Wikipedia

Management of migraine

(Redirected from Migraine treatment)

Migraine may be treated either prophylactic (preventive) or abortive (rescue) or acute.[1][2] Because migraine is an complex condition, there are various preventive treatments which have their effect by disrupting different links in the chain of events that occur during a migraine attack. As rescue treatments also target and disrupt different processes occurring during migraine, these are summarized, with their relative merits and demerits.

Preventive treatment edit

Main article: Prevention of migraine attacks

Because of the complexity of migraine, no preventive treatment modality is effective for all migraine sufferers.[3] For example, lifestyle (including trigger avoidance), diet changes, diet supplements, and treating conditions such as sleep apnea may all help prevent migraines. Dental appliances such as the Nociceptive Trigeminal Inhibition Tension Suppression System might be used in specific circumstances. Preventive treatments can be sub-divided into non-drug treatments, and treatment with medication. There are several non drug treatments suggested in the literature including weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease[4]

Rescue (or Abortive) treatment edit

Rescue treatment involves acute symptomatic control with medication.[5] Recommendations for rescue therapy of migraine include: (1) migraine-specific agents such as triptans, CGRP antagonists, or ditans for patients with severe headaches or for headaches that respond poorly to analgesics, (2) non-oral (typically nasal or injection) route of administration for patients with vomiting, (3)  avoid medication overuse headache by educating patients using prophylactic therapies.[6] Medications are more effective if used earlier in an attack.[5]

The frequent use of medication may result in medication overuse headache (MOH), in which the headaches become more severe and more frequent.[7] This may occur with triptans, ergotamines, and analgesics, especially opioids or narcotic analgesics.[7][8] Combination of opioids with other analgesics is thought to nearly double the risk of MOH.[9]

Spinal manipulation for treating an ongoing migraine headache is not supported by evidence.[10]

Ditans edit

Ditans are a class of abortive medication for the treatment of migraines.[11] Oral lasmiditan (Reyvow) is approved in the US by the FDA for acute treatment of migraine in adults.[12]

Analgesics edit

Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or the combination of acetaminophen (paracetamol), acetylsalicylic acid, and caffeine.[13] A number of NSAIDs have evidence to support their use. Ibuprofen provides effective pain relief in about 50%.[14] Diclofenac has been found effective.[15] Ibuprofen has been found to provide effective pain relief in about 50% of migraine attacks.[14] Acetylsalicylic acid (Aspirin) can relieve moderate to severe migraine pain, with an effectiveness similar to the triptans.[16] Ketorolac is available in an intravenous formulation.[13] The two main adverse drug reactions (ADRs) associated with NSAIDs relate to gastrointestinal (GI) effects and renal effects of the agents.

Paracetamol (also known as acetaminophen), either alone or in combination with metoclopramide (an anti-nausea drug), is another effective treatment with a low risk of adverse effects.[17]

Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or the combination of paracetamol (also known as acetaminophen), aspirin, and caffeine, although caffeine overuse can be a contributor to migraine chronification as well as a migraine trigger for many patients.[13][18] Several NSAIDs, including diclofenac and ibuprofen, have evidence to support their use.[19][20] Aspirin (900 to 1000 mg) can relieve moderate to severe migraine pain, with an effectiveness similar to sumatriptan.[21] Ketorolac is available in intravenous and intramuscular formulations.[13]

Paracetamol, either alone or in combination with metoclopramide, is another effective treatment with a low risk of adverse effects.[22] Intravenous metoclopramide is also effective by itself.[23][24] In pregnancy, paracetamol and metoclopramide are deemed safe as are NSAIDs until the third trimester.[13]

Naproxen by itself may not be effective as a stand-alone medicine to stop a migraine headache as it is only weakly better than a placebo medication in clinical trials.[25]

Triptans edit

Triptans such as sumatriptan are effective for both pain and nausea in up to 75% of migraineurs.[26] They are the initially recommended treatments for those with moderate to severe pain or those with milder symptoms who do not respond to simple analgesics.[13] The different forms available include oral, injectable, nasal spray, and oral dissolving tablets. In general, all the triptans appear equally effective, with similar side effects. However, individuals may respond better to specific ones.[13] Most side effects are mild, such as flushing; however, rare cases of myocardial ischemia have occurred. They are thus not recommended for people with cardiovascular disease.[13] They are not addictive, but they are an exceedingly potent cause of medication overuse headaches if used more than 10 days per month.[27]

