Migraine

Introduction

Migraine is a common primary headache disorder or unclear aetiology.

  • It occurs more commonly in women than in men.
  • It is recurrent in nature and classically presents as moderate-to-severe head pain lasting 4-72 hours.
It is typically unilateral with a pulsating quality, accompanied by nausea, vomiting, photophobia, and/or phonophobia, and may be preceded by aura that consists of sensory, motor or language symptoms.
  • Visual auras (accounts for ~90% of auras experienced) can take many forms, such as scotomas (blind spots), fortification spectra (zigzag lines) or flashing and flickering lights.
  • Photophobia and phonophobia often mean that patients will seek out a dark quiet room to relieve their symptoms.

NOTE: Headache is not a disease state or condition but rather a symptom, of which there are many causes.



Potential Trigger Factors

Triggers and strategies to reduce migraine attacks

  • Stress
    • Maintain regular sleep pattern.
    • Perform regular exercise.
    • Modify work environment.
    • Do relaxation techniques, such as yoga.
  • Diet - Any food can be potential trigger, but food that is implicated include cheese, citrus fruit, chocolate.
    • Maintain a food diary. If an attack occurs within 6 hours of food ingestion and is reproducible, it is likely that it is a trigger for migraine.
    • Eat regularly and do not skip meals.
    • Detecting triggers is complicated because they appear to be cumulative, jointly contributing to a threshold above which attacks are initiated.

In some women, the drop in oestrogen levels just before menstruation is a trigger for migraine, with symptoms generally occurring from 2 days before the start of bleeding up until 3 days after.



Treatment

For mild-to-moderate migraine attacks, consider simple oral analgesics such as paracetamol or NSAID.

  • When the response to a nonopioid analgesic is suboptimal, consider adding an antiemetic (especially metoclopramide) - the antiemetic can improve treatment response by increasing drug absorption.
  • In general, trial one nonopioid analgesic for a couple of migraine attacks. If this is not effective, change to a different nonopioid analgesic or a triptan.

For moderate-to-severe migraine attacks, consider sumatriptan 50-100 mg orally or other triptans if sumatriptan not effective.

  • Triptans should be taken at the first sign of a migraine for best efficacy.
  • Patients who do not respond well to one triptan may respond to another.
  • Based on limited evidence, it is still recommended that triptans be avoided in patients with hemiplegic migraine, basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal's angina and uncontrolled hypertension.
  • Combination with monoamine oxidase inhibitors is relatively contraindicated with triptans because of the risk of serotonin syndrome. Triptans should not be used within 24 hours of the of ergotamine preparations or a different triptan medication.

The combined use of a triptan and a NSAID to treat acute migraine appears to be more effective than using either drug class alone.

A variety of ergotamine preparations, alone and in combination with caffeine and other analgesics, have been used for the abortive treatment of migraine.

  • Most place-controlled trials of oral ergotamine alone have failed to show efficacy in the relief of migraine.
  • Ergotamine tartrate may be associated with significant side effects, and may worsen the nausea and vomiting associated with migraine. In addition, vascular occlusion and rebound headaches have been reported with oral doses exceeding 6 tablets per 24 hours or 10 tablets per week. Years of use also may be associated with valvular heart disease.
  • Ergots should be avoided in patients with coronary artery disease because they cause sustained coronary artery constriction, peripheral vascular disease, hypertension, and liver or renal disease.
  • In addition, ergotamine overuse has been associated with an increased risk of cerebrovascular, cardiovascular, and peripheral ischemic complications, particularly among those using cardiovascular drugs.
  • They also should not be used in patients who have hemiplegic migraine, migraine with brainstem aura, and migraine with prolonged aura because they may reduce cerebral blood flow.

For those with contraindications to or who do not tolerate triptans (e.g. coronary artery disease), a calcitonin gene-related peptide (CGRP) antagonist or lasmiditan may be effective.

  • CGRP antagonists
    • Examples: Ubrogepant, rimegepant, zavegepant
    • Long-term data are needed to better define safety and tolerability.
  • Lasmiditan
    • The most common adverse event is dose-dependent dizziness.
    • Patients should not drive a motor vehicle, operate machinery or engage in potentially hazardous activities for at least 8 hours after each dose of lasmiditan.

Frequent analgesic use can cause medication overuse headache.

  • Limit nonopioid analgesic use to less than 15 days per month, and limit triptan use (or drugs that contain opioid analgesic) to less than 10 days per month.



Prophylaxis

Consider migraine prophylaxis in patients who

  • Experience migraine attacks that reduce quality of life due to high frequency, severity or duration.
  • Experience attacks ≥4-5 days/month, even with no reported disability.
  • Cannot take acute therapies due to contraindications, adverse events or inadequate response.
  • Prefer prophylaxis, depending on physician judgement and type of migraine.

The choice of treatment depends on factors such as patient preference, adverse effects, drug interactions, medication cost and other co-morbidities.

  • For patients with hypertension who are nonsmokers and ≤60 years of age, reasonable options include metoprolol, propranolol or timolol in the absence of contraindications to beta blockers.
  • For patients with hypertension who are smokers or are >60 years of age, options include verapamil or flunarizine.
  • For patients with depression or mood disorder, reasonable options include amitriptyline or venlafaxine.
  • For patients with epilepsy, reasonable options include valproate or topiramate.
  • For patients with insomnia, amitriptyline is a reasonable option.
  • For patients with Raynaud phenomenon, reasonable options include verapamil or flunarizine.
  • Pizotifen may cause drowsiness (may be preferred in patients with insomnia) and weight gain.
  • Valproate should not be used for females of childbearing potential, because it is teratogenic and is associated with an increased risk of congenital anomalies.
  • If patients have not benefited from ≥3 trials of oral migraine prophylaxis treatment, may consider CGRP monoclonal antibodies (high cost and lack long-term safety and efficacy data).
Migraine Prophylaxis

Start at low dose and slowly titrate up to achieve desired effect.

  • Trial a prophylactic drug for migraine for at least 8 to 12 weeks to assess its efficacy.
  • A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks.

A review of ongoing prophylaxis should be considered after 6-12 months; treatment can be gradually withdrawn in many patients.



Supplements

Feverfew has been the herbal remedy most studied for the prevention of migraine, but evidence regarding benefit is conflicting.

There is only limited evidence supporting magnesium supplementation for migraine prevention in adults.

In a small, randomized controlled trial of 42 patients with migraine, CoQ10 was effective for migraine prevention; significantly more patients treated with CoQ10 (100 mg three times daily) experienced a ≥50 percent reduction in attack frequency at three months than patients treated with placebo (47.6 versus 14.4 percent).



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