Ensure delivery by adding featureseries@email.emedicine.com to your address book.

TREATMENT OF MIGRAINE HEADACHE: SYMPTOMATIC AND PROPHYLACTIC THERAPY

Migraine headache is a very common neurological disorder. According to the World Health Organization, migraine headache is one of the 10 most disabling chronic conditions. In the last decade, public awareness of migraine headache has increased, and treatment approaches have become better understood. The term brain attack is currently used to describe strokes. However, migraine may be more aptly described as a brain attack, during which a signal generated in the brain activates many neural networks. The activation of neural networks, in turn, releases an array of chemical substances that activate the blood vessels of the brain (known as the inflammatory soup). This triggers pain-causing nerve endings and, ultimately, headache. Migraine is not simply a headache; it is a syndrome that comprises emotional, psychological, and neurological symptoms.

Successful treatment of this chronic and often complex condition is a mix of art and science. Patients should be approached in the context of their social, economic, and psychological circumstances. The physician must understand how patients live, what they eat, what kind of work they do, how they exercise, and their relationships and environment during the course of a day. Treatment of migraine is about lifestyle changes; migraine cannot be treated in isolation.

SYMPTOMATIC THERAPY

Acute treatment depends on the severity, intensity, and duration of headaches. Even the earliest warning of an impending migraine should be taken seriously and treated right away. For the best chance of relieving migraine, medications should be taken within 15-30 minutes of the onset of headache and when the headache is mild. A simple analogy for the layperson is an asthma attack. If you wait to see what happens, it may be too late to treat it on your own, and you may end up in the emergency department.

Mild migraine

Primary care physicians may use simple analgesics to manage infrequent, mild migraine headaches of brief duration. Patients with such headaches can be treated with acetaminophen; nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen, tolfenamic acid, and aspirin; propoxyphene; isometheptene combination products (eg, Midrin); a combination of these options; or one of these options combined with caffeine.

Moderate migraine

Migraines that last longer, cause moderate disability, and do not respond well to simple analgesics should be managed by a neurologist, at least initially, to select a suitable regimen.

Migraine-specific medications include ergot alkaloids and triptans. These two types of medication have nearly identical mechanisms of action on the serotonin receptors in the brain. Seven medications in the triptan category are currently available on the US market: sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, eletriptan, and frovatriptan. Most patients can take ergot alkaloids or triptans orally. Nasal spray formulations are also available.

Severe migraine

Patients with very frequent and disabling severe migraines should be under the constant supervision of a neurologist. Their treatment may require subcutaneous or intravenous formulations of migraine-specific medications or combinations of these formulations. These patients may require hospitalization for short periods. About 40% of all migraine headaches do not respond to a given triptan or to any other substance. Patients with severe nausea and vomiting at the onset of a migraine may respond best to intravenous prochlorperazine. If all other treatments fail, intravenous steroids can also be administered for such intractable migraines.

PROPHYLACTIC THERAPY

For patients who have frequent migraines, a neurologist can prescribe daily preventive therapy in addition to acute abortive treatment. Daily therapy for a few months can break the headache cycle. However, the approach to managing these challenging cases should be multidisciplinary and multimodal. Especially in cases like these, the disease should be approached as a syndrome of a constellation of symptoms. In the author’s experience, treating the entire person in the framework of his or her personal, social, and psychological circumstances is the key to success. Treating the person, instead of just the headache, often requires gradual lifestyle changes.

Recognition and avoidance of triggers

The first step in treating a patient with migraine is the cheapest and most effective. This includes educating the patient to recognize and avoid factors that precipitate a migraine (eg, stress, certain foods, vasodilators, fatigue, lack of sleep). A brain predisposed to migraine headache does not respond well to change, so consistent sleeping, eating, and exercising are keys to avoiding the most common migraine triggers.

