Health professionals

Managing Migraine

The management of migraine begins by an explanation of certain things to the patient, notably:

• migraine is an inherited tendency to headache, and cannot be cured, but -
• migraine can be modified and controlled by life-style adjustment and the use of medicines
• migraine is not life threatening nor associated with serious illness (with the exception of females who smoke and are on the oestrogenic oral contraceptives), but migraine can make life a misery
• migraine management takes time and co-operation when information, such as that from a headache diary, has to be collected.

Non-Pharmacological Management

Put very simply, non-pharmacological management of migraine is to help the patient identify things that make the problem worse and encourage them to modify these. Some patients will not find any joy in this approach and should not be pilloried for this, however for those who do identify such factors, it will be a rewarding strategy.

Preventative Treatments for Migraine

The decision to start a patient on a preventative requires input from both doctor and migraineur. The basis of considering preventative treatment from a medical viewpoint is a combination of acute attack frequency and attack tractability. Attacks that are unresponsive to acute attack medications are easily considered for prevention while simply treated attacks may be less obviously candidates for prevention. The other part of the equation relates to what is happening with time. If a patient diary shows a clear trend for increased frequency it is better to get in early with prevention than wait for the problem to become chronic. A simple rule for frequency might be that for 1-2 headaches a month there is usually no need to start a preventative, for 3-4 it may be needed, but not necessarily, and for 5 or more a month prevention should definitely be on the agenda for discussion. Options available for treatment include pizotifen, propranolol, valproate and amitriptyline, which are covered in more detail elsewhere.

Acute Attack Therapies for Migraine

Acute attack treatments for migraine can be usefully divided into disease non-specific treatments, analgesics and NSAIDS, and disease specific treatments, ergot-related compounds and triptans (Table 2). It must be said at the outset that most acute attack medications seem to have propensity to aggravate headache frequency and induce a state of refractory daily or near-daily headache, Analgesic Associated Chronic Daily Headache. Codeine-containing compound analgesics are a particularly pernicious player on this field and in my practice I try to avoid them as though a pestilence. Not all patients who stop taking regular analgesics will have a miracle cure of their headache but almost all feel in some way better and will be easier to treat with standard preventatives.

Table 2. Acute migraine treatments

Non-Specific Treatments (often used with anti-emetic/prokinetics, such as domperidone or metaclopramide)	Specific Treatments
Aspirin Paracetamol NSAIDS Naproxen Ibuprofen Tolfenamic Aci	Ergot derivatives Ergotamine Dihydroergotamine Triptans sumatriptan naratriptan rizatriptan zolmitriptan

Given the array of options to control an acute attack of migraine, how does one start? The simplest approach to treatment has been described as Stepped Care. In this model all patients are treated, assuming no contraindications, with the simplest treatment such as aspirin 900mg with an anti-emetic. Aspirin is an effective strategy and has been proven so by double-blind controlled clinical trials. The alternative would be a strategy know as Stratified Care, in which the physician determines, or stratifies, treatment at the start based on likelihood of response to levels of care. Lipton and Stewart have proposed a migraine disability scale (MIDAS, Migraine Disability Assessment Scale) to make this decision. The scale is easy to use and freely available. Until data are available from the on-going studies with MIDAS, stepped-care with clinical modification seems most rational (Table 3).

Since simple things, such as aspirin (900mg) and paracetamol (1000mg), are cheap and can be very effective, they can be employed in many patients. Dosages should be adequate and the addition of domperidone (10mg po) or metaclopramide (10mg po) can be very helpful. NSAIDS can be very useful when tolerated. Their success is often limited by inappropriate dosing, and adequate doses of naproxen (500-1000mg po or pr with an anti-emetic), ibuprofen (400-800mg po) or tolfenamic acid (200mg po) can be extremely effective.

Tolfenamic acid has been shown in a double-blind placebo-controlled study to have comparable efficacy to sumatriptan 100mg, a result that reinforces the general clinical view that NSAIDs can be very useful compounds in migraine.

Table 3. Clinical stratification of acute migraine treatments

Clinical situation	Treatment options
Failed analgesics/NSAIDS	First tier Sumatriptan 50mg po Rizatriptan 10mg po Zolmitriptan 2.5mg po Ergotamine 1mg po (if headache infrequent) Second tier Naratriptan 2.5mg
Early nausea or problem taking tablets	Sumatriptan 20mg nasal spray Rizatriptan 10mg MLT wafer
Headache recurrence	Ergotamine(perhaps most effective pr) Naratriptan 2.5mg po
Tolerating acute treatments poorly	Naratriptan 2.5mg Sumatriptan 25mg pr (available in Europe) Sumatriptan 6mg sc
Menstrually-related headache	Prevention Ergotamine po nocte Oestrogen patches Treatment Triptans
Very rapidly developing symptoms	Sumatriptan 6mg sc

When simple measures fail or more aggressive treatment is required, the specific treatments are required. While ergotamine remains a useful anti-migraine compound its place as the first choice has slipped in recent years. There are particular situations in which ergotamine is very useful but its use must be strictly controlled as ergotamine overuse produces dreadful headache in addition to a host of vascular problems. The triptans have revolutionised the life of many patients with migraine and are clearly the most powerful option available to stop a migraine attack. They can be rationally applied by considering their pharmacological, physicochemical and pharmacokinetic features, as well as the formulations that are available.

Reproduced from The National Association of Fundholding Practices (Official Yearbook & Annual Review 1998) and with kind permission of Professor Peter J. Goadsby and Scorpio Publishing.

Migraine Diagnosis and Treatment Overview

Peter J. Goadsby BMedSc MB BS MD PhD DSc FRACP FRCP (Professor of Clinical Neurology at the Institute of Neurology, University College, Queen Square, London and a Medical Trustee of The Migraine Trust)