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Migraine headaches

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of migraine.

Treatment

Many effective headache remedies are available for treating a migraine attack. Still, a 2002 study that analyzed over 800,000 case of migraine, reported that most migraines are not treated according to any expert recommendations or accepted evidence. In the study, 30% of patients were treated with potentially addictive opioids -- most often Demerol. Furthermore, 70% of these patients were not offered effective and available anti-migraine drugs. Anti-nausea drugs that have no effect on headaches were used six times more often than drugs that reduce headaches.

As many as 30% of patients with migraine also have accompanying headaches resulting from tension, drugs, infections, or other causes. It is important to distinguish between headache types in order to determine appropriate treatment.

General Guidelines. The general goals of treatment are:

• On the advice of the doctor, choose drugs with as few side effects as possible. Patients should discuss various methods for administering the medication (pills, injections, nasal spray, or rectal suppositories) and begin with the one they believe will be the least distressing.
• Treat the attack rapidly, within an hour of symptom onset if possible. Start with low doses first and build up dosage slowly.
• Try to minimize the use of back-up or "rescue medications." (A rescue medication is typically an opiate, which the patient uses at home for pain relief when other medications fail.)
• Try to guard against rebound effect. Nearly all drugs used for migraine can cause rebound headache and none of the drugs should be taken for longer than 2 days per week.
• It may take 2 - 4 months for any drug to be effective.

Stepped-Up Treatment Approach . Some experts recommend a stepped-up treatment course for an acute migraine attack. This involves starting with the least potent treatments and taking increasingly more potent drugs until the pain stops. In this approach, patients may need up to five different medications to achieve pain relief. A typical stepped-up approach is the following:

• Patients first try general nonprescription pain relievers (NSAIDs, Excedrin Migraine) and stress-reduction techniques.
• If these are not effective within 2 hours, migraine-specific drugs should be tried next. Triptans are the first choice, then ergot derivatives.
• Injected or rectally administered drugs may be used for patients with migraines associated with severe nausea or vomiting. Nausea itself should be treated with specific anti-nausea drugs, such as metoclopramide (Reglan).
• If migraine medications fail to relieve symptoms within 4 hours, rescue drugs (opioids, corticosteroids) may be used.

Stratified Approach. Many doctors and patients now prefer the stratified approach. The doctor first estimates the severity of the patient's condition based on his or her history. Then, based on the severity of a typical attack, the doctor decides whether the patient should start with more or less potent drugs at the first signs of the migraine:

• Patients with less disabling migraines start with general pain relievers.
• Patients with a history of moderate to severe migraines start with migraine-specific prescription medicine, such as a triptan, at the onset of mild pain.

Some studies report dramatic relief with the stratified approach. In a 2002 study, zolmitriptan, a newer triptan, reduced the intensity of headaches within 2 hours in 70% of patients with moderate pain but only in 44% of those with severe headaches.

Side effects can be severe with many migraine drugs, although newer drugs, such as the recent generation triptans, may provide effective early relief without significant adverse effects.

Guidelines for Migraines in Children Studies estimate that between 5 - 10% of children may experience migraines but that the disorder is underdiagnosed in children. An interesting study reported that when children drew pictures in response to their doctors' questions about their migraines, the doctors were able to tell the difference between migraine and non-migraine headaches in the majority of cases. Symptoms in Children. The standard diagnostic criteria for migraine in adults may apply to only about two-thirds of migraines in children and adolescents. For example, the following differences have been observed: Headaches tend to last for a shorter time (as little as an hour) in children. Migraine pain tends to occur in the face and on both sides of the head in two-thirds of child patients. Children often have a form of migraine known as a migraine equivalent or abdominal migraine, which does not cause a headache at all. Instead children experience periodic bouts of nausea and vomiting (called cyclic vomiting syndrome) or other secondary symptoms found in adult migraine, such as a reaction against light or sound. Cyclic vomiting may occur in nearly 2% of school-aged children with or without a migraine association. Migraine triggers in children are similar to those in adults, but common ones in children are eating ice cream and anxiety and fear. Outlook in Children. Migraine in children is disabling, as it is in adults, and they tend to lose more school days than other children. Children with frequent headaches may also be at higher risk for headaches in adulthood and also for other physical and psychiatric problems. Treatments in Children. For most children with migraines, mild pain relievers and home remedies (such as ginger tea) may be sufficient. The American Academy of Neurology’s 2004 practice guidelines for children and adolescents recommend the following drug treatments: For children age 6 years and older, ibuprofen (Advil) is recommended. Acetaminophen (Tylenol) may also be effective. Acetaminophen works faster than ibuprofen, but the effects of ibuprofen last longer. For adolescents age 12 years and older, sumaptriptan (Imitrex) nasal spray is recommended. Preventive Measures in Children. Non-medication methods, including biofeedback and muscle relaxation techniques may be helpful. In one study of children with migraines and poor sleep habits, instructions in improving sleep without using medications reduced migraine attacks significantly. If these methods fail, then preventive drugs may be used, although evidence is weak on the effectiveness of standard migraine preventive drugs in children. Flunarizine (Sibelium), an anti-seizure drug that also blocks calcium channels, has been effective for children in trials but is not yet approved in the U.S.

Withdrawing from Medications

If rebound migraines develop because of medication overuse, the patients cannot recover without stopping the drugs. (If caffeine is the culprit, a person may need only to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient usually has the option of stopping abruptly or gradually and should expect the following course:

• Most headache drugs can be stopped abruptly, but the patient should be sure to check with the doctor before doing so. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal.
• If the patient chooses to taper off standard headache medications, withdrawal should be completed within three days or shorter. Otherwise the patient may become discouraged.
• Alternative medications may be administered during the first days. Examples of drugs that may be used include dihydroergotamine (with or without metoclopramide), NSAIDs (in mild cases), corticosteroids, or valproate.
• Whatever approach is used for stopping medication, the patient must expect a period of worsening headache afterward. Most people feel better within 2 weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).
• If the symptoms do not respond to treatment and cause severe nausea and vomiting, the patient may need to be hospitalized.

On the encouraging side, some patients experience dramatic long-term relief from all headaches afterward, and one study reported that 82% of patients significantly improved 4 months after medication withdrawal.

Investigational Treatments

New treatments in clinical trials include:

Neurostimulation Devices . Researchers are investigating a transcranial magnetic stimulation (TMS) device to help stop migraines before they occur. The hair dryer-size device is held to the back of the head and delivers quick magnetic pulses. The device is used when a patient experiences the first signs of a migraine. Preliminary research presented at the 2006 American Headache Society meeting suggested that the device helped stop or lessen migraine pain within 2 hours after treatment. Other types of nerve stimulation devices are also under investigation.

Inhalation Devices . These devices use heat to vaporize a drug so that it can be inhaled into the lungs. Clinical trials are currently testing this device with procholorperazine (Compazine), a tranquilizer drug that is used to treat nausea and vomiting.

Nasal Devices . New types of nasal sprays and powders are being researched. Some of them use capsaicin, the chemical found in cayenne peppers, to help relieve pain.

Skin Patches . The Actyve transdermal patch uses a small battery-powered system to deliver a triptan drug through the skin.

Drugs . New drugs in development include tonabersat (gap junction blocker), trexima (combination triptan and non-steroidal anti-inflammatory drug), and GW274150 (nitric oxide synthase inhibitor).

• Review Date: 10/2/2006
• Reviewed By: Harvey Simon, M.D., Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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