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Acute treatment of migraine

Acute treatment of migraine. Dr Mark Weatherall London Headache Centre 2010. The intangibles. Doctor-patient relationship Realistic expectations Education. Triggers. Hormonal Dietary Psychological Environmental Sleep Drugs. 10 steps to success. Make the diagnosis

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Acute treatment of migraine

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  1. Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010

  2. The intangibles • Doctor-patient relationship • Realistic expectations • Education

  3. Triggers • Hormonal • Dietary • Psychological • Environmental • Sleep • Drugs

  4. 10 steps to success • Make the diagnosis • Use the right drugs • Use effective doses • Treat early when the pains mild • Treat associated symptoms

  5. 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

  6. Where to start? • paracetamol 1 g • or, aspirin 900 mg • or, 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

  7. Variations on a theme • if early nausea, you can use: • soluble aspirin • suppositories*: • diclofenac 75 mg • domperidone 30 mg *be French!

  8. Headache response at 2 hr

  9. Problems, problems… • Not effective • dose? timing? route? combination? • Contraindications • asthma, upper GI problems, renal impairment • Side effects • GI, CNS

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

  11. 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

  12. Which triptan?

  13. Headache response at 2 hr

  14. Pain freedom at 2 hr

  15. Problems, problems… • Ineffective • dose? timing? route? switch? • Headache recurrence • switch? combination with NSAID? • Contraindications • HT, IHD • SE • nausea, GI, CNS, ‘triptan chest’

  16. 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

  17. 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

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