Migraine medical therapy: Difference between revisions

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{{Migraine}}
{{Migraine}}
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==Medical Therapy==
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs.  Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.


=== Trigger avoidance===
==Overview==
Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. Beyond an often pronounced [[placebo effect]], general dietary restriction has not been demonstrated to be an effective approach to treating migraine.<ref name="url[Alimentary trigger factors that provoke migraine an... [Schmerz. 2006] - PubMed - NCBI">{{cite web |url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15806385&query_hl=8&itool=pubmed_docsum |title=[Alimentary trigger factors that provoke migraine an... [Schmerz. 2006] - PubMed - NCBI |format= |work= |accessdate=2012-08-30}}</ref> Nonetheless, some people fervently claim that they have successfully identified foods that are likely to result in migraines, and by avoiding them, can decrease the likelihood of an episode.
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs.  Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. Medical therapy can be divided into two treatment regimens: non-specific treatment such as [[non-steroidal anti-inflammatory drug]] and [[analgesics]] and specific treatment such as [[triptans]] and [[ergot]] derivatives.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref> Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.


=== Abortive treatment ===
==Non Pharmacological Therapy==


Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. A cold or hot shower directed at the head, a hot or cold wet washcloth, a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed. Some headache sufferers are surprised to learn that a simple cup of coffee is used daily around the world to control minor vascular headaches that are not quite migraines. Minor vascular headaches are frequently associated with the hormonal fluctuations of menstrual periods, irregular eating, and unusually hard work. For migraineurs, a well-timed cup of coffee can prevent outright migraine under the same conditions. A simple treatment, which has been effective for some, is a counteracting "ice cream headache", briefly provoked by placing spoonfuls of ice cream on the soft palate at the back of the mouth.  (Hold them there with your tongue until they melt or become intolerable.)  This directs cooling to the [[hypothalamus]], which is suspected to be involved with the migraine feedback cycle, and for some it can stop even a severe headache very quickly. For patients who have been diagnosed with recurring migraines, doctors recommend taking migraine abortive medicines to treat the attack as soon as possible. Migraine without aura presenting without prodrome or nausea can present with sudden onset.  Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However, in many cases once an attack is underway, it can become intensely painful, last for a long time (sometimes even for several days), and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.  For sufferers of weather-related migraines there is a simple treatment known as the [[Valsalva maneuver]], which pilots and frequent fliers employ to relieve discomfort from pressure change.  By holding your nose and gently pushing the air in your mouth back towards your ears and "popping" them you are opening your eustachian tubes.  These normally open and close with regular chewing and talking but in some people may stay closed due to allergies or genetics.  Regular opening and closing of the eustachian tubes allows a person to continually equalize to any change in the ambient barometric pressure.  When this does not occur regularly the difference in pressure between the head and the environment can cause vascular swelling/constricting and trigger a migraine.  Migraines can be stopped by doing the Valsalva maneuver three or four times.  During changeable weather patterns doing the maneuver fifteen times per day can eliminate the headaches.
* Migraine sufferers usually develop their own coping mechanisms for the [[pain]] of a migraine attack. A cold or hot shower directed at the head, a hot or cold wet washcloth, a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed.


====Acetaminophen or Non-steroidal anti-inflammatory drug (NSAIDs)====
* Some headache sufferers are surprised to learn that a simple cup of [[coffee]] is used daily around the world to control minor vascular headaches that are not quite migraines. Minor vascular headaches are frequently associated with the [[hormonal]] fluctuations of [[menstrual]] periods, irregular eating, and unusually hard work. For migraineurs, a well-timed cup of [[coffee]] can prevent outright migraine under the same conditions.


The first line of treatment is [[over-the-counter]] [[abortive medication]].
* A simple treatment, which has been effective for some, is a counteracting "ice cream headache", briefly provoked by placing spoonfuls of ice cream on the soft palate at the back of the mouth.  This directs cooling to the [[hypothalamus]], which is suspected to be involved with the migraine feedback cycle, and for some it can stop even a severe headache very quickly.


* Regarding [[non-steroidal anti-inflammatory drug]]s, a [[randomized controlled trial]] found that [[naproxen]] can abort about one third of migraine attacks, which was 5% less that the benefit of [[sumatriptan]].<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443–54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>
* For sufferers of weather-related migraines there is a simple treatment known as the [[Valsalva maneuver]], which pilots and frequent fliers employ to relieve discomfort from pressure change.  By holding your nose and gently pushing the air in your mouth back towards your ears and "popping" them you are opening your [[eustachian tube]]s.  These normally open and close with regular chewing and talking but in some people may stay closed due to [[allergies]] or [[genetics]]. Regular opening and closing of the [[eustachian tube]]s allows a person to continually equalize to any change in the ambient barometric pressure.  When this does not occur regularly the difference in pressure between the head and the environment can cause [[vascular]] swelling/constricting and trigger a migraine. Migraines can be stopped by doing the [[Valsalva maneuver]] three or four times. During changeable weather patterns doing the maneuver fifteen times per day can eliminate the headaches.
* [[Acetaminophen]], at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a [[randomized controlled trial]].<ref name="pmid11112243">{{cite journal |author=Lipton RB, Baggish JS, Stewart WF, Codispoti JR, Fu M |title=Efficacy and safety of acetaminophen in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study |journal=Arch. Intern. Med. |volume=160 |issue=22 |pages=3486–92 |year=2000 |pmid=11112243 |doi=}}</ref>
* Simple analgesics combined with [[caffeine]] may help.<ref name="pmid10524663">{{cite journal |author=Goldstein J, Hoffman HD, Armellino JJ, ''et al'' |title=Treatment of severe, disabling migraine attacks in an over-the-counter population of migraine sufferers: results from three randomized, placebo-controlled studies of the combination of acetaminophen, aspirin, and caffeine |journal=Cephalalgia : an international journal of headache |volume=19 |issue=7 |pages=684–91 |year=1999 |pmid=10524663 |doi=}}</ref>


During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit. [[Excedrin]] is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an OTC treatment for migraine.Patients themselves often start off with [[paracetamol]] (known as [[acetaminophen]] in the USA), [[aspirin]], [[ibuprofen]], or other simple [[analgesic]]s that are useful for tension headaches. Some patients find relief from taking [[Benadryl]], an [[over-the-counter]] sedative antihistamine, or anti-nausea agents.  OTC drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".
* For patients who have been diagnosed with recurring migraines, doctors recommend taking migraine abortive medicines to treat the attack as soon as possible. Migraine without aura presenting without [[migraine history and symptoms#Prodrome Phase|prodrome]] or [[nausea]] can present with sudden onset. Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However, in many cases once an attack is underway, it can become intensely painful, last for a long time, and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.