Triptans such as sumatriptan are medications used to stop an active migraine headache (an abortive medication). Triptans are the initially recommended treatments for those with moderate to severe pain from an acute migraine headache or those with milder symptoms who do not respond to simple analgesics.[13] Triptans have been shown to be effective for both pain and nausea in up to 75% of people.[28][29] There are different methods or routes of administration to take sumatriptan including oral (by mouth), injectable (subcutaneous), rectal, nasal spray, and oral dissolving tablets.[30][31][32][33] For people with migraine symptoms such as nausea or vomiting, taking the abortive medicine by mouth or through the nose may be difficult. All route of administration have been shown to be effective at reducing migraine symptoms, however, nasal and injectable subcutaneous administration may result in more side effects.[33][32] The adverse effects associated with rectal administration have not been well studied.[31] Some people may find that they respond to one type of sumatriptan better than another.[13]

Most side effects are mild, including flushing; however, rare cases of myocardial ischemia have occurred.[30] They are thus not recommended for people with cardiovascular disease,[13] who have had a stroke, or have migraines that are accompanied by neurological problems.[34] In addition, triptans should be prescribed with caution for those with risk factors for vascular disease. While historically not recommended in those with basilar migraines there is no specific evidence of harm from their use in this population to support this caution.[35] Triptans are not addictive, but may cause medication overuse headaches if used more than 10 days per month.[36]

Sumatriptan does not prevent other migraine headaches from starting in the future.[32] For increased effectiveness at stopping migraine symptoms, a combined therapy that includes sumatriptan and naproxen may be suggested.[37]

Ergots edit

Ergotamine and dihydroergotamine (DHE) are older medications still prescribed for migraines, the latter in nasal spray and injectable forms. They appear equally effective to the triptans,[38] are less expensive,[39] and experience adverse effects that typically are benign.[40] In the most debilitating cases, such as those with status migrainosus, they appear to be the most effective treatment option.[40] The most common adverse effects are nausea, vomiting, abdominal pain, generalized weakness, tiredness, malaise, paresthesia, coldness, muscle pains, diarrhea, and chest tightness. These are less common with DHE than with ergotamine tartrate.[41]

Ergotamine and dihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms.[30][42] They appear equally effective to the triptans[43] and experience adverse effects that typically are benign.[44] In the most severe cases, such as those with status migrainosus, they appear to be the most effective treatment option.[44] They can cause vasospasm including coronary vasospasm and are contraindicated in people with coronary artery disease.[45]

Phenothiazines edit

Phenothiazines, often used for the treatment of nausea and vomiting, are also effective for treating migraine headache.[46][47] Prochlorperazine is typically used due to a more favorable treatment profile.[48]

Gepants edit

Gepants may be used for rescue as well as prevention. Some gepants are approved for different purposes in different jurisdictions. Zavegepant was approved for medical use in the United States in March 2023.[49][50][51]

Antiemetics edit

Metoclopramide is a recommended treatment for those who present to the emergency department.[13]

Other Medications edit

Intranasal lidocaine is an option.[13] A single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours.[52] It is recommended that opioids and barbiturates not be used.[13]

Intravenous metoclopramide, intravenous prochlorperazine, or intranasal lidocaine are other potential options.[13][24] Metoclopramide or prochlorperazine are the recommended treatment for those who present to the emergency department.[13][24] Haloperidol may also be useful in this group.[24][42] A single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours.[53] Spinal manipulation for treating an ongoing migraine headache is not supported by evidence.[54] It is recommended that opioids and barbiturates not be used due to questionable efficacy, addictive potential, and the risk of rebound headache.[13][55] There is tentative evidence that propofol may be useful if other measures are not effective.[56]

Magnesium is recognized as an inexpensive, over-the-counter supplement which can be part of a multimodal approach to migraine reduction. Some studies have shown to be effective in both preventing and treating migraine in intravenous form.[57] The intravenous form reduces attacks as measured in approximately 15–45 minutes, 120 minutes, and 24-hour time periods, magnesium taken orally alleviates the frequency and intensity of migraines.[58][59]

Migraine Treatment for Children edit

For children, ibuprofen or other NSAIDs help decrease pain.[60][61] Triptans are effective, though there is a risk of side effects such as nausea, coronary vasoconstriction, dizziness, paresthesia, flushing, tingling, neck pain, and chest tightness, known as "triptan sensations".[62]

Other Interventions edit

Occipital nerve stimulation, may be effective but has the downsides of being cost-expensive and has a significant amount of complications.[63]

There is modest evidence for the effectiveness of non-invasive neuromodulatory devices, behavioral therapies and acupuncture in the treatment of migraine headaches.[55] There is little to no evidence for the effectiveness of physical therapy, chiropractic manipulation and dietary approaches to the treatment of migraine headaches.[55] Behavioral treatment of migraine headaches may be helpful for those who may not be able to take medications (for example pregnant women).[55]

References edit

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