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Acute treatments for migraine

Acute treatments for migraine. Fayyaz Ahmed Chester Migraine Education Day 8 September 2012. YOUNG OR OLD. To set the scene.

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Acute treatments for migraine

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  1. Acute treatments for migraine Fayyaz Ahmed Chester Migraine Education Day 8 September 2012

  2. YOUNG OR OLD

  3. To set the scene... • “[Migraine] is a malady of which the student gains little practical knowledge in the course of his hospital work, unless he is so unhappy as to learn from the most effective of all instructors, personal suffering... It is common enough, but seems, to most of its subjects, by long experience so much an inevitable part of life that few seek relief.” William Gowers (1906) • “A doctor who cannot take a good history and a patient who cannot give one are danger of giving and receiving bad treatment” Anonymous

  4. 10 steps to success • Get the diagnosis right • Set realistic expectations • Consider non-pharmacological measures • Use the right drugs • Use effective doses • Treat early when the pains mild • Treat associated symptoms • Choose appropriate route of delivery • Avoid medication overuse • Use prophylactic treatments appropriately

  5. 1. Making the Right Diagnosis • ‘migraine’ - a disorder and an attack • the disorder is characterised by: • the tendency to repeated attacks • triggers • sleep, food, weather, chemical (EtOH/GTN), hormonal, sensory, stress-relaxation • family history • the attack • premonitory symptoms (20%+) • headaches typically unilateral, throbbing • associated with nausea +/- vomiting • sensitivity to light, sound, smells, movement • auras, usually visual, occur ~15-20% of patients

  6. Migraine or TTH? • phenotype the worst type of attack • patients with headaches that met criteria for migraine, probable migraine, and TTH, all headache types responded to triptans (Spectrum Study) • this was not true for patients with purely TTH • recurrent severe headaches are migraine, until proven otherwise

  7. 2. Set realistic expectations • there is no ‘cure’ • recognising the disorder • goal setting • trigger management • effective acute treatment • reducing attack frequency • appraisal of best available options • explaining the natural history

  8. 3. Non-pharmacological measures • lifestyle issues • Hectic lifestyle • No time for timely sleep or meals • Too much on your plate • trigger management • hormonal • dietary • psychological • CBT, relaxation • environmental • sleep • neck...

  9. 4. Use the right drug • START WITH Simple Painkillers • Aspirin, Paracetamol, Ibuprofen • ESCALATE TO TRIPTANS • AVOID CODEINE, CAFFEINE, BARBITURATE BASED COMBINATIONS

  10. Why simple painkillers first? • 50% Headache sufferers do not consult1 • ‘it is too inconvenient to see a doctor’ (53%) • ‘there is nothing a doctor could do’ (22%) • 70-80% would respond to first line and are self limiting1 • OTC availability – less use of healthcare resources 1. Steiner and Fontebasso 2002

  11. Why Ibuprofen than other NSAID? • Availability OTC • Less side effects and better tolerability1-2,10,11 • More evidence based3-4 • Recommended by guidelines5-9 1. Langman et al, Lancet 1994 2. Rainsford, 2009 3. Rabbie et al, 2010 Cochrane Collaboration 4. Haag et al, 2007 5. SIGN guidelines, 2010 6. British Association for the Study of Headache, 2010 7.Bendtsen et al EFNS guidelines 2010 8. EHF guidelines, 2009 Steiner, Marteletti 9. American Academy of Neurology, April 2012 10. Henry D et al, BMJ 1996 11.Doyle, 1999

  12. 5. Use effective doses • paracetamol 1 g • or, aspirin 900 mg • or, ibuprofen 600-800 mg • If early nausea • soluble aspirin • suppositories*: • diclofenac 75 mg *be French!

  13. 6. Treat early when mild • Benefit • Avoiding a disabling attack • Better response • Risk • Treating a wrong attack • Risking medication overuse

  14. 7. Rx associated symptoms • Avoid physical activity • Avoid bright lights • Avoid disturbing noises • Domperidone 10-20 mg

  15. 8. Choose appropriate route of delivery

  16. Problems, problems… • not effective • dose? timing? route? combination? diagnosis? • contraindications • asthma, upper GI problems, renal impairment • side effects • GI, CNS

  17. This is what patients do next

  18. Codeine…? • … is NOT a treatment for headache • the WHO analgesic ladder should NOT be applied to headache management

  19. 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

  20. Headache response at 2 hr

  21. Pain freedom at 2 hr

  22. advantages disadvantages Sumatriptan well-established expensive available OTC poorly absorbed now the cheapest s/c, nasal spray Zolmitriptan cheaper occasional confusion long acting nasal spray, melt Naratriptan cheaper slow onset long acting Rizatriptan rapid onset high recurrence melt Almotriptan cheaper low SE incidence Eletriptan cheaper pumped out of CNS long acting Frovatriptan longest half-life slow onset

  23. 9. Avoid medication overuse • Restrict to two doses per week • Use long acting triptans • Avoid combination analgesics • Can use triptan and NSAID such as sumatriptan and naproxen

  24. Problems, problems… • ineffective • dose? timing? route? switch? • headache recurrence • switch? combination with NSAID? • contraindications • HT, IHD • SE • nausea, GI, CNS, ‘triptan chest’

  25. 10. Use preventive treatment • Should be offered to patients with 6 or more headache days per month; 4 or more days with some impairment; or 3 or more days with severe functional impairment • Should be considered with 4–5 days per month with normal functioning; 3 days with some impairment and 2 days with severe impairment • Should not be given to patients with <4 days of headache per month with normal functioning; or no more than 1 day per month regardless of impairment

  26. The future • new drugs with novel targets • serotonin subtypes; CGRP; glutamate; TRPV1; nitric oxide; prostanoids; cortical spreading depression • new delivery mechanisms for existing drugs • inhaled DHE • inhaled, transdermal, needle-free triptans

  27. Neurostimulation • Transcranial Magnetic Stimulation • Vagal nerve stimulation (Gammacore)

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