====Serotonin agonists====
==Medical Therapy==


{{main|triptans}}
Medical therapy can be divided into two treatment regimens:<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>
* Non-specific treatment: [[Non-steroidal anti-inflammatory drug]] and [[analgesics]]
* Specific treatment: [[Triptans]] and [[ergot]] derivatives


[[Sumatriptan]] and related selective [[serotonin receptor agonist]]s are excellent for severe migraines or those that do not respond to [[NSAID]]s <ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, O'Carroll CP, Adelman JU, O'Donnell FJ, Alexander WJ, Spruill SE, Barrett PS, Lener SE |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=297 |issue=13 |pages=1443–54 |year=2007 |month=April |pmid=17405970 |doi=10.1001/jama.297.13.1443 |url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.297.13.1443 |accessdate=2012-08-30}}</ref> or other [[over-the-counter]] drugs.<ref name="pmid11112243">{{cite journal |author=Lipton RB, Baggish JS, Stewart WF, Codispoti JR, Fu M |title=Efficacy and safety of acetaminophen in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study |journal=[[Archives of Internal Medicine]] |volume=160 |issue=22 |pages=3486–92 |year=2000 |pmid=11112243 |doi= |url=http://archinte.jamanetwork.com/article.aspx?volume=160&page=3486 |accessdate=2012-08-30}}</ref> [[Triptans]] are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.====Ergot alkaloids====Until the introduction of sumatriptan in 1991, [[ergot]] derivatives (see [[ergoline]]) were the primary oral drugs available to abort a migraine once it is established.  Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine. However, [[ergotamine]] tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favour due to the problem of [[ergotism]]. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository (or Ergostat sublingual tablets made until circa 1992).  Ergotamine-caffeine 1/100 mg fixed ratio tablets (like [[Cafergot]], Ercaf, etc.) are much less expensive per headache than triptans, and are commonly available in Asia. They are difficult to obtain in the USA. Ergotamine-caffeine can't be regularly used to abort evening or night onset migraines due to debilitating caffeine interference with sleep. Pure ergotamine tartrate is highly effective for evening-night migraines, but is rarely or never available in the USA. [[Dihydroergotamine]] (DHE), which must be injected or inhaled, can be as effective as ergotamine tartrate, but is much more expensive than $2 USD Cafergot tablets.
===Non Specific Treatment===
Patients often start off with non specific analgesics such as [[paracetamol]] (known as acetaminophen in the USA), [[aspirin]], [[ibuprofen]], or other simple analgesics that are useful for tension headaches. Some patients find relief from taking over-the-counter sedative antihistamines or anti-nausea agents. Over the counter drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".


====Other agents====
Simple analgesics combined with [[caffeine]] may help.<ref name="pmid10524663">{{cite journal |author=Goldstein J, Hoffman HD, Armellino JJ, ''et al'' |title=Treatment of severe, disabling migraine attacks in an over-the-counter population of migraine sufferers: results from three randomized, placebo-controlled studies of the combination of acetaminophen, aspirin, and caffeine |journal=Cephalalgia : an international journal of headache |volume=19 |issue=7 |pages=684–91 |year=1999 |pmid=10524663 |doi=}}</ref>  During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit. [[Excedrin]] is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an OTC treatment for migraine. Patients themselves often start off with [[paracetamol]] (known as [[acetaminophen]] in the USA), [[aspirin]], [[ibuprofen]], or other simple [[analgesic]]s that are useful for tension headaches.


If over-the-counter medications do not work, or if triptans are unaffordable, the next step for many doctors is to prescribe [[Fioricet]] or [[Fiorinal]], which is a combination of [[butalbital]] (a [[barbiturate]]), [[acetaminophen]] (in Fioricet) or [[acetylsalicylic acid]] (more commonly known as [[aspirin]] and present in Fiorinal), and [[caffeine]]. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to [[rebound headache]]s. Barbiturate-containing medications are not available in many European countries. [[Narcotic]] pain killers (for example, [[codeine]], [[morphine]] or other [[opiate]]s) provide variable relief, but their side effects, the possibility of causing [[rebound headache]]s or analgesic overuse headache, and the risk of addiction contraindicates their general use.[[Amidrine]] (a cocktail of a pain reliever, a sedative, and a vasoconstrictor) is sometimes prescribed for migraine headaches.[[Anti-emetic]]s by [[suppository]] or [[medical injection|injection]] may be needed in cases where vomiting dominates the symptoms. The earlier these drugs are taken in the attack, the better their effect. [[Intravenous therapy|Intravenous]] [[chlorpromazine]] has proven very effective in treating status migrainosus&mdash;intractable and unremitting migraine.Status migraine is an extremely rare life-threatening condition. In otherwise uncomplicated, non-nauseated cases, it can be treated with 20 mg of prednisone tablets every eight hours until the migraine ends, followed by mandatory tapering off doses (the classic steroid taper). [[Prednisone]] is a cortisol-like semi-synthetic adrenal hormone, a non-anabolic steroid, which strongly stimulates biosynthesis of proteins from DNA. The replicated proteins include enzymes that cure the migraine through numerous metabolic boosts, including molecular construction of more natural serotonin to be stored in blood [[platelets]]. Prednisone risks include immune system suppression, adrenal axis suppression, non-addictive dependence, and long-term osteoporosis. Vitamin antioxidants taken with calcium and magnesium may reduce the damage caused by the extra free radicals released, and the bone lost, during long term prednisone use.
* NSAIDs such as, [[naproxen]], [[ibuprofen]], [[ketoprofen]] and [[diclofenac]], can be taken at the onset of the [[aura]] to avoid the subsequent headache, opposite to [[sumatriptan]]s which should only be started when the headache starts.
**[[Ketoprofen]] can be used for migraines with and without [[aura]].
**[[Ibuprofen]] can be used for mild and moderate migraines, with or without [[aura]].
**[[Naproxen]] can abort about one third of migraine attacks, which is 5% less that the benefit of [[sumatriptan]].<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443–54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>


==== Comparative studies ====
*[[Acetylsalicylic scid]] ([[aspirin]]) can be taken as monotherapy.  [[Metoclopramide]] could be co-administered in case of associated digestive symptoms ([[nausea]] and [[vomit]]).


Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial<ref name="ASADiener">{{cite journal | author = Diener H, Bussone G, de Liano H, Eikermann A, Englert R, Floeter T, Gallai V, Göbel H, Hartung E, Jimenez M, Lange R, Manzoni G, Mueller-Schwefe G, Nappi G, Pinessi L, Prat J, Puca F, Titus F, Voelker M | title = Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks. | journal = Cephalalgia | volume = 24 | issue = 11 | pages = 947-54 | year = 2004 | id = PMID 15482357}}</ref> reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain. Acetylsalicylic acid is OTC aspirin, ibuprofen is OTC Advil, and since migraineurs know they don't provide much relief, the results of this study are unexpected. They may be partly related to the dosage of acetylsalicylic acid used, which was considerably higher than the one or two 300 mg tablets normally recommended for OTC use. High doses of aspirin and ibuprofen may cause ringing of the ears, which is a sign of drug toxicity to the inner ear. Another [[randomized controlled trial]], funded by the manufacturer of the study drug, found that a combination of [[sumatriptan]] 85 mg and [[naproxen]] sodium 200 mg was better than either drug alone.<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443-54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>
*[[Acetaminophen]] (1000 mg) combined with [[metoclopramide]] is aas effective as oral [[sumatriptan]] 100 mg.<ref name="pmid23633349">{{cite journal| author=Derry S, Moore RA| title=Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. | journal=Cochrane Database Syst Rev | year= 2013 | volume= 4 | issue= | pages= CD008040 | pmid=23633349 | doi=10.1002/14651858.CD008040.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633349  }} </ref>


=== Preventive drugs<ref name="AFP0601">{{cite journal | author = Modi S, Lowder D | title = Medications for migraine prophylaxis. | journal = American Family Physician | volume = 73 | issue = 1 | pages = | year = 2006 | id =}}</ref> ===


Following treatment of an acute migraine, it is important to consider preventive measures. Factors that prompt consideration of such measures include:
Shown below is a table summarizing the doses of non specific analgesics commonly used for the treatment of mild to moderate migraine.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>


1) more than two migraines per month with disabilities lasting three or more days per month
{|Class="wikitable"
|-
| '''[[Analgesic]] and [[NSAID]]'''
| '''Doses'''
| '''Max Doses per day''' <br>
Not more that 3 times per week
|-
|[[Aspirin]]
|Tablet 1000mg
----
1000mg could be added
|4000mg
|-
|[[Ibuprofen]]
|Tablet 400mg
----
200 - 400mg could be added
|1200mg
|-
|[[Acetaminophen]]
|Tablet 500mg
----
500mg could be added
|4000mg
|-
|[[Naproxen]]
|Tablet 500 - 700mg
----
250 - 500mg could be added
|1250mg
|-
|[[Ketorolac]]
|IM 60mg
----
IV 30mg
|IM 120mg
----
IV 120mg
|}


2) failure of acute treatments
===Specific Treatment===
====Triptans====
* [[Sumariptans]] and related [[triptans]] are selective [[serotonin receptor agonist]]s, they act on the [[5HT1 receptor]]s, and so inhibit neurogenic inflammation and vasodilation.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>


3) contraindications to acute treatments
* Triptans are excellent for severe migraines or those that do not respond to [[NSAID]]s.<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, O'Carroll CP, Adelman JU, O'Donnell FJ, Alexander WJ, Spruill SE, Barrett PS, Lener SE |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=297 |issue=13 |pages=1443–54 |year=2007 |month=April |pmid=17405970 |doi=10.1001/jama.297.13.1443 |url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.297.13.1443 |accessdate=2012-08-30}}</ref> or other [[over-the-counter]] drugs<ref name="pmid11112243">{{cite journal |author=Lipton RB, Baggish JS, Stewart WF, Codispoti JR, Fu M |title=Efficacy and safety of acetaminophen in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study |journal=[[Archives of Internal Medicine]] |volume=160 |issue=22 |pages=3486–92 |year=2000 |pmid=11112243 |doi= |url=http://archinte.jamanetwork.com/article.aspx?volume=160&page=3486 |accessdate=2012-08-30}}</ref>  Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.


4) adverse reactions from acute treatments
* [[Triptans]] are proven to be efficient against [[photophobia]] and [[phonophobia]].


5) use of acute treatments more than twice a week or
* Before discontinuing them, [[triptans]] should be tested in at least three attacks, unless the patient shows [[intolerance]].  A patient that doesn´t respond to one type of [[triptan]] may respond to another.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>


6) presence of uncommon symptoms such as hemiplegia, prolonged, aura, or migraine infarction.
Shown below is a table summarizing the doses of different types of triptans.  Triptans are used among patients with moderate to severe [[headache]], with [[nausea]] or [[vomit]]ing, rapid progression to severe [[headache]] and mild to moderate [[headache]] that responds poorly to 1st-line treatment.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>


The main goal of preventive therapy is to reduce the frequency, severity, and durations of migraines, and to increase the effectiveness of abortive therapy. Another reason is to avoid medication overuse headache (MOH), otherwise known as [[rebound headache]], which is an extremely common problem among migraneurs. This occurs in part due to overuse of pain medications. MOH results in the development of chronic daily headache due to "transformed" migraine. Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a [[neurologist]] is advisable.  A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next.  Often preventive medications do not have to be taken indefinitely.  Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.  The most effective prescription medications include several drug classes:
{| Class="wikitable"
|-
| '''[[Triptan]]'''
| '''Doses'''
| '''Max Doses per day'''
|'''Side Effects'''
|-
|[[Almotriptan]]
|Tablet 12.5mg
|25mg
|Vasomotor hot flushes
[[Dizziness]] <br>
[[Weakness]] <br>
[[Asthenia]]<br>
[[Somnolence]]  <br>
[[Nausea]]<br>
[[Vomit]]s
|-
|[[Eletriptan]]
|Tablet 40mg
|80mg
|-
|[[Fovatriptan]]
|Tablet 2.5mg
|5mg
|-
|[[Naratriptan]]
|Tablet 2.5
|5mg
|-
|[[Rizatriptan]]
|Tablet 5 - 10mg
----
Dry powder 10mg
|20mg
|-
|[[Sumatriptan]]
| Tablet 50mg
----
SQ injection ampoule 6mg
----
Nasal spray 10 - 20mg
|300mg
----
12mg
----
40mg
|Moderate or severe [[hypertension]] <br>
heat sensation <br>
suffocating feeling <br>
pressure sensation
|-
|[[Zolmitriptan]]
|Tablet 2.5mg
|10mg
|}


