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ARTICLE IN PRESS+ModelRMU-25; No. of Pages 5Medicina Universitaria. 2015;xxx(xx):xxx---xxx

www.elsevier.es/rmuanl

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Document downloaded from http://www.elsevier.es, day 18/08/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. This early online article has been reviewed, accepted and posted on the Web before copyediting.cite this article in press as: Marl A. Migraine management. Medicina Universitaria. 2015..doi.org/10.1016/j.rmu.2015.05.001

e there is clinical doubt or whenever the patientus and wishes to be as certain as you can be.

e a valid reason; however it may increase the cost attention and can be problematic in institutions

volume of patients.nagement of migraines must contemplate two

anagement (abortive).ive management.

nding author at: Servicio de Neurologa del Hospital Dr. Jos Eleuterio Gonzlez, de la Universidade Nuevo Len. Av. Madero y Gonzalitos s/n Col. Mitrasterrey C.P. 64460, N.L., Mexico. Tel.: +52 81 83471059.ddress: amarl1@yahoo.com

Answering each and every one of these questions beforebeginning management is fundamental. It gives the man-agement sense and direction, for both the doctor as wellas the patient. Additionally, it brings the patient the feel-ing that he/she is able to do something, or cooperate in thetreatment, and thus the patient perceives he/she has somecontrol over his/her illness.

Abortive management

General guidelines:

1. To treat as early as possible. The instruction is: Take themedication, or do as indicated, as soon as the patientrecognizes if a crisis arises. Patients learn to recog-nize when this happens, and we know that abortive

oi.org/10.1016/j.rmu.2015.05.001 2015 Universidad Autnoma de Nuevo Len. Published by Masson Doyma Mxico S.A. This is an open access article under the

license (http://creativecommons.org/licenses/by-nc-nd/4.0/).S CORNER: A PERSONAL APPROACH

ne management

l

nd Non Oncologic Pain Clinic, Neurology Service at the Universidad Autnoma de Nuevo Len, Mexico

February 2015; accepted 24 February 2015

tion

are common illnesses. Studies conducted in 12ican cities, including two in Mexico, have foundvalence in our country is 15%. The rate in genderen/Men) worldwide.

gnostic criteria for migraines were published fore in 1988, in the rst edition of the InternationalClassication, promoted by the InternationalSociety, with its second edition in 2003, andta version that will probably be published inostic criteria for the different forms of migraines

described in this document, which has simpliedtion among doctors and made possible compar-een studies. The current migraine criteria (witht aura) are shown in Table 1.

primary headaches, paraclinic and imaging stud-mal and rarely necessary, exception made for the

In bpharm

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1. Are2. If s3. How4. Wh

a cma

5. How6. Whospital, Dr. Jos Eleuterio Gonzlez of

cases, the following pharmacological and non-gical measures must be contemplated.

ent generalities

inning management of a migraine, as in any otherl entity, we must ask ourselves, several ques-

ications necessary?e there parameters to choose one as the best?l results be measured?ill the success and failure criteria be to decidee in management? In other words, how long ton a medication before considering it did not work.g will a successful treatment last?

the a priori probability of recovery/recurrence?

Please http://dx

ARTICLE IN PRESS+ModelRMU-25; No. of Pages 52 A. Marl

Table 1 Diagnostic criteria of frequent migraines.

Migraine without auraA. At least ve attacksfullling criteria B---DB. Headache attacks lasting 4---72 hours (untreated or unsuccessfully treated)C. Headac

1. unila2. pulsa3. mode4. aggra . wa

D. During 1. nause2. Photo

E. Not bet

Migraine A. At leasB. One or

1. visua2. senso3. speec4. moto5. brain6. retin

C. At leas1. one a more2. each3. at lea4. the a e

D. Not bet schae

treatmein treat

2. To havelimits aof acute

3. If we arit in atfailure.

4. Rememabortiveused wabortivesituatiolike miglar cyclevolutiothus thmedica

Non-phar

Some patieate the paiis sleep. Thtemporal athere is pa

Document downloaded from http://www.elsevier.es, day 18/08/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. This early online article has been reviewed, accepted and posted on the Web before copyediting.he has at least two of the following four characteristics:teral locationting qualityrate or severe pain intensityvation by or causing avoidance of routine physical activity (e.gheadache at least one of the following:a and/or vomitingphobia and phonophobiater accounted for by another ICHD-3 diagnosis.

