Download - Acute and preventive treatments for migraine Mark Weatherall BASH public meeting High Wycombe 2012
Acute and preventive Acute and preventive treatments for migrainetreatments for migraine
Mark WeatherallBASH public meetingHigh Wycombe 2012
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. Get the diagnosis right1. Get the diagnosis right‘migraine’ is the disorder and attack
◦a situation analogous to epilepsy the disorder epilepsy is a tendency to... the attack: seizures
◦in migraine, both share the same name◦the disorder is characterised by:
the tendency to repeated attacks triggers
sleep, food, weather, chemical (EtOH/GTN), hormonal, sensory, stress-relaxation
certain associations: hangovers, motion sickness, CVS family history
Migraine: Migraine: headache +headache +premonitory symptoms (20%+)
◦ tiredness , difficulty concentrating, neck stiffness, yawning, frequent urination – dopaminergic?
headaches typically unilateral, throbbing◦ associated with nausea +/- vomiting◦ sensitivity to light, sound, smells, movement
auras, usually visual, occur ~15-20% of patients◦ sensory, dysphasic, motor, olfactory
frequently associated with disability◦ WHO: a day of severe migraine ≈ quadriplegia
Migraine or TTH?Migraine or TTH?recognise the disorderphenotype the worst type of attackthe SPECTRUM study showed that
in patients with headaches that met criteria for migraine, probable migraine, and TTH, all headache types responded to triptans◦ this was not true for patients with purely TTH
chronic TTH is very rarerecurrent 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
explaining the natural historyarranging follow-up (if necessary)
3. Non-pharmacological 3. Non-pharmacological measuresmeasureslifestyle issues – the ‘boring life’?trigger management
◦hormonal◦dietary◦psychological
CBT, relaxation
◦environmental◦sleep◦neck...
Then...Then...
4. Use the right drugs4. Use the right drugs5. Use effective doses5. Use effective doses6. Treat early when the 6. Treat early when the painspains
mildmild7. Treat associated 7. Treat associated symptomssymptoms8. Choose appropriate route 8. Choose appropriate route ofof
deliverydelivery
Where to start?Where to start?paracetamol 1 gor, aspirin 900 mgor, ibuprofen 600-800 mg
◦+/- domperidone 10-20 mgtaken as soon as possible*ª
* i.e. as soon as the patient knows that this is a migraine or TTH
ª if there is aura, take at the start of the headache phase
Variations on a themeVariations on a themeif early nausea, you can use:soluble aspirinsuppositories*:
◦diclofenac 75 mg◦domperidone 30 mg
*be French!
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
Problems, problems…Problems, problems…ineffective
◦dose? timing? route? switch?headache recurrence
◦switch? combination with NSAID?contraindications
◦HT, IHDSE
◦nausea, GI, CNS, ‘triptan chest’
Then...Then...
9. Avoid medication 9. Avoid medication overuseoveruse
10. Use prophylactic10. Use prophylactictreatments treatments
appropriatelyappropriately
Choice of preventive RxChoice of preventive Rxlikelihood of responselikelihood of tolerabilityhelpful additional
properties◦ anxiolytic, antidepressant,
weight reduction
logistical issues◦ availability, monitoring
je ne sais quoi
First line preventivesFirst line preventivestricyclics
◦amitriptiline, dosulepin (50-100 mg)anticonvulsants
◦topiramate (50 mg bd), valproate (600-1000 mg)
β-blockers◦propranolol (40-80 mg tds), atenolol
(75-100 mg)pizotifen (1.5-2 mg)
Second line preventivesSecond line preventivesGON injection/sother anticonvulsants
◦pregabalin (300-600 mg)◦gabapentin (900-1200 mg)
vitamin B2 (400 mg)Mg citrate (600 mg)Coenzyme Q10 (450 mg)Botox (CM only – PREEMPT
protocol)
Long shots...Long shots...yet more
anticonvulsants◦ levetiracetam,
zonisamide, lamotrigine
methysergideflunarizinephenelzineaspirin/clopidogrelolanzapine
memantinemontelukasthigh-dose pizotifen lithiumamiloride in-patient therapies
◦ IV DHE, IV steroids,IV valproate, lidocaine
In the end...In the end...start low, go slow, but get thereuse all available avenues:
◦physio, CBT, biofeedback, specialist nurse
the law of diminishing returns applies
‘first do no harm’it is good to travel hopefully…
but it is better to arrive… eventually
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
transcranial magnetic stimulation