1. Acute treatments for migraine Fayyaz Ahmed Chester Migraine Education Day 8 September 2012

2. YOUNG OR OLD

3. To set the scene... “[Migraine] is a malady of which the student gains little practical knowledge in the course of his hospital work, unless he is so unhappy as to learn from the most effective of all instructors, personal suffering... It is common enough, but seems, to most of its subjects, by long experience so much an inevitable part of life that few seek relief.” William Gowers (1906) “A doctor who cannot take a good history and a patient who cannot give one are danger of giving and receiving bad treatment” Anonymous

4. 10 steps to success Get the diagnosis right Set realistic expectations Consider non-pharmacological measures Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms Choose appropriate route of delivery Avoid medication overuse Use prophylactic treatments appropriately

5. 1. Making the Right Diagnosis ‘migraine’ - a disorder and an attack ◦ the disorder is characterised by:  the tendency to repeated attacks  triggers  sleep, food, weather, chemical (EtOH/GTN), hormonal, sensory, stress- relaxation  family history ◦ the attack  premonitory symptoms (20%+)  headaches typically unilateral, throbbing  associated with nausea +/- vomiting  sensitivity to light, sound, smells, movement  auras, usually visual, occur ~15-20% of patients

6. Migraine or TTH? phenotype the worst type of attack patients with headaches that met criteria for migraine, probable migraine, and TTH, all headache types responded to triptans (Spectrum Study) ◦ this was not true for patients with purely TTH recurrent severe headaches are migraine, until proven otherwise

7. 2. Set realistic expectations there is no ‘cure’ recognising the disorder goal setting ◦ trigger management ◦ effective acute treatment ◦ reducing attack frequency ◦ appraisal of best available options explaining the natural history

8. 3. Non-pharmacological measures lifestyle issues ◦ Hectic lifestyle ◦ No time for timely sleep or meals ◦ Too much on your plate trigger management ◦ hormonal ◦ dietary ◦ psychological  CBT, relaxation ◦ environmental ◦ sleep ◦ neck...

9. 4. Use the right drug START WITH Simple Painkillers  Aspirin, Paracetamol, Ibuprofen ESCALATE TO TRIPTANS AVOID CODEINE, CAFFEINE, BARBITURATE BASED COMBINATIONS

10. Why simple painkillers first? 50% Headache sufferers do not consult 1 ◦ ‘it is too inconvenient to see a doctor’ (53%) ◦ ‘there is nothing a doctor could do’ (22%) 70-80% would respond to first line and are self limiting 1 OTC availability – less use of healthcare resources 1. Steiner and Fontebasso 2002

11. Why Ibuprofen than other NSAID? Availability OTC Less side effects and better tolerability 1-2,10,11 More evidence based 3-4 Recommended by guidelines 5-9 1. Langman et al, Lancet 19942. Rainsford, 2009 3. Rabbie et al, 2010 Cochrane Collaboration 4. Haag et al, 20075. SIGN guidelines, 2010 6. British Association for the Study of Headache, 2010 7.Bendtsen et al EFNS guidelines 2010 8. EHF guidelines, 2009 Steiner, Marteletti 9. American Academy of Neurology, April 201210. Henry D et al, BMJ 1996 11.Doyle, 1999

12. 5. Use effective doses paracetamol 1 g or, aspirin 900 mg or, ibuprofen 600-800 mg ◦ If early nausea soluble aspirin suppositories*: ◦ diclofenac 75 mg *be French!

15. 6. Treat early when mild Benefit ◦ Avoiding a disabling attack ◦ Better response Risk ◦ Treating a wrong attack ◦ Risking medication overuse

16. 7. Rx associated symptoms Avoid physical activity Avoid bright lights Avoid disturbing noises Domperidone 10-20 mg

17. 8. Choose appropriate route of delivery

18. Problems, problems… not effective ◦ dose? timing? route? combination? diagnosis? contraindications ◦ asthma, upper GI problems, renal impairment side effects ◦ GI, CNS

19. This is what patients do next

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

21. 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

22. Headache response at 2 hr

23. Pain freedom at 2 hr

24. advantagesdisadvantages Sumatriptanwell-established expensive available OTCpoorly absorbed now the cheapest s/c, nasal spray Zolmitriptancheaperoccasional confusion long acting nasal spray, melt Naratriptancheaper slow onset long acting Rizatriptanrapid onsethigh recurrence melt Almotriptancheaper low SE incidence Eletriptancheaperpumped out of CNS long acting Frovatriptanlongest half-life slow onset

25. 9. Avoid medication overuse Restrict to two doses per week Use long acting triptans Avoid combination analgesics Can use triptan and NSAID such as sumatriptan and naproxen

26. Problems, problems… ineffective ◦ dose? timing? route? switch? headache recurrence ◦ switch? combination with NSAID? contraindications ◦ HT, IHD SE ◦ nausea, GI, CNS, ‘triptan chest’

27. 10. Use preventive treatment Should be offered to patients with 6 or more headache days per month; 4 or more days with some impairment; or 3 or more days with severe functional impairment Should be considered with 4 – 5 days per month with normal functioning; 3 days with some impairment and 2 days with severe impairment Should not be given to patients with <4 days of headache per month with normal functioning; or no more than 1 day per month regardless of impairment

28. The future new drugs with novel targets ◦ serotonin subtypes; CGRP; glutamate; TRPV1; nitric oxide; prostanoids; cortical spreading depression new delivery mechanisms for existing drugs ◦ inhaled DHE ◦ inhaled, transdermal, needle-free triptans

29. Neurostimulation Transcranial Magnetic Stimulation Vagal nerve stimulation (Gammacore)