Management Individualised for each Patient

 

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Assessment of Illness Severity

Individualising Care

Acute Medications.

• Goal: Acute medications should rapidly relieve the headache and other symptoms of migraine and permit the return to normal activities.
  
  
• Acute medications should be provided for all patients:
  
  
  • Patients should be given a portfolio of acute medications, to treat attacks of differing severities and provide rescue medication if the initial therapy fails.

Prophylactic Medications.

• Goal: Prophylactic medications should reduce headache frequency by > 50%.
  
  
• Prophylactic medications should be provided as additional medications for patients who:
  
  
  • Have frequent high-impact migraine attacks (>/= 4 per month).
    
    
  • Do not achieve satisfactory treatment with acute medications.
    
    
  • Have concomitant conditions that preclude the use of acute medications (e.g. the rare migraine variants).
    
    
  • Overuse headache medications and/or have chronic daily headache.

Choice of Therapy

Recommended Acute Therapies for Mild-to-moderate Migraine (with or without Aura). These are given in Table 9.^[15]

Recommended Acute Therapies for Moderate-to-severe Migraine (with or without Aura). These are given in Table 10.

• Patients who have unpredictable attacks may benefit from the orally dispersible tablet (ODT) formulations of zolmitriptan and rizatriptan (although it should be mentioned that they are not absorbed in the mouth), or the nasal spray formulations of sumatriptan and zolmitriptan.

• Patients with particularly severe attacks, those with a need for rapid response and those with nausea and (especially) vomiting may require nasal spray triptans or subcutaneous sumatriptan.

• Therapies that cannot be recommended include paracetamol monotherapy (due to lack of efficacy), opiates and barbiturates (due to safety concerns), ergotamine (due to side-effects and the triptans' superior clinical profiles), opiates (including codeine preparations) and barbiturates (due to safety concerns).^[15]

Recommended Prophylactic Therapies for Migraine. These are given in Table 11.^[39]

Other Therapies.

• Behavioural and physical therapies, including relaxation, biofeedback, stress reduction strategies, cervical manipulation, massage, exercise and the avoidance of migraine triggers, can be provided for all migraine sufferers to help prevent the development of attacks.^[40]

• Some complementary medications, including feverfew, magnesium, vitamin B₂, acupuncture and, possibly, low-dose aspirin may be used in addition to the patient's existing acute and/or prophylactic therapies.^[21]

• However, in these situations, patients should be encouraged to consult accredited complementary practitioners only.

Treatment of Chronic Daily Headache (CDH).

• Although outside the main scope of these guidelines, several principles can be used to manage CDH in primary care:
  
  
  • Physical exercises and/or physiotherapy to the neck.
    
    
  • Withdrawal of headache medications that the patient is abusing (>/= 2 days of use per week).
    
    
  • Initiate a prophylactic medication to prevent the development of headaches. Effective drugs include antidepressants (e.g. dothiepin and amitriptyline) and anticonvulsants (e.g. sodium valproate, gabapentin and topiramate).
    
    
  • Provide an acute medication to treat breakthrough headache attacks. This can be a triptan if the patient has a history of migraine attacks.
    
    
  • Referral to a specialist may be required if these initiatives fail.^[51]

http://www.medscape.com/viewarticle/446557_9