with Aurat two attacks fullling criteria B and Cmore of the following fully reversible aura symptoms:lryh and/or languagerstemalt two of the following four characteristics:ura symptom spreads gradually over 5 minutes, and/or two or

individual aura symptom lasts 5---60 minutesst one aura symptom is unilateralura is accompanied, or followed within 60 minutes, by headachter accounted for by another ICHD-3 diagnosis, and transient icite this article in press as: Marl A. Migraine m.doi.org/10.1016/j.rmu.2015.05.001

nt loses effect in a direct proportion to the delayment.

a record of the amount of analgesic used. Setnd have a plan B and plan C ready in case

therapeutic failure.e going to try a medication (i.e. a triptan), try

least two crises before declaring therapeutic

ber that the abortive treatment is exactly that:. Although there are exceptions; it must not be

ith a schedule. The principle is to NEVER give medication on a schedule. Exceptions would bens where we can anticipate the onset of the crisis,raines associated with menstruation (with regu-es) or episodic cluster headache. In general, then of the crisis in most migraines is predictable;e patient is able to know when to take thetion.

macological measures

nts learn some techniques which can help attenu-n or make it disappear. The most utilized methode physician can try to compress both supercialrteries in front of the tragus (or on the side wherein, if it is hemicranial) in order to try to abort the

crisis. Its e40%.

Diet is temporal rand the oing a restthe consumcanned fooor any forlar. The exrare.

A carefa restrictia headachnumber oftions, and diary will manageme

Medicatio

The best rtions. Indivhowever, weffective mrizatriptanlking or climbing stairs)

occur in succession

mic attack has been excluded.anagement. Medicina Universitaria. 2015.

ffectiveness is estimated to be between 30% and

reserved for those cases where there is a closeelationship between the dietary element imputednset of the crisis. There is no point in giv-rictive diet a priori. The idea of prohibitingption of specic food, like chocolate, cheese,ds, sausages, Chinese food, wine (especially red)m of alcohol, among others, is highly popu-perience in our center is that food trigger are

ul interrogatory is the best tool to indicateve diet. Therefore, it is mandatory to keepe diary where the patient must record the

attacks, intensity, time, response to medica-relationship to external events or foods. Thisgive us the parameters to make changes innt.

ns

esults of abortive treatment are with medica-idual sensitivity to a medication is unpredictable;e have probabilities of effectiveness. The mostedications are triptans, and within this group,

and eletriptan have the most favorable evidence.

Please management. Medicina Universitaria. 2015.http://dx

ARTICLE IN PRESS+ModelRMU-25; No. of Pages 5Migraine management 3

However, there is no way of predicting the result of a partic-ular medication in a particular patient. Furthermore, failureof one triptan does not predict the failure of another, thustrying out two or three different triptans may be justi-ed. Our protocol is to start with one of these two, totry it for they worketriptan. Ththe wafer tongue) ththe onset of the meding it; oncthem to wcrisis is noond hour (not disapption. The that: to cocompletelynitive symprobabilityas the rea24 h from abortive mheadachesthat the pamedication

Ergotama good oppatients. Ition/disappaddictive ing potentsupervise pcations to crisis is retions (two every half crisis abortare taken. period, or rebound haddiction. (four tablemedicationnext half aepisode.

Over-thmotu propications oror abort tthat it is ttion and tchronic onthe use, dThe same herbal medtheir use bciples thattreatment.

Table 2 Level of evidence for preventive medicines.

Level A: Medications with a well-established efciency(2 Class 1 clinical trials)A. Antiepileptics: Divalproex sodium, topiramate

ium Beta Tript

B: Mss 1 stideplafaxta blptan

C: Pdy)ACEIsARAs: candesartanAlpha agonists: clonidine, guaifenesinAntiepileptics: carbamazepinaBeta blockers: nebivolol, pindololntihistamines: cirpoheptadina

U: Insufcient or inadequate data to makeommendationsCarbonic anhydrase inhibitor: acetazolamideAntithrombotics: acenocoumarol, coumadin,otamideAntidepressants SISRs/SISNRs: uvoxamine,xetine

Antiepileptics: gabapentinTricyclics: protriptylineeta blockers: bisoprololCa channel blockers: nicardipine, nifedipine,odipine, verapamilVascular smooth muscle relaxants: cyclandelate

: Medications established as possibly/probablyffectiveEstablished as ineffective: lamotrigineProbably ineffective: clomipraminePossibly ineffective: acebutolol, clonazepam,umetone, oxcarbazepine, telmisartan

: angiotensin converting enzyme inhibitors; ARAs:tensin receptor antagonists; SISRs: selective inhibitors ofnin recovery; SISNR: selective inhibitors of serotonin andinephrine recovery.

