Michaels Got a Headache Yea Michaels Got a Headache Again
Am Fam Physician. 2011 Feb one;83(3):271-280.
Patient data: Encounter related handout on this topic at https://familydoctor.org/familydoctor/en/diseases-conditions/migraines.html.
Related letter: Responses to Handling of Acute Migraine Headache Commodity
Article Sections
- Abstract
- Diagnosis
- General Handling Principles
- Commencement-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
Migraine headache is a common and potentially debilitating disorder often treated past family physicians. Before diagnosing migraine, serious intracranial pathology must be ruled out. Treating acute migraine is challenging because of substantial rates of nonresponse to medications and difficulty in predicting individual response to a specific agent or dose. Information comparison dissimilar drug classes are relatively scarce. Abortive therapy should be used as early on as possible after the onset of symptoms. Effective first-line therapies for balmy to moderate migraine are nonprescription nonsteroidal anti-inflammatory drugs and combination analgesics containing acetaminophen, aspirin, and caffeine. Triptans are first-line therapies for moderate to astringent migraine, or mild to moderate migraine that has non responded to adequate doses of simple analgesics. Triptans should be avoided in patients with vascular disease, uncontrolled hypertension, or hemiplegic migraine. Intravenous antiemetics, with or without intravenous dihydroergotamine, are effective therapies in an emergency section setting. Dexamethasone may be a useful adjunct to standard therapy in preventing brusque-term headache recurrence. Intranasal lidocaine may too have a role in relief of astute migraine. Isometheptene-containing compounds and intranasal dihydroergotamine are too reasonable therapeutic options. Medications containing opiates or barbiturates should exist avoided for acute migraine. During pregnancy, migraine may exist treated with acetaminophen or nonsteroidal anti-inflammatory drugs (prior to tertiary trimester), or opiates in refractory cases. Acetaminophen, ibuprofen, intranasal sumatriptan, and intranasal zolmitriptan seem to be effective in children and adolescents, although data in these age groups are limited.
Migraine headache is one of the nigh common, yet potentially debilitating disorders encountered in primary care. Approximately 18 percent of women and 6 per centum of men in the U.s. have migraine headaches, and 51 percent of these persons written report reduced work or school productivity.1 Patients typically depict recurrent headaches with similar symptoms, and approximately i-third describe an aura preceding the headache.1 This commodity reviews treatment options for acute migraine headache.
SORT: Cardinal RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Show rating | References |
|---|---|---|
| Triptans are effective and safe for treatment of acute migraine. | A | 8 |
| Abortive therapy should be used equally early as possible in the class of a migraine. | B | 19 |
| Combination analgesics containing aspirin, caffeine, and acetaminophen are an effective first-line abortive treatment for migraine. | A | 7, 9 |
| Ibuprofen at standard doses is effective for acute migraine handling. | A | 21 |
| Intravenous metoclopramide (Reglan) is constructive for acute migraine handling. | B | 11 |
| Parenteral dexamethasone is useful equally an adjunctive treatment in the emergency department to help prevent short-term headache recurrence. | A | 12, 18 |
| Opiates and barbiturate-containing compounds should not be routinely used for bootless treatment of migraine. | C | 14, 34 |
Diagnosis
- Abstract
- Diagnosis
- Full general Handling Principles
- Start-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
Table one lists International Headache Society diagnostic criteria for migraine with and without aura.2 A thorough history and physical examination tin can assistance confirm the diagnosis of migraine and rule out emergent conditions. The mnemonic POUND is an prove-based aid for migraine diagnosis3:
-
Pulsatile quality of headache
-
One-day duration (four to 72 hours)
-
Unilateral location
-
Nausea or vomiting
-
Disabling intensity
In a primary care setting, the probability of migraine is 92 percent in patients who report at to the lowest degree four of the five POUND symptoms.4 The probability decreases to 64 percent in patients with 3 of the symptoms, and 17 percent in patients with two or less symptoms.iv
Table 1.
