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MIGRAINE

MIGRAINE. Background information Management overview stepwise management triptans. What is migraine? www.cks.library.nhs.uk/migraine; MeReC Bulletin 2002; 13: 5–8. Primary episodic headache disorder

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MIGRAINE

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  1. MIGRAINE • Background information • Management • overview • stepwise management • triptans

  2. What is migraine?www.cks.library.nhs.uk/migraine; MeReC Bulletin 2002; 13: 5–8 • 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

  3. Migraine management — overviewwww.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 (triptan+analgesia+anti-emetic) if triptan alone is ineffective • Consider using prophylactic treatment if attacks are frequent and troublesome

  4. Step 1 — simple analgesics www.cks.library.nhs.uk/migraine • E.g. aspirin 600–900mg, 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

  5. Step 2 — triptanswww.cks.library.nhs.uk/migrainehttp://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

  6. Comparison of the main efficacy and tolerability measures for oral triptans compared to sumatriptan 100mg Ferrari MD, et al. Lancet 2001; 358: 1668–75

  7. Comparison of oral triptans to sumatriptan 100mgFerrari MD, et al. Lancet 2001; 358: 1668–75 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 2–4 hours, in accordance with product licenses • Treatment should be individualised for each person

  8. 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

  9. Prophylactic drug treatmentwww.cks.library.nhs.uk/migraine • Consider in patients with: • > 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

  10. 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

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