A Type Botulinum Toxin
The efficiency of A type botulinum toxin has not been found in treatment of episodic migraine and tension type headache, but it has been shown to be superior to placebo in terms of the number of days with headache and the number of headache episodes in chronic migraine considering the total data of the PREEMPT1 and PREEMPT2 studies . BTA acts on peripheral sensitization by inhibiting release of substance P, calcitonin gene related peptide and glutamate from the primary trigeminal and cervical peripheral endings. It is a well tolerated treatment option .
Data Collection And Analysis
Studies were selected and data extracted by two independent reviewers. For migraine frequency data, standardized mean differences were calculated for individual studies and pooled across studies. For dichotomous data on significant reduction in migraine frequency, odds ratios and numbersneededtotreat were similarly calculated. Adverse events were analyzed by calculating numbersneededtoharm for studies using similar agents.
Which Treatment Is Right For You
When deciding on preventive therapies, it is important to review with your doctor several important management principles:
Ask your physician what you can expect from the medication regarding its efficacy. In other words, as What is the benefit likely to be for me when I take this medication?
Low doses are used at first and gradually increased to higher doses as needed. Therefore, you may need to increase medication dose until the desired response is achieved.
Lower dosing frequency is often convenient, however, some medications may need to be taken twice or even three or four times a day. Discuss the dosing frequency of the medications and make sure the plan is convenient and easy to follow. Otherwise, you may not take the medication as prescribed and the efficacy benefits may not be achieved.
It may take two to three months before you notice a decrease in the frequency or severity of attacks even after reaching the beneficial dose.
Treatment may be required for six to twelve months or longer.
All medications have potential side effects so any unusual symptoms should be reported to your physician. It is important to discuss potential side effects and how they may be avoided or treated if they appear. Different medications have different safety and costs factors and these may play a factor in deciding which medication is right for you.
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Brief Overview Of Current Management Drug Strategies
Migraine prophylaxis should be considered when one or more of the following are present: 1) recurring migraines that significantly interfere with the patients daily activities, despite acute treatment 2) frequent headaches 3) failure, overuse, or contraindication of acute treatments 4) adverse effects of acute treatment and/or 5) presence of rare migraine conditions which can potentially cause neurologic damage, such as hemiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction .
Whereas some patients will require prophylaxis for only brief periods of time encompassing a predictable triggering situation, most will require long-term treatment. Prevention can be viewed as being pre-emptive, short-term mini-prophylaxis, or chronic . A good example of a pre-emptive approach to treatment is the patient who suffers from migraine headaches triggered by sexual activity or by exercise. In these settings, single doses of nonsteroidal anti-inflammatory drugs such as indomethacin administered 1 or 2 hours prior to the known triggering activities may be effective . Women with pure menstrual migraine in whom, by definition, migraine headaches are restricted to the perimenstrual period in at least 2 out of 3 menstrual cycles , are a good example of an indication for mini-prophylaxis. The short-term use of triptans or NSAIDs during the perimenstrual period has shown variable success rates in this subset of patients .
Triptans And Ergot Alkaloids
The 2 categories of migraine-specific oral medications are triptans and ergot alkaloids. The specific ergot alkaloids include ergotamine and dihydroergotamine . The specific triptans include the following:
Although the triptans share a common mechanism of action, they differ in the available routes of administration, onset of action, and duration of action. Routes of administration include oral, intranasal, subcutaneous, and intramuscular. Transdermal patches have proved effective for the delivery of sumatriptan, and one such product has received FDA approval. The sumatriptan iontophoretic transdermal system was approved by the FDA in January 2013 for the acute treatment of migraine with or without aura in adults. The single-use patch also treats migraine-related nausea. In phase 3 trials involving 800 patients, the patches safely and effectively relieved migraine pain, migraine-related nausea, sonophobia, and photophobia within 2 hours of activation.
The FDA approved a low-dose intranasal sumatriptan powder for migraine in January 2016. The product consists of 22 mg of sumatriptan powder and is the first breath-powered intranasal medication delivery system to treat migraines. Approval was based on data from phase 2 and phase 3 trials, reference data on the use of sumatriptan, and safety data from more than 300 patients.
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Can Amitriptyline Interact With Other Medications
Amitriptyline can interact with other drugs, increasing your risk for side effects.
In particular, amitriptyline can interact with opioid painkillers such as codeine, oxycodone, or morphine. The combination can increase your risk for drowsiness and breathing difficulties.
Amitriptyline can also interact with another type of antidepressant called monoamine oxidase inhibitors , triggering dangerously high blood pressure. This can occur even after youve stopped taking MAOIs.
Before taking amitriptyline, talk with your doctor or pharmacist about substances youve taken or are currently taking, including herbal remedies, vitamins, and supplements.
Research shows that low doses of amitriptyline can be an effective treatment for preventing migraine attacks.
A 2010 review and meta-analysis evaluated the effectiveness and side effects of TCAs, including amitriptyline, in treating chronic migraine. The authors reported that TCAs pose an increased risk of side effects compared to other antidepressants and that they can be an effective treatment for migraine prevention.