International Headache Guild Diagnostic Criteria for Migraine Headache With and Without Aura
| Migraine without aura | |
| Diagnostic criteria: | |
| Headache lasts four to 72 hours (untreated or unsuccessfully treated) | |
| Headache has at least two of the following:
| |
| During headache, at least ane of the following:
| |
| Not attributed to another disorder | |
| History of at least five attacks fulfilling higher up criteria | |
| Migraine with aureola | |
| Recurrent disorder manifesting in headaches of reversible focal neurologic symptoms that usually develop gradually over five to 20 minutes and concluding for less than hour | |
| Headache with the features of migraine without aura usually follows the aura symptoms | |
| Less unremarkably, headache lacks migrainous features or is completely absent | |
| Diagnostic criteria: | |
| Aura consisting of at to the lowest degree i of the following, but no motor weakness:
| |
| At to the lowest degree ii of the post-obit:
| |
| Headache fulfilling criteria for migraine without aura begins during the aura or follows aureola inside 60 minutes | |
| Not attributed to another disorder | |
| History of at least two attacks fulfilling above criteria |
Table two outlines other serious causes of headache that must exist considered in the differential diagnosis of migraine, such as temporal arteritis, cluster headache, and astute glaucoma.3 Fever, meningismus, or altered mental status should prompt investigation for meningitis or subarachnoid hemorrhage. The U.S. Headache Consortium recommends because neuroimaging in patients with an unexplained abnormal finding on neurologic exam and in patients with atypical headache features or headaches that exercise not fulfill the strict definition of migraine or other master headache disorder.five The Consortium notes that neuroimaging generally is not indicated for patients with migraine and a normal neurologic examination.
In one study, age older than 50 years, sudden onset, and abnormal neurologic exam predicted serious intracranial pathology in adults presenting to an emergency section with nontraumatic headache; the presence of whatsoever one of these three features detected serious intracranial pathology with 98.vi percent sensitivity.half dozen
Table 2.
Differential Diagnosis of Migraine Headache
| Condition | Characteristics |
|---|---|
| Acute glaucoma | Associated with blurred vision, nausea, vomiting, and seeing halos around lights; ophthalmologic emergency |
| Acute or chronic subdural hematoma | Antecedent trauma; may have subacute onset; altered level of consciousness or neurologic deficit may exist nowadays |
| Astute severe hypertension | Marked blood pressure level summit (systolic > 210 mm Hg or diastolic > 120 mm Hg); may have defoliation or irritability |
| Benign intracranial hypertension (pseudotumor cerebri) | Frequently precipitous onset; associated with nausea, airsickness, dizziness, blurred vision, and papilledema; may have cranial nervus V1 palsy; aggravated by coughing, straining, or changing position |
| Carbon monoxide poisoning | May exist insidious or associated with dyspnea; occurs more commonly in colder months |
| Carotid autopsy | Cause of stroke; can be spontaneous or follow pocket-size trauma or sudden neck motion; unilateral headache or face pain; ipsilateral Horner syndrome |
| Cervical spondylosis | Worse with neck movement; posterior distribution; pain is neuralgic in character and sometimes referred to vertex or forehead; more common in older patients |
| Cluster headache | Uncommon; sudden onset; duration of minutes to hours; repeats over a course of weeks, and then may disappear for months or years; unilateral lacrimation and nasal congestion; severe unilateral and periorbital pain; more mutual in men; patient is restless during episode |
| Encephalitis | Neurologic abnormalities, confusion, contradistinct mental status or level of consciousness |
| Frontal sinusitis | Usually worse when lying down; nasal congestion; tenderness over afflicted sinus |
| Greater occipital neuralgia | Occipital location; tenderness at base of skull; pain is neuralgic in graphic symbol and referred to vertex or forehead |