* [[beta blockers]] such as [[propranolol]] and [[atenolol]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] of nine [[randomized controlled trials]] or [[crossover studies]], which together included 668 patients, found that [[propranolol]] had an "overall [[relative risk]] of response to treatment (here called the 'responder ratio')" was 1.94.<ref name="pmid15106196">{{cite journal | author = Linde K, Rossnagel K | title = Propranolol for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003225 | year = | id = PMID 15106196}}</ref>
====Ergot Alkaloids====
* [[anticonvulsants]] such as [[valproic acid]] and [[topiramate]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] of ten [[randomized controlled trials]] or [[crossover studies]], which together included 1341 patients, found [[anticonvulsants]] had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a [[number needed to treat]] of 3.8.<ref name="pmid15266476">{{cite journal | author = Chronicle E, Mulleners W | title = Anticonvulsant drugs for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003226 | year = | id = PMID 15266476}}</ref> However, concerns have been raised about the marketing of [[gabapentin]].<ref name="pmid16908919">{{cite journal | author = Steinman M, Bero L, Chren M, Landefeld C | title = Narrative review: the promotion of gabapentin: an analysis of internal industry documents. | journal = Ann Intern Med | volume = 145 | issue = 4 | pages = 284-93 | year = 2006 | id = PMID 16908919}}</ref>
* Until the introduction of sumatriptan in 1991, [[ergot]] derivatives, were the primary oral drugs available to abort a migraine once it is established. Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine.
* [[antidepressant]]s include [[tricyclic antidepressants]] (TCAs) such as [[amitriptyline]] and the newer [[selective serotonin reuptake inhibitors]] (SSRIs) such as [[fluoxetine]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] found [[selective serotonin reuptake inhibitors]] are no more effective than placebo.<ref name="pmid16034880">{{cite journal | author = Moja P, Cusi C, Sterzi R, Canepari C | title = Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD002919 | year = | id = PMID 16034880}}</ref> Another [[meta-analysis]] found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.<ref name="pmid11448661">{{cite journal | author = Tomkins G, Jackson J, O'Malley P, Balden E, Santoro J | title = Treatment of chronic headache with antidepressants: a meta-analysis. | journal = Am J Med | volume = 111 | issue = 1 | pages = 54-63 | year = 2001 | id = PMID 11448661}}</ref> A [[randomized controlled trial]] found that [[amitriptyline]] was better than placebo and similar to [[propranolol]].<ref name="pmid3579659">{{cite journal | author = Ziegler D, Hurwitz A, Hassanein R, Kodanaz H, Preskorn S, Mason J | title = Migraine prophylaxis. A comparison of propranolol and amitriptyline. | journal = Arch Neurol | volume = 44 | issue = 5 | pages = 486-9 | year = 1987 | id = PMID 3579659}}</ref>
*[[Ergotamine]] tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike [[triptan]]s), have fallen out of favor due to the problem of [[ergotism]]. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. [[Anti-nausea]] administration is available by [[ergotamine]] suppository. Pure [[ergotamine tartrate]] is highly effective for evening-night migraines, but is rarely or never available in the USA.
*[[Dihydroergotamine]] (DHE), which must be injected or inhaled, can be as effective as [[ergotamine tartrate]], but is much more expensive.


Other drugs:
Shown below is table summarizing the doses of the different types of ergot alkaloid derivatives.<ref name="pmid24400971">{{cite journal| author=Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A| title=Revised French guidelines for the diagnosis and management of migraine in adults and children. | journal=J Headache Pain | year= 2014 | volume= 15 | issue= 1 | pages= 2 | pmid=24400971 | doi=10.1186/1129-2377-15-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24400971  }} </ref>
* [[Sansert]] was withdrawn from the US market by [[Novartis]], but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including [[retroperitoneal fibrosis]].
* [[Namenda]], memantine HCI tablets, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
* [[ASA]] or [[Asprin]] can be taken daily in low doses such as 80 to 81 mg, the blood thinners in ASA has been shown to help some migrainures, especially those who have an aura.


====Physical therapy====
{|Class="wikitable"
|-
| '''[[Ergo]] derivatives'''
| '''Doses'''
| '''Max Doses per day'''
|'''Side Effects'''
|-
|[[Ergotamine]] Tartrate
|2 mg/ day
|6 mg/day
----
10mg/week
|[[Ergotism]] <br>
[[Nausea]] <br>
[[Vomit]]s
|-
|[[Dihydroergotamine]]
|Endonasal solution 1 spray 0.5 mg in each nostril
----
SQ/IM injectable solution 1mg
|2mg (4 sprays)/day <br>
4mg (8 sprays)/week
----
2 mg/day <br>
8 mg/week
|[[Ergotism]] <br>
Nasal obstruction and [[rhinorrhoea]] (with Endonasal solution) <br>
Precordalgia (with the injectable solution)
|}


Many physicians believe that [[exercise]] for 15-20 minutes per day is helpful for reducing the frequency of migraines.<ref>http://www.headachedrugs.com/pdf/HA2005.pdf] (PDF)</ref>[[Massage]] therapy and [[physical therapy]] are often very effective forms of treatment to reduce the frequency and intensity of migraines. However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can 'trigger' a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments.Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that [[Myofascial Release]] can relieve this tension and in doing so reduce or eliminate the stress headache element.
===Other Agents===