Similarly, a 2016 study evaluated amitriptylines long-term effectiveness among 178 people who were prescribed low doses for headaches. The authors found that doses between 2.5 and 100 mg per day were an effective treatment for chronic headaches, with approximately 75 percent of patients reporting an improvement in their symptoms.
A more recent
Enhancing Healthcare Team Outcomes
Around 18% of women and 6% of men in the United States suffer from migraine headaches, with an estimated total prevalence of around 16%. It is a common cause of ER and clinic visits and causes significant financial and health burden. Less than 13% of migraine patients are believed to be on prophylactic therapy, whereas it is estimated that around 38% of episodic migraine patients would actually benefit from prophylactic therapy. It is important to educate all headache patients about identifying their headache type and frequency. Simple strategies like maintaining a headache diary to help identify frequency, severity, and triggers of headaches can help identify patients needing prophylactic treatment.
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Treatment Of Nausea And Vomiting
Antiemetics are used to treat the emesis associated with acute migraine attacks. Patients with severe nausea and vomiting at the onset of an attack may respond best to intravenous prochlorperazine. These patients may be dehydrated, and adequate hydration is necessary.
Antiemetics are commonly combined with diphenhydramine to minimize the risk of akathisia. This combination of drugs has been found to be superior to subcutaneous sumatriptan when given intravenously in emergency patients.
The following may be considered indications for prophylactic migraine therapy:
Frequency of migraine attacks is greater than 2 per month
Duration of individual attacks is longer than 24 hours
The headaches cause major disruptions in the patients lifestyle, with significant disability that lasts 3 or more days
Abortive therapy fails or is overused
Symptomatic medications are contraindicated or ineffective
Use of abortive medications more than twice a week
Migraine variants such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurologic injury
The goals of preventive therapy are as follows:
Reduce attack frequency, severity, and/or duration
Improve responsiveness to acute attacks
Currently, the major prophylactic medications for migraine work via one of the following mechanisms:
Table 2. Preventive Drugs for Migraine
Table 3. Preventive Medication for Comorbid Conditions
Types Of Preventive Migraine Medicine
The preventive medicine that are recommended to treat migraine fall into seven categories. Most preventive medications currently available are repurposed from other conditions. Here is an overview of each category, and tables of the different types of drugs in these categories and how they are taken can be downloaded here .
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What To Expect Of The Assessment In The Emergency Room
When thinking about headaches, emergency care providers tend to group them into two categories benign and malignant . During the care providers assessment and management, they are looking for/seeking to identify features that are suggestive of a concerning cause for the headache. If no concerning features are present and a diagnosis of migraine is made, then the care provider will move on to deciding on how to manage the headache pain.
There are many different diseases that can cause worrisome headaches in patients. However, the majority of headaches seen in the Emergency Department are benign.
During the history-taking the part of the assessment where the care provider asks you questions, they will seek to determine if any concerning characteristics are present, and, if not, whether your headache meets criteria for one of the benign headaches, most commonly migraine in this setting. The care provider will ask questions seeking to identify any potential red flags . In identifying red flags, the characteristics of the headache are important to the physician, for example how long did it take to reach its very worst point? Other examples of worrisome headache characteristics include fever, neck stiffness, significant vomiting, visual changes, weakness or numbness, a headache that wakes a person at night, a headache in the elderly or a headache in an individual who is immunocompromised.
Appendix B: Validated Instruments For Measuring Response To Preventive Treatment
- Patient Global Impression of Change Scale .
- Migraine Functional Impact Questionnaire , a 26-item self-administered instrument for the assessment of the impact of migraine on physical functioning, usual activities, social functioning, and emotional functioning over the past 7 days.
- Migraine-Specific Quality of Life questionnaire version 2.1 .
- Migraine Physical Function Impact Diary , a 13-item self-administered instrument that assesses the impact of migraine on everyday activities and physical impairment in the past 24 h.
- Headache Impact Test .
- Migraine Disability Assessment .
- Work Productivity and Activity Impairment , a general instrument adapted for migraine that evaluates migraine-related disability and costs.
- Generic measures of HRQoL reflect the overall effect of an illness and the impact of treatment on a subject’s perception of their ability to live a useful and fulfilling life.,
As with acute treatment, the prescribing licensed clinician’s judgment on the best treatment option for a selected patient is sufficient to initiate a new treatment.
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Questions To Ask The Emergency Physician About Headaches
Most patients presenting to the Emergency Department with a headache will not need any imaging . If there are no concerning features on history or physical exam, it is usually unnecessary to carry out further investigations. If you are receiving a CT or an MRI scan, it is reasonable to ask the physician why they believe this is necessary, to ensure that imaging is only undertaken when appropriate.
When a patient has frequent visits to the ED due to migraine pain, and specific treatments have been effective for them in the past, the healthcare provider should be made aware of these treatments. If you have previously had specific treatments for your migraines that have alleviated the pain, then you should ask your ED care provider if it is reasonable to use the same treatments during this particular visit.