| Intracranial neoplasm | Worse on awakening; generally progressive; aggravated by cough, straining, or changing position |
| Medication-induced headache | Chronic headache with few features of migraine; tends to occur daily; hormone therapy and hormonal contraceptives are frequent culprits; includes analgesic rebound |
| Meningitis | Fever; meningeal signs |
| Postconcussion syndrome | Antecedent head trauma; vertigo, lightheadedness; poor concentration and retention; lack of energy; irritability and anxiety |
| Subarachnoid hemorrhage | Explosive onset of severe headache; 10 percent preceded by sentry headaches |
| Temporal arteritis | Almost exclusively in patients older than l years; associated with tenderness of scalp or temporal avenue and jaw claudication; visual changes |
| Temporomandibular joint dysfunction | Pain generally involves the temporomandibular joint and temporal areas; associated with symptoms when chewing |
| Tension-type headache | Mutual; duration of 30 minutes to 7 hours; typically bilateral; nonpulsating; mild to moderate intensity without limiting action; no nausea or vomiting |
| Trigeminal neuralgia | Cursory episodes of sharp, stabbing pain and trigeminal face distribution |
General Handling Principles
- Abstract
- Diagnosis
- General Treatment Principles
- First-Line Therapies
- Other Constructive Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
Several medications from dissimilar classes are bachelor to treat astute migraine (Table three 7–13). Considering relatively few trials have directly compared the dissimilar medication classes available to treat astute migraine, definitive handling algorithms cannot be adult. More than one-half of persons treat their migraine headaches with nonprescription medications, and patients often present to physicians after unsuccessfully trying multiple nonprescription therapies.7 The U.Southward. Headache Consortium guidelines offer a general strategy based on expert consensus.14 Nonsteroidal anti-inflammatory drugs (NSAIDs) or caffeine-containing combination analgesics may be first-line handling for balmy to moderate migraine, or severe migraine that has previously responded to these agents. Triptans are considered starting time-line abortive treatment of moderate to severe migraine, or mild attacks that accept not responded to nonprescription medicines. Ergotamine-containing compounds may too exist reasonable in this situation.14 Effigy 1 provides a suggested algorithm for management of acute migraine headaches.5,6,11,12,14–18
Tabular array 3.
Medications for Abortive Therapy of Acute Migraine
| Therapy | Dosing | Cost of generic (make)* | Major adverse effects | Comments | |
|---|---|---|---|---|---|
| First-line therapies | |||||
| Combination analgesics | |||||
| Acetaminophen, 250 mg/aspirin, 250 mg/caffeine, 65 mg (Excedrin Migraine) | ane or 2 tablets (or capsules) every half-dozen hours, not to exceed eight tablets per day | Varies | See private medications |
| |
| NSAIDs | |||||
| Ibuprofen | 200 to 800 mg orally every 6 to 8 hours, not to exceed 2.four g per day | Varies | Heartburn, gastric bleeding, ulcers, rebound headache, renal toxicity; can exacerbate heart failure and hypertension |
| |
| Naproxen | 250 to 500 mg orally every 12 hours, non to exceed i m per day | Varies | |||
| Triptans | |||||
| Almotriptan (Axert) | 6.25 to 12.5 mg orally, can be repeated in 2 hours, not to exceed 25 mg per mean solar day | NA ($154) for 12 tablets | Hypertension, vasospasm, chest pain, malaise, fatigue, rebound headache |
| |
| Eletriptan (Relpax) | 20 to 40 mg orally, can be repeated in > 2 hours, non to exceed 80 mg per day | NA ($155) for half dozen tablets | |||
| Frovatriptan (Frova) | 2.5 mg orally, tin can be repeated in 2 hours, not to exceed vii.5 mg per mean solar day | NA ($242) for nine tablets | |||
| Naratriptan (Amerge) | 1 to two.5 mg orally, tin can exist repeated in two hours, not to exceed 5 mg per day | NA ($276) for nine tablets | |||
| Rizatriptan (Maxalt) | v to 10 mg orally, tin can be repeated in 2 hours, not to exceed thirty mg per day | NA ($287) for 3 tablets | |||
| Sumatriptan (Imitrex) | Intranasal: v to 20 mg, tin can be repeated in 2 hours, not to exceed 40 mg per day | Intranasal: $39† ($55) | |||