==== Prism eyeglasses ====
* [[Melatonin]] may help.
** 3 mg regular release taken at bedtime for 12 weeks in a [[randomized controlled trial]] found a significant decrease of 1.6 headache days per month<ref name="pmid27165014">{{cite journal| author=Gonçalves AL, Martini Ferreira A, Ribeiro RT, Zukerman E, Cipolla-Neto J, Peres MF| title=Randomised clinical trial comparing melatonin 3 mg, amitriptyline 25 mg and placebo for migraine prevention. | journal=J Neurol Neurosurg Psychiatry | year= 2016 | volume= 87 | issue= 10 | pages= 1127-32 | pmid=27165014 | doi=10.1136/jnnp-2016-313458 | pmc=5036209 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27165014  }} </ref>. The benefit was similar to [[amitriptyline]].
** 3 mg regular release taken 30 minutes before bedtime for 8 weeks for chronic migraines in a [[randomized controlled trial]] found a significant decrease of 1.6 headache days per month<ref name="pmid28800342">{{cite journal| author=Ebrahimi-Monfared M, Sharafkhah M, Abdolrazaghnejad A, Mohammadbeigi A, Faraji F| title=Use of melatonin versus valproic acid in prophylaxis of migraine patients: A double-blind randomized clinical trial. | journal=Restor Neurol Neurosci | year= 2017 | volume= 35 | issue= 4 | pages= 385-393 | pmid=28800342 | doi=10.3233/RNN-160704 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28800342  }} </ref>. The result was similar to [[valproic acid]].
** 2 mg extended release 1 hour before bedtime for 8 weeks in a crossover trial found an insignificant decrease of 1.4 headache days per month<ref name="pmid20975054">{{cite journal| author=Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI| title=Prophylaxis of migraine with melatonin: a randomized controlled trial. | journal=Neurology | year= 2010 | volume= 75 | issue= 17 | pages= 1527-32 | pmid=20975054 | doi=10.1212/WNL.0b013e3181f9618c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20975054  }} </ref>.
*[[Anti-emetic]]s by [[suppository]] or [[medical injection|injection]] may be needed in cases where [[vomit]]ing dominates the symptoms.
*[[Intravenous therapy|Intravenous]] [[chlorpromazine]] has proven very effective in treating status migrainosus & mdash;intractable and unremitting migraine.Status migraine is an extremely rare life-threatening condition. In otherwise uncomplicated, non-nauseated cases, it can be treated with 20 mg of prednisone tablets every eight hours until the migraine ends, followed by mandatory tapering off doses (the classic steroid taper).


At least two British studies have shown a relationship between the use of eyeglasses containing prisms and a reduction in migraine headaches.  Turville, A. E. (1934) "Refraction and migraine". ''Br. J. Physiol. Opt.'' 8, 62&ndash;89, contains a good review of the literature and theories existing in 1934, and includes the vascular theory of migraine, which is popular today. In that study, Turville suggests that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism.   Wilmut, E. B. (1956) "Migraine". ''Br. J. Physiol. Opt.'' 13, 93&ndash;97, replicated Turville's work. Both studies are subject to criticism because of sample bias, sample size, and the lack of a control group.   Neither study is available online, but another study that found that precision tinted lenses may be an effective migraine treatment and which references the Turville and Wilmut studies can be found at <ref name="urlwww.essex.ac.uk">{{cite web |url=http://www.essex.ac.uk/psychology/overlays/OPO.2002.22%20130-142.pdf |title=www.essex.ac.uk |format= |work= |accessdate=2012-08-30}}</ref> .  Turville's and Wilmut's conclusions have largely been ignored since 1956 and it is widely believed that vision problems are not migraine triggers. Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.
====Comparative Studies====
Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial<ref name="ASADiener">{{cite journal | author = Diener H, Bussone G, de Liano H, Eikermann A, Englert R, Floeter T, Gallai V, Göbel H, Hartung E, Jimenez M, Lange R, Manzoni G, Mueller-Schwefe G, Nappi G, Pinessi L, Prat J, Puca F, Titus F, Voelker M | title = Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks. | journal = Cephalalgia | volume = 24 | issue = 11 | pages = 947-54 | year = 2004 | id = PMID 15482357}}</ref> reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain. Acetylsalicylic acid is OTC aspirin, ibuprofen is OTC Advil, and since migraineurs know they don't provide much relief, the results of this study are unexpected. They may be partly related to the dosage of acetylsalicylic acid used, which was considerably higher than the one or two 300 mg tablets normally recommended for OTC use. High doses of aspirin and ibuprofen may cause ringing of the ears, which is a sign of drug toxicity to the inner ear. Another [[randomized controlled trial]], funded by the manufacturer of the study drug, found that a combination of [[sumatriptan]] 85 mg and [[naproxen]] sodium 200 mg was better than either drug alone.<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443-54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>


==== Herbal and nutritional supplements ====
====Contraindicated medications====


50 mg or 75 mg/day of [[butterbur]] (''Petasites hybridus'') rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months.  Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex®, does not. [[Cannabis]] was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted. Some migraine sufferers report that cannabis increases throbbing and pain, especially if smoked. A  pharmaceutical company is currently conducting trials of a whole cannabis extract spray for migraine. Supplementation of [[coenzyme Q10]] has been found to have a beneficial effect on the condition of some sufferers of migraines.  In an [[open-label trial]],<ref name="CoenzymeRozen">{{cite journal | author = Rozen T, Oshinsky M, Gebeline C, Bradley K, Young W, Shechter A, Silberstein S | title = Open label trial of coenzyme Q10 as a migraine preventive. | journal = Cephalalgia | volume = 22 | issue = 2 | pages = 137-41 | year = 2002 | id = PMID 11972582}}</ref> Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.<ref>{{cite journal |author=Sándor PS, et al.|title=Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial |journal=Neurology |volume=64 |pages=713-715 |year=2005 |url = http://www.neurology.org/cgi/content/abstract/64/4/713}}</ref>The plant [[feverfew]] (''Tanacetum parthenium'') is a traditional herbal remedy believed to reduce the frequency of migraine attacks. Clinical trials have been carried out (example<ref name="urlEfficacy and safety of 6.25 mg t.i.d. feverfew C... [Cephalalgia. 2005] - PubMed - NCBI">{{cite web |url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16232154&query_hl=1&itool=pubmed_docsum |title=Efficacy and safety of 6.25 mg t.i.d. feverfew C... [Cephalalgia. 2005] - PubMed - NCBI |format= |work= |accessdate=2012-08-30}}</ref>), and appear to confirm that the effect is genuine (though it does not completely prevent attacks).  [[Kudzu]] root (''Pueraria lobata'') has been demonstrated to help with menstrual migraine headaches and [[cluster headaches]]. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors. Kudzu Monograph at Med-Owl<ref name="urlCash Advance | Debt Consolidation | Insurance | Free Credit Report | Cell Phones at Med-Owl.com">{{cite web |url=http://www.med-owl.com/clusterheadaches/tiki-index.php?page=Kudzu |title=Cash Advance &#124; Debt Consolidation &#124; Insurance &#124; Free Credit Report &#124; Cell Phones at Med-Owl.com |format= |work= |accessdate=2012-08-30}}</ref>. [[Magnesium citrate]] has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9-12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.<ref name="MagesiumPeikert">{{cite journal | author = Peikert A, Wilimzig C, Köhne-Volland R | title = Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. | journal = Cephalalgia | volume = 16 | issue = 4 | pages = 257-63 | year = 1996 | id = PMID 8792038}}</ref> The supplement Riboflavin or [[Vitamin B2]] has also been used, often with magnesium citrate, to reduce the number of migraines. Its effectiveness is less well documented.
{{MedCondContrAbs


