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Migraine

Simplified diagnostic criteria for migraine (from ICHD-II)

Repeated attacks of headache lasting 4-72 hours that have these features

1. Normal physical examination
2. No other reasonable cause for the headache
3. At least two of
   • Unilateral pain
   • Throbbing pain
   • Aggravation of pain by movement
   • Moderate or severe intensity of pain
4. At least one of
   • Nausea or vomiting
   • Photophobia and phonophobia

Chronic migraine (modified criteria of the ICHD-II3)

1. Current or prior headache fulfils criteria for migraine without aura
2. Headache on ≥ 15 days a month
    
3. At least 8 headache days a month for the previous 3 months fulfilling at least one of the following:
4. Not attributable to another disorder, including medication overuse headache

Criteria C and D for migraine without aura (see box 1)
Criteria C and D for migraine without aura with the exception of a single sub-criterion, and not meeting criteria for tension-type headache
Headache that the patient believes to be migraine and is relieved by a 5-HT1B/1D receptor agonist

Acute management

• Mild
  • Aspirin or Paracetamol with Metoclopramide or Domperidone. No published studies have shown the efficacy of paracetamol in acute migraine.
  • Tolfenamic acid or other NSAID, eg Ibuprofen, Naproxen.
• Moderate
  • Tolfenamic acid or other NSAID.
• Severe
  • First line
    • 5-HT antagonists (by injection, tablet or nasal spray). Sumatriptan is not effective during the aura phase of migraine.
    • Dihydroergotamine has a longer duration of action than sumatriptan and therefore has a lower recurrence rate. Ergotamine causes nausea.
  • Second line
    • Chlorpromazine 50mg IM
    • Prochlorperazine
  • Refractory
    • Ketorolac 30-60mg IM
    • Dexamethasone 8-20mg IM
• Ultra severe
  • Dihydroergotamine 0.5-1mg IV 8-hrly preceded by metoclopramide 10mg

Clinical stratification of acute migraine treatments

Failed analgesics or NSAIDs

• First tier—Sumatriptan 50 mg or 100 mg, rizatriptan 10 mg, almotriptan 12.5 mg, eletriptan 40 mg, zolmitriptan 2.5 mg (all tablets)
• For slower effect or better tolerability—Naratriptan 2.5 mg, frovatriptan 2.5 mg (tablets)
• Infrequent headache—Ergotamine 1-2 mg tablet, dihydroergotamine nasal spray 2 mg

Early nausea or difficulties taking tablets

• Sumatriptan 20 mg nasal spray, zolmitriptan 5 mg nasal spray, rizatriptan 10 mg dissolvable wafer, zolmitriptan 2.5 mg dispersible

Headache recurrence

• Ergotamine 2 mg (perhaps most effective taken rectally, usually with caffeine), naratriptan 2.5 mg tablet, eletriptan 80 mg tablet

Poor tolerance of acute treatments

• Naratriptan 2.5 mg, frovatriptan 2.5 mg (tablets)

Early vomiting

• Sumatriptan 25 mg suppository, sumatriptan 6 mg subcutaneous injection

Menstrually related headache

• Prevention—Ergotamine tablet taken at night, oestrogen patches
• Treatment—Triptans, dihydroergotamine nasal spray

Rapidly developing symptoms

• Sumatriptan 6 mg subcutaneous injection, dihydroergotamine 1 mg intramuscular injection

Preventive treatments in migraine

Agent Dose* Selected side effects Commonly used drugs     Pizotifen 0.5-2 mg daily Weight gain, drowsiness Beta blocker (propranolol) 40-120 mg twice daily Reduced energy, tiredness, postural symptoms, contraindicated in asthma Tricyclics (amitriptyline, dothiepin, nortriptyline)   25-75 mg nightly   Drowsiness (some patients are very sensitive and may need only a total dose of 10 mg, though 1-1.5 mg/kg body weight is generally required for a response) Anticonvulsants:     Valproate 400-600 mg twice daily Drowsiness, weight gain, tremor, hair loss, foetal abnormalities, haematological or liver abnormalities Topiramate   25-100 mg twice daily Paraesthesiae, cognitive dysfunction, weight loss, renal stones, glaucoma - now licensed for migraine Gabapentin 900-3600 mg daily Dizziness, sedation Methysergide 1-4 mg daily Drowsiness, leg cramps, hair loss, retroperitoneal fibrosis (1 month drug holiday required every 6 months) Flunarizine 5-10 mg daily Drowsiness, weight gain, depression, parkinsonism Metabolic enhancers     Riboflavin 400 mg daily   Coenzyme Q10 100 mg thrice daily   Non-pharmaceuticals     Feverfew     Butterbur     Other preventives with controlled evidence for efficacy Lisinopril 10-20 mg daily Cough Candesartan 16 mg daily   No convincing controlled evidence   Verapamil     Shown to have no effect by controlled trials   Nimodipine     Clonidine     Fluoxetine

^* Usual doses and common side effects are given, but the local national formulary should be consulted for detailed information.

  MIPCA migraine guidelines

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References

• Pryse-Phillips WE et al: Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Medical Assn J 1997.
• Recent advances in the diagnosis and management of migraine Peter J Goadsby
  http://bmj.com/cgi/content/full/332/7532/25?etoc
• International Headache Society (IHS). www.i-h-s.org/
• Masterclass for GPs - Headaches
• Migraine and cardiovascular disease: systematic review and meta-analysis  (BMJ 2009)    
  What this study adds
  • In this meta-analysis the risk of ischaemic stroke was approximately doubled among people with migraine, which was apparent for migraine with aura but not migraine without aura
  • The risk was further increased by being female, age less than 45 years, smoking, and oral contraceptive use
  • There was no association between migraine and myocardial infarction or death due to cardiovascular disease

   

• Brad Cheek: last updated Nov 2009
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