| Oral: 25 to 100 mg, can exist repeated in two hours, not to exceed 200 mg per 24-hour interval | Oral: $620 ($792) for 27 tablets | ||||
| Subcutaneous: four to six mg, may echo in 1 hour, non to exceed 12 mg per day | Subcutaneous: $184 for 2 vials ($445 for v vials) | ||||
| Zolmitriptan (Zomig, Zomig-ZMT‡) | Intranasal: 5 mg, may repeat in two hours, non to exceed 10 mg per day | Intranasal: NA ($38) | |||
| Oral disintegrating tablets: 2.5 mg, tin can exist repeated in 2 hours, not to exceed x mg per day | Oral disintegrating tablets: NA ($154) for 6 tablets | ||||
| Oral: 1.25 to two.five mg, can exist repeated in 2 hours, not to exceed 10 mg per day | Oral: NA ($156) for six tablets (2.5 mg) | ||||
| Combination triptans and NSAIDs | |||||
| Sumatriptan, 85 mg/naproxen, 500 mg (Trexima) | i tablet at onset, may echo in 2 hours, not to exceed 2 tablets per day | NA ($206 for 9 tablets) | See individual medications |
| |
| Other effective therapies | |||||
| Antiemetics | |||||
| Metoclopramide (Reglan) | 10 mg IV every 8 hours | $1† ($2†) for 5-mg vial | Dystonic reaction; parkinsonism with metoclopramide employ |
| |
| Prochlorperazine | 10 mg IV every 8 hours, not to exceed 40 mg per day | $3† for 5-mg vial | |||
| Dexamethasone [ corrected] | ten to 25 mg IV, one-fourth dimension dose | $42 for 25 vials (iv mg) | Hyperglycemia, mood changes, insomnia; multiple adverse effects with long-term use |
| |
| Ergotamines | |||||
| Dihydroergotamine (DHE; Migranal§) | Intranasal: 1 spray in each nostril, repeat in one case after 15 minutes; not to exceed 4 sprays per assail, six sprays per day, 8 sprays per week | Intranasal: NA ($100) | Nausea; rhinorrhea with intranasal use; similar adverse effects as triptans |
| |
| 4: 0.5 to 1 mg repeated every viii hours, or continuous Four infusion totaling three mg per 24 hours; not to exceed 3 mg per assault | IV: $32 ($124) | ||||
| Subcutaneous: 1 mg every hour; not to exceed three mg per day | Subcutaneous: $32 | ||||
| Isometheptene compounds | |||||
| Acetaminophen, 325 mg/dichloralphenazone, 100 mg/isometheptene, 65 mg (Midrin) | 1 to two capsules orally every iv hours; not to exceed 8 capsules per 24-hour interval | $43 ($22†) for 30 capsules | – |
| |
| Lidocaine (Xylocaine) | Intranasal: 0.5 mL of topical lidocaine 4% solution dripped into the nostril on the afflicted side over 30 seconds; administered by a clinician while patient lies in the supine position with head hyperextended and tilted to xxx degrees | NA ($22†) for l mL | Rare cardiac adverse effects if systemically absorbed |
| |
Direction of Astute Migraine Headache
Figure 1.
Algorithm for management of suspected migraine headache.
Information from references v,6,11,12, and 14 through 18
Predicting individual response to a specific medication is difficult. Complete pain relief is not always achievable. For example, studies written report complete pain relief within 2 hours in 45 to 77 per centum of patients taking triptans.i,8 Potential adverse effects, contraindications, pharmacokinetics, and road of administration are frequently chief determinants of medication choice. Patients with severe nausea and airsickness often require nonoral medication.
Show suggests that abortive therapy works all-time if taken shortly after the onset of migraine or during aura, earlier pain progresses. A trial using almotriptan (Axert) showed that early users (i.e., therapy initiated within one hr of headache onset) had greater relief and lower recurrence rates of pain than not-early users.19 Nonprescription analgesics have shown comparable effectiveness with triptans if used in adequate doses soon after headache onset.9
Prophylactic therapy may be advisable for selected patients. The U.Due south. Headache Consortium's recommended indications for prophylactic therapy in patients with migraine headache are20:
-
Contraindications or intolerance to abortive therapies
-
Headache symptoms occurring more than ii days per week
-
Headaches that severely limit quality of life despite bootless therapy
-
Presence of uncommon migraine conditions, including hemiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction.