==== Non-drug medical treatments ====
|MedCond =Migraine if patient is over age 35|Drospirenone and Ethinyl estradiol | Norelgestromin and Ethinyl Estradiol}}


[[Botulin toxin|Botox]] is being used by many headache specialists for patients with frequent or chronic migraines with encouraging results.<ref>Samton JB and Mauskop A. The treatment of headaches with Botulinum Toxin. Expert Review of Neurotherapeutics March 2006, Vol. 6, No. 3, Pages 313-322. </ref>[[Spinal Cord Stimulator|Spinal cord stimulator]]s are an implanted medical device sometimes used for those who suffer severe migraines several days each month.<ref name="SCSMatharu">{{cite journal | author=Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ | title=Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study | journal=Brain | year=2004 | pages=220-30 | volume=127 | issue=Pt 1 | id=PMID 14607792}}</ref>[[Transcranial magnetic stimulation|Transcranial Magnetic Stimulation]] (TMS): At the 49th Annual meeting of the [[American Headache Society]] in June 2006, scientists from Ohio State University  Medical Center<ref name="urlThe Ohio State University Wexner Medical Center">{{cite web |url=http://medicalcenter.osu.edu/ |title=The Ohio State University Wexner Medical Center |format= |work= |accessdate=2012-08-30}}</ref> presented medical research on 47 candidates that demonstrated that TMS &mdash; a medically non-invasive technology for treating depression, [[obsessive compulsive disorder]] and [[tinnitus]], among other ailments &mdash; helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.<ref name="urlTechnology | The Times">{{cite web |url=http://technology.timesonline.co.uk/article/0,,20409-2237003.html |title=Technology &#124; The Times |format= |work= |accessdate=2012-08-30}}</ref> In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light. Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.<ref name="TMSMohammad">{{cite conference  | first = Yousef  | last = Mohammad  | title = Magnets Zap Migraines  | booktitle = 49th Annual Scientific Meeting of the [[American Headache Society]]  | date = [[2006-06-22]]  | location = [[Los Angeles]], [[California]]  | url = http://researchnews.osu.edu/archive/headzap.htm  | accessdate = 2006-07-04 }}</ref>
==Therapeutic Approach==
Shown below is an algorithm depicting the management of acute migraine.


==== Alternatives ====
{{familytree/start}}
 
{{familytree | | | | | A01 | | | | | | | |A01= '''Acute Migraine'''  }}
Because the conventional approaches to migraine prevention are not 100% effective and can have unpleasant side effects, many seek alternative treatments.Some migraine sufferers find relief through [[acupuncture]], which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache.  In one controlled trial of acupuncture with a sham control in migraine,  the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.Additionally [[acupressure]] is used by some for relief.  For instance pressure between the thumbs and index finger  to help subside headaches if the headache or migraine isn't too severe.Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents.  Mauskop A, Fox B, ''What Your Doctor May Not Tell You About Migraines''. Warner Books, New York, 2001
{{familytree | | | | | |!| | | | | | | | | }}
 
{{familytree | | | | | B01 | | | | | | | |B01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Administer [[NSAID]]s <br>
[[Biofeedback]] has been used successfully by some to control migraine symptoms through training and practice. Mauskop A, Fox B, ''What Your Doctor May Not Tell You About Migraines''. Warner Books, New York, 2001There is evidence that [[Magnesium in biological systems|magnesium]] supplements can reduce the frequency of migraine headaches. Riboflavin (vitamin B2), co-enzyme Q10 and butterbur extract has been also subjected to double-blind studies suggesting their efficacy in preventing migraine headaches. Mauskop A: "Alternative therapies in headache: Is there a role?" In: ''Medical Clinics of North America'' 85 (4): 1077-1084, 2001. Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.[[Diet (nutrition)|Diet]], [[visualization (cam)|visualization]], and [[self-hypnosis]] are also alternative treatments and prevention approaches.[[Bruxism]], clenching or grinding of teeth, especially at night, is a trigger for many migraineurs.  A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching.  It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth.  It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.[[Sexual activity]] has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases. In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
❑ Administer [[triptan]]s as a rescue medication in case of no relief within 1-2 hour after taking the [[NSAID]] </div> }}
{{familytree | | | | | |!| | | | | | | | | }}
{{familytree | | | | | C01 | | | | | | | |C01= ❑ Reevaluate the patient after 3 attacks }}
{{familytree | | | | | |!| | | | | | | | | }}
{{familytree | | | | | D01 | | | | | | | |D01= '''Was the [[NSAID]] effective after 1- 2hours?''' }}
{{familytree | | | |,|-|^|-|.| | | | | | | }}
{{familytree | | | E01 | | E02 | | | | | |E01= '''Effective''' <br> (At least 2 out of 3 times) |E02= '''Not Effective''' <br> (At least 2 out of 3 times) }}
{{familytree | | | |!| | | |!| | | | | | | }}
{{familytree | | | F01 | | F02 | | | | | |F01= ❑ Consider [[NSAID]]s a 1st line medication | F02= ❑ Consider [[triptan]]s a 1st line medication }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | G01 | | | | | |G01= ❑ Reevaluate the patient after 3 attacks }}
{{familytree | | | | | |,|-|^|-|.| | | | | }}
{{familytree | | | | | H01 | | H02 | | | |H01= [[Triptan]] is effective and tolerated <br> (At least 2 out of 3 times) |H02= [[Triptan]] is ineffective and/or poorly tolerated <br> (At least 2 out of 3 times) }}
{{familytree | | | | | |!| | | |!| | | | | }}
{{familytree | | | | | I01 | | I02 | | | |I01= ❑ Consider [[triptan]] a 1st line medication  |I02= ❑ Change to a different [[triptan]] <br> ❑ Reevaluate after 3 attacks }}
{{familytree | | | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | | J01 | | J02 | |J01= [[Triptan]] is effective and tolerated |J02= [[Triptan]] is ineffective }}
{{familytree | | | | | | | |!| | | |!| | | }}
{{familytree | | | | | | | K01 | | K02 | | K01= ❑ Consider [[triptan]]s a 1st line medication |K02= ❑ Consider combined therapy of [[NSAID]] and [[triptan]] }}
{{familytree/end}}


