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Treatment options for the management of migraine

Headache is a common presenting symptom in primary care and may reflect a primary headache disorder, migraine, tension headache or cluster headache, or represent a secondary headache disorder such as medication overuse headache, meningitis, diabetes or more rarely a brain tumour. Manuela Fontebasso reviews the acute and preventive treatment options

Manuela Fontebasso
MB ChB
GP and GP with Special Interest in Headache
Department of Neurosciences
York District Hospital

Making the correct diagnosis is the first step to offering the most appropriate acute treatment. Migraine is a high-impact headache and finding the right treatment for any one individual is often about understanding what has been tried before, how effective it was in terms of time to reduction in symptoms, time to being headache-free, time to being able to function normally, and the sustained pain-free response.

Simple analgesia and antiemetics
Simple analgesia can be taken at the start of the premonitory phase, the aura or the headache.(1) The dose can be repeated during the course of the headache to ensure the resolution of the headache or prevent recurrence of headache symptoms. Trying a variety of different agents will enable the patient to find the best option for them (see Table 1).(2)

[[nip44_table1_42]]

Adding in a gastric emptying antiemetic will promote gastric emptying and aid absorption of the analgesic agent. The delivery system may become important, especially if nausea or vomiting occur early in the attack, so a suppository such as diclofenac and domperidone may be the best choice, if acceptable to the patient.
British Association for the Study of Headache   (BASH) guidelines suggest:(1)

  • Aspirin 600-900 mg up to four times daily, ideally soluble.
  • Ibuprofen 400-600 mg up to four times daily.
  • Naproxen 750-825 mg, with a further 250-275 mg up to twice in 24 hours.

The above can be combined with metoclopramide 10 mg or domperidone 20 mg to promote gastric emptying and hence improve efficacy.
If nausea and vomiting occurs early in the attack then diclofenac suppositories (100 mg) could be used to treat the pain and domperidone suppositories (30-60 mg) can treat the nausea and vomiting.
Table 1 shows the results of trial data evaluating the efficacy of different analgesic agents used to treat migraine.(2) Trial data does not always reflect patient response in the clinical setting, so it is important to review the patient in order to be flexible enough to find the best treatment for every patient. The response can vary from person to person and from attack to attack.

Triptans
Triptans work by targeting serotonin receptor sites within the dura, trigeminal nucleus, brainstem and the meningeal, dural, cerebral and pial vessels, which have been implicated in the pathogenesis of the migraine attack.(2) These receptors are not just located on cranial vessels and as such may explain the side-effect profile of triptans. They should be taken as the headache starts, and not earlier in the attack, ideally within an hour of the headache starting.
A meta-analysis of 53 triptan trials showed that when compared to sumatriptan, each of the currently available triptans showed varying degrees of efficacy at two hours, consistency of effect, tolerability and sustained pain-free response.(3) The measures and endpoints used in research trials do not reflect use in clinical practice so it is again important to offer flexibility in choice of triptan, dosage and delivery system. The response needs to be evaluated in three out of three attacks, and all triptans should be tried in order to find the optimal choice for any one individual.
Table 2 shows the range of triptan formulations available in the UK as well as their drug interactions and side-effects.(4,5)

[[nip44_table2_43]]

Prophylaxis
Managing headache is about minimising the total number of headache days.(1) This can be done by optimising the acute treatment to ensure a sustained pain-free response, but if headache recurrence continues to occur despite trying the full range of acute treatment options, either in isolation or in combination, then preventive medication might be appropriate. Preventive medication might be indicated if acute treatments don't work well, are associated with unacceptable side-effects or the overall headache frequency remains high.
Deciding when to try prophylaxis and knowing which drug to choose is never easy. Comorbid conditions, previously tried drugs and concerns about side-effects as well as efficacy all need to be considered. Preventive medication will not stop all headaches, but will stop some of the headaches, in some of the people, some of the time. The medication has to be taken at the right dose for long enough to assess how effective it is. Current guidelines suggest a slow uptitration to an initial target dose, and reviewing the patient after three months at each agreed target dose.
BASH guidelines suggest that, provided there is no contraindication, ß-blockers should be used as the firstline for migraine.(1) The side-effect profile suggests that atenolol, is better than metoprolol, and in turn both are less likely to cause side-effects than propranolol. Amitriptyline is indicated if tension-type headache, disturbed sleep, depression or other chronic pain conditions coexist with migraine. Other tricyclics could be tried if side-effects are a problem, and can be minimised by starting at 10 mg and slowly increasing the dose until an effect is achieved, setting clear goals for dosing and duration at each dose titration.
BASH suggests sodium valproate and topiramate as secondline agents (topiramate was licensed for use on migraine prophylaxis in 2005). Gabapentin has been shown to have limited efficacy but can be used as a thirdline agent.
Table 3 shows the different classes of drugs used in migraine prophylaxis, the range of doses recommended, side-effects, cautions and contraindications.(4-6)

[[nip44_table3_44]]

Supporting the patient
Patients need to understand how to use their medication correctly, what to do if their acute treatment does not work and how to be flexible in their treatment. Offering them a review appointment will give them the opportunity to optimise their acute treatment, assist in titration of their preventive medication, review possible side-effects and discuss dose changes as well as possible drug changes.
Diary cards are a valuable tool to review acute treatment response, total number of headache days and efficacy of drugs being used. Acute treatments should be assessed on the basis of response in three out of three attacks, and preventive drugs are best assessed in three-month blocks.

Conclusion
Headache is a common symptom and migraine is a high-impact headache that needs an effective acute treatment to minimise the number of headache days. Frequent headache days increase the risk of medication overuse headache developing so the threshold at which prophylaxis is used needs to reflect this as well as the needs and expectations of the patient.
Offering flexibility to the patient and involving them in the decision-making will encourage them to take control of their medication and, by finding the most effective treatment, feel in control of their headache. Reviewing the patient on an ongoing basis will facilitate the optimisation of both acute and preventive treatment options and ensure that the patient continues to treat their migraine effectively.

References

  1. British Association for the Study of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. London: BASH; 2007. Available from http://www.bash.org.uk
  2. Ferrari MD. Migraine. Lancet 1998;351:1043-51.
  3. Ferrari MD, Goadsby PJ, Roon KI, et al. Triptans (serotonin 5-HT1B/1D agonists) in migraine: detailed results and meta-analyisis of 53 trials. Cephalalgia 2002;22:633-58.
  4. British National Formulary 55. Appendix 1: Interactions. 2008;724-5.
  5. British National Formulary 55. 5HT1 agonists. 2008;239-41.
  6. Silberstein SD, Goadsby PJ. Migraine: preventative treatment. Cephalalgia 2002;22:491-512.