important to keep in mind that the ideal objective ofent is not to use abortive medications, because there

more episodes. important not to mix ergotamines and triptans in theession of treatment. It is a paramount contraindica-at one must keep in mind.

ntive treatment

are publications of international guidelines fortive management of episodic migraines with medi-s. Table 2 shows the different groups of drugs with

Document downloaded from http://www.elsevier.es, day 18/08/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. This early online article has been reviewed, accepted and posted on the Web before copyediting.cite this article in press as: Marl A. Migraine.doi.org/10.1016/j.rmu.2015.05.001

at least 2 crises, and decide whether or notd. If they did not work, switch to a differente instruction to the patient is: take (or placeof rizatriptan or zolmitriptan over/under the

e medication as soon as the patient recognizesof a crisis. Keep in mind that the effectivenessication decreases with the interval before tak-

e the rst dosage of medication is taken we askait for an hour; if at the end of the hour thet over, take the second dose. If after the sec-an hour after the second dose), the crisis haseared, begin with a second, different, medica-concept of crisis disappearance is preciselympletely stop not only the pain (which should

disappear), but also the autonomic and cog-ptoms, etc. If residual symptoms persist, the

of recurrence is greater. Recurrence is denedppearance of a crisis in a period shorter thantreatment. It is important to remember that alledications, if used frequently, can cause rebound. Thus the need to keep track of any medicationtient may take, even if they are over-the-counters.ine is also effective and low-cost, making ittion for institutions with a high volume of

t has an effectiveness of 40---60% in pain reduc-earance. The main problem is that it is highly

and we must take all precautions when utiliz-ially addictive drugs: keep track of medication,rescriptions, and review results frequently. Indi-the patient are: initiate treatment as soon as acognized; start with 1 mg of the usual presenta-tablets of 0.5 mg) and give an additional 0.5 mghour until one of these three things occur: thes, the patient starts vomiting, or 6 tablets (3 mg)The consumption of more than 6 tablets in a 24 h16 (8 mg) in a week is the threshold to developeadaches, in addition to increasing the risk ofIf the episode ceases at, let us suppose, 2 mgts), and the pain returns within the following 24 h,

will be given to the patient as if it were then hour If longer, it will be considered as a new

e-counter medications are commonly utilized,rio, by patients. Many learn that certain med-

a combination of analgesics give them reliefhe crisis. The problem with self-medication ishe single most important factor for chronica-he transformation of an episodic migraine to ae. There will always be the need to investigateosage, frequency, etc. of such self-medication.principle applies with natural medications oricine. The physician should intentionally ask for

ecause there may be active pharmacological prin- can complicate the evolution or result of the

sodB. C.

Levelcla

A. Anven

B. BeC. Tri

LevelstuA. B. C. D. E. F. A

LevelrecA. B. picC. uoD. E. F. BG. nimH.

OtherineA. B. C. nab

ACEIsangioserotonorep

It istreatmare no

It issame stion th

Preve

There prevencationvalproateblockers: metoprolol, propranolol, timololans: frovatriptan

edications that are likely to be effective (1tudy/2 class 2 studies)ressants/SISRs/SISNRs/ATT: Amitriptyline,ine

ockers: atenolol, nadolols: naratriptan, zolmitriptan

ossibly effective medications (one class 2

: lisinopril

Please mhttp://dx

ARTICLE IN PRESS+ModelRMU-25; No. of Pages 54 A. Marl

their levels of evidence from the American Academy of Neu-rology guidelines, 1 that in general agree with the rest ofinternational organizations.

In our country there is no hard data on the effec-tiveness of medications in our population, however thereis some useful information. In 2005, the Headache StudyGroup of the Mexican Academy of Neurology publisheda consensuing experielower dosemented onLatin Amerdoses genelower. Regour group neurologistmigraines.2

Non phar

As mentionering factonot very for excess ointense ligthe producan idea thas a risk ished respas in othehygiene.

Preventiv

In Table 2 tThe recom

1. Alwaysof cristoms, or advwithouresult scale con act

2. There preventhe nuWith twof medbeginnwith mular ctreatmonset other the on

3. Learn ably fr

4. Consider comorbidities. Rule out if the patient ishypertensive, suffers from asthma, anxiety, depression,obesity or other conditions that may indicate or con-traindicate a specic medication.

