Management of migraine

Last updated

Migraine may be treated either prophylactically (preventive) or abortively (rescue) for acute attacks. [1] Migraine is a complex condition; there are various preventive treatments which disrupt different links in the chain of events that occur during a migraine attack. Rescue treatments also target and disrupt different processes occurring during migraine.

Contents

Preventive treatment

Because of the complexity of migraine, no preventive treatment modality is effective for all migraine sufferers. [2] For example, lifestyle (including trigger avoidance), diet changes, diet supplements, and treating conditions such as sleep apnea may all help prevent migraines. Dental appliances such as the Nociceptive Trigeminal Inhibition Tension Suppression System might be used in specific circumstances. Preventive treatments can be sub-divided into non-drug treatments, and treatment with medication. There are several non drug treatments suggested in the literature including weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease. [3]

Rescue (or abortive) treatment

Rescue treatment involves acute symptomatic control with medication. [4] Recommendations for rescue therapy of migraine include: (1) migraine-specific agents such as triptans, CGRP antagonists, or ditans for patients with severe headaches or for headaches that respond poorly to analgesics, (2) non-oral (typically nasal or injection) route of administration for patients with vomiting, (3)  avoid medication overuse headache by educating patients using prophylactic therapies. [5] Medications are more effective if used earlier in an attack. [4]

The frequent use of medication may result in medication overuse headache (MOH), in which the headaches become more severe and more frequent. [6] This may occur with triptans, ergotamines, and analgesics, especially opioids or narcotic analgesics. [6] [7] Combination of opioids with other analgesics is thought to nearly double the risk of MOH. [8]

Spinal manipulation for treating an ongoing migraine headache is not supported by evidence. [9]

Ditans

Ditans are a class of abortive medication for the treatment of migraines. [10] Oral lasmiditan (Reyvow) is approved in the US by the FDA for acute treatment of migraine in adults. [11]

Analgesics

Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or the combination of acetaminophen (paracetamol), acetylsalicylic acid (aspirin), and caffeine, although caffeine overuse can be a contributor to migraine chronification as well as a migraine trigger for many patients. [12] [13] Aspirin (900 to 1000 mg) can relieve moderate to severe migraine pain, with an effectiveness similar to sumatriptan. [14] [15] Paracetamol, either alone or in combination with metoclopramide (an anti-nausea drug), is an effective treatment with a low risk of adverse effects. [16] [17] In pregnancy, paracetamol and metoclopramide are deemed safe as are NSAIDs until the third trimester. [12] Intravenous metoclopramide is also effective by itself. [18] [19]

Several NSAIDs, including diclofenac and ibuprofen, have evidence to support their use. [20] [21] Ibuprofen provides effective pain relief in about 50%. [22] Diclofenac has been found effective. Ketorolac is available in intravenous and intramuscular formulation. [12] The two main adverse drug reactions (ADRs) associated with NSAIDs relate to gastrointestinal (GI) effects and renal effects of the agents.Naproxen by itself may not be effective as a stand-alone medicine to stop a migraine headache as it is only weakly better than a placebo medication in clinical trials. [23]

Triptans

Triptans such as sumatriptan are effective for both pain and nausea in up to 75% of migraineurs. [24] [25] [26] They are the initially recommended treatments for those with moderate to severe pain or those with milder symptoms who do not respond to simple analgesics. [12] The different forms available include oral, injectable, nasal spray, rectal, and oral dissolving tablets. [27] [28] [29] [30] For people with migraine symptoms such as nausea or vomiting, taking the abortive medicine by mouth or through the nose may be difficult. All route of administration have been shown to be effective at reducing migraine symptoms, however, nasal and injectable subcutaneous administration may result in more side effects. [30] [29] The adverse effects associated with rectal administration have not been well studied. [28] In general, all the triptans appear equally effective, with similar side effects. However, individuals may respond better to specific ones. [12]

Most side effects are mild, including flushing; however, rare cases of myocardial ischemia have occurred. [27] They are thus not recommended for people with cardiovascular disease, [12] who have had a stroke, or have migraines that are accompanied by neurological problems. [31] In addition, triptans should be prescribed with caution for those with risk factors for vascular disease. While historically not recommended in those with basilar migraines there is no specific evidence of harm from their use in this population to support this caution. [32] Triptans are not addictive, but may cause medication overuse headaches if used more than 10 days per month. [33] [34]

Sumatriptan does not prevent other migraine headaches from starting in the future. [29] For increased effectiveness at stopping migraine symptoms, a combined therapy that includes sumatriptan and naproxen may be suggested. [35]

