Pharmacological management of migraine
Migraine is the most common severe form of primary headache, affecting one in seven people, and it is a significant cause of disability. It is estimated to cost the UK around £3bn a year in terms of healthcare, lost productivity and disability. This guideline provides recommendations based on current evidence for best practice in the prophylactic management of adults with migraine using pharmacological therapies. It includes management of acute migraine and preventative treatment in patients with episodic or chronic migraine, and medication-overuse headache.
Migraine is often underdiagnosed, misdiagnosed and undertreated in both primary and secondary care. In recent years there have been advances in diagnosis, and there are new therapies on the horizon for both acute and preventative treatment. A number of devices are also available for the treatment of migraine that could potentially avoid the need for medication.Patients may have different perspectives on healthcare outcomes from those of healthcare professionals. Common concerns include:
Migraine is subdivided into migraine with and without aura. It is defined as episodic or chronic.
Episodic migraine occurs on less than 15 days per month, subdivided into low frequency (1–9 days a month) and high frequency (10–14 days a month).
Chronic migraine occurs on 15 or more days a month.
Medication-overuse headache (MOH) is headache on 15 or more days a month that has evolved with the frequent use of medication for more than 3 months.
– all headaches and their severity
– medication taken
– normal activities missed
– food and drink
– sleep times
– stressful days
– complementary therapies used
Follow up after 2 weeks to consolidate the first consultation, and then again after 6–8 weeks to review migraine diary, discuss lifestyle improvements, review medication and any changes needed. Review of current medication should include dose, side effects and headache recurrence if it occurs after initial acute treatment. Consider whether referral is needed, e.g. because of treatment failure or uncertain diagnosis.
Medical treatment is divided into acute and preventative.
Acute treatment should be taken as early as possible in the headache phase with the aim of aborting an attack. It is given one, with the option of repeating after 2 hours if there is inadequate response.
Preventative treatment is taken continuously to reduce the frequency and severity of migraine attacks.
Often a combination of acute and preventative treatment is needed.
Choice of treatment should take into account:
Patients have a variable response to triptans, so it is worth sequencing through the triptans to find the most effective treatment. When starting a preventative treatment, start with a low dose and increase gradually. Use the minimum effective dose, which may vary between patients, and review the need for ongoing prophylaxis after 6 – 12 months.
Paracetamol is not recommended as first-line treatment but can be considered for patients with acute migraine who are unable to take other acute therapies. Its safety profile makes it the first choice for the short-term relief of mild to moderate headache in pregnancy (all trimesters).
The numbers needed to treat (NNT) for acute migraine therapies for an outcome of pain free at two hours in patients with moderate to severe pain, versus placebo, are shown in the table below.
Metoclompramide should not be used regularly due to the risk of extrapyramidal side effects such as tremor, slurred speech, dystonia, anxiety and distress.
PREVENTION OF MIGRAINE
Migraine can have considerable impact on quality of life and daily function. Modest improvements in the frequency or severity of migraine headaches may provide considerable benefits to an individual. In clinical trials, a reduction in severity and/or frequency of 30–50% is regarded as a successful outcome. The decision to start migraine prophylaxis is best guided by establishing the impact of migraine on the patient, rather than the absolute number of headaches or migraines per month. Prophylactic treatment should be used for at least 3 months at the maximum tolerated dose before deciding whether or not it is effective. In many patients, prophylaxis can be successfully phased out again, and the need for ongoing prophylaxis should be reviewed after 6-12 months.
First line prophylactic treatments
Patients using rizatriptan and propranolol should be given a maximum dose of 5mg rizatriptan due to the risk of interactions, and rizatriptan should bot be taken within 2 hours of taking propranolol.
Menstrual migraine prophylaxis
The drop in oestrogen just prior to menstruation is a known migraine trigger, and in women, migraine is more frequent, more severe and harder to treat just before and during menstruation. In some women, migraine only occurs (menstrual migraine) or predominantly occurs (menstrually-related migraine) from 2 days before the start of bleeding until 3 days after. In these women, perimenstrual strategies may be used instead of, or in addition to standard, continuous prophylaxis. The menstrual cycle has to be regular for this approach to treatment to be effective.
Most medication-overuse headache is a complication of migraine. Frequent use of acute medications for migraine increase the frequency and intensity of headache. The treatment becomes the cause, rather than the cure, and a vicious cycle of increased medication use and increasing headache ensues. Withdrawing the overused medication can reduce the headache frequency and intensity again, although can be associated at first with transient worsening of symptoms.
While it is clear that medication overuse should be addressed, there is no clear evidence for the best strategy for withdrawal, so this should be tailored to the individual patient. Strategies include:
DEVICES FOR MIGRAINE THERAPY
Devices may offer an alternative or an addition to pharmacological therapies, but the evidence for their efficacy and safety is extremely limited. Such devices include vagus nerve stimulation, transcutaneous nerve stimulation and transcranial magnetic stimulation.
1. Scottish Intercollegiate Guidelines Network. SIGN 155 Pharmacological management of migraine, February 2018. https://www.sign.ac.uk/assets/sign155.pdf
2. NICE TA260. Botulinum toxin type A for the prevention of headaches in adults with chronic migraine, 2012. https://www.nice.org.uk/guidance/ta260
SIGN 155, February 2018
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