Management of migraine

It is important to differentiate between migraine and cluster headaches. The treatments are different.

Migraine

  • Pain can occur in any location.
  • Pain is severe and throbbing. Patients want to lie down.
  • Attack lasts 4-72 hours.
  • No peri-orbital autonomic features.
  • Nausea, vomiting, photophobia or phonophobia.

Cluster headache

  • Pain in peri-orbital.
  • Pain is very severe and piercing. Patients pace the room.
  • Attack lasts 15-180 minutes and come in clusters.
  • Autonomic features around the eye on side of pain.

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:

  • relaxation after stress;
  • changes in habit (missing meals, missing sleep/lying in late);
  • bright lights and loud noise;
  • dietary factors: some alcoholic drinks, cheese, citrus fruit, chocolate;
  • hormonal fluctuations.

The suggested approach to treatment is:

  • Avoidance of trigger factors.
  • Relief of acute attack - 'step up' through the treatments in response to a failure of simpler treatments to control attacks.
  • Prophylaxis if attacks are frequent.

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.

Relief of acute migraine attack

Step 1

  • NSAID
  • ± paracetamol
  • ± prokinetic agent or antiemetic

As many patients respond to simple analgesics, it is sensible to try these first. Advise self-treatment rather than prescribing if appropriate

Step 2

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.

Prophylaxis of migraine

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.

Propranolol

Notes

  1. Beta-blockers without partial agonism are first line agents unless contra-indicated. Propranolol is specifically licensed for this indication. It should be started at low dose and titrated up to a target of 160mg SR daily. There is some limited evidence that atenolol is effective in the prophylaxis of migraine. Although it remains unlicensed in this indication it is recognised that some specialists recommend its use.

Topiramate

  • See section 4.8.1 Control of epilepsies
  • Topiramate is licensed for migraine prophylaxis. The starting dose for topiramate is 25mg at night for one week followed by weekly increases of 25mg/day. If the patient is unable to tolerate the titration, longer intervals between dose adjustments can be used. Recommended total daily dose is 100mg/day in two divided doses. Some patients may experience benefit from 50mg/day.

Notes

  1. Topiramate use for migraine prophylaxis is contra-indicated in pregnancy and in women of child-bearing potential if not using an effective method of contraception. Patients on long term treatment should be regularly weighed and monitored for continued weight loss. If clinically significant weight loss occurs, consider stopping treatment. Topiramate is associated with depression.

Amitriptyline

Notes

  1. Amitriptyline is not licensed for migraine prophylaxis but has been used for many years and clinical practice supports its use.

Pizotifen

Notes

  1. Pizotifen is licensed for migraine prophylaxis but evidence of its efficacy is limited. Weight gain may be a troublesome side effect.
  2. Although maybe ineffective in adults, maybe useful in children

Sodium valproate

  • See section 4.8.1 Control of epilepsies
  • Initially 200mg twice daily, increased if necessary to 1.2–1.5g daily in divided doses (unlicensed indication)

Methysergide and clonidine are not recommended due to high incidence of side effects.

 

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