Migraine treatment MEDECIN ABONNE

Treatment of migraine attacks.

The crisis is only for 2 hours for a minimum duration of 24 hours.

Treatment for analgesics

The initial treatment of the crisis uses the analgesics of shield 1 in first intention (paracetamol, AINS, acide acétylsalicylique) associé éventuellement au Métoclopramide.

followed in case of ineffectiveness of taking a triptan

Management recommendations

 

  • Explain the goals of acute treatment, namely complete headache relief two hours after treatment  with a sustained response of 24 hours and no adverse events
  • Explain to patients suffering from migraine with aura that there is currently no pharmacological treatment proven effective to stop aura
  • Explain that acute treatments must be taken early (within an hour after the onset of the headache), with an adequate dose, dosage and route adapted to the severity of digestive symptoms
  • Explain that the use of acute treatments should be limited to a maximum of eight days per month, because medication overuse carries a risk of medication overuse headaches. If this limit is exceeded, consider implementing basic treatment.
  • Encourage patients to use a headache calendar (headache frequency, intensity, and acute medication), which will be reviewed at each visit.
  • Prescribe acute treatment with an NSAID and a triptan, both chosen based on previous treatments and patient preference. In case of moderate headache, take the NSAID then the triptan 1 hour later if it is ineffective. In case of severe headache, take the triptan immediately and the NSAID 1 hour later if insufficient.
  • Provide Education on Acute Migraine Treatment Strategy:
    When the headaches are mild, the patient should take an NSAID, and add a triptan if insufficient. In cases of migraine with aura, the patient should take an NSAID at the onset of the aura and a triptan at the onset of the headache.
  • Avoid prescribing opiates to treat migraine due to risks of misuse, abuse, and overuse of medications. Prescribe a combination of paracetamol and metoclopramide in patients with contraindications or intolerance to NSAIDs, aspirin and triptans
  • Prescribe metoclopramide orally or parenterally (suppository or intravenously) to treat attacks with nausea or vomiting.
  • Explain that the effectiveness and tolerability of acute treatment is assessed after three attacks, and schedule a follow-up visit.

Evaluation and optimization of acute treatment:

  • Use the Migraine Treatment Optimization Questionnaire (M-TOQ) at each visit and optimize the acute treatment Scale-mTOQ-5. Modify treatment in any patient answering “No” to one or more items:
  • Choose one or more strategies to optimize the effectiveness and/or tolerability of acute treatment and educate the patient:
    • Treat as early as possible in the headache phase.
    • Increase the dose of NSAIDs and/or triptan if necessary.
    • Simultaneously combine a triptan and an NSAID when attacks resist a triptan alone and/or when relapses are bothersome
    • Switch to a non-oral formulation (NSAID suppository; sumatriptan nasal or subcutaneous spray) and/or add metoclopramide if bothersome digestive symptoms occur.
  • After replacing the NSAID with another NSAID and failure in at least 3 attacks
  • Triptans only after total ineffectiveness of at least two triptans, used at appropriate dose and route, each tested on at least three separate attacks.

Basic treatment of migraine attacks.

Drug treatment:

Medicinal therapeutic possibility

  • Oral medications with demonstrated effectiveness in migraine prophylaxis are listed in the table below. This effectiveness is demonstrated in the prevention of episodic diseases for amitriptyline, flunarizine, metoprolol, pizotifen, propranolol, topiramate and valproate. Several beta-blockers (atenolol, bisoprolol, timolol) and two other antihypertensives (lisinopril, candesartan), an antiepileptic (levetiracetam), an antidepressant (venlafaxine) and an antihistamine (oxetorone) are available in France. Additionally, study evidence supports the use of lamotrigine in the prophylaxis of migraine with aura.
  • A Gepant
  • Once-daily dosing may improve compliance with oral migraine prophylactic medications.
  • Evidence shows the effectiveness of anti-CGRP and anti-CGRP-monoclonal antibodies against receptors (CGRP-MAB) in both episodic and chronic migraine. Evidence shows that onabotulinum toxin A is an effective prophylactic treatment for chronic (but not episodic) migraine diseases.

