CONFERENCE PAPER
Management of Migraine in Adults MacGregor, MBBS Registrar, The City of London Migraine Clinic, Dr E A
22 Charterhouse
Square, London,
EC21M 6DX
INTRODUCTION
TRIGGERS
There are many numerous ways available to manage migraine headaches and many differing views. In this paper, I am presenting my own personal view on management based on my own clinical experience. The basis of this is to advise each migraine sufferer as to what they can do to help themselves to their best advantage. Migraine affects people for many years of their lives and it is important that the treatment does not cause more problems for the patient than the condition. The most important point in management is startlingly obvious but cannot be over-emphasized. That is - correct
All treatment is likely to be more effective if the patient understands how and why it is supposed to work. The identification of trigger factors is an example of this and is simple non drug prophylactic. The patient is given a list of triggers to look out for in each migraine attack. Many patients comment that sometimes a certain trigger seems to be involved but at other times they can get away with it. A likely explanation of this is that it is a build up of several different trigger factors that in combination can cross the threshold to initiate an attack. These triggers are many and varied - they may change with time and also change for each attack. The most common triggers that have been identified are: ~ lack of food ~ specific foods - cheese, chocolate, alcohol, citrus fruits etc . changes in sleeping pattern - lack of sleep, lying in . hormonal change in women . head and neck pain . environmental changes - bright lights, loud noises, strong smells . exercise - if overdone or not regular . travel . stress - often after a period of stress Stress is a trigger in itself but also results in other triggers poor sleep, missing meals, drinking too much coffee etc. Again, keeping a diary card is the easiest way to identify these triggers. Obviously, not all triggers can be prevented hormonal changes and stress, for example. However, by minimising as many factors as possible, patients may still be able to keep below the attack threshold. Furthermore, identification of triggers allows the patient to recognise situations which may result in an attack. This enables them to take attack therapy early.
diagnosis. When migraine attacks present as the only headache, there is little problem. What is much more difficult to deal with, is the presence of several different headaches in the
patient. Daily headaches are not migraine, but migraine attacks may be superimposed on a background daily headache. Careful questioning when taking the history may establish the problem. Examination and investigations are frequently non-contributory. If there is any uncertainty in diagnosis, an important tool is the patient diary card. same
In such a situation, it is often easier to tackle each headache separately, treating the non-migraine headaches first. Otherwise failure of treatment may result, particularly if the patient cannot easily distinguish between the different headaches which are often superimposed. Furthermore, they may already be taking drugs for their headaches on a frequent basis. I will return to this point later. Once migraine has been diagnosed, it is important to take the time to reassure the patient. Many are frightened that they may have a brain tumour or even that a blood vessel will burst during an attack. I am frequently asked by patients to ’cure’ their migraine. One has to be honest and say that no ’cure’ is yet available but that it is possible to control migraine attacks both with and without the use of
drugs. Treatment falls into four main ~ Acute drug treatment ~ Acute non drug treatment ~ ~
categories:
Prophylactic drug treatment Prophylactic non drug treatment
-
-
ACUTE DRUG TREATMENT The earlier in the attack that treatment is taken, the more effective it will be. Even simple over-the-counter remedies can work if taken at the right time. Patients should be encouraged to carry a dose of the attack therapy with them at all times and use it at the earliest point of recognition of their attacks - either at the onset of the aura,
39 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
if present, or as soon as the headache starts. Some patients are of prodromal symptoms prior to the headache. Often these are only subtle changes in mood or behaviour which are more readily noticed by other people rather than the patient
ADVANCES IN MIGRAINE THERAPY
aware
Many new developments are taking place in the therapy of migraine, particularly in drug options. The development of drugs such as sumatriptan has implicated specific
Lethargy or the opposite, excessive energy, are of examples prodromal symptoms. Some people also have cravings for certain foods, particularly sweet foods. These symptoms are usually present up to a day before the onset of headache. It may be possible to prevent the full attack proceeding by minimising triggers during this time or even taking treatment before going to bed. If over-the-counter drugs are not effective, I find this step up the ladder of therapeutic options is a useful guide:
mechanisms and the involvement of neurotransmitters such as 5-hydroxytryptamine. This had greatly advanced our knowledge of the disease and possible ways of treating it. However, we still have a long way to go before we can fully understand the mechanism of an attack.
themself.
PROPHYLACTIC DRUG TREATMENT Unfortunately for some people, avoidance of known triggers and specific attack therapy is not sufficient to keep control.
