Migraine

Diagnostic criteria

Differential diagnosis

• In subarachnoid haemorrhage, the pain has an explosive onset, and it is often associated with a decreased level of consciousness Intracranial Aneurysm and Subarachnoid Haemorrhage (SAH).
• In meningitis, there is neck stiffness, fever, a decreased level of consciousness and confusion in addition to headache Meningitis in Adults.
• Cluster headache causes brief, intense pain lasting 15-180 minutes in the region of one eye and is associated with lacrimation Cluster Headache (Horton's Syndrome).
• Tension headache typically consists of only headache with no additional symptoms, squeezing bilateral pain, no prodromal symptoms, nausea or sensory sensitivity; exercise improves the condition Tension Headache.

Paracetamol and NSAIDs

• Paracetamol 1 000 mg Paracetamol with or Without an Antiemetic for Acute Migraine
• NSAIDs
  • Aspirin 1 000 mg Aspirin with or Without Antiemetic for Acute Migraine Headaches in Adults
  • Diclofenac 50 mg p.o. Diclofenac for Acute Migraine
  • Ketoprofen 50-100 mg p.o.
  • Naproxen 500-1 000 mg p.o. Naproxen for Acute Migraine Headaches in Adults
  • IbuprofenIbuprofen for Acute Migraine 800-1 200 mg p.o.

Triptans

• Triptans are drugs of first choice in severe or incapacitating migraine attacks Triptans for Migraine.
  • Almotriptan 12.5 mg p.o.
  • Eletriptan 40-80 mg p.o.
  • Frovatriptan 2.5 mg p.o.
  • NaratriptanNaratriptan for Acute Migraine 2.5-5 mg p.o.
  • Rizatriptan 5-10 mg p.o.
  • Sumatriptan 50-100 mg p.o. Oral Sumatriptan for Acute Migraine, 6 mg s.c. Subcutaneous Sumatriptan in Migraine, 20 mg nasal spray Intranasal Sumatriptan for Acute Migraine (25 mg suppository Rectal Sumatriptan for Acute Migraine)
  • ZolmitriptanZolmitriptan for Acute Migraine 2.5-5 mg p.o., 5 mg nasal spray
• Triptans are taken after a possible aura, at the onset of the headache.
• It is worthwhile to try at least 3 different kinds of triptans before concluding that triptans are not helpful for the patient.
• Additional effect in the treatment of an attack may be achieved by combining a triptan with an NSAID Sumatriptan Plus Naproxen for Acute Migraine Attacks in Adults.
• Triptans are not indicated in migraine that has as aura symptoms either hemiplegia or brainstem symptoms (vertigo combined with loss of vision, dysarthria, disturbances of eye movements, tinnitus, ataxia, lowered alertness).
• There is a risk of drug-induced headache if triptans are used on 10 or more days per month.
• Contraindications for triptans include ischaemic heart disease, Prinzmetal angina, TIA, cerebral infarction, subarachnoid haemorrhage, untreated or uncontrolled high blood pressure and severe renal failure.

Other drugs

• Diazepam 2-10 mg p.o./rectally
• Opioids are not used for the treatment of migraine. Their efficacy is not superior to that of NSAIDs, and they are associated with a risk of drug dependence and analgesic rebound headache.

Medication during pregnancy and lactation

• Paracetamol can be used throughout pregnancy. Ibuprofen and naproxen can be used in early pregnancy.
• Triptansare contraindicated during pregnancy and lactation. Occasional use of sumatriptan (less than 4 times) during pregnancy is probably not harmful. Sumatriptan is known to be excreted in breast milk in small amounts; conventional doses should not cause any harm to the infant.

Menstrual migraine

• Menstrual migraine is a type of migraine without aura that begins between 2 days before or 2 days after the first day of bleeding.
• The beginning of the attack is associated with a rapid decline in oestrogen levels.
• Menstrual migraine may be prolonged and intense.
• If menstrual migraine occurs regularly, the following can be used prophylactically:
  • Naproxen 500 mg twice daily starting 2 days before the menstrual period and continuing until the end of period (at maximum for 7 days).
  • Triptans starting 1-2 days before the period and continuing for 5-7 days, provided that the menstrual cycle and associated migraine are very regular. Drugs for this purpose include:
    • frovatriptan 2.5 mg twice daily
    • zolmitriptan 2.5 mg three times daily
    • naratriptan 2.5 mg twice daily.

Treatment of an acute prolonged migraine attack

• Status migrainosus is a migraine attack with severe symptoms continuing for several days.
• Treatment should be started without delay on the emergency ward if a patient reports his/her typical migraine symptoms and no secondary causes are suspected.
• Subcutaneously injected triptans act rapidly.
• Analgesics and antiemetics should be given parenterally.
• 500 mg of hydrocortisone and 200 mg of indomethacin mixed with 1 000 ml of sodium chloride 0.9% and glucose 5% solution (NaCl 0.9/G5) can be given intravenously over 6-8 hours.
• On discharge, the patient should be instructed to contact outpatient care to revise his/her migraine treatment plan.

Intervention in chronic daily headache

• Chronic migraine or chronic daily headache can be diagnosed if there have been 15 or more headache days per month for 3 months.
• This is frequently a combination of chronic migraine, tension headache and medication overuse.
• If drug-induced headache is identified, it is necessary to reduce any overuse of migraine medication or discontinue or wean the patient off medication. At the same time, starting migraine prophylaxis is recommended.
• When analgesics are tapered off over 1-3 weeks, sickness absence may be necessary during the first few days.
• When planning further treatment, non-pharmacological and pharmacological prophylaxis of various types of headaches should be considered. The patient should be instructed to document the use of headache drugs and rescue medication.