Choice Of Drug For Migraine Prophylaxis
The choice of treatment depends on factors such as patient preference, drug interactions, and other comorbidities. Treatment should be started at a low dose and gradually increased to the maximum effective and tolerated dose.Preventative treatment should be tried for at least three months at the maximum tolerated dose, before deciding whether or not it is effective. 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. Patients should be referred to a neurology or specialist headache clinic if trials with three or more drugs have been unsuccessful.
GalcanezumabNICE has issued guidance on the use of the humanised monoclonal antibody galcanzumabthat binds to the calcitonin gene-related peptide ligand, blocking its binding to the receptor. For migraine that has not responded to at least three preventative treatments, clinical trial evidence shows that galcanezumab works better than best supportive care in both episodic and chronic migraine.
NICE therefore recommends galcenezumab as an option for migraine prophylaxis for patients with at least four migraine days a month and for whom at least three preventative drug treatments have failed. It should only be considered if the company provides it according to the commercial arrangement agreed with the NHS.
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Future Management Strategies In Migraine Combining Prophylaxis And Acute Management
A combined migraine treatment plan that considers avoidance of triggering factors, acute symptomatic treatment, and prophylaxis is indispensable to obtain maximum long-term benefit . While preventives are aimed at containing the incidence and vulnerability to attacks, episodic acute treatment is of paramount importance to reduce migraine-related disability during those episodes. A critical step in the prolonged management of migraineurs is to prevent medication overuse headache, which can render prophylactics ineffective. This is a common problem seen in specialty headache practice. A reasonable rule of thumb to avoid this problem is to limit acute symptomatic treatment such as triptans, among others, to not more than 2 days a week on average. Through a decrease in need for acute treatment, preventives assist in accomplishing this goal.
Other special settings that markedly benefit from combination therapy are those of menstrual migraine and menstrually related migraine. Attacks during this period can be particularly difficult to treat and may not respond to acute analgesics . Women with severe menstrual migraine often respond better to acute treatment while on a chronic prophylactic agent . Consequently, combined chronic preventive with a short-term prophylaxis during the vulnerable period is a logical approach in some of these patients.
Anticonvulsant Drugs For Migraine Prophylaxis
This review has been split and updated in a series of four new reviews, all with the author byline Linde M, Mulleners WM, Chronicle EP, McCrory DC. New titles are:
1. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010610. DOI: 10.1002/14651858.CD010610.
2. Valproate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010611. DOI: 10.1002/14651858.CD010611.
3. Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010609. DOI: 10.1002/14651858.CD010609.
4. Antiepileptics other than gabapentin, pregabalin, topiramate, and valproate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010608. DOI: 10.1002/14651858.CD010608.
Readers are referred to those reviews for updated results.
- Available in
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Strategies To Avoid Emergency Department Visits For Migraine
The best strategy to avoid Emergency Department visits for migraine is to avoid having a migraine in the first place. There are two main components to trying to avoid migraines: 1. Using preventive strategies and 2. Navigating triggers.
All patients with migraine should follow the SEEDS strategy for success in headache management1 . The SEEDS strategy is comprised of lifestyle modifications that can reduce the chances of having migraine attacks. These strategies are an integral part of managing migraines and should not be overlooked even when medications are being used as part of the treatment plan.
When migraines are not controlled with lifestyle measures alone, then preventive medications may be used to help reduce the frequency and severity of headaches. If you are experiencing more than 4 headaches per month, it is important to talk to your physician about whether you should be on daily preventive medication. For individuals who are already on daily preventive medications, it is important to take them as prescribed, as they are unlikely to work if they are not taken consistently. Sometimes people stop taking preventive medications because of perceived side effects or because they feel that they are not effective. If either of these scenarios occurs, it is best to talk to your physician prior to stopping the medication so that they can discuss alternative treatment options with you.
Er Treatment Of Migraines Vary
Pharmacologic interventions used to treat acute migraine come in a variety of forms: some are given by mouth, while other options are inhaled, given by intravenous or by injection. The majority of the medications that have been studied for use in the ED setting are given by intravenous, but a few other options are available. There are over 20 different medications that have been studied for relieving migraine in the ED1. Very few of these medications are migraine-specific, as most have other indications for which they are used. For example, many of these medications are also anti-nauseants, some are used to relieve all types of pain, while others are used in higher doses as antipsychotics . There are varying levels of evidence associated with medications used for migraine in this setting. For example, there is relatively strong evidence that prochlorperazine, sumatriptan, metoclopramide and ketorolac are effective for migraine relief in the ED1, whereas opioid medications, like morphine and tramadol, have less evidence for efficacy1 and may be associated with higher rates of return visits within a week of discharge from the ED2. It is not uncommon for emergency physicians to use a combination of two or more medications to try and break the migraine. There is some evidence that combination therapy is more effective than using a single medication3.
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