Preventative treatments

Transcription

1 Preventative treatments

2 Many migraine patients manage their condition very effectively with acute treatments (i.e. triptans and painkillers). However, these should not be taken more often than on two or three days each week. A single migraine attack can last between 4 and 72 hours and migraineurs might need to take maximum amounts of their chosen medication on each of these days. If this level of medication is required every week or for more than 15 days a month for 3 months or more, other options should be considered. Such a high intake of painkillers or triptan drugs can actually make matters worse and may lead to medication overuse headache. Scientists have now identified a genetic defect linked to migraine. A flawed gene found in a family of migraineurs could help trigger the severe headaches, a study in Nature Medicine suggests. This gene normally controls the levels of a brain chemical called glutamate, which acts as a chemical messenger transmitting signals between neurons in the brain. The defective gene in Chromosome 8 appears to lead to a build-up of glutamate at the junctions or synapses of the brain cells, which prolongs the nerve signals that can trigger the pain of migraine. The prospect of future developments in blocking the action of this gene and any others that are found is a very exciting new target for migraine treatments which will be specific and will help migraineurs in the years to come. For the 1 in 7 migraineurs in the UK, the threshold at which an attack is triggered is believed to be lower. This threshold can be raised or lowered by many different factors, both internal, such as hormonal changes, and external, such as weather conditions. When an individual s threshold is particularly low, fewer of his or her personal trigger factors are required to cause an attack. Preventative (prophylactic) medication is believed to raise this threshold. It is normally considered if the patient has very frequent or severe attacks, if attacks cause substantial disruption to their normal activities, considerably impairing their quality of life or if the patient particularly requests it. Most types of preventative medication bring a reduction in the frequency of attacks by around 50%. They may also reduce the severity and / or duration of the attacks that do still occur so that, in some cases, they can be treated with over-the-counter painkillers instead of prescription drugs. Preventative treatment seldom eliminates attacks entirely and a compatible acute treatment is still required. The choice of preventative treatment depends on many factors including the needs and wishes of the individual patient, their medical history, other medication they may be taking and the side effects that they may experience.

3 Preventative treatment needs to be taken daily, whether or not the patient has any migraine symptoms. Such treatments are not designed to treat individual attacks. If prophylaxis is to be effective, it must be: used for long enough. A course should be followed for 3-6 months. Many patients do not give it a fair chance. If they start on the course of treatment and a migraine occurs a few days later, they assume that it is not working; in fact, it can take several weeks to show full benefit. Some people stop taking their preventative medication after a few days because of the side effects. However, if you persevere the side effects often disappear or become less troublesome. taken at a regular time each day. It can be difficult to take medication every day, especially two or three times a day, when you are feeling perfectly well. A research project by Dr Steiner and colleagues at the Princess Margaret Migraine Clinic showed, by the use of a bottle with a time recording mechanism in the cap, that patients seldom remembered to take their medication at the same time every day; some missed several days. The patients who take their medication most irregularly are likely to derive the least benefit. in an adequate dose. Most GPs will normally initially prescribe the lowest therapeutic dose but this can be increased and adjusted to suit the needs of the individual. If a prescribed treatment seems to help a little and does not have any adverse side effects, a larger dose many be more effective. Conversely, if migraine is improved but the side effects are troublesome, the dose may be reduced. If preventative treatment is not effective all 3 of the above should be checked. If this is still the case after these issues have been addressed, the diagnosis of migraine needs to be re-checked.

4 Preventative treatments usually prescribed are: Beta blockers (e.g. propanolol, atenolol, metoprolol, nadolol and timolol) were originally developed for the treatment of high blood pressure, they have been found to be effective for migraine prophylaxis and are particularly helpful for migraineurs who have muscle tension, high blood pressure or suffer from stress. Side effects can include drowsiness, disturbed sleep, nightmares, cold extremities and tummy upsets. A low dose of beta blockers can be effective, e.g. 10mg is usually the starting dose for propanolol, but if needed this can be increased to a maximum of 240mg daily, divided over 3 doses. These drugs are not suitable for people who have asthma, obstructive airways disease, heart problems or circulation problems and should not be taken concurrently with ergotamine based drugs (e.g. cafergot, migril etc.). Propanalol should not be taken with 10mg tablets or wafers of Maxalt either. Serotonin receptor angonists act to prevent the release of serotonin into the bloodstream from its storage sites in the brain. The one usually prescribed is pizotifen (Sanomigran) and it can be particularly helpful for children or those with a poor appetite. The dosage is 0.5 to 1.5mg daily 2 hours before bedtime. Side effects can include drowsiness, increased appetite and weight gain. Methysergide (Deseril) is less frequently used because of the possibility of development of retroperitoneal fibrosis (scar tissue at the back of the abdomen). However, it can be very effective and retroperitoneal fibrosis can be avoided if a one month break is taken after each six months of treatment. Anti-depressants can be prescribed in low doses purely for the prevention of migraine so, if your doctor suggests them, it does not mean that you are depressed or neurotic. Amitriptyline is the one most frequently prescribed and it can be particularly helpful for migraineurs who do not sleep well or are depressed. The dosage is 10-50mg daily, 3 hours before bedtime. Selective serotonin reuptake inhibitors (SSRIs) are also sometimes prescribed (e.g. Seroxat, Prozac). Side effects may include drowsiness, dry mouth and nausea.