Ergots

Ergotamine and dihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms. [27] [36] They appear equally effective to the triptans, [37] [38] are less expensive, [39] [38] and experience adverse effects that typically are benign. [40] [41] In the most debilitating cases, such as those with status migrainosus, they appear to be the most effective treatment option. [40] [41] The most common adverse effects are nausea, vomiting, abdominal pain, generalized weakness, tiredness, malaise, paresthesia, coldness, muscle pains, diarrhea, and chest tightness. These are less common with DHE than with ergotamine tartrate. [42] Ergots can cause vasospasm including coronary vasospasm, and are contraindicated in people with coronary artery disease. [43]

Phenothiazines

Phenothiazines, often used for the treatment of nausea and vomiting, are also effective for treating migraine headache. [44] [45] Prochlorperazine is typically used due to a more favorable treatment profile. [46]

Gepants

Gepants may be used for rescue as well as prevention. Some gepants are approved for different purposes in different jurisdictions. Zavegepant was approved for medical use in the United States in March 2023. [47] [48] [49]

Antiemetics

Metoclopramide is a recommended treatment for those who present to the emergency department. [12]

Other Medications

Intravenous metoclopramide, intravenous prochlorperazine, or intranasal lidocaine are other potential options. [12] [19] Metoclopramide or prochlorperazine are the recommended treatment for those who present to the emergency department. [12] [19] Haloperidol may also be useful in this group. [19] [36] A single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours. [50] [51] Spinal manipulation for treating an ongoing migraine headache is not supported by evidence. [52] It is recommended that opioids and barbiturates not be used due to questionable efficacy, addictive potential, and the risk of rebound headache. [12] [53] There is tentative evidence that propofol may be useful if other measures are not effective. [54]

Magnesium is recognized as an inexpensive, over-the-counter supplement which can be part of a multimodal approach to migraine reduction. Some studies have shown to be effective in both preventing and treating migraine in intravenous form. [55] The intravenous form reduces attacks as measured in approximately 15–45 minutes, 120 minutes, and 24-hour time periods, magnesium taken orally alleviates the frequency and intensity of migraines. [56] [57]

Migraine Treatment for Children

For children, ibuprofen or other NSAIDs help decrease pain. [58] [59] Triptans are effective, though there is a risk of side effects such as nausea, coronary vasoconstriction, dizziness, paresthesia, flushing, tingling, neck pain, and chest tightness, known as "triptan sensations". [60]

Other Interventions

Occipital nerve stimulation, may be effective but has the downsides of being cost-expensive and has a significant amount of complications. [61]

There is modest evidence for the effectiveness of non-invasive neuromodulatory devices, behavioral therapies and acupuncture in the treatment of migraine headaches. [53] There is little to no evidence for the effectiveness of physical therapy, chiropractic manipulation and dietary approaches to the treatment of migraine headaches. [53] Behavioral treatment of migraine headaches may be helpful for those who may not be able to take medications (for example pregnant women). [53]

Related Research Articles

<span class="mw-page-title-main">Headache</span> Pain in the head, neck, or face

Headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.

<span class="mw-page-title-main">Paracetamol</span> Common medication for pain and fever

Paracetamol, or acetaminophen, is a non-opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain. It is a widely used over-the-counter medication. Common brand names include Tylenol and Panadol.

<span class="mw-page-title-main">Common cold</span> Common viral infection of the upper respiratory tract

The common cold or the cold is a viral infectious disease of the upper respiratory tract that primarily affects the respiratory mucosa of the nose, throat, sinuses, and larynx. Signs and symptoms may appear in as little as two days after exposure to the virus. These may include coughing, sore throat, runny nose, sneezing, headache, and fever. People usually recover in seven to ten days, but some symptoms may last up to three weeks. Occasionally, those with other health problems may develop pneumonia.

<span class="mw-page-title-main">Cluster headache</span> Neurological disorder

Cluster headache is a neurological disorder characterized by recurrent severe headaches on one side of the head, typically around the eye(s). There is often accompanying eye watering, nasal congestion, or swelling around the eye on the affected side. These symptoms typically last 15 minutes to 3 hours. Attacks often occur in clusters which typically last for weeks or months and occasionally more than a year.

<span class="mw-page-title-main">Tension headache</span> Medical condition

Tension headache, stress headache, or tension-type headache (TTH), is the most common type of primary headache. The pain usually radiates from the lower back of the head, the neck, the eyes, or other muscle groups in the body typically affecting both sides of the head. Tension-type headaches account for nearly 90% of all headaches.

<span class="mw-page-title-main">Metoclopramide</span> Medication

Metoclopramide is a medication used for stomach and esophageal problems. It is commonly used to treat and prevent nausea and vomiting, to help with emptying of the stomach in people with delayed stomach emptying, and to help with gastroesophageal reflux disease. It is also used to treat migraine headaches.