5. Encourage the patient to comply with non-pharmmeal s

cessgientableciishinand

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Document downloaded from http://www.elsevier.es, day 18/08/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. This early online article has been reviewed, accepted and posted on the Web before copyediting.cite this article in press as: Marl A. Migraine.doi.org/10.1016/j.rmu.2015.05.001

s on the management of migraines. Combin-nces, we proposed that our population requireds than those published. This data has been com-

international meetings and our colleagues inica and Spain concur with the impression that therally needed in our respective populations arearding the preferences of medications, in 2008conducted a national survey on the behavior ofs and neuropediatricians in the management of

macological treatment

ed above, one must identify the individual trigg-rs, should there exist. Even though they arerequent, they can be: dietary elements, lackf sleep, irregular meal times, and exposure to

ht. The causal relationship between stress andtion of a crisis is hard to prove, even if it isat sounds good. Obesity has been provenfactor for migraine chronication and dimin-onse to medication. Thus it is recommended,r situations, to comply with general rules of

e medications

here is a list of medications with better evidence.mendations for non-neurologists are:

keep a headache diary recording the numberes, intensity, duration, time, associated symp-triggers, effect of used medications, unwantederse effects, need of rescue medication and dayst pain. It is fundamental in order to assess theof the treatment. Aside from this, the MIDASan be used to assess the impact of the diseaseivities of daily living.are no specic guidelines or criteria to start ative treatment. In general, we take into accountmber of crises and the impact on quality of life.o or more crises per month the risk/benet ratioications is considered satisfactory to justify theing of treatment. In some people (i.e. womenigraines associated with menstruation and reg-

ycles) we are able to begin short preventiveents, three days before and after the expectedof the crisis, in each cycle. The same happens intypes of headaches where we are able to predictset of a crisis.to manage two or three medications well. Prefer-om two different groups.

exhy

6. Esspplabbeth

7. ThduIntrfo3 tomm

8. Ataba bewsoen

9. Atan

10. Wtoicthbea mep

11. In(mdo

Migsometconcepconditetc.), minedpay ato cobe accooper

Con

The auanagement. Medicina Universitaria. 2015.

acological measures: enough sleep, regularchedules, weight loss, regular exercise, avoidinges of food, drinks and alcohol and other generale measures.ish, along with the patient, a treatment plan withc measurable goals and commit him to accom-g them. The incidence of non compliance oronment of treatments is high and should alwaysestigated in each visit, since it may be a cause ofeutic failure.is not a guideline or specic evidence on then of a successful treatment. The intervals vary.

national survey, most neurologists and pedia-s considered maintaining a successful treatment8 months. However, there were responses from2 months. In general, a treatment is plannedt 8 months without a crisis. The rst twos are useful to assess the effectiveness of theation.

beginning of treatment we know there is a prob- of effectiveness. We must maintain the use ofication for at least two months at proper doses

deciding it is not working. A frequent cause ofment failure is not giving it enough time toThis should be clearly explained to the patientt he/she cooperates during this period and exert

patience. end of the planned period, stop the medicationserve. The rate of recurrence is 30---40%.the goal is zero crises, sometimes a few may beed, either because of low tolerability of the med-

or because the patient is reluctant to increasese. In these cases there are no specic num-bout the cure/recurrence rate after completingtment. We must explain to the patient thatnes are diseases that tend to recur in different

in life.e of recurrence after a successful treatments or years later), the most reasonable thing to

o restart the treatment which was useful.

s are a condition which can be controlled and, cured. We ought to understand that thef curing is similar to that of other chronicof difcult prognosis (rheumatics, oncological,ch is the absence of recurrence in a deter-od of time after treatment. The doctor shouldion to the details of the treatment in ordernicate to the patient what he is trying tolish, and thus be able to gain his trust andn.

of interest

has no conicts of interest to declare.

Please mhttp://dx

ARTICLE IN PRESS+ModelRMU-25; No. of Pages 5Migraine management 5

Funding

No nancial support was provided.

References

1. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C,Ashman E. Evidence-based guideline update: pharmacologic

treatment for episodic migraine prevention in adults. Report ofthe Quality Standards Subcommittee of the American Academyof Neurology and the American Headache Society. Neurology.2012;78:1337---45.

2. Marl-Rivera A, Marl-Garza BA, Ramrez-Monterrubio LE,Cant-Moreno D, Quintanilla-Muniz IJ. Patrones de conductateraputica de neurologos mexicanos en la migrana. Rev MexNeuroci. 2013;14:21---8.

Document downloaded from http://www.elsevier.es, day 18/08/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. This early online article has been reviewed, accepted and posted on the Web before copyediting.cite this article in press as: Marl A. Migraine.doi.org/10.1016/j.rmu.2015.05.001anagement. Medicina Universitaria. 2015.