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  • Migraine Clinical Guidelines and Treatment - Migraine
    case the initial therapy fails The MIDAS and Headache Impact Test HIT tests can be useful for helping the doctor implement a stratified treatment plan More From This Section Prophylactic Treatments for Migraine Prophylactic Treatments for Migraine The role of prevention is to achieve a reduction in the frequency severity and duration of attacks Effective prophylaxis can achieve up to a 50 reduction in the frequency in approximately 50 of read more General Information on Triptan Therapy Triptan Therapy There are six Triptans available in Ireland Almotriptan 12 5mg orally Frovatriptan 2 5mg orally Sumatriptan 50mg 100mg orally 20mg 40mg intranasally mg subcutaneously on a named patient basis Zolmitriptan 2 5 g read more General Principles of Migraine Prophylaxis Migraine Prophylaxis There are no sound criteria for preferring one prophylactic drug over another However the following should be taken into account 1 Comorbidities 2 Drug interactions 3 Possible side effects 4 Lifestyle issues e g a read more Options in Migraine Prophylaxis Migraine Prophylaxis β Blockers The β Blockers have been used for prophylaxis for more than 25 years and continue to be a strong option unless contraindicated in patients with asthma or peripheral vascular disease Propranolol 80mg 160mg is read more Chronic Daily Headache Chronic Daily Headache Successful management of CDH depends on Identification of the cause of the CDH e g medication reliance co morbidities injury Commitment from patient and doctor There is no simple answer so a thorough approach to read more Cluster Headache Cluster Headache Acute Drug Treatment The goal of treatment for cluster headache is to decrease the pain severity and duration of each attack Early intervention is critical yet difficult since a single cluster headache can be as short as 15 read more Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Migraine Clinical Guidelines and Treatment In the absence of a cure for migraine the aims of migraine management at primary care level are The successful treatment of the migraineur s acute attack The prevention and limitation of future attacks To encourage migraine sufferers to continue with their care The identification and referral of the minority of patients who need specialist services The Stratified Care approach The Stratified Care approach is the approach of choice when treating headache disorders whereby the doctor decides what treatment is necessary based on the evidence for that treatment and the individual patient s needs Recent best practice guidelines on the management of migraine such as the Migraine in Primary Care Advisors MIPCA guidelines from the UK the US Headache Consortium and the Primary Care Network guidelines are based on the Stratified Care model Stratified Care has now largely superceded the stepped care approach which began with analgesics perhaps with an anti emetic for all patients regardless of headache impact severity or frequency and if those are not effective the patient is stepped up to the next level of treatment reserving the more powerful triptans as third line options Under a stratified approach Each patient should have

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/#usermessagea (2014-07-21)
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  • Acute Treatment of Migraine - Migraine
    of their migraine Therefore these patients should be prescribed a Triptan before trying drugs that are not as migraine specific Mode of Action The triptans have potent agonist activity at the 1B 1D receptor sites The specificity of these drugs to these receptors sites limits their side effect profile and make them well tolerated The triptans have three sites of action They cause vasoconstriction of the dilated meningeal dural extracerebral and pial blood vessels by stimulating the 5HT 1B receptors located on these blood vessels They inhibit the release of C G R P substance P and neurokinin from the periphereal end of the trigeminal nerve by stimulating the 5 HT 1d receptor sites located on the pre synaptic nerve terminals They have a high affinity for the 5 HT 1D located centrally in the region of the trigeminal nucleus caudalis in the brainstem This site of action modulates in coming nociceptive or painful sensory information from the periphery and inhibits its upward transmission to the thalamus and higher brain centres where pain is perceived Adverse Events Triptans are generally well tolerated The most common side effects with the triptans are paresthesias flushing fatigue nausea dizziness and feeling warm Chest and throat tightness occurs occasionally and is thought to be non cardiac in origin Contraindications Pregnant or lactating women Because of their vasoconstrictive properties triptans act on coronary blood vessels as well as meningeal arteries Therefore all of the triptans are contra indicated in patients with coronary disease cerebrovascular disease or untreated hypertension They should also be used with extreme caution in patients with risk factors for cardiovascular disease Patients with Hemiplegic Migraine or Basilar Migraine two rare forms of migraine thought to be associated with excessive cerebral vasoconstriction Home Health Professionals and Migraine Acute Treatment of Migraine Acute Treatment of Migraine Acute