hrs
Avoid aspirin if < 16 yrs of age
Metoclopramide is not recommended for children or adolescents
Diclofenac suppository 100 mg ( up to 200 mg in 24 hrs )
Domperidone suppository 30-60 mg ( up to 120 mg in 24 hrs )
Diarrhoea may prevent effective use during migraine

Triptans should be taken at the start of the headache phase ( they are ineffective if used during aura ) Sumatriptan – most clinical experience and was launched first ie first choice based on efficacy , safety profile and cost
Available OTC as Imigran RECOVERY® or Migraleve ULTRA Triptans can be give orally , S/C , intranasal and IM Try each triptan in at least 3 attacks before rejecting – patients with poor response to one triptan can benefit from another in subsequent attacks Consider S/C sumatriptan or Zolmitriptan nasal spray ( 5 mg ) if vomiting is a problem Contraindications to Triptans ♦ uncontrolled hypertension ♦ risk factors for CVD or CAD All triptans can be taken again within 2 hrs if needed with a max 2 doses in 24 hrs Little information on use of triptans over 65s ( trials on people aged 18-65 )

Ask for f/u after 1st pack of triptans has been used If effective –> continue treatment indefinitely If inadequate or poorly tolerated –> reconfirm diagnosis , reassess lifestyle advice, check usage and r/o MOH Consider preventative treatment – if the person has tried two or more triptans unsuccessfully or treatment works but attacks are frequent

migraine prophylaxis- 
 Migraine attacks cause frequent disability eg
♦ two or more attacks / month that produce disability lasting 3 days or more
 Person at risk of medication overuse headache ( MOH )
♦ R/O MOH before initiating preventative treatment
♦ Use of triptans or analgesics on two or more days / week on a regular basis –> review (1 ) how the drugs are being used (2) diagnosis
 Standard analgesia and triptans are contraindicated or ineffective Discuss benefits and risks and explain that acute treatment will still be required

topiramate- Initially 25 mg nocte for1 week Increase in steps of 25 mg at weekly intervals Usual dose 50-100 mg in 2 divided doses Max is 200 mg Associated with risk of fetal malformations Can impair effectiveness of hormonal contraception

propranolol-R/O contraindications as
○ asthma
○ uncontrolled heart failure
○ peripheral vascular disease or
○ COPD 80 mg daily ( 40 mg bd or 80 mg MR ) Can use from 160 to 240 in divided doses or MR

Amitriptyline @ 10-50 mg at or 1-2 hrs before bed Consider when migraine co-exists with
♦ troublesome tension type headache
♦ another chronic pain condition
♦ disturbed sleep
♦ depression

References

 Guideline 155 : Pharmacological management of migraine – Full guideline SIGN February 2018 British Association for All Healthcare Professionals in the Diagnosis and Management of Migraine 3rd edition ( 1st revision 2010 ) BMJ Best Practice Migraine headache in adults CKS NHS Migraine revised February 2018 Guideline for primary care management of headache in adults Canadian Family Physician Migraine Headache Treatment and Management Medscape Jan 2018 https://www.nice.org.uk/guidance/cg150/
ifp/chapter/treatments-for-migraine

References

 Guideline 155 : Pharmacological management of migraine – Full guideline SIGN February 2018 British Association for All Healthcare Professionals in the Diagnosis and Management of Migraine 3rd edition ( 1st revision 2010 ) BMJ Best Practice Migraine headache in adults CKS NHS Migraine revised February 2018 Guideline for primary care management of headache in adults Canadian Family Physician Migraine Headache Treatment and Management Medscape Jan 2018 https://www.nice.org.uk/guidance/cg150/
ifp/chapter/treatments-for-migraine

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