Here’s a great talk by James U Adleman from the Headache and Wellness Centre in North Carolina about migraine management.
MANAGING MIGRAINE —James U. Adelman, MD, Associate Clinical Professor of Medicine, Department of Neurology, University of North Carolina, Chapel Hill, and Staff Neurologist, Headache Wellness Center, Greensboro, NC
Introduction: only about one-half of patients with migraine correctly diagnosed; of those diagnosed incorrectly, 42% diagnosed as having sinus-type headache and 32% as having tension-type headache; survey showed that 94% of patients who sought treatment in physicians’ offices had migraine (migraine is type of headache that gets severe enough for patients to seek treatment); although tension-type headache most common in population, it usually responds readily to over- the-counter analgesics, and patients do not seek physicians’ help.
What is migraine? currently defined as episodic headache with any type of disability; disability not necessarily absence from work or school (impaired performance at work or school also qualifies as disability); current approach is to stop individual headaches and to reduce frequency of headaches; order in which to address problems depends on individual patient’s circumstances; rather than asking patient how many headaches he or she has per month, speaker asks how many days per month patient is headache-free (if asked how many headaches per month, patients tend to count only “bad” headaches, but on further questioning, admit to having some degree of headache almost every day); if patient free of headache most days, focus therapy on preventing or stopping individual headaches; if patient has headache most days, focus on reducing frequency.
Components of treatment: education; behavioral therapy (“which is terribly important”); pharmacologic therapy; abortive therapy; preventive treatment; stages of migraine include prodrome, aura (in patients who have auras), mild stage, moderate to severe stage, and postdrome.
Acute care treatment: “window of opportunity” occurs in first hour after patient senses he or she is getting headache (prodrome and mild stage); ≈65% of patients report that headache can be prevented with treatment (speaker prefers nonsteroidal anti-inflammatory drug, “perhaps with metoclopramide”).
Aura: unclear whether to treat during aura stage; 2 studies showed that treating with subcutaneous (SQ) sumatriptan and eletriptan during aura not effective, but in other studies, some patients did benefit from oral triptan during aura; some patients report that treating too early not effective, so speaker recommends that patient wait until mild stage to take oral triptan.
Bottom line: acute care treatment depends on ultimate pain level and on rapidity with which headache develops; if pain rises to moderate to severe level over 0.5 to 1.5 hr, specific (as opposed to nonspecific) pain medications needed, and triptans specific.
Triptans: attack 5HT1B and 1D receptors; because of specificity, side effects fewer; work rapidly and efficiently; SQ injection—most rapid onset with SQ sumatriptan, available in 6-mg and 4-mg injections; only triptan available in injectable form; recommended for patients who awaken with headache, nausea, or vomiting; nasal sprays— sumatriptan available in 20-mg and 5-mg doses; speaker prefers 20-mg dose; zolmitriptan available in 5-mg dose; oral agents—rapidly dissolving tablets include zolmitriptan (Zomig-ZMT) in 2.5- and 5-mg doses and rizatriptan (Maxalt-MLT) in 5- and 10-mg doses; all triptans available in oral form that is not rapidly acting; naratriptan and frovatriptan act slowly, and speaker considers them not very effective.
Efficacy: assessed as moderate to severe pain reduced to mild or no pain in 2 hr; frovatriptan, 2-hr efficacy ≤40%; naratriptan, ≈45% to 49%; almotriptan, eletriptan, “old form of” sumatriptan, ≈60%; sumatriptan rapid-release tablets (RT) ≈70%; “old form of” zolmitriptan, ≈65%; zolmitriptan RT, ≤77%.
Safety: all products similar; early concern about adverse cardiovascular events not supported by more recent data
Preventive treatment: “not as good as the acute care treatment”; consider preventive treatment if headaches occur more than twice weekly on regular basis; behavioral therapy crucial; components of behavioral therapy include diet, regulation of circadian rhythms, exercise, elimination of triggers, elimination of overused substances, fun, and relaxation training.
Preventive medications: only FDA-approved medications methysergide (no longer available in United States), propranolol, timolol, valproic acid, and topiramate; other treatments that may be effective include antidepressants, antihypertensives, neural stabilizers, serotonin antagonists, and alternative therapies; select medication by comorbidity; efficacy of all agents similar and “unfortunately, not as good as we want it to be”; adverse effects difficult to predict for individual patients; once-a-day regimens preferred to bid or tid; oral formulations preferred for ease of administration; “costs can vary tremendously”.
β-Blockers: all nonsympathomimetic β-blockers equally effective; propranolol most commonly used, but speaker prefers atenolol (inexpensive; can be given once daily, typically at night; fewer side effects); end point for β-blockers is pulse rate in low 70s or upper 60s, and dose determined accordingly; in studies, 45% to 60% of patients reported 50% reduction in headaches.
Calcium channel blockers: good for cluster headaches, not good for migraine; use doses higher than those for treatment of hypertension; may be effective if aura prominent feature; in studies, verapamil and amlodipine took up to 3 mo to achieve effect.
Tricyclic antidepressants: low doses effective (for amitriptyline, doxepin, and imipramine, 50 mg/day); with amitriptyline and doxepin, end point is sleep without daytime sedation; side effects with amitriptyline and doxepin include weight gain; with nortriptyline and imipramine, all side effects less; when using nortriptyline, prescribe by generic name, which costs ≈$17/mo (brand name [Pamelor] costs $575/mo); desipramine and protriptyline nonsedating and not associated with weight gain (protriptyline currently available only by brand name [Vivactil]).
Other antidepressants: SSRIs and bupropion not effective in migraine; venlafaxine effective; in study, patients with anxiety benefitted from duloxetine; monoamine oxidase inhibitors effective, but have numerous side effects.
Neural stabilisers: previously called anticonvulsants; divalproex (Depakote) and topiramate FDA-approved; both have significant side effects, including weight gain, hair loss, and fetal neural tube defects; in study, only 36% of patients responded to gabapentin.
Serotonin antagonists: speaker uses cyproheptadine in children; methysergide effective, but no longer available in United States due to side effect profile.
Alternative treatments: riboflavin—in small study, 59% of patients responded; magnesium—should be effective; known that patients with migraine have low levels of magnesium in brain; shown that intravenous magnesium stops headache; feverfew—effectiveness not clear; coenzyme Q10—effective in some studies; butterbur (Petasites hybridus)—in study, efficacy ≤71%, but efficacy of placebo 59%; botulinum toxin type A (Botox)—no clinical profile; anecdotally, some patients respond, others do not; large trial now under way.
Recommendations: clinicians who do not specialize in headache select amitriptyline, imipramine, or venlafaxine as first-line medications; speaker recommends using β-blocker second, and prefers atenolol; use neural stabilizer third (speaker prefers topiramate).
Conclusions: episodic headache with any disability (especially nausea and/or photophobia) is migraine; acute care treatment is race against central sensitization; preventive treatment selected on basis of comorbidity; aggressive treatment prevents progression to chronic migraine.