Making headway in migraine

Ciara Gavin presents a clinical overview of the characteristics of migraine, its effect on a patient’s quality of life and how the pharmacist can help to alleviate the symptoms

Migraine is a chronic, genetically-determined, episodic neurological condition.^1,2 About one-third of migraine sufferers experience transient neurological symptoms, known as auras — this group are referred to as ‘migraine with aura’ or ‘MA’,¹ although aura can occur without headache.² 

Migraines, although complex, are considered a common neurological condition.³ The World Health Organisation classified migraines as the seventh-most disabling disease worldwide, the fourth for women, and the sixth-highest cause of years lost due to disability worldwide.^3,4 As this statistic shows, female gender is a risk factor for migraines. Other risk factors include family history of migraine, high caffeine intake, and stress.^2,5 

Migraines can have the following features:⁶ 

• The pain can be located as unilateral or bilateral.

• The pain can be described as ‘pulsating’. 

• The intensity of the pain a person feels is considered moderate or severe.

• The pain is aggravated by routine activities of daily living.

• Usually, the patient will complain of sensitivity to light and/or sound, nausea and/or vomiting.

• A migraine headache typically lasts four-to-72 hours in adults.

• Can be episodic (occurring less than 15 days per month), or chronic (equal to or more than 15 days per month for more than three months).

Migraines with aura⁶ include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory symptoms, such as numbness and/or pins and needles; and/or speech disturbance.

Symptoms can occur with or without headache. These symptoms are:

• Fully reversible.

• Develop over at least five minutes.

• Last five-to-60 minutes.

Some women are affected by menstrual –related migraine.⁶ These migraines predominantly occur between two days before and three days after the start of menstruation in at least two out of three consecutive menstrual cycles.^2,6 

Acute treatment

Treatment options remain the same, whether treating a migraine with or without aura.

Combination therapy consisting of: 

• Oral triptan + an NSAID^6,7,8 (NSAID options include: Aspirin, ibuprofen 300-400mg up to four times a day, naproxen 500mg up to twice a day, diclofenac  50-to-75mg maximum of 150mg in 24 hours).

• Oral triptan + paracetamol.^6,7

• For patients who prefer monotherapy, then consider treatment with an oral triptan alone, NSAID, aspirin or paracetamol.^6,7

• Patients should consider an antiemetic in addition to other treatment, even in the absence of nausea and vomiting.⁶ Antiemetics are considered for their nausea and/or for the prokinetic effect, such as: Domperidone 10mg up to three times a day; Metoclopramide 10mg up to three times a day; or prochlorperazine 3-6mg as a buccal preparation (max 12mg/day) — unlicensed.^7,8 

• Do not offer ergots or opioids for the acute treatment of migraine.⁶ 

• For those who cannot tolerate oral preparations for the treatment of acute migraine, consider:

• Non-oral preparation of metoclopramide or prochlorperazine⁶ and a non-oral NSAID or triptan.⁶

Triptans

Triptans are 5HT 1B/1D receptor agonists. Their action is due to vasoconstrictive effects on blood vessels.⁷ There are seven triptans available in Ireland — these are: Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan.^7,8 

Triptans should be used at the start of the headache phase of a migraine, as there is no evidence of efficacy if taken during the preceding aura.⁷ Triptans can be associated with overuse headaches and therefore are reserved to be used no more than two days a week and no more than 10 days per month.^2,7 

The choice of triptan to use is dependent on cost, route, formulation available and patient-dependant factors. Patients’ response to triptans is a key factor; some patients may experience recurrence headaches within 24-to-48 hours and respond to a second dose, while others respond better to change in formulation.^2,7 

Example scenarios:

Patients suffering early nausea and vomiting may benefit from treatment with non-oral triptan formulations, such as:⁷ 

• Sumatriptan nasal spray 10mg, or

• Zolmitriptan 5mg nasal spray, or

• An orodispersible triptan formulation, such as zolmitriptan 2.5mg melts or rizatriptin 10mg wafers.

Patients may be suffering recurrence of headaches, therefore a longer-acting oral triptan may be more beneficial, ie:7 

• Naratriptan 2.5mg. 

• Almotriptan 12.5mg. 

• Frovatriptan 2.5mg. 

Information on triptans

The side-effects for triptans include dizziness, drowsiness, flushing and nausea.^7,8 The side-effects tend to be related to the speed of onset of medication action; therefore people taking subcutaneous sumatriptan report more adverse effects than oral sumatriptan. Triptans with longer half-lives and slower onset of action, ie, naratriptan and frovatriptan have fewer side-effects.⁷ Subcutaneous sumatriptan has the most rapid onset of action and greatest efficacy, but the most adverse effects.⁹

Dizziness and sedation occur more with rizatriptan and zolmitriptan than with sumatriptan and naratriptan.⁷ For specific information related to product side-effects, access the medications’ SPC. 

Triptans are not recommended in those with uncontrolled hypertension, cardiovascular and/or cerebrovascular disease due to the 5HT1B receptors present on vascular smooth muscles.⁷ 

Preventive therapy

Along with encouraging reduction of modifiable risk factors such as reduced stress and reduction in caffeine intake, patients should be encouraged to keep a headache diary in order to record the frequency, duration and severity of headaches, help identify triggers and assess the effectiveness of treatment.⁶ 

If a prescriber deems it necessary due to interference with quality of life, pharmacological prophylactic therapy can be considered. 

Treatment options include:

• Antiepileptic drugs:^6,11 Topiramate and valporate have been shown to reduce migraine frequency by 50 per cent in some cases.

• Antidepressants:^6,11 Amitriptyline has been shown to reduce migraine frequency by 50 per cent. 

• Beta blockers:^6,11 Propranolol and atenolol have been shown to be beneficial in migraine prevention.

• Some studies show the benefit of ACE and ARB inhibitors and calcium channel blockers  in migraine prophylaxis, including the more commonly-seen candesartan.¹¹