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Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.

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Presentation on theme: "Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009."— Presentation transcript:

1 Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009

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3 The intangibles Doctor-patient relationship Realistic expectations Education

4 Triggers Hormonal Dietary Psychological Environmental Sleep Drugs

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6 10 steps to success Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms

7 10 steps to success Choose appropriate route of delivery Observe contraindications Use prior experience to select/reject drugs Avoid drugs with high potential for MOH Combine medications if necessary

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9 Where to start? paracetamol 1 g or, aspirin 900 mg or, ibuprofen mg +/- domperidone mg taken as soon as possible*ª * i.e. as soon as the patient knows that this is a migraine ª if there is aura, take at the start of the headache phase

10 Variations on a theme if early nausea, you can use: soluble aspirin suppositories*: diclofenac 75 mg domperidone 30 mg *be French!

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14 Headache response at 2 hr

15 Problems, problems… Not effective dose? timing? route? combination? Contraindications asthma, upper GI problems, renal impairment Side effects GI, CNS

16 This is what patients do next

17 Codeine…? … is NOT a treatment for headache the WHO analgesic ladder should NOT be applied to headache management

18 Triptans 5-HT 1B/1D receptor agonists seven different formulations options for route of delivery oral tablets or melts nasal spray subcutaneous injection taken as soon as possible*ª¹ * i.e. as soon as the patient knows that this is a migraine ª if there is aura, take at the start of the headache phase ¹ this is a race against the development of allodynia

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20 Which triptan?

21 Headache response at 2 hr

22 Pain freedom at 2 hr

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25 advantagesdisadvantages Sumatriptanwell-established expensive £4.60available OTCpoorly absorbed s/c (£22.10), melt (£4.14), nasal spray (£6.14) Zolmitriptancheaperoccasional confusion £4.00long acting nasal spray (£6.75), melt (£4.00) Naratriptancheaper slow onset £4.09long acting Rizatriptanrapid onsethigh recurrence £4.46melt (£4.46) Almotriptancheaper £3.02low SE incidence Eletriptancheaperpumped out of CNS £3.75long acting Frovatriptancheapestslow onset £2.78longest half-life

26 Problems, problems… Ineffective dose? timing? route? switch? Headache recurrence switch? combination with NSAID? Contraindications HT, IHD SE nausea, GI, CNS, ‘triptan chest’

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28 Is the future ‘pants’? CGRP antagonists two with data recently published proof-of-concept trial of intravenous BIBN4096BS (now called olcagepant) was published in NEJM in 2004 phase II study of oral CGRP antagonist MK-0974 (now called telcagepant) presented at IHS 2007 and published in Neurology in 2008

29 multicentre phase III R-PT-PC-DB-T of oral telcagepant 150 or 300 mg vs zolmitriptan 5 mg and placebo published in The Lancet in last four weeks

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34 A&E/in-patient options sumatriptan s/c 6 mg alternatively nasal spray 20 mg high dose NSAIDs aspirin 1 g (available as IV formulation – useful as rescue medication in medication withdrawal) indometacin 100 mg (can be given IM)

35 Refractory migraine dihydroergotamine (DHE) mg iv/im (2 mg nasal spray) anticonvulsants sodium valproate 500 mg iv in 100 mL normal saline over 15 min (? role for SVP infusion in status migrainosus) clonazepam 1 mg/mL slow push

36 … or … dopamine antagonists metoclopramide mg IV (rpt to mg over 2 hrs) droperidol mg every 10 mins (average effective dose 3.15 mg) prochlorperazine 10 mg iv over 2 min (may rpt after 30 min) metoclopramide & prochlorperazine can be followed with DHE mg over 10 mins

37 … or … magnesium sulphate 1 g iv over 15 min dexametasone 8-20 mg iv over 5-10 min; hydrocortisone mg iv over 10 min, every 8-12 hrs for 24 hours (again, useful in status) ketorolac mg iv/im

38 A final thought: listening is therapy in itself … and you’ve listened long enough!


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