5 Anti-convulsants were originally developed to treat epilepsy, they have been found to also be effective, in low doses, for migraine prophylaxis. Topiramate (Topamax) is licensed for migraine prevention and available on prescription only. Trials have shown efficacy in reducing migraine attacks. Side effects include tingling / pins and needles, fatigue, nausea and diarrhoea. The initial target dose recommended is 50mg twice daily, but patients may experience improvement to symptoms at lower doses. There are two other drugs which are also commonly prescribed off license: sodium valproate (Epilim) which can be particularly beneficial for people who have other types of headache in addition to migraine; and gabapentin that is also sometimes prescribed and may be helpful for women whose migraine has worsened around the menopause. Some of the treatments mentioned can be combined if necessary e.g. amitriptyline and propanolol. Other drugs which are used for migraine prevention include: Clonidine (Dixarit) is less frequently used now but it can be particularly helpful for women whose migraine has worsened around the time of the menopause as it can also reduce hot flushes. Side effects include drowsiness and dry mouth. Calcium antagonists: Flunarizine is the drug for which there is the most evidence of efficacy but this is not available in the UK. Verapamil is sometimes prescribed and is most effective in treating familial hemiplegic migraine. Aspirin / non steroidal anti-inflammatory drugs (NSAIDS), taken daily in low doses (e.g. 75 mg aspirin daily), can also be helpful. However, the risk of gastro-intestinal bleeding needs to be considered.

6 BOTOX (botulinum toxin type A) has now been licensed in the UK as a preventative treatment for adults who have chronic migraine. To be eligible for this treatment, individuals need to experience headaches for 15 or more days per month, with migraine on at least 8 of these days. [ 1. ]. However, we know that doctors will also consider the impact that chronic migraine is having on your life, how disabled you are, if you are unable to work or if you suffer from other conditions that are common with chronic migraine, for example, depression, anxiety or other pain related conditions like arthritis or fibromyalgia. BOTOX is a generally well-tolerated and effective prophylactic (preventative) treatment for adults with chronic migraine. After treatment for nearly a year over 70% of people using BOTOX found that their headaches reduced by 50%, reducing days of headache from an average of nearly 20 per month to under 10. In the research trial, patients received up to 5 courses of BOTOX every 12 weeks. Reported side effects include headache, migraine, facial paresis (partial loss of movement), eyelid ptosis (drooping), pruritus (itching), rash, neck pain, musculoskeletal pain, musculoskeletal stiffness, muscle spasms, muscle tightness and muscular weakness and injection site pain. Side effects were mild to moderate and resolved without further problems.

7 The recommended BOTOX dose for treating chronic migraine is 155 U to 195 U administered intramuscularly (IM) using a 30-gauge, 0.5 inch needle as 0.1 ml (5 U) injections to between 31 and 39 sites. Injections are divided across 7 specific head / neck muscle areas as specified in the diagrams below. Unfortunately, just because a drug is licensed, doesn t mean that it will be readily available on the NHS. Some will argue that this isn t a high priority treatment, although headache specialists are keen to push to have this as an available headache treatment option. We hope that BOTOX will be more readily available on the NHS in the near future, it all depends on whether the NHS managers will allow some of their resources to be allocated to this area. Unfortunately some PCTs will fund the drug but not the doctor s clinic time currently.

8 Herbal remedies and vitamin or mineral supplements are also claimed to have migraine preventative properties. The ones for which there is some evidence of efficacy are: Butterbur (Petasites hybridus) is very toxic unless purified. It is a member of the asteraceae family and is a fleshy, extensively creeping plant, with a short root, growing somewhat slanted on the ground. A randomised, controlled trial of 245 patients with an average of 4.8 migraine days per month saw 68% of patients that took Petadolex 75mg twice daily improved their frequency and intensity of migraines by over 50%. The trial was conducted over 3 months in Long term safety appears okay for Petadolex but there is no data available for other preparations. [2.]. Feverfew (Tanacetum parthenium) is a herbal extract and the active ingredient is parthenolide. A 2006 study of 147 patients who experienced an average of 4.8 migraines per month found that their migraines decreased by 1.8 days per month on average. This was a ramdomised, controlled trial over a 3 month period and patients took 6.25mg of feverfew three times a day. However, feverfew was only positive for those patients who experienced more than 4 migraines per month. [3.]. Co-enzyme Q10 100mg three times per day showed very few side effects in a 2006 study of 42 patients and for 47% of patients it improved their migraines by over 50%. This was a ramdomised, controlled trial that was conducted over a 4 month period. [4.]. Vitamin B2 (riboflavin) 400mg per day also show very few side effects in a 1998 study of 80 patients. For 59% of patients their migraines improved by more than 50%. This was a ramdomised, controlled trial that was conducted over a 4 month period. [5.].

