Which medications are used in the treatment of acute migraine?
Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications. Headache. 2012;52(3):467–482. doi: 10.1111/j.1526-4610.2012.02097.x.
What is the objective of the acute treatment of migraine?
The main objective of the acute treatment of migraine is to decrease functional disability through the reduction of attack duration and severity.
What is the best triptan for migraine?
In general, triptans are indicated for the treatment of moderate-to-severe migraine attacks [82]. Subcutaneous injection of sumatriptan 6 mg has the lowest number needed to treat (NNT) for any triptan formulation. Among the oral triptans, eletriptan 40 mg and rizatriptan 10 mg conferred the highest pain-free rates at 2 h.
Are opioids overprescribed for migraine treatment?
Opioids have utility in migraine treatment, but they are often overprescribed, which may be hurting patients. Stephen Silberstein, MD, FAHS says a lack of physician education is to blame
What NSAIDs are used for migraines?
[ 22, 23; Class IV]. Most single-agent NSAID studies were performed about 10 years ago or earlier. Among the NSAIDs, aspirin, ibuprofen, naproxen sodium, tolfenamic acid, diclofenac, ketoprofen, piroxicam, and the combination of acetaminophen and aspirin plus caffeine have been reviewed as demonstrating the most consistent evidence of efficacy for acute migraine [ 23, 24; Class IV]. The data are strongest for ibuprofen, naproxen, aspirin, aspirin-acetaminophen-caffeine, and the dissolvable version of diclofenac [ 25, Class I].
What is the best medication for migraine?
According to evidence-based guidelines, NSAIDs and triptans are the most effective acute therapies for attacks of migraine in adults [ 12, 13; Class I]. Although listed as first-line therapy, NSAIDs have often been tried and have failed prior to the patient’s initial clinical consultation, but timing and dosing must be considered before confirming the failure of the entire class. Seven triptans are approved by the US Food and Drug Administration (FDA) and currently marketed for the acute treatment of migraine. All are approved for adults; only almotriptan has received approval for adolescent migraine. No triptans are yet approved for children. The triptan class is preferred to alternatives because of its favorable side-effect profile and neurovascular-specific mechanism of action [ 14 •, Class IV]. Although the triptans are pharmacologically diverse, it has been difficult to establish that differences between them translate into predictable distinctions in clinical efficacy, consistency, tolerability, or safety [ 15, Class IV].
How long does migraine last?
By definition, such attacks last between 4 and 72 h without treatment, with the disability arising from a variety of factors including severe pain, gastrointestinal symptoms such as nausea or vomiting, and sensory sensitivities to light, noise, or odor. All these features may be exacerbated by stimulation, motion, or activity, often rendering the patient completely immobile. Although retreat and rest, coupled with local application of ice, may provide some measure of comfort, most of those with migraine hunt for therapeutic solutions. In designing acute headache treatment strategies, it is imperative for clinicians to recognize the variability between individuals in the frequency, intensity, and duration of attacks. Certain patients require more aggressive options. It is also crucial to identify the significant intra-individual variability of migraine; most patients describe an assortment of headaches of different intensities and time to disability. Less intense episodes, which patients often term sinus, tension, or regular headaches, usually represent milder versions of migraine, simplifying both diagnostic and therapeutic approaches. Evidence-based guidelines and clinical experience support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of mild to moderate migraine attacks. Recommend migraine-specific agents (triptans and dihydroergotamine) when the attacks are more severe or have consistently failed to respond to the use of NSAIDs in the past. Encourage those with less frequent episodic migraine to use their acute agents at the earliest signs of headache. Advise those with frequent headache (>10 days per month) to limit acute treatments to only the most disabling episodes in order to avoid the “medication overuse” phenomenon. Consider rescue or back-up therapy. Do not use compounds containing butalbital or opiates (or place extreme limits on them), out of concern for progression to chronic migraine.
Is naproxen sodium effective for migraines?
A meta-analysis of over-the-counter naproxen sodium reported that the available evidence suggests that it is more effective than placebo in the acute treatment of moderate to severe migraine. It is effective in reducing headache intensity, resolving pain completely at 2 h, and improving migraine-associated symptoms. However, its effectiveness relative to other active comparators needs to be better defined by appropriate head-to-head clinical trials [ 27, Class I].
Is ketoprofen a dual release?