Treatment of Migraine In acute therapy the key concerns to be addressed from the patient s perspective are The efficacy of the treatment The time to onset of action The consistency of response form one attack to the next The tolerability of the medication The two main options in the acute treatment of migraine are Analgesics NSAIDs and Triptans Analgesics NSAIDs Up to 1 3 of migraineurs effectively manage their attacks without needing to consult their GP Paracetamol aspirin or ibuprofen can be effective for some patients with mild moderate migraine although the data suggests that their efficacy is limited to about 1 3 of patients Analgesics are more effective if taken early in the headache phase Although generally well tolerated frequent use can lead to the development of Analgesic Rebound Headache Simple analgesics can be combined with other medications to improve their efficacy in migraine treatment If nausea is a symptom then the concomitant use of the pro kinetic drugs Domperidone or Metoclopramide will relieve the nausea and also prevent the gastric stasis associated with migraine which can slow absorption Combination analgesics containing caffeine or codeine are also effective for some but there is an inherent

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/acute-treatment-of-migraine/#usermessagea (2014-07-21)
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  • General Information on Triptan Therapy - Migraine
    to predict who will or will not respond Failure with one Triptan does not necessarily mean that the patient will not benefit from another in the family An evaluation of each patient as to his or her clinical needs should drive the choice of Triptan Evaluation of efficacy for a particular patient should be based over three consecutive attacks with the aid of a migraine diary Patients with Nausea Although oral administration is the simplest it may not be appropriate for many of the 70 of migraineurs who have associated nausea and vomiting When taken intranasally or subcutaneously Triptan onset of action may be as fast as fifteen minutes Alternatively an oral Triptan can be taken with 10 mg metoclopramide to encourage absorption Rebound Headache Medication induced headaches can result from overuse of triptans but are less likely to result from triptans than analgesics or ergotamine If a patient is taking a Triptan more often than three days per week Triptan therapy should be discontinued and replaced by preventive therapy A Note on Ergotamine Since Triptans have a more favourable side effect profile they have now largely replaced ergotamine as a first line migraine treatment Ergotamine is a vasoconstrictor that specifically counteracts the dilation of some arteries and arterioles primarily the branches of the external carotid artery It has also been closely linked to Rebound Headache For these reason it can no longer be recommended as an alternative to the Triptans Please remember that all information contained on the migraine ie website is intended for informational and educational purposes The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment General Information on Triptan Therapy General Information on Triptan Therapy Triptan Therapy There are six Triptans available in Ireland Almotriptan 12 5mg orally Frovatriptan 2 5mg orally Sumatriptan 50mg 100mg orally 20mg 40mg intranasally mg subcutaneously on a named patient basis Zolmitriptan 2 5 g orally conventional and orally disintegrating formulation Naratriptan 2 5mg Eletriptan 40mg Meta analysis has confirmed that although minor variations exist among the Triptans in terms of efficacy and tolerability no one Triptan is substantially superior to another especially in oral format For reasons that are unclear some patients respond better to one Triptan than another so it is important to be familiar with them all as well as the different formulations available Almotriptan Almogran Available in a 12 5mg dose Almotriptan has few drug interactions and a low adverse event profile It also has a low headache recurrence rate The drug s onset of action is similar to that of sumatriptan Frovatriptan Frovex Frovatriptan is a long duration Triptan with a half life of approximately 25 hours It also has a lower headache recurrence rate than the other triptans However its onset of action is slower than that of the shorter duration triptans Frovatriptan may be

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/general-information-on-triptan-therapy/#usermessagea (2014-07-21)
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  • Prophylactic Treatments for Migraine