1 st Line: 1. an oral anti-emetic with an effect on gastric motility 10 mg metoclopramide or
20-30mg domperidone with 2.
analgesics 900mg aspirin +/- codeine 100mg paracetamol (preferably
in soluble
or
effervescent form) all
repeated 4 hourly if necessary
2nd Line: useful if nausea prevents the
use
of oral medication
1. 1-2 domperidone suppositories with 2. 1 indomethacin suppository
In these cases, a short course of prophylactic may be necessary. The most suitable drug can often be selected on the basis of its side effects, or its effect on other problems that the patient has. A short course only should be given, under regular review. If prophylaxis is not effective, review the diagnosis. 1. Propranolol - useful if stress or hypertension are also present. I often start with a dose as low as 10 mg tds although some advocate that higher doses are required. Starting with such a low dose enables the doctor to slowly increase if necessary whilst minimising side effects. 2. Amitriptyline - useful in depression or if there is difficulty in sleeping. 3. Pizotifen - useful when there is poor appetite or difficulty in sleeping. 4. Clonidine - can help the hot flushes of the 5. Methysergide - an effective prophylactic, limited by its association with retroperitoneal fibrosis. It should therefore be given on a 5 months on, 1 month off
menopause.
.
repeated every 6-8 hours
basis. 6.
3rd Line:
7.
oral
Ergotamine is a very useful drug for migraine when correctly used. It can be given in any of the above forms, in combination with
an
Prostaglandin Inhibitors - may be useful for migraine particularly associated with menstruation. Aspirin - may be a useful prophylactic but further attacks
ergotamine - inhaler suppositories
anti-emetic if necessary.
Poor
bioavailability limits the efficacy of the oral form particularly. The inhaler and suppositories are especially useful when an attack has ’set in’, although I reiterate that all drugs should be taken early for maximum benefit.
ACUTE NON DRUG TREATMENT Once an attack has started, sleep, when possible, is the best natural remedy. Local applications of alternating hot and cold applications to the site of pain may also help. A small snack eaten in the attack before nausea has taken hold often helps and patients should be encouraged to eat little and often when they can.
studies are required. 8. Feverfew - can be suggested if little else works but no long term assessment has been made of its safety. However, controlled trials have shown it to be a useful and effective prophylactic. It should not be to pregnant women as it stimulates uterine muscle. It may take 6 weeks of continuous use before any effect is noticed.
given
NON DRUG PROPHYLAXIS Non drug treatments should not be forgotten. Simple instruction in neck exercise and posture or referral to a physiotherapist can help ease neck and shoulder muscle tension. Temporomandibular dysfunction or teeth grinding may necessitate a visit the the dentist or referral to an orthodontist. Stress may be alleviated with regular exercise or massage. The benefit from a healthy diet with regular
40 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
I
meals should not be forgotten. These simple measures can make a vast amount of difference. Complementary medicine should be used as an adjunct to conventional treatment.
DAILY HEADACHES I end my paper with a mention of the problem patient. Anyone who has treated patients with headache will be able to
bring to mind at least one person for whom no treatment
seems to
work.
All too often, patients end up taking large amounts of medication - both over-the-counter and prescription drugs. Some can take upwards of 50-60 analgesics a week. Most of these patients have a history of migraine that have become more frequent requiring more treatment. This vicious cycle continues until they find they are getting headaches nearly every day. ’Ergotamine abuse headache’ has been recognised for many years. It is only recently that the prevalence of chronic analgesic headache has been reported by different workers including Rapoport and co workers in America and Isler in Switzerland (Rapoport, 1989; Isler, 1982). It has been defined as a chronic headache, additional to the primary headache in patients who take daily doses of a substance for more than 3 months. This is a difficult concept as it is only seen in people taking these drugs for a headache disorder, and not seen in those who take them for other conditions eg arthritis. However, you will find that if you can persuade these patients to reduce their drug intake (if necessary as an inpatient, but preferably by slow reduction as an outpatient under regular review) the secondary headache can be relieved. The primary headache will remain but can be treated in the ways I have outlined above. During substance withdrawal it is again important to get the patients to keep a clear record of their headaches in addition to their drug intake. This brings me back to the start of my paper when I tressed the importance of the headache diary. I finish with words of Gracian from ’The Art of Worldy Wisdom’ written in 1647: ’It takes a wise doctor to know when not to prescribe’.
