MIGRAINE

1
MIGRAINE

• Background information
• Management
• overview
• stepwise management
• triptans

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What is migraine?www.cks.library.nhs.uk/migraine
MeReC Bulletin 2002 13 58

• Primary episodic headache disorder
• Characterised by various combinations of
  neurological, gastrointestinal and autonomic
  changes
• Affects about 10 of the population
• 15 of women and 6 of men
• Diagnosis is based on headache characteristics
  and associated symptoms

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Migraine management overview www.cks.library.nhs
.uk/migraine

• Identify any trigger factors, and avoid them if
  possible
• Treat in a stepwise manner until symptoms are
  controlled
• first-line treatment is oral analgesia, with or
  without anti-emetics
• if first-line treatments are ineffective, treat
  with a triptan
• consider using combination therapy
  (triptananalgesiaanti-emetic) if triptan alone
  is ineffective
• Consider using prophylactic treatment if attacks
  are frequent and troublesome

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Step 1 simple analgesics www.cks.library.nhs.uk
/migraine

• E.g. aspirin 600900mg, NSAID, paracetamol /-
  anti-emetics
• Start acute treatment early in the attack
• Gastric stasis during the migraine attack reduces
  drug absorption
• soluble forms may be preferable as these are more
  quickly absorbed
• anti-emetics increase rate of absorption of
  analgesic
• Codeine and other opioid drugs, or combinations
  containing these, should be avoided
• little additional benefit, risk of medication
  overuse headache, adverse effects e.g. reduced
  gastric motility

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Step 2 triptanswww.cks.library.nhs.uk/migraine
http//emc.medicines.org.uk/

• Triptans should not be taken too early in an
  attack, unlike standard analgesia
• Evidence suggests that the first dose should be
  taken when the pain is beginning to develop (i.e.
  is mild), but not before this stage (e.g. during
  the aura stage)
• Finding the best one for an individual patient
  may involve a degree of trial and error
• Sumatriptan is the most established triptan with
  the greatest associated clinical experience
• High-dose sumatriptan (100mg) has been used most
  often as a comparator drug in clinical trials,
  but offers little advantage over the lower 50mg
  dose for most people

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Comparison of the main efficacy and tolerability
measures for oral triptans compared to
sumatriptan 100mg Ferrari MD, et al. Lancet
2001 358 166875
Initial 2hr relief Sustained pain-free Consistency Tolerability
Sumatriptan 50mg /
Sumatriptan 25mg /
Zolmitriptan 2.5mg
Zolmitriptan 5mg
Naratriptan 2.5mg
Rizatriptan 5mg
Rizatriptan 10mg
Eletriptan 20mg
Eletriptan 40mg / /
Eletriptan 80mg ()
Almotriptan 12.5mg
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Comparison of oral triptans to sumatriptan 100mg
Ferrari MD, et al. Lancet 2001 358 166875
www.cks.library.nhs.uk/migraine

• Differences between the triptans were found to be
  small but may be clinically relevant to the
  individual patient
• There was a high degree of variability in
  individual response to specific triptans
• if a particular triptan is not effective in an
  individual, another can be tried which may be
  effective
• if a triptan is poorly tolerated it can be
  switched
• If the initial dose of triptan proves ineffective
  a further dose is unlikely to be effective and
  should not be taken (except zolmitriptan)
• If the triptan successfully relieves pain, but
  there is relapse, the dose can be repeated within
  24 hours, in accordance with product licenses
• Treatment should be individualised for each
  person

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Adverse effects www.cks.library.nhs.uk/migraine

• There is no evidence that any particular triptan
  is safer than another
• 'Triptan sensations' include a warm-hot
  sensation, tightness, tingling, flushing, and
  feelings of heaviness or pressure in areas such
  as the face and limbs, and occasionally the chest
  
• can mimic angina pectoris and cause considerable
  alarm. However, when patients are forewarned
  about these feelings, they rarely cause problems
• There are theoretical concerns that triptans may
  increase the likelihood of myocardial infarction,
  but extensive experience with these drugs,
  especially sumatriptan, have shown this is very
  rare
• Discontinue if there are intense chest pains or
  sensations, as this could indicate coronary
  vasoconstriction or anaphylaxis

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Prophylactic drug treatment www.cks.library.nhs.uk
/migraine

• Consider in patients with
• gt 2 attacks per week
• increasing headache frequency
• significant disability despite acute treatments
• cannot take suitable treatment
• Propranolol or amitriptyline are suitable
  first-choices
• good evidence to support use for the prevention
  of migraine
• metoprolol, timolol and atenolol are alternative
  beta-blockers
• Sodium valproate or topiramate are suitable
  second-line
• good evidence of efficacy
• clinical utility of topiramate limited and
  specialist input needed

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Summary

• Migraine
• a primary episodic headache disorder
• characterised by neurological, gastrointestinal
  and autonomic changes (aura experienced by around
  25 of patients)
• affects about 10 of the population, with women
  being affected more than men
• Treatment
• start acute treatment with simple analgesic
  anti-emetic early
• triptans are effective second-line options but
  should not be taken too early in an attack
• differences between triptans are small but may be
  clinically relevant to the individual patient
• Consider prophylaxis in those with
  frequent/worsening attacks