Acute treatments for Acute treatments for migrainemigraine

Fayyaz AhmedChester Migraine Education Day8 September 2012

YOUNG OR OLD

To set the scene...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

10 steps to success10 steps to successGet the diagnosis rightSet realistic expectationsConsider non-pharmacological measuresUse the right drugsUse effective dosesTreat early when the pains mildTreat associated symptomsChoose appropriate route of deliveryAvoid medication overuseUse prophylactic treatments appropriately

1. Making the Right 1. Making the Right DiagnosisDiagnosis‘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

Migraine or TTH?Migraine or TTH?

phenotype the worst type of attackpatients 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

2. Set realistic 2. Set realistic expectationsexpectationsthere is no ‘cure’recognising the disordergoal setting

◦trigger management◦effective acute treatment◦reducing attack frequency◦appraisal of best available options

explaining the natural history

3. Non-pharmacological 3. Non-pharmacological measuresmeasures 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...

4. Use the right drugSTART WITH Simple Painkillers

Aspirin, Paracetamol, Ibuprofen

ESCALATE TO TRIPTANS

AVOID CODEINE, CAFFEINE, BARBITURATE BASED COMBINATIONS

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

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

5. Use effective dosesparacetamol 1 gor, aspirin 900 mgor, ibuprofen 600-800 mg

◦If early nauseasoluble aspirinsuppositories*:

◦diclofenac 75 mg*be

French!

6. Treat early when mildBenefit

◦ Avoiding a disabling attack

◦ Better response

Risk ◦ Treating a wrong

attack◦ Risking

medication overuse

7. Rx associated symptomsAvoid physical activityAvoid bright lightsAvoid disturbing noisesDomperidone 10-20 mg

8. Choose appropriate route of delivery

Problems, problems…Problems, problems…not effective

◦dose? timing? route? combination? diagnosis?

contraindications◦asthma, upper GI problems, renal

impairmentside effects

◦GI, CNS

This is what patients do This is what patients do nextnext

Codeine…?Codeine…?… is NOT a treatment for

headache◦the WHO analgesic ladder should NOT be applied to headache management

TriptansTriptans5-HT1B/1D receptor agonistsseven different formulationsoptions 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

Headache response at 2 Headache response at 2 hrhr

Pain freedom at 2 hrPain freedom at 2 hr

advantages disadvantages

Sumatriptan well-established expensiveavailable OTC poorly absorbednow the cheapests/c, nasal spray

Zolmitriptan cheaper occasional confusion

long actingnasal spray, melt

Naratriptan cheaper slow onsetlong acting

Rizatriptan rapid onset high recurrencemelt

Almotriptan cheaperlow SE incidence

Eletriptan cheaper pumped out of CNSlong acting

Frovatriptan longest half-life slow onset

9. Avoid medication overuseRestrict to two

doses per weekUse long acting

triptansAvoid

combination analgesics

Can use triptan and NSAID such as sumatriptan and naproxen

Problems, problems…Problems, problems…ineffective

◦dose? timing? route? switch?headache recurrence

◦switch? combination with NSAID?contraindications

◦HT, IHDSE

◦nausea, GI, CNS, ‘triptan chest’

10. Use preventive treatmentShould 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

The futureThe futurenew 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

Neurostimulation Transcranial Magnetic Stimulation

Vagal nerve stimulation (Gammacore)