he
References ISLER H (1982). Migraine Treatment as a cause of Chronic Migraine, In Advance in Migraine Research and Therapy pp 159164 (F Clifford Rose) New York, Rave Press RAPOPORT A (1989). Characteristics & Treatment of Analgesic Rebound Headache, Berlin Springer
41 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
Management of Migraine in Adults MacGregor, MBBS Registrar, The City of London Migraine Clinic, Dr E A
22 Charterhouse
Square, London,
EC21M 6DX
INTRODUCTION
TRIGGERS
There are many numerous ways available to manage migraine headaches and many differing views. In this paper, I am presenting my own personal view on management based on my own clinical experience. The basis of this is to advise each migraine sufferer as to what they can do to help themselves to their best advantage. Migraine affects people for many years of their lives and it is important that the treatment does not cause more problems for the patient than the condition. The most important point in management is startlingly obvious but cannot be over-emphasized. That is - correct
All treatment is likely to be more effective if the patient understands how and why it is supposed to work. The identification of trigger factors is an example of this and is simple non drug prophylactic. The patient is given a list of triggers to look out for in each migraine attack. Many patients comment that sometimes a certain trigger seems to be involved but at other times they can get away with it. A likely explanation of this is that it is a build up of several different trigger factors that in combination can cross the threshold to initiate an attack. These triggers are many and varied - they may change with time and also change for each attack. The most common triggers that have been identified are: ~ lack of food ~ specific foods - cheese, chocolate, alcohol, citrus fruits etc . changes in sleeping pattern - lack of sleep, lying in . hormonal change in women . head and neck pain . environmental changes - bright lights, loud noises, strong smells . exercise - if overdone or not regular . travel . stress - often after a period of stress Stress is a trigger in itself but also results in other triggers poor sleep, missing meals, drinking too much coffee etc. Again, keeping a diary card is the easiest way to identify these triggers. Obviously, not all triggers can be prevented hormonal changes and stress, for example. However, by minimising as many factors as possible, patients may still be able to keep below the attack threshold. Furthermore, identification of triggers allows the patient to recognise situations which may result in an attack. This enables them to take attack therapy early.
diagnosis. When migraine attacks present as the only headache, there is little problem. What is much more difficult to deal with, is the presence of several different headaches in the
patient. Daily headaches are not migraine, but migraine attacks may be superimposed on a background daily headache. Careful questioning when taking the history may establish the problem. Examination and investigations are frequently non-contributory. If there is any uncertainty in diagnosis, an important tool is the patient diary card. same
In such a situation, it is often easier to tackle each headache separately, treating the non-migraine headaches first. Otherwise failure of treatment may result, particularly if the patient cannot easily distinguish between the different headaches which are often superimposed. Furthermore, they may already be taking drugs for their headaches on a frequent basis. I will return to this point later. Once migraine has been diagnosed, it is important to take the time to reassure the patient. Many are frightened that they may have a brain tumour or even that a blood vessel will burst during an attack. I am frequently asked by patients to ’cure’ their migraine. One has to be honest and say that no ’cure’ is yet available but that it is possible to control migraine attacks both with and without the use of
drugs. Treatment falls into four main ~ Acute drug treatment ~ Acute non drug treatment ~ ~
categories:
Prophylactic drug treatment Prophylactic non drug treatment
-
-
ACUTE DRUG TREATMENT The earlier in the attack that treatment is taken, the more effective it will be. Even simple over-the-counter remedies can work if taken at the right time. Patients should be encouraged to carry a dose of the attack therapy with them at all times and use it at the earliest point of recognition of their attacks - either at the onset of the aura,
39 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
if present, or as soon as the headache starts. Some patients are of prodromal symptoms prior to the headache. Often these are only subtle changes in mood or behaviour which are more readily noticed by other people rather than the patient
ADVANCES IN MIGRAINE THERAPY
aware
Many new developments are taking place in the therapy of migraine, particularly in drug options. The development of drugs such as sumatriptan has implicated specific
Lethargy or the opposite, excessive energy, are of examples prodromal symptoms. Some people also have cravings for certain foods, particularly sweet foods. These symptoms are usually present up to a day before the onset of headache. It may be possible to prevent the full attack proceeding by minimising triggers during this time or even taking treatment before going to bed. If over-the-counter drugs are not effective, I find this step up the ladder of therapeutic options is a useful guide:
mechanisms and the involvement of neurotransmitters such as 5-hydroxytryptamine. This had greatly advanced our knowledge of the disease and possible ways of treating it. However, we still have a long way to go before we can fully understand the mechanism of an attack.
themself.
PROPHYLACTIC DRUG TREATMENT Unfortunately for some people, avoidance of known triggers and specific attack therapy is not sufficient to keep control.
