Migraine treatment overview

Some medications provide migraine pain relief, while other migraine medications attack other symptoms.

Migraine

Migraine_brain_largeThe orbits, acute glaucoma is associated with vision problems, meningitis with fevers, and subaracchnoid hemorrhage with a very fast onset. Tension headaches typically occur on both sides, are not pounding, and are less disabling. Those with stable headaches which meet criteria for migraines should not receive neuroimaging to look for other intracranial disease. This requires that other concerning findings such as papilledema are not present. People with migraines are not at an increased risk of having another cause for severe headaches. Prevention Preventive treatments of migraines include medications, nutritional supplements, lifestyle alterations, and surgery. Prevention is recommended in those who have headaches more than two days a week, cannot tolerate the medications used to treat acute attacks, or those with severe attacks that are not easily controlled. The goal is to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy. Another reason for prevention is to avoid medication overuse headache. This is a common problem and can result in chronic daily headache. Medication Preventive migraine medications are considered effective if they reduce the frequency or severity of the migraine attacks by at least 50%. Guidelines are fairly consistent in rating topiramate, divalproex/sodium valproate, propranolol, and metoprolol as having the highest level of evidence for first-line use. Recommendations regarding effectiveness varied however for gabapentin. Timolol is also effective for migraine prevention and in reducing migraine attack frequency and severity, while frovatriptan is effective for prevention of menstrual migraine. Amitriptyline and venlafaxine are probably also effective. Angiotensin inhibition by either an angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist may reduce attacks. Botox has been found to be useful in those with chronic migraines but not those with episodic ones. Alternative therapies While acupuncture may be effective, “true” acupuncture is not more efficient than sham acupuncture, a practice where needles are placed randomly. Both have a possibility of being more effective than routine care, with fewer adverse effects than preventative medications. Chiropractic manipulation, physiotherapy, massage and relaxation might be as effective as propranolol or topiramate in the prevention of migraine headaches; however, the research had some problems with methodology. The evidence to support spinal manipulation is poor and insufficient to support its use. Of the alternative medicines, butterbur has the best evidence for its use. Devices and surgery Medical devices, such as biofeedback and neurostimulators, have some advantages in migraine prevention, mainly when common anti-migraine medications are contraindicated or in case of medication overuse. Biofeedback helps people be conscious of some physiological parameters so as to control them and try to relax and may be efficient for migraine treatment. Neurostimulation uses implantable neurostimulators similar to pacemakers for the treatment of intractable chronic migraines with encouraging results for severe cases. Migraine surgery, which involves decompression of certain nerves around the head and neck, may be an option in certain people who do not improve with medications. Management There are three main aspects of treatment: trigger avoidance, acute symptomatic control, and pharmacological prevention. Medications are more effective if used earlier in an attack. The frequent use of medications may result in medication overuse headache, in which the headaches become more severe and more frequent. This may occur with triptans, ergotamines, and analgesics, especially narcotic analgesics. Due to these concerns simple analgesics are recommended to be used less than three days per week at most. Analgesics Recommended initial treatment for those with mild to moderate symptoms are simple analgesics such as non-steroidal anti-inflammatory drugs or the combination of paracetamol, acetylsalicylic acid, and caffeine. Several nsaids have evidence to support their use. Ibuprofen has been found to provide effective pain relief in about half of people and diclofenac has been found effective.Aspirin can relieve moderate to severe migraine pain, with an effectiveness similar to sumatriptan. Ketorolac is available in an intravenous formulation. Paracetamol, either alone or in combination with metoclopramide, is another effective treatment with a low risk of adverse effects. In pregnancy, paracetamol and metoclopramide are deemed safe as are nsaids until the third trimester. Triptans Triptans such as sumatriptan are effective for both pain and nausea in up to 75% of people. They are the initially recommended treatments for those with moderate to severe pain or those with milder symptoms who do not respond to simple analgesics. The different forms available include oral, injectable, nasal spray, and oral dissolving tablets. In general, all the triptans appear equally effective, with similar side effects. However, individuals may respond better to specific ones. Most side effects are mild, such as flushing; however, rare cases of myocardial ischemia have occurred. They are thus not recommended for people with cardiovascular disease, who have had a stroke, or have migraines that are accompanied by neurological problems. In addition, triptans should be prescribed with caution for those with risk factors for vascular disease. While historically not recommended in those with basilar migraines there is no specific evidence of harm from their use in this population to support this caution. They are not addictive, but may cause medication overuse headaches if used more than 10 days per month. Ergotamines Ergotamine and dihydroergotamine are older medications still prescribed for migraines, the latter in nasal spray and injectable forms. They appear equally effective to the triptans, are less expensive, and experience adverse effects that typically are benign. In the most debilitating cases, such as those with status migrainosus, they appear to be the most effective treatment option. Other Intravenous metoclopramide or intranasal lidocaine are other potential options. Metoclopramide is the recommended treatment for those who present to the emergency department. A single dose of intravenous dexamethasone, when added to standard treatment of a migraine attack, is associated with a 26% decrease in headache recurrence in the following 72 hours. Spinal manipulation for treating an ongoing migraine headache is not supported by evidence. It is recommended that opioids and barbiturates not be used. Prognosis Long term prognosis in people with migraines is variable. Most people with migraines have periods of lost productivity due to their disease however typically the condition is fairly benign and is not associated with an increased risk of death. There are four main patterns to the disease: symptoms can resolve completely, symptoms can continue but become gradually less with time, symptoms may continue at the same frequency and severity, or attacks may become worse and more frequent. Migraines with aura appear to be a risk factor for ischemic stroke doubling the risk. Being a young adult, being female, using hormonal contraception, and smoking further increases this risk. There also appears to be an association with cervical artery dissection. Migraines without aura do not appear to be a factor. The relationship with heart problems is inconclusive with a single study supporting an association. Overall however migraines do not appear to crease the risk of death from stroke or heart disease. Preventative therapy of migraines in those with migraines with auras may prevent associated strokes. Epidemiology Worldwide, migraines affect nearly 15% or approximately one billion people. It is more common in women at 19% than men at 11%. In the United States, about 6% of men and 18% of women get a migraine in a given year, with a lifetime risk of about 18% and 43% respectively. In Europe, migraines affect 12–28% of people at some point in their lives with about 6–15% of adult men and 14–35% of adult women getting at least one yearly. Rates of migraines are slightly lower in Asia and Africa than in Western countries. Chronic migraines occur in approximately 1.4 to 2.2% of the population. These figures vary substantially with age: migraines most commonly start between 15 and 24 years of age and occur most frequently in those 35 to 45 years of age. In children, about 1.7% of 7 year olds and 3.9% of those between 7 and 15 years have migraines, with the condition being slightly more common in boys before puberty. During adolescence migraines becomes more common among women and this persists for the rest of the lifespan, being two times more common among elderly females than males. In women migraines without aura is more common than migraines with aura, however in men the two types occur with similar frequency. During perimenopause symptoms often get worsebefore decreasing in severity. While symptoms resolve in about two thirds of the elderly,

