Migraine

1. Acute treatment

The patient will need to determine which acute treatment, either single drug or combination of medication, is most effective. Ensure adequate anti-nausea medication provided.

a) Simple analgesics: consider initially: 2 Paramax or  2 Paracetamol Rapid or 2 Panadol Extra taken as early as possible, with or without NSAID or aspirin (Ibuprofen 400 – 800mg, Naproxen sodium 550 – 825mg, Diclofenac short acting 50 – 100mg or 100mg suppository or aspirin 900 – 1000mg).

b) Triptans: Sumatriptan 50 – 100mg orally, Maxalt 10mg wafer, or Sumatriptan 6mg subcutaneously.

The triptan may be taken with Paramax, Paracetamol, NSAID or aspirin if this combination is more effective than the triptan alone.

The triptan should still be effective if taken later in the course of the migraine as long as it is adequately absorbed if taken orally (note: Maxalt is not absorbed through buccal mucosa but through normal gastric absorption).

Do not use more than 2 doses of subcutaneous Sumatriptan, 3 doses of oral Sumatriptan (300mg), 3x Maxalt in 24 hours.

c) Others: if triptans not tolerated or ineffective, consider Cafergot, Tramadol or Codeine Phosphate.

Note: Avoid simple analgesics on more than 15 days per month and avoid triptan/Cafergot on more than 8 – 10 days per month to prevent medication overuse headache. Consider preventive medication if high acute treatment use.

Note: Narcotics have a high rate of medication overuse headache in addition to dependence and their use should be kept to a minimum.

2. Preventive treatment

Consider potential side effects and concurrent medical problems when choosing a drug. Usual trial is for 3 months.

a) Betablockers: if no asthma: Propanolol 10 – 160mg/day or Nadolol 40 – 160mg/day.

b) Nortriptyline: beginning with 10 - 12.5mg at night and increasing every 5 - 7 days as required / tolerated to 100mg nocte.

Note: patients should be encouraged to increase slowly and continue for 3 to 6 months as benefit may be greater after 3 to 6 months of treatment.

c) Topiramate: 25mg nocte for 1 - 2 weeks, increasing by 25mg each 1 – 2 weeks to 50mg bd. Maximum dose 200mg/day.

d) Sodium valproate: 200mg daily increasing by 200mg increments to max 1000mg bd.

e) Sandomigran: 0.5 – 3mg nocte.

Less convincing evidence that Gabapentin, Lamotrigine or SSRIs are effective in migraine prevention. Discuss lifestyle factors, particularly the role of stress in exacerbating headache. Avoid excessive caffeine and alcohol. Regular exercise can help headache and stress. Dietary factors should be considered but are rarely consistent triggers. Regular meals and adequate sleep are important.

 NB: Brain imaging is not required in longstanding intermittent migraine.

Tension-type Headache

Often associated with a high level of daily niggle/stress. Component of muscle tension considered present.

Often respond to simple analgesics but avoid overuse (no more than 15 days per month).

Consider prevention if frequent medication use:

Nortripyline starting at 10 – 12.5mg nocte, increasing if required / tolerated to 100mg nocte.

A simple headache diary recording headache and medication use is very helpful in managing headache.

Note: Full information on dosage and side effects has not been provided and will need to be obtained by the prescribing doctor.