9 Magnesium 400mg per day: side effects from increased magnesium intake are not common because the body removes excess amounts. Studies have shown that migraineurs have low brain magnesium during migraine attacks. [6.]. Two controlled trials have shown that oral magnesium supplementation (taking in by [7., 8.]. mouth) can be effective in headache prevention. Ginger: Can be helpful in treating the nausea associated with migraine and there is some evidence of efficacy in preventing attacks. St. John s Wort: This has been shown to be effective in the treatment of depression and it has also been used for migraine prophylaxis. However, if taken alongside the triptan drugs, it can increase their effect and the Committee on Safety of Medicines currently recommend that the two are not taken together.

10 Of course, drug treatment is not the only way of avoiding migraine. Much can be achieved with self help measures, such as trigger avoidance. Migraine triggers are numerous and varied and not all known triggers affect all migraineurs. It is pointless to adopt a blanket avoidance of triggers that you have heard can cause attacks in other people. A diary can help you to identify factors that may be implicated in your attacks and you can then eliminate these one at a time to see if it makes any difference. Things to consider include: Insufficient food: Low blood sugar levels can be implicated in headache and migraine, so it is important to eat regularly and in sufficient quantities. Avoid gaps of more than 4 hours between meals or a fast of more than 12 hours overnight. Try to include slow release carbohydrate foods in your diet and avoid sugary snacks. Specific foods: An allergy results in a speedy reaction to a substance so anyone who has an allergy usually knows about it and has learnt to avoid that substance. However, sensitivities can also cause problems but because they take longer to show any effect they can be more difficult to identify. There are various methods for testing sensitivities and it has been claimed that avoiding foods to which you are sensitive can bring a dramatic improvement in migraine, especially in children. If you suspect a food of triggering your migraine, it is a good idea to eliminate it from your diet for a month to see whether this makes a difference, if not reintroduce it and try another suspect food. If you decide to completely cut out a food that you are currently consuming a lot of (e.g. caffeine or wheat), bear in mind that you may initially suffer withdrawal symptoms (possibly including severe headache) for a few days before you derive any benefit. Sleep: Over tiredness can trigger migraine, as can too much sleep. It is best to try to maintain a regular sleep pattern, avoiding too many late nights or long lie-ins.

11 Head and neck pain: Pain may not always be felt at the site where the problem exists. Head pain can be caused by problems in the neck which can be treated with physiotherapy, or underlying causes, such as sinus congestion, can be treated with inhalants or antibiotics. It is important to identify any physical problems which may be contributing to your migraine and have them appropriately treated. Emotional triggers: Stress and worry can be migraine triggers for many people, or relaxation after a period of stress can be the time that an attack occurs. These can be overcome by adopting stress management techniques and developing methods of relaxation. Regular exercise can also help to relieve stress and tension. Environmental: Bright, flickering or flashing lights, loud noise and strong smells are well known migraine triggers. Problems with strong sunlight can be overcome by wearing a hat and sunglasses but noise and strong smells can be more difficult to avoid. Weather conditions can also induce attacks in some people, as can stuffy or smoky rooms. Hormonal changes: The fact that women suffer 2-3 time more than men is due to hormonal influences and many women think their attacks are influenced by their menstrual cycle. However, true menstrual migraine (attacks which only occur within 2 days either side of the first day of a menstrual period) is relatively rare. Hormonal preventative treatment can be considered for such women. Many women also notice that their migraine becomes worse as they approach the menopause and HRT can be helpful for some. Women seem to become more sensitive to other migraine triggers, such as missed meals, around the time of their period so it is sensible to try to avoid other triggers at this time. It is important to remember the threshold theory when considering triggers. For most people, a known trigger will not cause an attack every time and may only do so in combination with other factors. Try to balance triggers so that they do not accumulate to reach your migraine threshold. In a study at the City of London Migraine Clinic, patients reduced their number of attacks by half with non-drug prophylaxis, such as trigger management and sensible life style changes (e.g. taking up exercise, taking regular breaks from work, eating regularly, drinking plenty of water, getting some fresh air every day, maintaining a regular sleep pattern etc.).

12 Web: For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling , ing or visiting the charity s website at All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit to support one of our projects or visit to become a member. Acknowledgments Migraine Action would like to thank our Medical Advisory Board for reviewing and providing information used in this booklet. References 1. BOTOX Summary of Product Characteristics. 2. Lipton et al Neurology. 2004; 63: Pfaffenrath et al Cephalalgia Sep;22(7): Sándor et al Neurology 2005 Feb 64(4) Schoenen et al Neurology Feb;50(2): Ramadan NM, Halvorson H, Vande-Linde A. Low brain magnesium in migraine. Headache. 1989;29: Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. 1991; 31: Peikert A, Wilimzig C, Kohne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multicenter, placebo-controlled and double-blind randomized study. Cephalalgia. 1996;16: th Floor, 27 East Street, Leicester. LE1 6NB. Tel: Fax: info@migraine.org.uk Web: Registered Charity No Copyright 2010 Migraine Action This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.