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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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Migraine l.jpg

MIGRAINE

  • Background information

  • Management

    • overview

    • stepwise management

    • triptans


What is migraine www cks library nhs uk migraine merec bulletin 2002 13 5 8 l.jpg

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


Migraine management overview www cks library nhs uk migraine l.jpg

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


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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


Step 2 triptans www cks library nhs uk migraine http emc medicines org uk l.jpg

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


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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: 1668–75


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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


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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


Prophylactic drug treatment www cks library nhs uk migraine l.jpg

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


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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


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