First-Line Therapies
- Abstruse
- Diagnosis
- General Treatment Principles
- Showtime-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
COMBINATION ANALGESICS
The combination analgesic acetaminophen/aspirin/caffeine (Excedrin Migraine) is effective, inexpensive, bachelor without prescription, and free from near vascular contraindications associated with triptans. Its utilise in migraine treatment has shown favorable results when compared with 50 mg of sumatriptan (Imitrex) in i trial and with placebo in previous trials.9 Patients with severe pain were included, but patients requiring bed rest or who were consistently vomiting during headaches were excluded.9 A report that included these more severe cases reported that acetaminophen/aspirin/caffeine is superior to 400 mg of ibuprofen.7
NSAIDS
NSAIDs are a user-friendly first-line therapy for mild to moderate migraine or historically responsive severe attacks. A 2007 meta-assay of ibuprofen for moderate to severe migraine showed that 200-mg and 400-mg doses were effective for brusque-term hurting relief, but had 24-60 minutes pain-free rates similar to placebo.21 The 400-mg dose also helped relieve photophobia and phonophobia. A study comparison ketoprofen with zolmitriptan (Zomig) showed zolmitriptan to be modestly more effective (two-60 minutes relief in 61.6 versus 66.8 pct of participants, respectively), but it was associated with more agin events, such as tight throat and flushing.22 Ketorolac, a parenteral NSAID commonly used in emergency departments, was found to be constructive in reducing self-reported headache symptoms ane 60 minutes afterwards injection, including one written report showing more effectiveness than intranasal sumatriptan.23
TRIPTANS
Triptans are migraine-specific drugs that demark to serotonergic receptors. They are considered first-line therapy for moderate to astringent migraine, or mild to moderate attacks unresponsive to nonspecific analgesics.xiv Seven triptans are currently available, only data guiding which to select for an individual patient are limited. A Cochrane review found that all triptans are similar in effectiveness and tolerability.24 A meta-analysis of 53 trials using oral triptans found that the three most effective agents for pain relief were ten mg of rizatriptan (Maxalt), 80 mg of eletriptan (Relpax), and 12.5 mg of almotriptan. 8 A Cochrane review found a dose of 100 mg of sumatriptan to be more than effective than lower doses.24 Information technology is sometimes necessary to increment the dose of an private agent earlier judging response. Trials propose that nonresponders to one triptan may respond to another; therefore, switching triptans is also reasonable.25
Triptans differ from i some other in pharmacokinetics. Rizatriptan has a quicker onset of action than sumatriptan; frovatriptan (Frova), naratriptan (Amerge), and eletriptan have longer half-lives than sumatriptan.26 In practice, route of administration or pharmacokinetics often guide choice. Some triptans are available as nasal sprays, rapidly dissolving tablets (absorbed despite airsickness), or subcutaneous injections. Some physicians choose a triptan by matching pharmacokinetics to the temporal pattern of their patient's migraine (e.g., rapid-onset medication for short grade of migraine versus longer-acting medication with slower onset for longer lasting symptoms); however, at that place is no definitive testify to support this arroyo.
The vasoconstrictive properties of triptans forestall their use in patients with ischemic heart disease, stroke, uncontrolled hypertension, or hemiplegic or basilar migraine. However, the chest pain occurring in three to 5 percent of oral triptan users has non been associated with electrocardiographic changes and is rarely ischemic.8 A post-marketing written report of subcutaneous sumatriptan in 12,339 patients without ischemic heart disease revealed 36 cardiac events, merely ii of which occurred within 24 hours of sumatriptan use.27 Nonetheless, if patients taking triptans develop suspected cardiac symptoms, triptans should be discontinued pending further evaluation. Cardiac evaluation is reasonable earlier triptan initiation in patients with multiple vascular risk factors.28
Triptans are contraindicated in patients taking monoamine oxidase inhibitors.14 Combining triptans with selective serotonin reuptake inhibitors tin atomic number 82 to serotonin syndrome, a potentially life-threatening condition characterized by altered mentation, autonomic instability, diarrhea, neuromuscular hyperactivity, and fever. The true incidence of serotonin syndrome in this setting is unknown. A 2006 U.S. Food and Drug Assistants (FDA) alert cited 29 case reports over five years, although most 700,000 patients per year are prescribed both selective serotonin reuptake inhibitors and triptans.29 Physicians treating patients who are taking triptans and selective serotonin reuptake inhibitors should be vigilant for serotonin syndrome, and should minimize drug dosages.