    other headache disorders Latest News Latest News and Research from the Migraine World 17th July 2014 Read our submission on chronic migraine and medical card eligibility 14th July 2014 Loss of funding may cost MAI one third of staff 26th June 2014 Take this important survey on chronic migraine and medical card eligibility View All News Become a Member Sign up or Log in Events Upcoming Events from the MAI No events View All Events Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Prophylactic Treatments for Migraine Prophylactic Treatments for Migraine Prophylactic Treatments for Migraine The role of prevention is to achieve a reduction in the frequency severity and duration of attacks Effective prophylaxis can achieve up to a 50 reduction in the frequency in approximately 50 of migraineurs Prophylaxis cannot be expected to eliminate migraine completely It is thought that while about 50 of all people with migraine are candidates for prophylaxis only about 10 are actually on a preventative medication Indications for Prophylaxis Prophylaxis is indicated in patients who Experience two or more attacks per month and do not respond satisfactorily to acute therapy Suffer from concomitant co morbidities Suffer from a medical illness precluding first line acute therapy Suffer attacks that significantly interfere with the patients daily routine Demonstrate regular patterns to their attacks Experience long duration attacks Have Basilar or Hemiplegic migraine Are at risk of Medication induced headache from over use of acute treatments Mode of Action of Prophylactic Agents The preventative therapies are thought to mediate their benefit by antagonism of central serotonergic receptors by regulation of calcium ion channels and by enhancement of central antinociceptive mechanisms This results in raising the threshold for both cortical spreading depression and trigeminovascular activation Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Prophylactic Treatments for Migraine Prophylactic Treatments for Migraine Prophylactic Treatments for Migraine The role of prevention is to achieve a reduction in the frequency severity and duration of attacks Effective prophylaxis can achieve up to a 50 reduction in the frequency in approximately 50 of migraineurs Prophylaxis cannot be expected to eliminate migraine completely It is thought that while about 50 of all people with migraine are candidates for prophylaxis only about 10 are actually on a preventative medication Indications for Prophylaxis Prophylaxis is indicated in patients who Experience two or more attacks per month and do not respond satisfactorily to acute therapy Suffer from concomitant co morbidities Suffer from a medical illness precluding first line acute therapy Suffer attacks that significantly interfere with the patients daily routine Demonstrate regular patterns to their attacks Experience long duration attacks Have Basilar or Hemiplegic migraine Are at risk of Medication induced headache from over use of acute treatments Mode of Action of Prophylactic Agents The preventative therapies are thought to mediate their benefit by antagonism of central serotonergic receptors by regulation of calcium ion channels and by enhancement of central antinociceptive mechanisms This results in raising the threshold for both cortical spreading depression

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/prophylactic-treatments-for-migraine/#usermessagea (2014-07-21)
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  • Migraine Prophylaxis
    eligibility 14th July 2014 Loss of funding may cost MAI one third of staff 26th June 2014 Take this important survey on chronic migraine and medical card eligibility View All News Become a Member Sign up or Log in Events Upcoming Events from the MAI No events View All Events Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment General Principles of Migraine Prophylaxis General Principles of Migraine Prophylaxis Migraine Prophylaxis There are no sound criteria for preferring one prophylactic drug over another However the following should be taken into account 1 Comorbidities 2 Drug interactions 3 Possible side effects 4 Lifestyle issues e g a preventative that lead to weight gain may not be the best option in young women with a tendency to gain weight A once daily dose can help improve patient compliance Start low and go slow To minimise possible side effects patients should be started on the lowest dose of a prophylactic medicine and increased gradually if required Allow an adequate time for the drug to show benefit An appropriate trial length for most preventive medications is 8 to 12 weeks Patients should be maintained on preventatives for at least 6 9 months before reduction and gradual withdrawal is considered As with acute treatments many patients will not respond well to certain medications and responses cannot be predicted Patients should keep a Migraine Diary to record of the frequency severity and duration of attacks and of medications consumed for each attack This is the most reliable way to know if the preventive medication is having the desired effect Remember that while on a course of prophlyactic treatment patients still need to have access to an effective acute treatment to deal with breakthrough attacks Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment General Principles of Migraine Prophylaxis General Principles of Migraine Prophylaxis Migraine Prophylaxis There are no sound criteria for preferring one prophylactic drug over another However the following should be taken into account 1 Comorbidities 2 Drug interactions 3 Possible side effects 4 Lifestyle issues e g a preventative that lead to weight gain may not be the best option in young women with a tendency to gain weight A once daily dose can help improve patient compliance Start low and go slow To minimise possible side effects patients should be started on the lowest dose of a prophylactic medicine and increased gradually if required Allow an adequate time for the drug to show benefit An appropriate trial length for most preventive medications is 8 to 12 weeks Patients should be maintained on preventatives for at least 6 9 months before reduction and gradual withdrawal is considered As with acute treatments many patients will not respond well to certain medications and responses cannot be predicted Patients should keep a Migraine Diary to record of the frequency severity and duration of attacks and of medications consumed for each attack This is the most reliable way to know if the preventive medication is having