Any change in stress hormones can trigger a migraine. These changes in stress level can include both those generally reported as negative and those generally reported as positive. For example, a change in stress on the first day of a vacation, when stress hormones are presumably at their lowest, can trigger a migraine headache. Encouraging the use of a diary to document headache patterns is an effective method to follow the course of the disease. After 3 months of diary use, many patients return to the physician in utter amazement, having discovered certain patterns of behavior or food habits of which they were previously unaware and that they now suspect are triggers for migraine. Documenting symptoms and triggers in a diary can also help patients become more objective in how they determine if a particular treatment is working.

Preventive therapy

The second step is to provide preventive therapy based on patient preference, comorbidities, and other patient-driven factors. As discussed in issue 2 of eMedicine’s Migraine Feature Series, the 3 classes of medications that are effective for migraine prevention include antiepileptic agents, antidepressants, and antihypertensives.

1. Antiepileptic agents

• Topiramate (Topamax) is indicated for migraine prophylaxis and is tolerated well. The principal adverse effects include weight loss and dysesthesia.
• Valproic acid (Depakote) is approved by the US Food and Drug Administration (FDA) as a migraine prevention agent and is a useful first-line agent. The medication is also a good mood stabilizer and can benefit patients who have concomitant mood swings.
• Only limited data are available on the efficacy of other antiepileptics (eg, gabapentin, lamotrigine, oxcarbazepine) in treating migraine headache.

2. Antidepressants

• Tricyclic antidepressants or beta-blockers are good second-line treatment alternatives based on their adverse-effect profiles and efficacy data. Currently available data indicate that amitriptyline and nortriptyline are the most efficacious agents in this category.
• Selective serotonin reuptake inhibitors (SSRIs) are widely used, but only limited data are available regarding their efficacy for migraine prevention.

3. Antihypertensives

• Beta-blockers are approved by the FDA for migraine prophylaxis but may not be the ideal choice for patients who are elderly or have depression, thyroid problems, or diabetes.
• Calcium channel blockers are the third line of treatment for migraine prophylaxis.
• Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril (Prinivil, Zestril) and angiotensin receptor blockers such as candesartan (Atacand) have recently been shown to be efficacious for migraine prevention.

Physical reeducation

The third step in successful preventive treatment is to add physical therapy (what the author calls physical reeducation) to a patient’s daily regimen. Physical reeducation is important for multiple reasons.

First, an experienced physical therapist can evaluate for musculoskeletal components of headache by examining the patient’s cervical range of motion, posture, and other physical characteristics. Most patients with migraine have some musculoskeletal triggers; addressing these triggers decreases some aspects of the pain cycle. Second, most patients with chronic migraine have a psychological comorbidity (eg, depression, anxiety disorder, panic disorder). Exercise in any form releases serotonin, which can improve the symptoms of psychological conditions. Completing a 30-minute exercise regimen for even a mere 2 weeks has been shown to improve a patient’s sense of well-being.

Psychological reeducation

The fourth step in treating patients whose migraines are difficult to treat is psychotherapy (what the author calls psychological reeducation). Some complementary and alternative medicine techniques are supported by good scientific evidence and have been proven by studies to be effective in preventing migraine. Biofeedback and behavioral therapy should be part of the standard of care for patients whose migraines are difficult to treat. A pain psychologist can provide a psychological perspective on the stress-related triggers and help modify them. Pain psychologists can also help the physician manage patient expectations and change the patient’s overall perspective of the disability.

REFERENCES

Sahai-Srivastava S. Migraine Headaches: Pharmacologic and nonpharmacologic options. eMedicine Journal [serial online]. 2006. Migraine Feature Series 1, Issue 2. Available at: http://www.emedicine.com/email/migraine/issue1-2.htm.

Sahai-Srivastava S, Cowan R, Ko DY. Pathophysiology and Treatment of Migraine and Related Headache. eMedicine Journal [serial online]. 2006. Available at: http://www.emedicine.com/neuro/topic517.htm. Accessed November 14, 2006.

Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical Practice. 2nd ed. London: Taylor & Francis; 2002: 69-111.

Silberstein SD. Migraine. Lancet. 2004;363:381-91.

Lipton RB, Bigal ME. Migraine: Epidemiology, impact, and risk factors for progression. Headache. 2005;45(Suppl 1):S3-S13.