==References==
==References==
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[[Category:Needs overview]]
[[Category:Migraine]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Headaches]]
[[Category:Head and neck]]

Latest revision as of 22:44, 29 July 2020

Migraine Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Overview

Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs. Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. Medical therapy can be divided into two treatment regimens: non-specific treatment such as non-steroidal anti-inflammatory drug and analgesics and specific treatment such as triptans and ergot derivatives.[1] Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.

Non Pharmacological Therapy

  • Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. A cold or hot shower directed at the head, a hot or cold wet washcloth, a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed.
  • Some headache sufferers are surprised to learn that a simple cup of coffee is used daily around the world to control minor vascular headaches that are not quite migraines. Minor vascular headaches are frequently associated with the hormonal fluctuations of menstrual periods, irregular eating, and unusually hard work. For migraineurs, a well-timed cup of coffee can prevent outright migraine under the same conditions.
  • A simple treatment, which has been effective for some, is a counteracting "ice cream headache", briefly provoked by placing spoonfuls of ice cream on the soft palate at the back of the mouth. This directs cooling to the hypothalamus, which is suspected to be involved with the migraine feedback cycle, and for some it can stop even a severe headache very quickly.
  • For sufferers of weather-related migraines there is a simple treatment known as the Valsalva maneuver, which pilots and frequent fliers employ to relieve discomfort from pressure change. By holding your nose and gently pushing the air in your mouth back towards your ears and "popping" them you are opening your eustachian tubes. These normally open and close with regular chewing and talking but in some people may stay closed due to allergies or genetics. Regular opening and closing of the eustachian tubes allows a person to continually equalize to any change in the ambient barometric pressure. When this does not occur regularly the difference in pressure between the head and the environment can cause vascular swelling/constricting and trigger a migraine. Migraines can be stopped by doing the Valsalva maneuver three or four times. During changeable weather patterns doing the maneuver fifteen times per day can eliminate the headaches.
  • For patients who have been diagnosed with recurring migraines, doctors recommend taking migraine abortive medicines to treat the attack as soon as possible. Migraine without aura presenting without prodrome or nausea can present with sudden onset. Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However, in many cases once an attack is underway, it can become intensely painful, last for a long time, and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.

Medical Therapy

Medical therapy can be divided into two treatment regimens:[1]

Non Specific Treatment

Patients often start off with non specific analgesics such as paracetamol (known as acetaminophen in the USA), aspirin, ibuprofen, or other simple analgesics that are useful for tension headaches. Some patients find relief from taking over-the-counter sedative antihistamines or anti-nausea agents. Over the counter drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".

Simple analgesics combined with caffeine may help.[2] During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit. Excedrin is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an OTC treatment for migraine. Patients themselves often start off with paracetamol (known as acetaminophen in the USA), aspirin, ibuprofen, or other simple analgesics that are useful for tension headaches.


Shown below is a table summarizing the doses of non specific analgesics commonly used for the treatment of mild to moderate migraine.[1]

Analgesic and NSAID Doses Max Doses per day

Not more that 3 times per week

Aspirin Tablet 1000mg

1000mg could be added

4000mg
Ibuprofen Tablet 400mg

200 - 400mg could be added

1200mg
Acetaminophen Tablet 500mg

500mg could be added

4000mg
Naproxen Tablet 500 - 700mg

250 - 500mg could be added

1250mg
Ketorolac IM 60mg

IV 30mg

IM 120mg

IV 120mg

Specific Treatment

Triptans

  • Triptans are excellent for severe migraines or those that do not respond to NSAIDs.[3] or other over-the-counter drugs[5] Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.
  • Before discontinuing them, triptans should be tested in at least three attacks, unless the patient shows intolerance. A patient that doesn´t respond to one type of triptan may respond to another.[1]

Shown below is a table summarizing the doses of different types of triptans. Triptans are used among patients with moderate to severe headache, with nausea or vomiting, rapid progression to severe headache and mild to moderate headache that responds poorly to 1st-line treatment.[1]

Triptan Doses Max Doses per day Side Effects
Almotriptan Tablet 12.5mg 25mg Vasomotor hot flushes

Dizziness
Weakness
Asthenia
Somnolence
Nausea
Vomits

Eletriptan Tablet 40mg 80mg
Fovatriptan Tablet 2.5mg 5mg
Naratriptan Tablet 2.5 5mg
Rizatriptan Tablet 5 - 10mg

Dry powder 10mg

20mg
Sumatriptan Tablet 50mg

SQ injection ampoule 6mg

Nasal spray 10 - 20mg

300mg

12mg

40mg

Moderate or severe hypertension

heat sensation
suffocating feeling
pressure sensation

Zolmitriptan Tablet 2.5mg 10mg

Ergot Alkaloids

  • Until the introduction of sumatriptan in 1991, ergot derivatives, were the primary oral drugs available to abort a migraine once it is established. Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine.
  • Ergotamine tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favor due to the problem of ergotism. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository. Pure ergotamine tartrate is highly effective for evening-night migraines, but is rarely or never available in the USA.
  • Dihydroergotamine (DHE), which must be injected or inhaled, can be as effective as ergotamine tartrate, but is much more expensive.