1 st Line: 1. an oral anti-emetic with an effect on gastric motility 10 mg metoclopramide or
20-30mg domperidone with 2.
analgesics 900mg aspirin +/- codeine 100mg paracetamol (preferably
in soluble
or
effervescent form) all
repeated 4 hourly if necessary
2nd Line: useful if nausea prevents the
use
of oral medication
1. 1-2 domperidone suppositories with 2. 1 indomethacin suppository
In these cases, a short course of prophylactic may be necessary. The most suitable drug can often be selected on the basis of its side effects, or its effect on other problems that the patient has. A short course only should be given, under regular review. If prophylaxis is not effective, review the diagnosis. 1. Propranolol - useful if stress or hypertension are also present. I often start with a dose as low as 10 mg tds although some advocate that higher doses are required. Starting with such a low dose enables the doctor to slowly increase if necessary whilst minimising side effects. 2. Amitriptyline - useful in depression or if there is difficulty in sleeping. 3. Pizotifen - useful when there is poor appetite or difficulty in sleeping. 4. Clonidine - can help the hot flushes of the 5. Methysergide - an effective prophylactic, limited by its association with retroperitoneal fibrosis. It should therefore be given on a 5 months on, 1 month off
menopause.
.
repeated every 6-8 hours
basis. 6.
3rd Line:
7.
oral
Ergotamine is a very useful drug for migraine when correctly used. It can be given in any of the above forms, in combination with
an
Prostaglandin Inhibitors - may be useful for migraine particularly associated with menstruation. Aspirin - may be a useful prophylactic but further attacks
ergotamine - inhaler suppositories
anti-emetic if necessary.
Poor
bioavailability limits the efficacy of the oral form particularly. The inhaler and suppositories are especially useful when an attack has ’set in’, although I reiterate that all drugs should be taken early for maximum benefit.
ACUTE NON DRUG TREATMENT Once an attack has started, sleep, when possible, is the best natural remedy. Local applications of alternating hot and cold applications to the site of pain may also help. A small snack eaten in the attack before nausea has taken hold often helps and patients should be encouraged to eat little and often when they can.
studies are required. 8. Feverfew - can be suggested if little else works but no long term assessment has been made of its safety. However, controlled trials have shown it to be a useful and effective prophylactic. It should not be to pregnant women as it stimulates uterine muscle. It may take 6 weeks of continuous use before any effect is noticed.
given
NON DRUG PROPHYLAXIS Non drug treatments should not be forgotten. Simple instruction in neck exercise and posture or referral to a physiotherapist can help ease neck and shoulder muscle tension. Temporomandibular dysfunction or teeth grinding may necessitate a visit the the dentist or referral to an orthodontist. Stress may be alleviated with regular exercise or massage. The benefit from a healthy diet with regular
40 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
I
meals should not be forgotten. These simple measures can make a vast amount of difference. Complementary medicine should be used as an adjunct to conventional treatment.
DAILY HEADACHES I end my paper with a mention of the problem patient. Anyone who has treated patients with headache will be able to
bring to mind at least one person for whom no treatment
seems to
work.
All too often, patients end up taking large amounts of medication - both over-the-counter and prescription drugs. Some can take upwards of 50-60 analgesics a week. Most of these patients have a history of migraine that have become more frequent requiring more treatment. This vicious cycle continues until they find they are getting headaches nearly every day. ’Ergotamine abuse headache’ has been recognised for many years. It is only recently that the prevalence of chronic analgesic headache has been reported by different workers including Rapoport and co workers in America and Isler in Switzerland (Rapoport, 1989; Isler, 1982). It has been defined as a chronic headache, additional to the primary headache in patients who take daily doses of a substance for more than 3 months. This is a difficult concept as it is only seen in people taking these drugs for a headache disorder, and not seen in those who take them for other conditions eg arthritis. However, you will find that if you can persuade these patients to reduce their drug intake (if necessary as an inpatient, but preferably by slow reduction as an outpatient under regular review) the secondary headache can be relieved. The primary headache will remain but can be treated in the ways I have outlined above. During substance withdrawal it is again important to get the patients to keep a clear record of their headaches in addition to their drug intake. This brings me back to the start of my paper when I tressed the importance of the headache diary. I finish with words of Gracian from ’The Art of Worldy Wisdom’ written in 1647: ’It takes a wise doctor to know when not to prescribe’.
he
References ISLER H (1982). Migraine Treatment as a cause of Chronic Migraine, In Advance in Migraine Research and Therapy pp 159164 (F Clifford Rose) New York, Rave Press RAPOPORT A (1989). Characteristics & Treatment of Analgesic Rebound Headache, Berlin Springer
41 Downloaded from rsh.sagepub.com at UNIV CALGARY LIBRARY on May 24, 2015