COMBINATION TRIPTANS AND NSAIDS
A fixed-dose combination of sumatriptan, 85 mg/naproxen, 500 mg (Trexima) is an option for acute handling. 1 trial showed that the combination provided superior pain relief compared with either monotherapy.10 Another trial constitute similar results in previous nonresponders to triptans.fifteen Patients also may take triptans and NSAIDs concurrently.
Other Constructive Therapies
- Abstract
- Diagnosis
- General Treatment Principles
- First-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
ANTIEMETICS
Prove supports a role for parenteral antiemetics in acute migraine, independent of their antinausea furnishings. A meta-assay of 13 randomized controlled trials concluded that intravenous metoclopramide (Reglan) should be considered a primary agent in the treatment of migraine in emergency departments.11 Given the potential for rebound and dependence associated with opiates, antiemetics offer a reasonable alternative in acute settings. No testify supports migraine-specific effects of oral antiemetics, other than relieving nausea.
DEXAMETHASONE
Intravenous dexamethasone has been used every bit adjunctive therapy for migraine in emergency departments. Two meta-analyses, each with seven randomized controlled trials in which dexamethasone was added to other standard therapies, showed that about 10 patients needed treatment to prevent headache recurrence within 24 to 72 hours12,18. [ corrected]
ERGOTAMINES
Like triptans, ergotamines and dihydroergotamine (DHE) are migraine-specific drugs that demark to serotonergic receptors. Although their use has been largely supplanted by triptans, ergot alkaloids nevertheless have a part in selected patients. Little evidence supports the apply of oral ergotamines. Poor assimilation and high rates of adverse events preclude their use in most situations. Combination medications containing ergotamines (e.yard., ergotamine/caffeine [Cafergot]) may have fewer agin effects than pure ergotamines.xxx
Nine placebo-controlled trials have demonstrated the effectiveness of dihydroergotamine nasal spray (Migranal), making it an choice for nonoral medication.30 Comparing with subcutaneous sumatriptan showed lower effectiveness but fewer adverse furnishings.31 Intravenous dihydroergotamine, combined with antiemetics, may exist a reasonable choice in emergency departments. A meta-assay showed comparable effectiveness to opiates and ketorolac when combined with an antiemetic, but inferiority to phenothiazines and triptans when used alone.sixteen Trials comparing subcutaneous dihydroergotamine with subcutaneous sumatriptan showed that dihydroergotamine had inferior effectiveness only fewer adverse events and headache recurrences.32
ISOMETHEPTENE COMPOUNDS
The combination drug acetaminophen/isometheptene/dichloralphenazone (Midrin) includes a sympathomimetic (isometheptene) and a musculus relaxant (dichloralphenazone). 1 trial showed like effectiveness to low-dose sumatriptan when used early in balmy to moderate migraine.17 Due to sympathomimetic effects, it should be used cautiously in patients with cardiac risk factors.
LIDOCAINE
Intranasal lidocaine (Xylocaine) has a rapid onset of activeness and may be useful every bit a temporizing measure until longer-acting treatment can accept outcome. Lidocaine 4% solution administered into the nostril, either past a clinician or self-administered past patients, resulted in rapid symptom reduction compared with command, although recurrences were common.xiii,33
Non-Preferred Therapies
- Abstract
- Diagnosis
- Full general Treatment Principles
- Get-go-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
Acetaminophen lonely is not constructive therapy for acute migraine.xxx In that location are no placebo-controlled trials documenting the effectiveness of barbiturate-containing analgesics (due east.g., butalbital/aspirin/caffeine [Fiorinal]) for astute migraine.30 The U.S. Headache Consortium recommends limiting opiate apply in migraine treatment because of its potential for abuse and rebound headache.14 Intranasal butorphanol is effective, simply its employ should be limited because of these concerns.14 One report linked opiate or barbiturate employ with an increased chance of episodic migraine becoming chronic.34 Opiates or barbiturate-containing medications should be used but in patients with migraine headaches resistant to other therapies.
