Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.
-
Upload
jazlyn-dyson -
Category
Documents
-
view
217 -
download
1
Transcript of Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.
![Page 1: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/1.jpg)
Acute treatment of migraine
Mark Weatherall
BASH meeting, Hull 2009
![Page 2: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/2.jpg)
![Page 3: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/3.jpg)
The intangibles
Doctor-patient relationship Realistic expectations Education
![Page 4: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/4.jpg)
Triggers
Hormonal Dietary Psychological Environmental Sleep Drugs
![Page 5: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/5.jpg)
![Page 6: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/6.jpg)
10 steps to success
Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms
![Page 7: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/7.jpg)
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
![Page 8: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/8.jpg)
![Page 9: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/9.jpg)
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
![Page 10: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/10.jpg)
Variations on a theme
if early nausea, you can use: soluble aspirin suppositories*:
diclofenac 75 mg domperidone 30 mg
*be French!
![Page 11: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/11.jpg)
![Page 12: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/12.jpg)
![Page 13: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/13.jpg)
![Page 14: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/14.jpg)
Headache response at 2 hr
![Page 15: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/15.jpg)
Problems, problems…
Not effective dose? timing? route? combination?
Contraindications asthma, upper GI problems, renal impairment
Side effects GI, CNS
![Page 16: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/16.jpg)
This is what patients do next
![Page 17: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/17.jpg)
Codeine…?
… is NOT a treatment for headache the WHO analgesic ladder should NOT be
applied to headache management
![Page 18: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/18.jpg)
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
![Page 19: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/19.jpg)
![Page 20: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/20.jpg)
Which triptan?
![Page 21: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/21.jpg)
Headache response at 2 hr
![Page 22: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/22.jpg)
Pain freedom at 2 hr
![Page 23: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/23.jpg)
![Page 24: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/24.jpg)
![Page 25: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/25.jpg)
advantages disadvantages
Sumatriptan well-established expensive£4.60 available OTC poorly absorbed
s/c (£22.10), melt (£4.14), nasal spray (£6.14)
Zolmitriptan cheaper occasional confusion
£4.00 long actingnasal spray (£6.75), melt (£4.00)
Naratriptan cheaper slow onset£4.09 long acting
Rizatriptan rapid onset high recurrence£4.46 melt (£4.46)
Almotriptan cheaper£3.02 low SE incidence
Eletriptan cheaper pumped out of CNS£3.75 long acting
Frovatriptan cheapest slow onset£2.78 longest half-life
![Page 26: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/26.jpg)
Problems, problems…
Ineffective dose? timing? route? switch?
Headache recurrence switch? combination with NSAID?
Contraindications HT, IHD
SE nausea, GI, CNS, ‘triptan chest’
![Page 27: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/27.jpg)
![Page 28: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/28.jpg)
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
![Page 29: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/29.jpg)
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
![Page 30: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/30.jpg)
![Page 31: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/31.jpg)
![Page 32: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/32.jpg)
![Page 33: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/33.jpg)
![Page 34: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/34.jpg)
A&E/in-patient options
sumatriptan s/c 6 mg alternatively nasal spray 20 mg
high dose NSAIDs aspirin 1 g
(available as IV formulation – useful as rescue medication in medication withdrawal)
indometacin 100 mg (can be given IM)
![Page 35: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/35.jpg)
Refractory migraine
dihydroergotamine (DHE) 0.5-1.0 mg iv/im (2 mg nasal spray)
anticonvulsants sodium valproate 500 mg iv in 100 mL normal
saline over 15 min (? role for SVP infusion in status migrainosus)
clonazepam 1 mg/mL slow push
![Page 36: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/36.jpg)
… or …
dopamine antagonists metoclopramide 10-20 mg IV
(rpt to 30-60 mg over 2 hrs) droperidol 0.625 mg every 10 mins
(average effective dose 3.15 mg) prochlorperazine 10 mg iv over 2 min
(may rpt after 30 min) metoclopramide & prochlorperazine can be
followed with DHE 0.5-1.0 mg over 10 mins
![Page 37: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/37.jpg)
… or …
magnesium sulphate 1 g iv over 15 min dexametasone 8-20 mg iv over 5-10 min;
hydrocortisone 100-250 mg iv over 10 min, every 8-12 hrs for 24 hours
(again, useful in status)
ketorolac 30-60 mg iv/im
![Page 38: Acute treatment of migraine Mark Weatherall BASH meeting, Hull 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062620/551ac0405503466b6a8b4c18/html5/thumbnails/38.jpg)
A final thought: listening is therapy in itself
… and you’ve listened long enough!