Oral ketoprofen (75 mg or 150 mg) in a dual-release formulation is an effective and well-tolerated drug for the acute treatment of migraine attacks [ 42, Class I]. Both doses compared favorably with zolmitriptan.
How long does migraine last?
By definition, such attacks last between 4 and 72 h without treatment, with the disability arising from a variety of factors including severe pain, gastrointestinal symptoms such as nausea or vomiting, and sensory sensitivities to light, noise, or odor. All these features may be exacerbated by stimulation, motion, or activity, often rendering the patient completely immobile. Although retreat and rest, coupled with local application of ice, may provide some measure of comfort, most of those with migraine hunt for therapeutic solutions. In designing acute headache treatment strategies, it is imperative for clinicians to recognize the variability between individuals in the frequency, intensity, and duration of attacks. Certain patients require more aggressive options. It is also crucial to identify the significant intra-individual variability of migraine; most patients describe an assortment of headaches of different intensities and time to disability. Less intense episodes, which patients often term sinus, tension, or regular headaches, usually represent milder versions of migraine, simplifying both diagnostic and therapeutic approaches. Evidence-based guidelines and clinical experience support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of mild to moderate migraine attacks. Recommend migraine-specific agents (triptans and dihydroergotamine) when the attacks are more severe or have consistently failed to respond to the use of NSAIDs in the past. Encourage those with less frequent episodic migraine to use their acute agents at the earliest signs of headache. Advise those with frequent headache (>10 days per month) to limit acute treatments to only the most disabling episodes in order to avoid the "medication overuse" phenomenon. Consider rescue or back-up therapy. Do not use compounds containing butalbital or opiates (or place extreme limits on them), out of concern for progression to chronic migraine.
What is a chronic headache?
Opinion statement: Chronic daily headache (CDH), defined as a primary headache occurring at least 15 days per month, is a problem of worldwide scope, which is seen in 3% to 5% of the population. Though it has been recognized since ancient times, only recently have there been attempts to define and classify it. CDH usually consists of a mixture of migraine and tension-type headaches (TTH), with the more severe headaches having migraine features and the less severe headaches fitting the definition of TTH. Some patients have pure chronic TTH and no migrainous features, and others have only migraine, but most have a mixed migraine-TTH pattern. New daily persistent headache, a CDH pattern that comes on over a few days, constitutes 9% to 10% of this group and is otherwise indistinguishable from CDH. Hemicrania continua (1% of CDH) appears to be unique in being absolutely responsive to indomethacin. Accurate diagnosis of CDH is critical to management, as all organic etiologies of chronic headache must be ruled out. Problems often associated with CDH and complicating the diagnosis are head injury or medication overuse (rebound-withdrawal headache). These accompanying issues must be recognized and treated appropriately in the management plan. Finally, psychiatric problems (unipolar depression, bipolar disease, generalized anxiety disorder, and obsessive/compulsive disorder) often accompany CDH, as they are comorbid with migraine. These conditions must be recognized and treated along with the headache itself for treatment to succeed fully. Treatment of CDH is multimodal. The cornerstone of therapy is the use of prophylactic antimigraine medications to prevent or modulate the next headache. Amitriptyline, topiramate, valproic acid, and gabapentin have all had class I studies showing effectiveness in reducing headache occurrence. Recent studies with botulinum toxin have also shown effectiveness in reducing the headache burden. Recognition and treatment of medication overuse headache (MOH) must be carried out as part of the initial approach. Use of acute symptomatic treatments such as triptans or NSAIDs must be undertaken with care, as frequent use of these agents can lead to MOH. Educating the patient about the condition and reasonable expectations for therapy is essential to success. Recognition and appropriate treatment of psychiatric disorders is likewise essential. Adjunctive nondrug therapies and lifestyle changes round out the requirements for a management plan. The chances for long-term remission or significant improvement are up to 65%. The patient and physician must understand that CDH is a long-term process with relapses and remissions. A strong and trusting relationship between patient and physician is a major asset in managing this condition.
Is sumatriptan effective for migraine?
