ICHD-II Diagnostic Criteria for Migraine Migraine without aura A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least 2 of the following characteristics: Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least 1 of the following: Nausea and/or vomiting Photophobia and phonophobia E. Not attributed to another disorder Migraine with aura A. At least 2 attacks fulfilling criterion B B. Migraine aura fulfilling criteria B-C for one of the subforms (typical aura with migraine headache, typical aura with non-migraine headache, typical aura without headache, familial hemiplegic migraine, sporadic hemiplegic migraine, or basilar-type migraine) C. Not attributed to another disorder
Level A = >2 Class I studies Level B = 2 Class II studies Level C = 1 Class II study Level U = Inadequate data Class I: RTC Class II: Cohort Class III: other controlled studies. Class IV: uncontrolled studies
Drug name (in alphabetical order) Acetaminophen Beta Blockers Dosage information Side effects Misc. -Some patients find 500mg or 1000mg effective -Propranolol: starting dose is usually 20mg and usual effective dose 80-240mg -Timolol: starting dose is usually 10mg and usual effective dose is 20-30mg -Nadolol: starting dose is 40mg and usual effective dose is 40-80mg -Metoprolol: effective dose is usually 200mg/day -Hepatotoxicity at doses over 4g/day in average adults. Caution in patients with liver disease -Side effects include fatigue, sedation, weight gain, orthostatic hypotension -Contraindicated in patients (1) with diabetes since it may mask the response to hypoglycemia (2) asthmatic patients (3) depressed patients Typically if one beta blocker fails, better results are not often obtained with other beta blockers Butter Burr (also known as Petasite hybridus plant extract, marked as under the brand name Petadolex) Butorphanol (opiate agonist-antagonist) Calcium Channel Blockers Dihydroergotamine (serotonin, dopamine, catecholamine receptor agonist) -50mg to 75mg BID -Available as a nasal spray. Usual dosage is 2mg to 4mg -When effective, the usual dose of verapamil is between 80 and 240mg /day -Most commonly administered IV form as part of the Raskin protocol but also has nasal spray and subcutaneous formulations. -Chemically unstable when exposed to air or light and must be kept -Safety of prolonged use is not established. Can cause upset stomach predominantly burping. Can have liver toxicity -Can cause dysphoria, hallucinations, and sedation -A small group of patients may respond well to calcium channel blockers and these patients often have tacyphylaxis after 2 or 3 months and need a period of at least 1 month off the medication to restore responsiveness -Metabolites accumulate with repeated dosing and can cause irritability, sedation, peripheral edema, and vasoconstriction
Ergotamine (5HT-1-B and 1-D agonists) refrigerated in the dark -1mg at onset of headache, 1 mg at 30minutes if needed, 1mg/hr up to 6mg/day. Maximum 6mg/d or 10mg/wk -Also available as a suppository -Much lower incidence of peripheral and coronary vasospasm than ergotamine -Can cause coronary vasoconstriction. -Long term use can cause peripheral cyanosis, acroparethesia, and peripheral neuropathy. These effects may be because of microvascular constriction of separate neurotoxic effects of ergotamine -Frequent use may trigger rebound headaches Feverfew -100mg daily -may cause GI upset and irritation of mouth and tongue Gabapentin Isometheptene combinations (most common brand formation is Midrin; combination of isomethephen mucate, dichloralphenazone and acetaminophen) -Start at 100mg to 300mg/day. Increase every 3 to 7 days to 900mg to 1800mg/day. The effective dose is usually between 600mg/day and 2,400mg/day -Up to six capsules per day -Side effects are sedation, irritability, depression and difficulty thinking -Side effects are drowsiness, bad taste and elevated blood pressure Magnesium -300mg daily -Side effects are cramping, diarrhea N-alpha-methylhistamine -1-10ng 2 times/week SC -Transient itching at the injection site NSAIDs -At times, larger doses such as 1000mg aspirin, 800mg ibuprofen, 500mg naproxen may be necessary -Can cause GI irritation. Riboflavin (Vitamin B2) -400mg daily Topiramate -Start at 25mg/day and increase by -May cause somnolence, -effect thought to be mediated by prostaglandin inhibition.
Tricyclic antidepressants Triptans (serotonin agonists) 25mg/day. Most patients respond between 25mg and 200mg/day -Can dose one third in the morning and two thirds at night. Some patients prefer to receive entire dose at night -Amitriptyline s starting dose is 10 to 25mg and is increased every 1 to 2 weeks by 10 mg to 25mg with maximum dose 300mg/day -At doses greater than 200mg/day, the tricyclic blood level should be measured and if it is greater than 300mg/mL the dose should be decreased -The dose should be divided in two or three times a day with the largest dose at bedtime -Dosage can be repeated in 2 hours. -Max daily doses: Sumatriptan PO (200mg), nasal (40mg) and SC (12mg), Zolmitriptan PO (10mg) and nasal (10mg), Rizatriptan PO (20mg), Naratriptan PO (10mg), Eletriptan PO (160mg), Almotriptan PO (25mg), Frovatriptan PO (5mg) --Frovatriptan can be particularly useful for menstrual migraines 2.5mg bid. Two days prior to expected onset of menstrual migraines can take 2.5mg bid, then on second treatment day can take 2.5mg daily for five limb paraesthesias, word finding difficulty, metallic taste -May have weight loss of up to 5-7% of body mass. -May precipitate kidney stone formation -May trigger acute glaucoma -Has an increased risk of cleft palate in the fetus -anticholingeric effects (Dry mouth, constipation, difficult/slow urination) -2%-5% will have paradoxical anxiety and stimulation -may lower seizure threshold and should not be given to patient with seizure history who is not on AEDs -Can cause arrhythmias so in patients 50 years or older or patients with cardiac disease ECG is recommended before administration -contraindicated in patients with ischemic heart disease or ischemic cerebrovascular syndromes -can cause dizziness, fatigue, flushing -Favored in patients with chronic daily headaches -Sometimes is combined with propranolol. Some patient experience an additive effect -For oral administration response onset is within 30 to 60 minutes and peaks at about 2 hours -Sumatriptan subcutaneous has the fastest onset of relief in 10 to 20 minutes -Rizatriptan and zolmitriptan have rapidly melting tablets. -Sumatriptan and zolmitriptan nasal sprays can be used when the patient is too nauseated to take the tablet. Zolmitriptan nasal spray is faster onset than the tablet
Valproic Acid Venlafexine (Effexor) consecutive days. If only mildly effective, this regimen can be doubled to 5mg bid x 1 day, then 5mg daily x 5 days -Start at 250mg daily or bid and increase by 250mg/day each week to a maximum of 500mg tid. -Doses higher than 1,500mg/d usually do not provide further improvement in headache -Start at 37.5mg or 75mg and can increase by at most 75mg every 4 day -doses of 150mg ER daily shown to be effective -Caution in women: there is an increased risk of neural tube closure defects (1%) and polycystic ovarian syndrome -Potential of hepatoxicity because of effect on carnitine metabolism. Risk is higher in children -headache, somnolence, dizziness -Response to the triptans tend to be idiosyncratic therefore individual patients may respond well to one triptan and less well to another References: Jose Biller, Practical Neurology (Philadelphia: Lippincott, Williams, and Wilkins, 2009), 671-687. Stephen Silberstein et al., Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55 754. Stephen Silberstein et al., Evidence-based guideline update: Pharmacological treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1337-1345. Stephen Silberstein et al., Evidence-based guideline update: NSAIDS and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1346-1352.