Current Treatment

The management of migraine may be divided into three parts. First, the diagnosis, which rests on a careful clinical history and neurological examination.4 Second, after an explanation of what can and cannot be done, and particularly advice about lifestyle in the context of migraine as an episodic, probably ionopathic disorder. Third, physicians can offer preventive treatment to reduce the attack frequency and severity, or acute attack treatment for individual attacks.

6.16.5.1 Preventive Treatments for Migraine

The basis of considering preventive treatment from a medical viewpoint is a combination of acute attack frequency and attack tractability. Attacks that are unresponsive to abortive medications are easily considered for prevention, while simply treated attacks may be less obviously candidates for prevention. The other part of the equation relates to what is happening with time. If a patient diary shows a clear trend of an increasing frequency of attacks it is better to get in early with prevention than wait for the problem to become chronic.

A simple rule for frequency might be that for 1-2 headaches a month there is usually no need to start a preventive, for 3-4 it may be needed but not necessarily, and for 5 or more a month, prevention should definitely be on the agenda for discussion. Options available for treatment4 vary somewhat by country in the European Union and again compared to North America. The largest problem with preventives is not that there are none, but that they have fallen into migraine from other indications. They have disparate mechanisms of action and thus it is difficult to make too many

Table 3 Oral acute migraine treatments

Nonspecific treatments

Specific treatments

(often used with antiemetic/prokinetics, such as domperidone (10 mg) or metaclopramide (10 mg))

Aspirin (900 mg)

Acetaminophen (1000 mg)

NSAIDs

* Naproxen (500-1000 mg)

* Ibuprofen (400-800 mg)

* Tolfenamic acid (200 mg)

Ergot derivatives

* Ergotamine (1-2 mg) Triptans

* Sumatriptan (50 or 100 mg)

* Rizatriptan (10 mg)

* Zolmitriptan (2.5 or 5mg)

generic conclusions about migraine from its preventive treatments. Often the doses required to reduce headache frequency produce marked and intolerable side effects. While it is not absolutely clear how preventives work, it seems likely that they modify the brain sensitivity that underlies migraine.53

6.16.5.2 Acute Attack Therapies for Migraine

Acute attack treatments for migraine can be usefully divided into disease nonspecific treatments - analgesics and NSAIDs - and relatively disease-specific treatments - ergot-related compounds and triptans (Table 3). It must be said at the outset that most acute attack medications seem to have a propensity to aggravate headache frequency and induce a state of refractory daily or near-daily headache - medication overuse headache. This propensity appears related to migraine biology. Codeine-containing compound analgesics are a particularly pernicious problem when available in over-the-counter preparations.

6.16.5.2.1 Treatment strategies

Given the array of options to control an acute attack of migraine, how does one start? The simplest approach to treatment has been described as stepped care. In this model all patients are treated, assuming no contraindications, with the simplest treatment, such as aspirin 1 900 mg or acetaminophen 2 1000 mg with an antiemetic. Aspirin is an effective strategy, has been proven so in double-blind controlled clinical trials, and is best used in its most soluble formulations. The alternative would be a strategy known as stratified care, by which the physician determines, or stratifies, treatment at the start based on likelihood of response to levels of care.54 An intermediate option may be described as stratified care by attack. The latter is what many headache authorities suggest and what patients often do when they have the options. Patients use simpler options for their less severe attacks, relying on more potent options when their attacks or circumstances demand them.

6.16.5.2.2 Nonspecific acute migraine attack treatments

Since simple drugs, such as aspirin 1 and acetaminophen 2 are inexpensive and can be very effective, they can be employed in many patients. Dosages should be adequate and the addition of domperidone 3 (10 mg p.o.)55 or metaclopramide 4 (10 mg p.o.)56 can be very helpful. NSAIDs can very useful when tolerated. Their success is often limited by inappropriate dosing, and adequate doses of naproxen 5 (500-1000 mg p.o. or p.r., with an antiemetic),57 ibuprofen 6 (400-800 mg p.o.),58 or tolfenamic acid (200 mg p.o.)59 can be extremely effective.

The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

Are Constant Headaches Making Your Life Stressful? Discover Proven Methods For Eliminating Even The Most Powerful Of Headaches, It’s Easier Than You Think… Stop Chronic Migraine Pain and Tension Headaches From Destroying Your Life… Proven steps anyone can take to overcome even the worst chronic head pain…

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