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/general-principles-of-migraine-prophylaxis/#usermessagea (2014-07-21)
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  • Migraine Prophylaxis - Migraine
    adverse effects increased appetite with associated weight gain and drowsiness Tricyclic Anti Depressants Low dose tricyclic anti depressants such as Amitriptyline have shown continued efficacy in migraine prophylaxis for several decades and are most beneficial in those who suffer from concurrent tension type or chronic daily headache and in those for whom migraine and depression are co morbid Antidepressant therapy also may prove helpful in patients refractory to other standard forms of treatment The effective dose range is 20mg to 75mg per day Side effects include dry mouth drowsiness arterial hypotension and urinary retention Contraindications for their use are glaucoma prostatism and heart disease They should also not be used with drugs that inhibit monoamine oxidase or with medications that slow the brain s processes Epinephrine should not be used with amitriptyline since the combination can cause severe high blood pressure Calcium Antagonists Flunarizine Flunarizine has a long half life and is a good alternative if β blockers are contraindicated The dose is 5 10mg daily at bedtime and is frequently prescribed for patients with prolonged aura or for patients who frequently awaken with migraine Side effects can be severe and include sedation and Parkinsonian symptoms after long term use due to anti dopaminergic actions Other side effects include weight gain edema constipation and depression Verapamil The suggested dose range of Verapamil is 180 to 320 mg per day The rationale for using these agents stems from their effect on intracranial vasoconstriction In addition to this marked selectivity verapamil has also demonstrated antiplatelet effect Verapamil may reduce the elimination and increase the blood levels of carbamazepine simvastatin atorvastatin and lovastatin This can lead to toxicity from these drugs Drugs with limited and or unproven efficacy Clonidine SSRIs NSAIDs Cyproheptadine Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Options in Migraine Prophylaxis Options in Migraine Prophylaxis Migraine Prophylaxis β Blockers The β Blockers have been used for prophylaxis for more than 25 years and continue to be a strong option unless contraindicated in patients with asthma or peripheral vascular disease Propranolol 80mg 160mg is the preferred dose and can be titrated up to 320mg Propranolol has been shown to lead to a 50 reduction in attack frequency in 35 60 of patients though it has no impact on the severity or duration of attacks that actually occur It may take 12 weeks at an adequate dose to begin to work Propranolol is lipophilic crosses the blood brain barrier and has actions at adrenergic nonadrenergic and 5 HT2 receptors Other β Blockers known to confer benefit are Atenolol and metoprolol β Blockers are contraindicated in patients with depression asthma type 1 diabetes heart block and hypotension They are all generally well tolerated Side effects can include fatigue arterial hypotension impotence decreased endurance and depression Anti Convulsants Topiramate In 2004 Topiramate was licensed in Ireland for migraine prophylaxis in adults unresponsive to or intolerant of other treatments The recommended total daily dose of topiramate for prophylaxis of migraine is 100 mg

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/options-in-migraine-prophylaxis/#usermessagea (2014-07-21)
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  • Chronic Daily Headache - Migraine
    is considered the lifeline to a normal life Gradual tapering off the offending medication e g 10 weekly reduction in the consumption of the medication is usually easier than abrupt withdrawal and compliance is more likely Patient Doctor Dialogue To encourage compliance the patient needs to be made aware that it may take a few months of being off the offending medications before CDH will improve The patient must also be told that the headaches are likely to worsen in the short term if an abrupt withdrawal is initiated Using a diary will also provide key information in the management of CDH Prophylaxis Prophylactic treatments such as Amitriptyline Gabapentin or Topiramate can also be prescribed but only after a detoxification programme is underway Otherwise the preventive drug is unlikely to be beneficial Standard migraine preventative drugs can be used in the prophylaxis of Transformed Migraine Acute treatment of breakthrough attacks The patient will also require a suitable acute treatment e g a Triptan if the daily headaches are accompanied by breakthrough migraine attacks If the patient has been overusing Triptans a prophylactic treatment plan is recommended instead Generally once a patient has overused a specific medication future treatment programmes should avoid that particular therapeutic class Co morbidities Co morbid conditions include stress anxiety and