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MIGRAINE

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MIGRAINE Background information Management overview stepwise management triptans What is migraine? www.cks.library.nhs.uk/migraine; MeReC Bulletin 2002; 13: 5 8 ... – PowerPoint PPT presentation

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Title: MIGRAINE


1
MIGRAINE
  • Background information
  • Management
  • overview
  • stepwise management
  • triptans

2
What is migraine?www.cks.library.nhs.uk/migraine
MeReC Bulletin 2002 13 58
  • Primary episodic headache disorder
  • Characterised by various combinations of
    neurological, gastrointestinal and autonomic
    changes
  • Affects about 10 of the population
  • 15 of women and 6 of men
  • Diagnosis is based on headache characteristics
    and associated symptoms

3
Migraine management overview www.cks.library.nhs
.uk/migraine
  • Identify any trigger factors, and avoid them if
    possible
  • Treat in a stepwise manner until symptoms are
    controlled
  • first-line treatment is oral analgesia, with or
    without anti-emetics
  • if first-line treatments are ineffective, treat
    with a triptan
  • consider using combination therapy
    (triptananalgesiaanti-emetic) if triptan alone
    is ineffective
  • Consider using prophylactic treatment if attacks
    are frequent and troublesome

4
Step 1 simple analgesics www.cks.library.nhs.uk
/migraine
  • E.g. aspirin 600900mg, NSAID, paracetamol /-
    anti-emetics
  • Start acute treatment early in the attack
  • Gastric stasis during the migraine attack reduces
    drug absorption
  • soluble forms may be preferable as these are more
    quickly absorbed
  • anti-emetics increase rate of absorption of
    analgesic
  • Codeine and other opioid drugs, or combinations
    containing these, should be avoided
  • little additional benefit, risk of medication
    overuse headache, adverse effects e.g. reduced
    gastric motility

5
Step 2 triptanswww.cks.library.nhs.uk/migraine
http//emc.medicines.org.uk/
  • Triptans should not be taken too early in an
    attack, unlike standard analgesia
  • Evidence suggests that the first dose should be
    taken when the pain is beginning to develop (i.e.
    is mild), but not before this stage (e.g. during
    the aura stage)
  • Finding the best one for an individual patient
    may involve a degree of trial and error
  • Sumatriptan is the most established triptan with
    the greatest associated clinical experience
  • High-dose sumatriptan (100mg) has been used most
    often as a comparator drug in clinical trials,
    but offers little advantage over the lower 50mg
    dose for most people

6
Comparison of the main efficacy and tolerability
measures for oral triptans compared to
sumatriptan 100mg Ferrari MD, et al. Lancet
2001 358 166875
Initial 2hr relief Sustained pain-free Consistency Tolerability
Sumatriptan 50mg /
Sumatriptan 25mg /
Zolmitriptan 2.5mg
Zolmitriptan 5mg
Naratriptan 2.5mg
Rizatriptan 5mg
Rizatriptan 10mg
Eletriptan 20mg
Eletriptan 40mg / /
Eletriptan 80mg ()
Almotriptan 12.5mg
7
Comparison of oral triptans to sumatriptan 100mg
Ferrari MD, et al. Lancet 2001 358 166875
www.cks.library.nhs.uk/migraine
  • Differences between the triptans were found to be
    small but may be clinically relevant to the
    individual patient
  • There was a high degree of variability in
    individual response to specific triptans
  • if a particular triptan is not effective in an
    individual, another can be tried which may be
    effective
  • if a triptan is poorly tolerated it can be
    switched
  • If the initial dose of triptan proves ineffective
    a further dose is unlikely to be effective and
    should not be taken (except zolmitriptan)
  • If the triptan successfully relieves pain, but
    there is relapse, the dose can be repeated within
    24 hours, in accordance with product licenses
  • Treatment should be individualised for each
    person

8
Adverse effects www.cks.library.nhs.uk/migraine
  • There is no evidence that any particular triptan
    is safer than another
  • 'Triptan sensations' include a warm-hot
    sensation, tightness, tingling, flushing, and
    feelings of heaviness or pressure in areas such
    as the face and limbs, and occasionally the chest
  • can mimic angina pectoris and cause considerable
    alarm. However, when patients are forewarned
    about these feelings, they rarely cause problems
  • There are theoretical concerns that triptans may
    increase the likelihood of myocardial infarction,
    but extensive experience with these drugs,
    especially sumatriptan, have shown this is very
    rare
  • Discontinue if there are intense chest pains or
    sensations, as this could indicate coronary
    vasoconstriction or anaphylaxis

9
Prophylactic drug treatment www.cks.library.nhs.uk
/migraine
  • Consider in patients with
  • gt 2 attacks per week
  • increasing headache frequency
  • significant disability despite acute treatments
  • cannot take suitable treatment
  • Propranolol or amitriptyline are suitable
    first-choices
  • good evidence to support use for the prevention
    of migraine
  • metoprolol, timolol and atenolol are alternative
    beta-blockers
  • Sodium valproate or topiramate are suitable
    second-line
  • good evidence of efficacy
  • clinical utility of topiramate limited and
    specialist input needed

10
Summary
  • Migraine
  • a primary episodic headache disorder
  • characterised by neurological, gastrointestinal
    and autonomic changes (aura experienced by around
    25 of patients)
  • affects about 10 of the population, with women
    being affected more than men
  • Treatment
  • start acute treatment with simple analgesic
    anti-emetic early
  • triptans are effective second-line options but
    should not be taken too early in an attack
  • differences between triptans are small but may be
    clinically relevant to the individual patient
  • Consider prophylaxis in those with
    frequent/worsening attacks
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