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It is important to differentiate between migraine and cluster headaches. The treatments are different.
Migraine is often accompanied by medication overuse headache. This can occur when taking analgesics as little as three or more times a week. Weak opioids, e.g. codeine, are particularly implicated but even paracetamol can cause problems. Three or more triptans a week can cause medication overuse headache. The consumption of six triptans tablets a month is an indication for reassessment and possible preventative medication.
Migraine patients may be sensitive to changes in their internal and external environments. It is therefore important to keep mealtimes, drinking and sleeping patterns as constant as possible.
Trigger factors may be important for some individuals but most attacks have no obvious trigger. Trigger factors which have been identified include:
The suggested approach to treatment is:
Migraine in children
Studies suggest that approximately 10% of children suffer with migraine. The characteristics are different from adults- headaches are shorter, more commonly bilateral and nausea, phonophobia and photophobia may be absent. Paracetamol and ibuprofen are useful for acute attacks. If nausea is present, domperidone can be used (unlicensed). Sumatriptan nasal spray is licensed in children aged 12 years or over; sumatriptan and zolmitriptan are occasionally recommended by specialist paediatricians for off-label use, more information can be found in the BNF for children. Pizotifen and propranolol are useful preventative drugs. Doses are in the BNF for children.
As many patients respond to simple analgesics, it is sensible to try these first. Advise self-treatment rather than prescribing if appropriate
Triptans should be taken at the earliest onset of pain.
See notes above for information about medication overuse headache.
Triptans are contra-indicated in ischaemic heart disease, previous MI/ CVE/TIA, coronary vasospasm, uncontrolled hypertension and peripheral vascular disease.
As triptans vary in receptor subtype binding affinity, there is merit in trying alternative triptans if the first proves ineffective. Almotriptan and frovatriptan act on a wider range of receptors than sumatriptan.
There are no convincing data to differentiate most triptans on clinical effectiveness grounds and the choice can be made on cost grounds.
Orodispersible and 'Melt' formulations of triptans are not included in the formulary, they offer no clinical advantage and are for convenience only.
If trigger factors are found, these are best avoided wherever possible and exclude medication overuse headache.
Consider prophylactic therapy for patients who are getting recurrent migraine which responds to therapy and where no trigger is identified. The decision to initiate prophylaxis should be made in conjunction with the patient taking into account the number of attacks per month and the impact of these on the patient's life.
Good practice is to regularly review the need for continuing treatment and it is suggested that this should occur at six monthly intervals.
Methysergide and clonidine are not recommended due to high incidence of side effects.