depression and are important predisposing risk factors If present anxiety and depression should be treated separately Non drug Measures Physiotherapy biofeedback or chiropractic may be useful to some patients especially those whose headaches are related to a history of head neck injury Massage and stress management may also benefit patients In some cases counselling may be used Botilinum Toxin has been suggested for CDH in recent years but its effectiveness has not yet been ascertained Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Chronic Daily Headache Chronic Daily Headache Chronic Daily Headache Successful management of CDH depends on Identification of the cause of the CDH e g medication reliance co morbidities injury Commitment from patient and doctor There is no simple answer so a thorough approach to the patient is highly recommended Managing patients with chronic headache disorders especially those not attributable to medication overuse often demands intensity beyond the scope of general primary care teams Some patients with CDH also require interdisciplinary treatment from a variety of medical specialists and in extreme cases they may require hospitalisation Medication Overuse Headache Withdrawal In cases where the patient is clearly overusing acute medications then the medication must be stopped This can be frightening to the patient because the medication is considered the lifeline to a normal life Gradual tapering off the offending medication e g 10 weekly reduction in the consumption of the medication is usually easier than abrupt withdrawal and compliance is more likely Patient Doctor Dialogue To encourage compliance the patient needs to be made aware that it may take a few months of being off the offending medications before CDH will improve The patient must also be told that the headaches are

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/chronic-daily-headache/#usermessagea (2014-07-21)
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  • Cluster Headache-Migraine
    or two cluster attacks per day Cluster attacks usually respond within 10 15 minutes Smaller doses of two to three mg may also be enough to relieve the attacks It should be used with a prophylactic so as to avoid dependency Intranasal sumatriptan 20 mg has been shown to have some efficacy but is generally regarded as not being as effective as the subcutaneous injection Note that subcutaneous sumatriptan is available on a named patient basis only Prophylactic Drug Treatment The two main goals of preventive treatment for cluster are To rapidly suppress individual attacks Maintain that remission throughout the patient s typical cluster period Verapamil Verapamil is the gold standard in the treatment of Cluster Headache Treatment can be initiated at 120 mg daily and titrated up to 480 mg a day Side effects are rare but constipation is common Other side effects include dizziness nausea edema bradycardia fatigue and hypotension Corticosteroids Prednisone 60mg a day and Dexamethasone 4 8mg a day are fast acting transitional prophylactic drugs that are used usually in specialist centres for Cluster headache prophylaxis Side effects include insomnia restlessness hyponatremia edema hyperglycemia osteoporosis myopathy and gastric ulcers The use of corticosteroids is discouraged in the long term in patients with chronic cluster headaches because the incidence of side effects increases with prolonged use Lithium Sometimes used in specialist centres Lithium carbonate has been shown to be effective against episodic and chronic cluster headaches Of cluster headache patients 78 of patients with chronic clusters and 63 of patients with episodic clusters respond to lithium The usual daily dose ranges from 600 to 900 mg in divided doses Side effects might include tremor polyuria and diarrhea Nephrotoxicity and hypothyroidism can occur with long term use Home Health Professionals and Migraine Migraine Clinical Guidelines and Treatment Cluster Headache Cluster Headache Cluster Headache Acute Drug Treatment The goal of treatment for cluster headache is to decrease the pain severity and duration of each attack Early intervention is critical yet difficult since a single cluster headache can be as short as 15 minutes Non oral routes of administration for medications are therefore preferable Oxygen Oxygen inhalation is the first line therapy for cluster headache Treatment is initiated with 100 oxygen at max flow rate of 7 to 10 liters per minute Treatment should continue for 15 minutes Although up to 70 of patients experience relief within five to ten minutes some patients report that oxygen suppresses rather than aborts the attack and that pain may return There are no side effects with this treatment Sumatriptan Sumatriptan 6 mg administered subcutaneously is an effective acute treatment for episodic and chronic cluster headaches but it is most useful for patients who report one or two cluster attacks per day Cluster attacks usually respond within 10 15 minutes Smaller doses of two to three mg may also be enough to relieve the attacks It should be used with a prophylactic so as to avoid dependency Intranasal sumatriptan 20 mg has been shown

    Original URL path: http://www.migraine.ie/health-professionals-and-migraine/migraineclinical-guidelines-and-treatment/cluster-headache/#usermessagea (2014-07-21)
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