In between 3 and 10% they persist. History An early description consistent with migraines is contained in the Ebers papyrus, writtenaround 1500 BCE in ancient Egypt. In 200 BCE, writings from the Hippocratic school of medicine described the visual aura that can precede the headache and a partial relief occurring through vomiting. A second-century description by Aretaeus of Cappadocia divided headaches into three types: cephalalgia, cephalea, and heterocrania. Galen of Pergamon used the term hemicrania, from which the word migraine was eventually derived. He also proposed that the pain arose from the meninges and blood vessels of the head. Migraines were first divided into the two now used types – migraine with aura and migraine without aura in 1887 by Louis Hyacinthe Thomas, a French Librarian. Trepanation, the deliberate drilling of holes into a skull, was practiced as early as 7,000 BCE. While sometimes people survived, many would have died from the procedure due to infection. It was believed to work via “letting evil spirits escape”. William Harvey recommended trepanation as a treatment for migraines in the 17th century. While many treatments for migraines have been attempted, it was not until 1868 that use of a substance which eventually turned out to be effective began. This substance was the fungus ergot from which ergotamine was isolated in 1918. Methysergide was developed in 1959 and the first triptan, sumatriptan, was developed in 1988. During the 20th century with better study design effective preventative measures were found and confirmed. Society and culture Migraines are a significant source of both medical costs and lost productivity. It has been estimated that they are the most costly neurological disorder in the European Community, costing more than €27 billion per year. In the United States direct costs have been estimated at $17 billion, Nearly a tenth of this cost is due to the cost of triptans. Including $15 billion in indirect costs, of which missed work is the greatest component. In those who do attend work with a migraine, effectiveness is decreased by around a third. Negative impacts also frequently occur for a person’s family. Research Calcitonin gene related peptides have been found to play a role in the pathogenesis of the pain associated with migraine. CGRP receptor antagonists, such as olcegepant and telcagepant, have been investigated both in vitro and in clinical studies for the treatment of migraine. In 2011, Merck stopped phase III clinical trials for their investigational drug telcagepant. Transcranial magnetic stimulation shows promise as has transcutaneous supraorbital nerve stimulation. References Notes Olesen, Jes. The headaches.. Philadelphia: Lippincott Williams & Wilkins. ISBN 9780781754002.  External links Migraine at DMOZ

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