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Acute treatment of migraine
Mark Weatherall
BASH meeting, Hull 2009
The intangibles
Doctor-patient relationship Realistic expectations Education
Triggers
Hormonal Dietary Psychological Environmental Sleep Drugs
10 steps to success
Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms
10 steps to success
Choose appropriate route of delivery Observe contraindications Use prior experience to select/reject drugs Avoid drugs with high potential for MOH Combine medications if necessary
Where to start?
paracetamol 1 gor, aspirin 900 mgor, ibuprofen 600-800 mg+/- domperidone 10-20 mg taken as soon as possible*ª
* i.e. as soon as the patient knows that this is a migraine
ª if there is aura, take at the start of the headache phase
Variations on a theme
if early nausea, you can use: soluble aspirin suppositories*:
diclofenac 75 mg domperidone 30 mg
*be French!
Headache response at 2 hr
Problems, problems…
Not effective dose? timing? route? combination?
Contraindications asthma, upper GI problems, renal impairment
Side effects GI, CNS
This is what patients do next
Codeine…?
… is NOT a treatment for headache the WHO analgesic ladder should NOT be
applied to headache management
Triptans
5-HT1B/1D receptor agonists seven different formulations options for route of delivery
oral tablets or melts nasal spray subcutaneous injection
taken as soon as possible*ª¹* i.e. as soon as the patient knows that this is a migraine
ª if there is aura, take at the start of the headache phase
¹ this is a race against the development of allodynia
Which triptan?
Headache response at 2 hr
Pain freedom at 2 hr
advantages disadvantages
Sumatriptan well-established expensive£4.60 available OTC poorly absorbed
s/c (£22.10), melt (£4.14), nasal spray (£6.14)
Zolmitriptan cheaper occasional confusion
£4.00 long actingnasal spray (£6.75), melt (£4.00)
Naratriptan cheaper slow onset£4.09 long acting
Rizatriptan rapid onset high recurrence£4.46 melt (£4.46)
Almotriptan cheaper£3.02 low SE incidence
Eletriptan cheaper pumped out of CNS£3.75 long acting
Frovatriptan cheapest slow onset£2.78 longest half-life
Problems, problems…
Ineffective dose? timing? route? switch?
Headache recurrence switch? combination with NSAID?
Contraindications HT, IHD
SE nausea, GI, CNS, ‘triptan chest’
Is the future ‘pants’?
CGRP antagonists two with data recently published proof-of-concept trial of intravenous BIBN4096BS
(now called olcagepant) was published in NEJM in 2004
phase II study of oral CGRP antagonist MK-0974 (now called telcagepant) presented at IHS 2007 and published in Neurology in 2008
multicentre phase III R-PT-PC-DB-T of oral telcagepant 150 or 300 mg vs zolmitriptan 5 mg and placebo published in The Lancet in last four weeks
A&E/in-patient options
sumatriptan s/c 6 mg alternatively nasal spray 20 mg
high dose NSAIDs aspirin 1 g
(available as IV formulation – useful as rescue medication in medication withdrawal)
indometacin 100 mg (can be given IM)
Refractory migraine
dihydroergotamine (DHE) 0.5-1.0 mg iv/im (2 mg nasal spray)
anticonvulsants sodium valproate 500 mg iv in 100 mL normal
saline over 15 min (? role for SVP infusion in status migrainosus)
clonazepam 1 mg/mL slow push
… or …
dopamine antagonists metoclopramide 10-20 mg IV
(rpt to 30-60 mg over 2 hrs) droperidol 0.625 mg every 10 mins
(average effective dose 3.15 mg) prochlorperazine 10 mg iv over 2 min
(may rpt after 30 min) metoclopramide & prochlorperazine can be
followed with DHE 0.5-1.0 mg over 10 mins
… or …
magnesium sulphate 1 g iv over 15 min dexametasone 8-20 mg iv over 5-10 min;
hydrocortisone 100-250 mg iv over 10 min, every 8-12 hrs for 24 hours
(again, useful in status)
ketorolac 30-60 mg iv/im
A final thought: listening is therapy in itself
… and you’ve listened long enough!