To assess the long-term tolerability and efficacy of NP101, a novel transdermal sumatriptan patch being developed for the acute treatment of migraine. Nausea (with or without vomiting) and gastroparesis have been characterized as being among the most problematic challenges affecting migraine care today. Migraine-associated nausea can cause patients to delay or avoid taking oral medication with a resultant loss or reduction of therapeutic efficacy. Migraine-associated gastroparesis can impair absorption and reduce bioavailability of oral migraine medications and thereby reduce and delay therapeutic efficacy. The non-oral triptan formulations that have been used to overcome these challenges are associated with other shortcomings that can limit their use. Designed to overcome these shortcomings and treatment limitations imposed by gastrointestinal signs and symptoms, the NP101 patch avoids the need for oral administration, does not depend upon gastrointestinal absorption, and provides more consistent, predictable plasma concentrations than oral and intranasal formulations of sumatriptan and a lower maximum plasma concentration than sumatriptan injection. Patients diagnosed with migraine who had participated in a randomized, double-blind, Phase III study of the NP101 patch were given the option to use NP101 to treat migraine episodes with moderate or severe headache pain for up to 12 months in this open-label trial. One hundred eighty-three patients applied 2089 study patches. The most common adverse events involved the patch application site (45% of patients). The only non-application-site adverse events reported in >2% of patients were nausea (n=6, 3.3%), upper respiratory tract infection (n=6, 3.3%), and nasopharyngitis (n=4, 2.2%). The incidence of triptan-associated adverse events was 1.6%. Across all visits for investigator assessments, the majority of patients (ranging from 74.7% at Month 1 to 92.2% at Month 9) were scored as having no erythema at patch application sites. For patient assessments, the percentage of patch placement sites scored as having no or minimal redness was 38.2% at the time of patch removal and 65.4% 24 hours after patch activation. Two hours after patch activation across all patch treatments over the 12-month study, 23.8% of initial acute migraine episodes were scored as being free from headache pain, 58.2% as having headache pain relief,78.9% as nausea free, 60.1% as phonophobia free, 53.4% as photophobia free, and 20.7% as migraine free. No evidence of waning tolerability or efficacy was observed over the 12-month study period. NP101, a transdermal sumatriptan formulation in development for the acute treatment of migraine, demonstrated tolerability and efficacy with successive uses over 12 months in this clinical trial.
Is migraine a debilitating condition?
Migraine remains a common debilitating condition that exerts a high social and economic burden worldwide. Despite the widespread availability of various medications for migraine, many patients are dissatisfied with their treatment. Rapid and effective treatment at an early stage in an attack is vital in migraine to prevent central sensitization leading to attacks that are difficult to treat. Most migraineurs prefer oral medications but this is not always the most rapid or efficient route into the bloodstream. Intranasal administration of migraine treatment provides a rapid, convenient and reliable alternative to oral and other routes. AVP-825 is an intranasal medication delivery system approved by the US Food and Drug Administration in January 2016 as ONZETRA™ Xsail™ (sumatriptan nasal powder [Avanir Pharmaceuticals, Aliso Viejo, CA]) for the acute treatment of migraine with or without aura in adults. AVP-825 contains low dose sumatriptan powder and takes advantage of some unique aspects of the nasal anatomy to confer rapid pain relief in the acute treatment of migraine. In two Phase III trials, AVP-825 was well tolerated and showed significantly faster migraine pain relief and relief from other symptoms including photophobia, phonophobia, and nausea than placebo or oral sumatriptan. This benefit was achieved with substantially lower drug exposure than oral sumatriptan. Additional analyses of data from the Phase III trials show that significantly more patients with migraine receiving AVP-825 reported clinically meaningful relief, sustained relief, pain freedom, lower migraine-related disability and more consistent relief across multiple attacks than those receiving oral sumatriptan. The rapid and sustained action of AVP-825 and its convenience creates the potential for this unique treatment to reduce the burden of migraine in many patients.
Is chadiao powder safe for headaches?
