1. Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010

2. The intangibles Doctor-patient relationship Realistic expectations Education

3. Triggers Hormonal Dietary Psychological Environmental Sleep Drugs

5. 10 steps to success Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms

6. 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

7. Where to start? paracetamol 1 g or, aspirin 900 mg or, ibuprofen 600-800 mg +/- domperidone 10-20 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

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

12. Headache response at 2 hr

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

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

15. 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

17. Which triptan?

18. Headache response at 2 hr

19. Pain freedom at 2 hr

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

23. 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

24. 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