Download 10 steps to success - British Association for the Study of Headache

Acute treatment of
migraine
Mark Weatherall
BASH meeting, Hull 2009
The intangibles
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Doctor-patient relationship
Realistic expectations
Education
Triggers
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Hormonal
Dietary
Psychological
Environmental
Sleep
Drugs
10 steps to success
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Make the diagnosis
Use the right drugs
Use effective doses
Treat early when the pains mild
Treat associated symptoms
10 steps to success
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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
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
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* 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
Variations on a theme
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if early nausea, you can use:
soluble aspirin
suppositories*:
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diclofenac 75 mg
domperidone 30 mg
*be French!
Headache response at 2 hr
Problems, problems…
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Not effective
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Contraindications
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dose? timing? route? combination?
asthma, upper GI problems, renal impairment
Side effects
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GI, CNS
This is what patients do next
Codeine…?
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… is NOT a treatment for headache
the WHO analgesic ladder should NOT be
applied to headache management
Triptans
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5-HT1B/1D receptor agonists
seven different formulations
options for route of delivery
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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
Which triptan?
Headache response at 2 hr
Pain freedom at 2 hr
advantages
disadvantages
Sumatriptan
£4.60
well-established
expensive
available OTC
poorly absorbed
s/c (£22.10), melt (£4.14), nasal spray (£6.14)
Zolmitriptan
£4.00
cheaper
occasional confusion
long acting
nasal spray (£6.75), melt (£4.00)
Naratriptan
£4.09
cheaper
long acting
slow onset
Rizatriptan
£4.46
rapid onset
melt (£4.46)
high recurrence
Almotriptan
£3.02
cheaper
low SE incidence
Eletriptan
£3.75
cheaper
long acting
pumped out of CNS
Frovatriptan
£2.78
cheapest
longest half-life
slow onset
Problems, problems…
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Ineffective
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Headache recurrence
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switch? combination with NSAID?
Contraindications
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dose? timing? route? switch?
HT, IHD
SE
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nausea, GI, CNS, ‘triptan chest’
Is the future ‘pants’?
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CGRP antagonists
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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
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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
A&E/in-patient options
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sumatriptan s/c 6 mg
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alternatively nasal spray 20 mg
high dose NSAIDs
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aspirin 1 g
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(available as IV formulation – useful as rescue
medication in medication withdrawal)
indometacin 100 mg
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(can be given IM)
Refractory migraine
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dihydroergotamine (DHE) 0.5-1.0 mg iv/im
(2 mg nasal spray)
anticonvulsants
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sodium valproate 500 mg iv in 100 mL normal
saline over 15 min
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(? role for SVP infusion in status migrainosus)
clonazepam 1 mg/mL slow push
… or …
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dopamine antagonists
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metoclopramide 10-20 mg IV
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droperidol 0.625 mg every 10 mins
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(average effective dose 3.15 mg)
prochlorperazine 10 mg iv over 2 min
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(rpt to 30-60 mg over 2 hrs)
(may rpt after 30 min)
metoclopramide & prochlorperazine can be
followed with DHE 0.5-1.0 mg over 10 mins
… or …
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magnesium sulphate 1 g iv over 15 min
dexametasone 8-20 mg iv over 5-10 min;
hydrocortisone 100-250 mg iv over 10 min,
every 8-12 hrs for 24 hours
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(again, useful in status)
ketorolac 30-60 mg iv/im
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A final thought: listening is therapy in itself
… and you’ve listened long enough!