Headache have been recognized as major causes of public ill-health, whereas there currently are the limitations of conventional therapies available. Chuanxiong Chadiao Powder (CXCP) is a well-known classic TCM herbal prescription with respect to treating headache for more than 1000 years. The objective of this study is to systematically assess the clinical efficacy and safety of CXCP for headache. A systematic literature search in four databases, up to May of 2014, was performed to identify randomized controlled trials (RCTs), which compared CXCP monotherapy or adjunct therapy with western conventional medicine (WCM) or placebo for headache. The primary outcome measures were headache frequency, headache duration, pain intensity scales, globe assessment, patients self report outcomes, and quality of life. The second outcome measures were the total clinical effective rate and adverse events. The methodological quality of RCTs was assessed independently based on the 7 criteria recommended by the Cochrane Back Review Group. A total of 3680 participants were included in 37 eligible studies. The methodological quality was generally poor and there was only one high quality trial. Meta-analyses of the studies found that significant effects of CXCP for improving headache frequency and headache duration and the total clinical effective rate compared with WCM or placebo control in treating headache (P<0.01). Adverse event monitoring was reported in 22 studies (59%), while the other 15 studies (41%) did not mentioned. The evidence from present study is supported but limited for CXCP clinical use in the management of headache because of methodological flaws. Larger sample-sizes and rigorously designed RCTs are required in the future. Copyright © 2015 Elsevier Ltd. All rights reserved.
What is the American Headache Society?
The Society’s objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Society’s work and find out how you can become a member today.
What is the role of being proactive in pain management?
Being proactive in your treatment regime can play a role in successful pain relief. Silberstein recommends patients develop an emergency department plan with their doctors so they are not given opioids unnecessarily or misjudged as “drug-seeking” and denied necessary care.
Can you take opioids while pregnant?
In those cases, opioids may be the only treatment option for relief from a severe headache. Pregnant women who experience frequent migraine attacks will often abstain from acute medication during pregnancy, and may be prescribed opioids under the supervision of their physician to provide occasional symptom relief.
Is triptan contraindicated for migraines?
That’s why it is crucial to ensure that both simple anal gesics and triptans are contraindicated before considering prescribing an opioid medication. These acute medications treat the source of the pain, not just the pain itself, and are less likely to induce migraine progression.
Can elderly take triptans?
Patients with a history of cardiovascular disease are unable to take triptans or NSAIDs due to their side effects: for this reason, triptans and NSAIDs are contraindicated for the elderly due to their increased risk for cardiovascular disease. In those cases, opioids may be the only treatment option for relief from a severe headache.
Can opioids be used for migraines?
For certain groups of patients with migraine, like the elderly and pregnant women who often avoid triptans or nonsteroidal anti-inflammatory drugs (NSAIDs), opioid medications could potentially be used for occasional pain management. But in today’s treatment landscape where migraine-specific medications that target the source of a patient’s symptoms are effective and available, opioids continue to be prescribed at unnecessarily high rates, a practice that can have devastating effects on individuals, according to Stephen Silberstein, MD, FAAN, FACP, FAHS, director of the Headache Center at Jefferson University Hospital.
How long should I take steroids for migraines?
These are usually given as a taper over three to six days. Dexamethasone has the greatest glucocorticoid potency of the three. Steroids should not be given for more than an average of three days per month. Particular caution is advised in patients with diabetes and precautions for bone health should be taken for patients who use steroids on a recurring basis.
Does dopamine cause nausea?
Dopamine is implicated in migraine pathogenesis. Symptoms such as yawning, mood changes, nausea, lightheadedness, and restlessness may be attributable to a surge of or hypersensitivity to dopamine. Neuroleptics have been shown to be effective in both the prodromal and acute stages of migraine, regardless of the presence of nausea. The strongest evidence exists for chlorpromazine, prochlorperazine, metoclopraminde, droperidol, and haloperidol. Some patients also derive benefit from the newer atypical neuroleptic olanzapine. All neuroleptics tend to be sedating, which limits their regular use. They may also cause acute dystonia or akathisia. Additionally, all but metoclopramide may prolong the QTc interval to varying degrees, thus necessitating baseline evaluation and monitoring if used frequently. Finally, patients need to be counseled on the risk of tardive dyskinesia and metabolic syndrome with ongoing use.
Is migraine a non-opiod?
Migraine is conventionally considered to be a non-opioid-responsive syndrome, and great concern is always present regarding the potential for abuse, addiction, and medication overuse headache. However, select patients may do well with occasional opioid usage, and for some, these are their only options. The strongest evidence exists for tramadol, meperidine, butorphanol, fentanyl, and codeine.Tramadol is particularly appealing due to its lower opioid potency, its additional mechanisms of serotonin and norepinephrine reuptake inhibition, and its reduced abuse potential. The ideal patient to receive opioids has no history of substance abuse or psychiatric illness, a limited need for pain medication, and contraindication or intolerance to other less problematic agents.