Experimental Therapies
- Abstract
- Diagnosis
- Full general Treatment Principles
- First-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
Calcitonin gene-related peptide is a neuropeptide thought to be central to migraine pathogenesis. Intravenous infusion of a calcitonin cistron-related peptide antagonist showed promising results in one small report.35 Transcranial magnetic stimulation, a modality where a magnetic field is generated on the scalp to create currents in the adjacent cortex, seems promising. A controlled trial of 200 patients who had migraine with aura showed that this therapy is superior to sham in 2-hr pain relief and sustained responses over 24 to 48 hours.36 Further inquiry is needed to evaluate its role in treating migraine without aura and in migraine prophylaxis.
Special Populations
- Abstract
- Diagnosis
- General Treatment Principles
- Beginning-Line Therapies
- Other Effective Therapies
- Non-Preferred Therapies
- Experimental Therapies
- Special Populations
- References
PREGNANCY
Acetaminophen, despite questionable effectiveness, is reasonable in the handling of migraine in pregnant women because of its established rubber. NSAIDs are effective and generally considered prophylactic until the 3rd trimester. The combination analgesic acetaminophen, 250 mg/aspirin, 250 mg/caffeine, 65 mg likewise must be used with caution; aspirin is FDA pregnancy category C, but is downgraded to category D for third trimester utilize, and consuming more than than 100 mg of caffeine daily is associated with mild fetal growth restriction, although the clinical significance of this is unclear.37 The American Congress of Obstetricians and Gynecologists recommends limiting daily caffeine consumption to 300 mg during pregnancy.38 Abstention of triptans is recommended during pregnancy, although limited data on first-trimester exposures are reassuring. 17,25 Metoclopramide is FDA pregnancy category B and may be used intravenously for migraine or orally for associated nausea. Opiates may be used for intractable cases, simply pose risks of neonatal withdrawal and maternal dependence. The safety of isometheptene in pregnancy is unknown, then its use is not recommended. Ergotamines are abortifacients and are therefore absolutely contraindicated in pregnant women and women of childbearing age who are not using reliable contraception. Given scant data and cautions regarding medication prophylactic, preventive approaches are fundamental.
MENSTRUAL MIGRAINE
Many women report migraine or migraine exacerbations occurring exclusively near the fourth dimension of menses. Long-acting triptans frovatriptan and naratriptan, taken perimenstrually effectually-the-clock for short-term prevention, have been found effective in reducing frequency and severity of menstrual migraine.39 For abortive therapy, the highest-quality evidence supports the utilize of sumatriptan, rizatriptan, and the NSAID mefenamic acid (Ponstel).39
CHILDREN AND ADOLESCENTS
Limited evidence is available to guide pharmacologic treatment of astute migraine in children and adolescents.40 A systematic review institute acetaminophen and ibuprofen condom and constructive in children.41 Triptans are often prescribed, although this is non FDA-approved or recommended by drug manufacturers. Intranasal sumatriptan and nasal zolmitriptan, merely not oral formulations, take shown effectiveness in children and adolescents, perhaps because of the quicker onset of nasal formulations and shorter duration of migraines in children.forty,41 Given limited information, prevention is important.
Data Sources: A PubMed search was completed in Clinical Queries using the key terms migraine and handling, with separate searches for specific drug classes. A similar search was performed using Google Scholar. The Cochrane database was searched for relevant reviews, and the National Guideline Clearinghouse was searched for relevant guidelines. Nosotros also searched the Evidence Summary provided by AFP for relevant articles. Search date: January four, 2010, repeated September twenty, 2010.
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REFERENCES
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