RISK FACTORS: Specific foods, alcohol, missing meals, menstrual cycle, excessive sleep, fatigue, emotional stress, let down (relief of stress), Medications (estrogen replacement, BCPs, vasodilators), Family history of migraine, Female gender
GENERAL MEASURES
β’ Compression to ipsilateral temporal artery or tender areas of scalp or neck
β’ Cold compresses to area of pain
β’ Rest with pillows comfortably supporting head or neck in area devoid of sensory stimulation, including light,
sound, and odors
β’ Withdrawal from stressful surroundings
β’ Sleep is desirable
β’ Biofeedback and early psychologic intervention in appropriate cases or when pain behaviors are first
identified
β’ Most patients manage attacks with self-care
ACTIVITY In bed in a dark quiet environment
DIET Maintain fluid intake. Avoid dietary precipitants of migraine.
PATIENT EDUCATION
β’ Emphasize migraine can not be cured, but symptoms can be managed
β’ Encourage use of diary and patient education
β’ Emphasize proper use of all medications
β’ Encourage lifestyle modifications
DRUG(S) OF CHOICE
β’ 5-HT-1 agonists (triptans) intervention during the mild phase of headache offers greatest effi cacy. For all triptans
- oral tablets more effective in early mild headache phase; oral tablets slower in onset than injection or nasal spray; restore normal function for most; appropriate patient selection important.
. Sumatriptan (Imitrex), most effective during early mild headache phase of migraine. 6 mg self-administered
injection with efficacy of 70-85%; nasal spray of 20 mg, or 25, 50 and 100 mg tablets with effi cacy of 65%. 50 mg and 100 mg dose more effective than 25 mg. If initial injection fails to relieve migraine after 1 hour, dont repeat injection. If headache returns, repeat injection, nasal spray or oral tablets.
. Zolmitriptan (Zomig, Zomig-ZMT) 2.5 mg tablet at onset of migraine. 5 mg tablet available. Efficacy
approximately 65%.
. Naratriptan (Amerge) 2.5 mg initially; 1 mg tablet available. Slower to act than other triptans, but fewer adverse effects
. Rizatriptan (Maxalt) tablet and orally disintegrating tablet; initially 10 mg. 5 mg available and recommended
for patients on propranolol. Effi cacy similar to other triptans. May have faster onset in moderate-severe headache.
. Almotriptan 6.25 or 12.5 mg tablet similar effi cacy to other triptans
. Frovatriptan (Frova) 2.5 mg at onset; up to 3 doses (2.5 mg tablets) in 24 hr period
. Eletriptan (Relpax) 20 mg and 40 mg oral tablets; similar efficacy to other triptans
. Ergotamines
. Dihydroergotamine (DHE). Drug of choice in status migrainosus
- Most effective ergotamine; available as IV, IM, or SC injection. Also available as nasal spray (Migranol)
- 0.5-1 mg dose with up to 3 mg IM or 2 mg IV in 24 hours. Maximum weekly doses of 4-6 mg. Many protocols utilize antiemetic, such as, metoclopramide or prochlorperazine 5-10 mg IM or IV prior to DHE administration.
- Dihydroergotamine (Migranal) nasal spray 2 mg intranasal (0.5 mg in each nostril repeated in 15 minutes). Low recurrence rate of migraine reported in trials.
. Ergotamine tartrate
- Oral preparations contain 1 mg of ergotamine and 100 mg of caffeine. Two tablets at onset of symptoms.
Repeat after 30 minutes up to maximum dose of 6 mg per day. Avoid chronic daily or near-daily use.
. Nonsteroidal anti-inflammatories: No clear superiority in efficacy established for any particular agent; early
administration improves efficacy.
. Combination drugs
. Isometheptene - dichloralphenazone - acetaminophen (Midrin) 2 at onset then 1 q hr if needed up to 5 per 12 hour period
Contraindications:
. Avoid 5-HT-1 agonists (triptans) in coronary heart disease, peripheral vascular disease, uncontrolled
hypertension, and complex migraine, such as basilar or hemiplegic migraine. Avoid within 2 wks of MAO
usage (except Imitrex injection and Amerge tablets).
Pregnancy category C.
. 5-HT-1 agonists (triptans) should not be used within 24 hours of an ergot derivative or a different 5-HT-1
agonist
. Selective 5-HT-1 agonists (triptans) pregnancy category C. Ergotamines pregnancy category X.
. Avoid NSAIDs if danger of gastric erosion, renal, or hepatic disease
. Avoid acetaminophen in hepatic disease or with alcohol consumption
. Avoid drugs containing narcotics or butalbital in addiction prone patients
. Avoid vasoconstrictors in uncontrolled hypertension, coronary heart disease, peripheral vascular disease
. Avoid sumatriptan, zolmitriptan, and rizatriptan within 2 weeks of MAO usage
. Avoid eletriptan within 72 hours of potent CYPA34 inhibitor such as ketoconazole, itraconazole, nefazodone,
troleandomycin, or clarithromycin
ALTERNATIVE DRUGS
. Any analgesic, antiemetic, or sedative
. Narcotics including butorphanol (Stadol) are reserved for rescue therapy
. In emergency department: sumatriptan, DHE, adequate analgesics, antiemetic (chlorpromazine or prochlorperazine) and fluid replacement
. Other 5-HT-1 agonists
. A different route of delivery of 5-HT-1 agents or a different 5-HT-1 agent
. A wide variety of vasoconstrictors, analgesics, anti-inflammatories, antiemetics, and sedatives used alone
or in combination are prescribed based on symptoms and other factors. Except for parenteral 5-HT-1
agonists and antiemetics, drugs are most effective when taken early in migraine attacks.
PATIENT MONITORING
. Early intervention assist management
. Monitor frequency of attacks, pain behaviors. medication usage
. Encourage lifestyle modifications
PREVENTION/AVOIDANCE
. Avoid precipitants of attacks
. Prescribe biofeedback and psychologic intervention early if pain behavior evident
. Prophylactic therapy: If attacks significantly interfere with lifestyle or are not adequately controlled by appropriate acute interventions, daily prophylactic therapy may be appropriate. Regularly scheduled follow-up is mandatory.
. Propranolol (Inderal) 80-320 mg daily
. Atenolol (Tenormin) 50-100 mg daily
. Nadolol (Corgard) 40-80 mg daily
. Timolol (Blocadren) 10-20 mg daily
. Metoprolol (Lopressor) 100-450 mg daily
. Amitriptyline (Elavil) 10-150 mg daily
. Nortriptyline (Pamelor) 10-150 mg daily
. Verapamil (Calan, Isoptin) 80-120 mg daily
. Valproic acid (Depakene) or divalproex (Depakote) 250-1500 mg daily
. Cyproheptadine (Periactin) 4-16 mg daily
. Topiramate 100-200 mg
. Consultation/referral
. Obscure diagnosis, concomitant medical conditions, significant psychopathology
. Unresponsive to usual treatment
. Analgesic dependent headache patterns
POSSIBLE COMPLICATIONS
β’ Rare status migrainosus
β’ Rare cerebral ischemic events
β’ Iatrogenic effects of treatment
EXPECTED COURSE/PROGNOSIS
β’ With age - reduction in severity, frequency, and disability of attacks
β’ Most attacks subside within 72 hours