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

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
  • Affects about 10 of the population
  • 15 of women and 6 of men
  • Diagnosis is based on headache characteristics
    and associated symptoms

Migraine management overview www.cks.library.nhs
  • Identify any trigger factors, and avoid them if
  • Treat in a stepwise manner until symptoms are
  • 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

Step 1 simple analgesics www.cks.library.nhs.uk
  • E.g. aspirin 600900mg, NSAID, paracetamol /-
  • 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
  • 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

Step 2 triptanswww.cks.library.nhs.uk/migraine
  • 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

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
Comparison of oral triptans to sumatriptan 100mg
Ferrari MD, et al. Lancet 2001 358 166875
  • 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
  • if a triptan is poorly tolerated it can be
  • 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

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
  • Discontinue if there are intense chest pains or
    sensations, as this could indicate coronary
    vasoconstriction or anaphylaxis

Prophylactic drug treatment www.cks.library.nhs.uk
  • 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
  • good evidence to support use for the prevention
    of migraine
  • metoprolol, timolol and atenolol are alternative
  • Sodium valproate or topiramate are suitable
  • good evidence of efficacy
  • clinical utility of topiramate limited and
    specialist input needed

  • 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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