Shown below is table summarizing the doses of the different types of ergot alkaloid derivatives.[1]

Ergo derivatives Doses Max Doses per day Side Effects
Ergotamine Tartrate 2 mg/ day 6 mg/day

10mg/week

Ergotism

Nausea
Vomits

Dihydroergotamine Endonasal solution 1 spray 0.5 mg in each nostril

SQ/IM injectable solution 1mg

2mg (4 sprays)/day

4mg (8 sprays)/week

2 mg/day
8 mg/week

Ergotism

Nasal obstruction and rhinorrhoea (with Endonasal solution)
Precordalgia (with the injectable solution)

Other Agents

  • Melatonin may help.
    • 3 mg regular release taken at bedtime for 12 weeks in a randomized controlled trial found a significant decrease of 1.6 headache days per month[6]. The benefit was similar to amitriptyline.
    • 3 mg regular release taken 30 minutes before bedtime for 8 weeks for chronic migraines in a randomized controlled trial found a significant decrease of 1.6 headache days per month[7]. The result was similar to valproic acid.
    • 2 mg extended release 1 hour before bedtime for 8 weeks in a crossover trial found an insignificant decrease of 1.4 headache days per month[8].
  • Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms.
  • Intravenous chlorpromazine has proven very effective in treating status migrainosus & mdash;intractable and unremitting migraine.Status migraine is an extremely rare life-threatening condition. In otherwise uncomplicated, non-nauseated cases, it can be treated with 20 mg of prednisone tablets every eight hours until the migraine ends, followed by mandatory tapering off doses (the classic steroid taper).

Comparative Studies

Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial[9] reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain. Acetylsalicylic acid is OTC aspirin, ibuprofen is OTC Advil, and since migraineurs know they don't provide much relief, the results of this study are unexpected. They may be partly related to the dosage of acetylsalicylic acid used, which was considerably higher than the one or two 300 mg tablets normally recommended for OTC use. High doses of aspirin and ibuprofen may cause ringing of the ears, which is a sign of drug toxicity to the inner ear. Another randomized controlled trial, funded by the manufacturer of the study drug, found that a combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone.[3]

Contraindicated medications

Migraine if patient is over age 35 is considered an absolute contraindication to the use of the following medications:

Therapeutic Approach

Shown below is an algorithm depicting the management of acute migraine.

 
 
 
 
Acute Migraine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer NSAIDs
❑ Administer triptans as a rescue medication in case of no relief within 1-2 hour after taking the NSAID
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Reevaluate the patient after 3 attacks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Was the NSAID effective after 1- 2hours?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Effective
(At least 2 out of 3 times)
 
Not Effective
(At least 2 out of 3 times)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider NSAIDs a 1st line medication
 
❑ Consider triptans a 1st line medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Reevaluate the patient after 3 attacks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Triptan is effective and tolerated
(At least 2 out of 3 times)
 
Triptan is ineffective and/or poorly tolerated
(At least 2 out of 3 times)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider triptan a 1st line medication
 
❑ Change to a different triptan
❑ Reevaluate after 3 attacks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Triptan is effective and tolerated
 
Triptan is ineffective
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider triptans a 1st line medication
 
❑ Consider combined therapy of NSAID and triptan
 

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Lanteri-Minet M, Valade D, Geraud G, Lucas C, Donnet A (2014). "Revised French guidelines for the diagnosis and management of migraine in adults and children". J Headache Pain. 15 (1): 2. doi:10.1186/1129-2377-15-2. PMID 24400971.
  2. ↑ Goldstein J, Hoffman HD, Armellino JJ; et al. (1999). "Treatment of severe, disabling migraine attacks in an over-the-counter population of migraine sufferers: results from three randomized, placebo-controlled studies of the combination of acetaminophen, aspirin, and caffeine". Cephalalgia : an international journal of headache. 19 (7): 684–91. PMID 10524663.
  3. ↑ 3.0 3.1 3.2 Brandes JL, Kudrow D, Stark SR; et al. (2007). "Sumatriptan-naproxen for acute treatment of migraine: a randomized trial". JAMA. 297 (13): 1443–54. doi:10.1001/jama.297.13.1443. PMID 17405970.
  4. ↑ Derry S, Moore RA (2013). "Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults". Cochrane Database Syst Rev. 4: CD008040. doi:10.1002/14651858.CD008040.pub3. PMID 23633349.
  5. ↑ Lipton RB, Baggish JS, Stewart WF, Codispoti JR, Fu M (2000). "Efficacy and safety of acetaminophen in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study". Archives of Internal Medicine. 160 (22): 3486–92. PMID 11112243. Retrieved 2012-08-30.
  6. ↑ Gonçalves AL, Martini Ferreira A, Ribeiro RT, Zukerman E, Cipolla-Neto J, Peres MF (2016). "Randomised clinical trial comparing melatonin 3 mg, amitriptyline 25 mg and placebo for migraine prevention". J Neurol Neurosurg Psychiatry. 87 (10): 1127–32. doi:10.1136/jnnp-2016-313458. PMC 5036209. PMID 27165014.
  7. ↑ Ebrahimi-Monfared M, Sharafkhah M, Abdolrazaghnejad A, Mohammadbeigi A, Faraji F (2017). "Use of melatonin versus valproic acid in prophylaxis of migraine patients: A double-blind randomized clinical trial". Restor Neurol Neurosci. 35 (4): 385–393. doi:10.3233/RNN-160704. PMID 28800342.
  8. ↑ Alstadhaug KB, Odeh F, Salvesen R, Bekkelund SI (2010). "Prophylaxis of migraine with melatonin: a randomized controlled trial". Neurology. 75 (17): 1527–32. doi:10.1212/WNL.0b013e3181f9618c. PMID 20975054.
  9. ↑ Diener H, Bussone G, de Liano H, Eikermann A, Englert R, Floeter T, Gallai V, Göbel H, Hartung E, Jimenez M, Lange R, Manzoni G, Mueller-Schwefe G, Nappi G, Pinessi L, Prat J, Puca F, Titus F, Voelker M (2004). "Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks". Cephalalgia. 24 (11): 947–54. PMID 15482357.

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