Pain, General | June 3, 2014 | Author: The Super Pharmacist
Migraines are underdiagnosed and misdiagnosed. There are four phases of migraine but are not always present. Prodrome, Aura, Pain phase and Postdromal symptoms.
About 60% of people who experience migraines report premonitory symptoms that occur hours to days before headache onset. Although the prodromal features vary, they tend to be consistent for a given individual and may include the following:
The migraine aura is a complex of neurologic symptoms that may precede or accompany the headache phase or may occur in isolation. It usually develops over 5-20 minutes and lasts less than 60 minutes. The aura can be visual, sensory, or motor or any combination of these. When an aura is not followed by a headache, it is called a migraine equivalent, silent migraine or acephalic migraine.
Visual symptoms: Auras most commonly consist of visual symptoms, which may be negative or positive.
Sensory symptoms: Paresthesias (commonly referred to as pins and needles), occurring in 40% of cases, are the next most common aura; they often present with tingling starting in the hand, migrating to the arm, and then jumping to involve the face, lips, and tongue. As with visual auras, positive symptoms typically are followed by negative symptoms (paresthesias may be followed by numbness).
Motor symptoms: Motor symptoms occur in 18% of patients and usually are associated with sensory symptoms. Motor symptoms often are described as a sense of heaviness of the limbs before a headache but without any true weakness. Speech and language disturbances have been reported in 17-20% of patients. These disturbances are commonly associated with upper extremity heaviness or weakness.
The typical migraine headache is unilateral, throbbing, with moderate to severe intensity aggravated by physical activity. The pain may be bilateral at the onset or start on one side and become generalised. The location of the headache usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides and usually lasts between 4 to 72 hours in adults and 1 to 48 hours in children. The frequency of attacks is extremely variable, from a few in a lifetime to several each week. The average migraine patient experiences one to three headaches a month. The head pain varies greatly in intensity.
Postdromal symptoms (symptoms experienced after the headache has subsided), may persist for 24 hours after the headache and can include the following:
A history of migraine triggers may be identified.
Biofeedback, cognitive-behavioral therapy, and relaxation therapy are frequently effective against migraine headaches and may be used adjunctively with pharmacologic treatments.
Patients should avoid factors that precipitate a migraine attack (e.g. lack of sleep, fatigue, stress, certain foods, use of vasodilator medications). Patients should be encouraged to use a daily diary to document the headaches. Patients may need to discontinue any medications that exacerbate their headaches.
Occipital nerve stimulators may be helpful in patients whose headaches are refractory to other forms of treatment.
In 2013, the FDA approved the Cerena Transcranial Magnetic Stimulator (Cerena TMS), the first device to relieve pain caused by migraine headache with aura for use in patients aged 18 years and older.
Users hold the device with both hands to the back of the head and press a button to release a pulse of magnetic energy that stimulates the occipital cortex. The recommended daily usage of the device is not to exceed one treatment in 24 hours.
Based upon a previous randomised trial (the Disability in Strategies of Care, or DISC study), choosing a treatment strategy matched to the severity of headache-related disability proved superior to a step-care approach. A step-care approach recommends all patients are initially treated with simple analgesics, and treatment escalates if necessary. The stratified approach produced a significantly faster relief from headache symptoms, and reduced disability time compared to the step-care approach.
The use of abortive therapy alone in the acute management of migraine may be an appropriate option for patients who experience fewer than two migraines per month or who use abortive medications less than two days per week.
Analgesics. Analgesics used in migraine include paracetamol, NSAIDs, and narcotic analgesics (e.g. oxycodone and morphine). Drugs marketed especially for migraines, such as the mixture of paracetamol and caffeine, also may relieve mild to moderate migraine discomfort but are insufficient alone for extreme migraines. If taken excessively or for a long time, some of these medications can result in ulcers, gastrointestinal bleeding as well as rebound headaches.
Triptans and ergot alkaloids. The two categories of migraine-specific oral medications are triptans and ergot alkaloids. The specific ergot alkaloids include:
The specific triptans include:
The efficacy of the ergots and triptans is primarily based on their interaction at the serotonin (5-HT) receptors. Both classes of drugs constrict the pain-producing intracranial, extracerebral blood vessels in the meninges.
For many individuals with migraine attacks, triptans are the drug of preference. They are efficient in relieving the pain, nausea, and sensitivity to light and sound, which are associated with migraine headaches.
With the exception of sumatriptan which is listed on Australia's Pharmaceutical Benefits Scheme (PBS) as both an oral tablet and nasal spray, the other triptans are only available as oral tablets.
Sumatriptan transdermal patches have been proven effective for migraine, and one such product has received FDA approval but is not yet listed on the PBS.
Ergotamine and caffeine combination drugs (Cafergot), which is no longer available as a suppository, are generally less effective than triptans. They seemed most reliable in those whose pain lasts for over 48 hours or who had difficulty keeping oral medications down as a result of vomiting.
Anti-emetics. Anti-emetics (e.g. prochlorperazine, promethazine) are used to treat the nausea associated with acute migraine attacks.
First line agents. The first-line agents with the greatest efficacy are β-blockers, tricyclic antidepressants (TCAs), and valproic acid.
Second line agents
Third line agents. Two medications that have proved effective in prophylaxis but are reserved for severe or refractory cases are:
Both should be reserved for use only by specialists in headache treatment. Because of its side-effects profile, numerous precautions, and contra-indications, methysergide has become a last-line drug. Longer than 6 months of continuous use can lead to fatal retropleural, retroperitoneal or cardiac fibrosis, and drug holidays must be instituted when methysergide is used.
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