<span class="mw-page-title-main">Granisetron</span> Serotonin 5-HT3 antiemetic

Granisetron is a serotonin 5-HT3 receptor antagonist used as an antiemetic to treat nausea and vomiting following chemotherapy and radiotherapy. Its main effect is to reduce the activity of the vagus nerve, which is a nerve that activates the vomiting center in the medulla oblongata. It does not have much effect on vomiting due to motion sickness. This drug does not have any effect on dopamine receptors or muscarinic receptors.

<span class="mw-page-title-main">Sumatriptan</span> Medication used for migraines & cluster headaches

Sumatriptan, sold under the brand name Imitrex among others, is a medication used to treat migraine headaches and cluster headaches. It is taken orally, intranasally, or by subcutaneous injection. Therapeutic effects generally occur within three hours.

<span class="mw-page-title-main">Peripheral neuropathy</span> Nervous system disease affecting nerves beyond the brain and spinal cord

Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropathies affecting motor, sensory, or autonomic nerve fibers result in different symptoms. More than one type of fiber may be affected simultaneously. Peripheral neuropathy may be acute or chronic, and may be reversible or permanent.

<span class="mw-page-title-main">Triptan</span> Class of pharmaceutical drugs

Triptans are a family of tryptamine-based drugs used as abortive medication in the treatment of migraines and cluster headaches. This drug class was first commercially introduced in the 1990s. While effective at treating individual headaches, they do not provide preventive treatment and are not considered a cure. They are not effective for the treatment of tension–type headache, except in persons who also experience migraines. Triptans do not relieve other kinds of pain.

<span class="mw-page-title-main">Zolmitriptan</span> Medication used in treatment of migraines

Zolmitriptan, sold under the brand name Zomig among others, is a serotonergic medication which is used in the acute treatment of migraine attacks with or without aura and cluster headaches. It is taken by mouth as a swallowed or disintegrating tablet or as a nasal spray.

<span class="mw-page-title-main">Prochlorperazine</span> Medication for nausea, psychosis, and anxiety

Prochlorperazine, formerly sold under the brand name Compazine among others, is a medication used to treat nausea, migraines, schizophrenia, psychosis and anxiety. It is a less preferred medication for anxiety. It may be taken by mouth, rectally, injection into a vein, or injection into a muscle.

<span class="mw-page-title-main">Nabilone</span> Synthetic cannabinoid

Nabilone, sold under the brand name Cesamet among others, is a synthetic cannabinoid with therapeutic use as an antiemetic and as an adjunct analgesic for neuropathic pain. It mimics tetrahydrocannabinol (THC), the primary psychoactive compound found naturally occurring in Cannabis.

<span class="mw-page-title-main">Dihydroergotamine</span> Chemical used to treat migraines

Dihydroergotamine (DHE), sold under the brand names D.H.E. 45 and Migranal among others, is an ergot alkaloid used to treat migraines. It is a derivative of ergotamine. It is administered as a nasal spray or injection and has an efficacy similar to that of sumatriptan. Nausea is a common side effect.

<span class="mw-page-title-main">Antimigraine drug</span> Medication intended to reduce the effects or intensity of migraine headache

Antimigraine drugs are medications intended to reduce the effects or intensity of migraine headache. They include drugs for the treatment of acute migraine symptoms as well as drugs for the prevention of migraine attacks.

<span class="mw-page-title-main">Naratriptan</span> Chemical compound

Naratriptan (trade names include Amerge) is a triptan drug marketed by GlaxoSmithKline and is used for the treatment of migraine headaches. It is a selective 5-HT1 receptor subtype agonist.

<span class="mw-page-title-main">Post-dural-puncture headache</span> Common side effect of lumbar puncture or spinal anaesthesia

Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater. The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are also common.

Paracetamol/metoclopramide hydrochloride is an oral fixed dose combination prescription medication containing the analgesic paracetamol (500 mg) and the anti-emetic metoclopramide hydrochloride (5 mg). Formulated as a tablet and as sachets of a water-soluble powder, it is sold under the trade name Paramax by Sanofi-Synthelabo, and in Switzerland as Migraeflux MCP, in Australia it is sold as Meteclomax and Anagraine.

Sumatriptan/naproxen, sold under the brand name Treximet among others, is a fixed-dose combination medication used to treat migraines. It is taken by mouth. It contains sumatriptan, as the succinate, a serotonin 5-hydroxytryptamine (5-HT) 1b/1d receptor agonist (triptan); and naproxen as the sodium salt, a member of the arylacetic acid group of nonsteroidal anti-inflammatory drugs (NSAIDs).

Preventive treatment of migraine can be an important component of migraine management. The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraine attacks, and to increase the effectiveness of abortive therapy. Another reason to pursue prevention is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which can arise from overuse of pain medications, and can result in chronic daily headache. Preventive treatments of migraine include medications, nutritional supplements, lifestyle alterations, and surgery. Prevention is recommended in those who have headaches more than two days a week, cannot tolerate the medications used to treat acute attacks, or those with severe attacks that are not easily controlled.

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