2011 Current Medical Diagnosis & Treatment by Stephen J. McPhee & Maxine A. Papadakis & Michael W. Rabow

Author:Stephen J. McPhee & Maxine A. Papadakis & Michael W. Rabow
Language: eng
Format: epub
Publisher: McGraw-Hill
Published: 2011-06-14T16:00:00+00:00

Treatment

Management of migraine consists of avoidance of any precipitating factors, together with prophylactic or symptomatic pharmacologic treatment if necessary.

A. Symptomatic Therapy

During acute attacks, many patients find it helpful to rest in a quiet, darkened room until symptoms subside. A simple analgesic (eg, aspirin, acetaminophen, ibuprofen, or naproxen) taken right away often provides relief, but treatment with prescription therapy is sometimes necessary. To prevent medication overuse, use of simple analgesics should be limited to 15 days or less per month, and combination analgesics should be limited to < 10 days per month.

Cafergot, a combination of ergotamine tartrate (1 mg) and caffeine (100 mg), is often particularly helpful; one or two tablets are taken at the onset of headache or warning symptoms, followed by one tablet every 30 minutes, if necessary, up to six tablets per attack and no more than 10 days per month. Because of impaired absorption or vomiting during acute attacks, oral medication sometimes fails to help. Cafergot given rectally as suppositories (one-half to one suppository containing 2 mg of ergotamine) or dihydroergotamine mesylate (0.5–1 mg intravenously or 1–2 mg subcutaneously or intramuscularly) may be useful in such cases. Alternatively, prochlorperazine administered rectally (25 mg suppository) or intravenously (10 mg) may be prescribed. Ergotamine-containing preparations may affect the gravid uterus and thus should be avoided during pregnancy.

Sumatriptan, which has a high affinity for serotonin1 receptors, is a rapidly effective agent for aborting attacks when given subcutaneously by an autoinjection device (4–6 mg once subcutaneously, may repeat once after 2 hours if needed; maximum dose 12 mg/24 h). It can also be taken in a nasal form, but absorption is limited, and an oral preparation is available. Zolmitriptan, another selective serotonin1 receptor agonist, has high bioavailability after oral administration and is also effective for the immediate treatment of migraine. The optimal initial oral dose is 5 mg, and relief usually occurs within 1 hour; may repeat once after 2 hours. It is also available in a nasal formulation, which has a rapid onset of action; the dose is 5 mg in one nostril once and it may be repeated once after 2 hours. The maximum dose for both formulations is 10 mg/24 h. A number of other triptans are available, including rizatriptan (5–10 mg orally at onset, may repeat every 2 hours twice [maximum dose 30 mg/24 h]); naratriptan (1–2.5 mg orally at onset, may repeat once after 4 hours [maximum dose 5 mg/24 h]); almotriptan (6.25–12.5 mg orally at onset, may repeat dose once after 2 hours [maximum dose 25 mg/24 h]); frovatriptan (2.5 mg orally at onset, may repeat after 2 hours once [maximum dose 7.5 mg/24]); and eletriptan (20–40 mg orally at onset; may repeat after 2 hours once [maximum dose 80 mg/24 h]).

Eletriptan is useful for immediate therapy and frovatriptan, which has a longer half-life, may be worthwhile for patients with prolonged attacks. Triptans may cause nausea and vomiting. They should probably be avoided in women who are pregnant, in patients with hemiplegic or basilar migraine,

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