 

Medication management recommendation

  • Determine each patient’s eligibility for prophylaxis based on their preferences, headache diary or calendar, severe migraine and chronic migraine criteria, HIT-6 and HAD (Migraine) scales.
  • Initiate prophylactic treatment in any patient if:
    • He has been using seizure medication eight or more days per month for at least three months
    • With severe migraine according to French criteria
    • With chronic migraine according to ICHD-3 criteria (Migraine)
    • With a HIT-6 scale of 60 or more (Migraine)
    • With debilitating migraine attacks despite optimization of attack treatment.
  • Concerning patient education and the optimal follow-up plan, the objectives of migraine prophylactic treatment must be explained:
    • The goal is to reduce monthly migraine days by 50% in cases of episodic migraine and by 30% in cases of chronic migraine.
    • Efficacy will be judged during the third month of treatment (weeks 8 to 12)
    • Prophylaxis also aims to reduce the consumption of acute treatments, the intensity and duration of attacks, and improve quality of life.
    • Failure may be due to insufficient effectiveness and/or tolerance
  • Start oral prophylaxis as monotherapy and at a low dose, and gradually increase to reach an optimal daily dose, taking into account possible side effects.
  • Explain that compliance with prophylaxis is obligatory. If necessary, prescribing a dose once a day helps improve compliance.
  • As first-line prophylaxis for episodic migraine:
    • Prescribe propranolol or metoprolol as first-line medication in any appropriate patient with episodic migraine.
    • Prescribe amitriptyline, candesartan, or topiramate as first-line therapy in patients with episodic migraine for whom beta-blockers are unsuitable, depending on comorbidities and patient preferences.
  • As first-line prophylaxis against chronic migraine:
    • Prescribe topiramate as first-line treatment in any fit patient with chronic migraine, due to the high level of evidence of effectiveness.
    • Prescribe other recommended prophylaxis in chronic migraine patients unsuitable for topiramate, based on patient preference and comorbidities
      Strong
  • In patients with chronic migraine and medication overuse headache, prescribe first-line prophylactic treatment  and advise outpatient withdrawal of the overused acute medication.
  • To evaluate and adapt prophylactic treatment:
    • Evaluate effectiveness, tolerability, compliance, and migraine burden by interview, schedule review, and routine use of the HIT-6 and HAD scales at each visit.
    • The effectiveness of prophylaxis must be evaluated after the third month of treatment except for onabotulinum toxin A, the effectiveness of which must be evaluated after six months.
    • If effective and well tolerated, continue prophylaxis for 6 to 12 months, then slowly reduce before considering stopping. Repeat the same treatment if the frequency of attacks increases again during the course of the decrease or after stopping.

Non-drug treatment

Physical exercises:

Aerobic physical activity reduces the number of migraine attacks. Yoga has not been shown to be effective on migraine attacks.

Food supplements

Studies show that supplementation with coenzyme Q10 (mainly 300 mg/day), high-dose riboflavin (vitamin B2, 400 mg/day), oral magnesium (600 mg/day), and oral melatonin (mainly 3 mg free release immediate)  could be potentially beneficial for migraine. Some data suggests that feverfew may have a
small positive effect on migraine prophylaxis. Studies show that butterbur is effective in migraine prophylaxis  but the preparations are heterogeneous with a risk of hepatotoxicity in those containing pyrrolizidine alkaloids.

Diet

No proof of effectiveness currently

Neurostimulation techniques

Supraorbital transcutaneous neurostimulation

This technique is of low effectiveness in the treatment of migraine attacks but seems interesting in preventing attacks in certain patients.

Repetitive transcranial magnetic nerve stimulation (RTMS)

This technique seems interesting in the prevention of migraine attacks. However, its cumbersomeness (3 stimulation sessions with the neurologist, for 4 weeks) and the low number of current studies do not support its use at present.

Remote electrical neuromodulation

Seems to improve migraine with aura.

Neurostimulation of the vagus nerve by left atrial stimulation.

Not recommended because it is not effective on migraine and its prevention

Acupuncture

Effective in preventing migraine attacks in the short term but no long-term studies.

Behavioral treatments and mindfulness meditation.

The results of the different studies are very heterogeneous. However, given the few side effects of these techniques, they can be used in patients who wish.

Closure of the patent foramen ovale

Patent foramen ovale (PFO) is more common in migraineurs than non-migraineurs but in randomized controlled trials PFO closure in migraine has not demonstrated a significant effect.
Closure of the PFO is not recommended for migraine prophylaxis (strong level of evidence).

Nerve decompression techniques not recommended

 

Post operative chronic pain