HEADACHE: how to relieve a headache or migraine with reflexology
Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010.
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Transcript of Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010.
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Acute treatment of migraine
Dr Mark Weatherall
London Headache Centre
2010
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The intangibles
Doctor-patient relationship Realistic expectations Education
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Triggers
Hormonal Dietary Psychological Environmental Sleep Drugs
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10 steps to success
Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms
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10 steps to success
Choose appropriate route of delivery Observe contraindications Use prior experience to select/reject drugs Avoid drugs with high potential for MOH Combine medications if necessary
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Where to start?
paracetamol 1 gor, aspirin 900 mgor, ibuprofen 600-800 mg+/- domperidone 10-20 mg taken as soon as possible*ª
* i.e. as soon as the patient knows that this is a migraine
ª if there is aura, take at the start of the headache phase
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Variations on a theme
if early nausea, you can use: soluble aspirin suppositories*:
diclofenac 75 mg domperidone 30 mg
*be French!
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Headache response at 2 hr
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Problems, problems…
Not effective dose? timing? route? combination?
Contraindications asthma, upper GI problems, renal impairment
Side effects GI, CNS
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Codeine…?
… is NOT a treatment for headache the WHO analgesic ladder should NOT be
applied to headache management
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Triptans
5-HT1B/1D receptor agonists seven different formulations options for route of delivery
oral tablets or melts nasal spray subcutaneous injection
taken as soon as possible*ª¹* i.e. as soon as the patient knows that this is a migraine
ª if there is aura, take at the start of the headache phase
¹ this is a race against the development of allodynia
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Which triptan?
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Headache response at 2 hr
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Pain freedom at 2 hr
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Problems, problems…
Ineffective dose? timing? route? switch?
Headache recurrence switch? combination with NSAID?
Contraindications HT, IHD
SE nausea, GI, CNS, ‘triptan chest’
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Is the future ‘pants’?
CGRP antagonists two with data recently published proof-of-concept trial of intravenous BIBN4096BS
(now called olcagepant) was published in NEJM in 2004
phase II study of oral CGRP antagonist MK-0974 (now called telcagepant) presented at IHS 2007 and published in Neurology in 2008
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multicentre phase III R-PT-PC-DB-T of oral telcagepant 150 or 300 mg vs zolmitriptan 5 mg and placebo published in The Lancet in last four weeks
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