How to Get Rid of a Migraine Headache: Treatments and Tips || Pharmacyteach.com

 

MIGRAINE HEADACHE

1. What is a migraine?

A migraine is a neurological disorder that causes recurrent attacks of moderate to severe headache. The pain is often throbbing and may occur on one side of the head, although both sides can be affected.

2. Common symptoms

 Pain: Crescendo pattern; headache usually pulsating/throbbing, but not always; unilateral. Pain is aggravated with routine physical activity.

 Duration: 4 to 72 hours

•  Patient retreats to a dark, quiet room
•  Nausea, vomiting, and anorexia
•  Photophobia: Sensitivity to light
•  Phonophobia: Sensitivity to sound
•  Osmophobia: Fear of smell/odors

 Migraine with aura (Focal disturbances of neurological function) → Visual disturbances occur commonly and may consist of field defects (scotoma), or luminous visual hallucinations such as stars, sparks, unformed light flashes (photopsia), geometric patterns, or zigzags of light, or of some combination of field defects and luminous hallucinations (scintillating scotomas). Other focal disturbances such as aphasia or numbness, paresthesia, clumsiness, dysarthria, disequilibrium, or weakness in a circumscribed distribution may also occur.

Potential triggers: Emotional or physical stress, Lack or excess of sleep, bright light, loud noises, Variations in caffeine intake, alcoholic beverages, chocolate, cheese, nitrates, tyramines, Hormonal changes, menstruation, or use of OCPs

 

DIAGNOSTIC CRITERIA WITHOUT AURA

At least five attacks fulfilling the following criteria: untreated headache lasting 4 to 72 hours

Group A (2 of 4):

1. Unilateral headache

2. Throbbing or pulsating pain

3. Moderate to severe pain that inhibits ability to function

4. Pain aggravated by routine physical activity

Group B (1 of 2):

1. Presence of nausea or vomiting

2. Presence of photophobia and Phonophobia

3. Underlying disorders that may cause secondary headaches must be ruled out

 

ACUTE MIGRAINE HEADACHE TREATMENT

 Inj. Ketorolac 30mg/1ml (Toradol, Ketor) at dose 3060mg + Inj. Metoclopramide 10mg/2ml (Maxolon, Metaclon) x diluted in 3ml 0.9% NS x IV once.

     OR Inj. Ketorolac 30 to 60mg (Toradol, Ketor) x IM once

     OR Inj. Diclofenac sodium 75mg/3ml (Voren) x IM once

 Read more about: ketorolac inj, and their uses

Migraine-specific medications: Do not combine the agents

 Triptans:

     Zavegepant 10mg (ZAVZPRET nasal spray) at dose 10mg as a single spray in one nostril. Max 10mg/24hour

     OR Zolmitriptan 2.5mg nasal spray (Zolimpine, Zolmist) at dose 5 mg: 2 intranasal sprays once; may repeat once after 1 hour as needed.

     OR Tab. Zolmitriptan 2.5mg (Zomig, Triptan, Limigzole) x at dose 1.25 to 2.5 mg PO once; may repeat once after 2 hours as needed (max. dose 10 mg/24 hours)

     OR Tab. Sumatriptan 85mg + Naproxen sodium 500mg (SynflexM, Sumoxen, Imtaxen) x One tablet once at the onset of the headache. Maximum 2 tablets/24 hours.

     OR Tab. Sumatriptan 50mg or 100mg (Imigran, Sumig, Sumatec) at a dose of 50 mg to 100mg x once; may repeat once after 2 hours if needed. (Maximum: 200mg/day).

 Ergotamine: Tab. Ergotamine 1mg + Caffeine 100mg (Migril, Cafergot) at a dose of 12 tabs at the onset of headache.

TREATMENT OF MILD TO MODERATE MIGRAINE

 Behavioral modification: Avoid triggers, Regular sleeping patterns and Minimize stress

 Tab. Paracetamol 500mg (Panadol, Calpol) 2 tablets x TDS

    Dosage: 500mg to 1000mg x TDS

    OR Tab. Diclofenac sodium 50mg or 75mg (Voren, Arnil)

    Dosage: 100mg – 150mg mg, divided into two doses per day

    OR Tab. Naproxen sodium 250mg or 500mg (Flexin, Proxen)

    Dosage: 250mg to 500mg x two times a day

 

    Note: Long-term NSAIDs (Mefenamic acid, Naproxen) cause peptic ulcers; PPIs such as Cap. Omeprazole 40mg (Risek) or Esomeprazole 40mg (Nexum) should be added once daily.

Recommendations for use of prophylactic migraine medication

 Start with a low dose and titrate slowly

 Decrease in headache frequency may be imperceptible the 1st month:

    » For the first month, a 10% decrease in frequency is considered successful

    » Improvement is cumulative, may take 6 months to reach efficacy

    » Success = 50% reduction in frequency

 After a 6-month period of headache stability, periodically evaluate.

 Read About:  Pentavalent Combination Vaccine: A Detailed Overview of DTwP-HepB-Hib.

OTHER EFFECTIVE MEDICATION FOR MIGRAINE PROPHYLAXIS:

 Tab. Candesartan 8mg (Advant) at dosage 8 mg up to 32 mg once daily

 Tab. Verapamil (Calan, Isoptin, Zavera)

 Tab. Divalproex sodium 500mg (Epival CR)

 Tab. Amitriptyline 10mg: Probably effective; unrelated to antidepressant activity.

Dosage: 25mg orally at bedtime; increase dose by 25mg every 2 to 4 weeks twice weekly, until response is adequate.

 Tab. Venlafaxine: at dose 37.5 mg – 150 mg (extended release), orally once daily.

 Tab. Riboflavin (Vitamin B2): 400mg daily

 Tab. Pizotifen 10mg (Mosigar) x OD/BD OR Syp. Pizotifen 5mg/5ml (Mosigar) x 10ml HS/BD

 Read about: Pediatric Drug Dose Calculation Formula With Examples. 

 NSAIDs: use for prophylaxis of known triggers (e.g., start before menses for menstrual migraine)

 Topiramate may cause weight loss. Consider the side effect of weight loss for obese patients.

 Avoid frequent use of opioids due to the risk of rebound headaches and medication overuse headache.

For Prophylaxis prescription #1

1. Tab. Topiramate 25mg or 50mg (Hitop, Topamax, Torate)

Dosage: Start at dose 25mg Once at night titrated weekly by 25mg x twice daily, titrated up to 200mg/day.

OR Tab. Valproic acid 250mg or 500mg (Epival, Dapakan) at dose 5001000mg in 2 divided doses x I – 0 – I (BD)

OR Tab. Propranolol 10mg or 40mg (Inderal, Cardinal)

Dosage: 80mg to 240mg in 24 divided doses x BD/TDS/QID

 Read About: Loading Dose vs Maintenance Dose: Differences, Formulas, and Examples

NSAIDs may be given as adjunctive therapy for 12 weeks

2. Tab. Naproxen 250mg or 500mg (Flexin, Neoprox) at dose 250mg to 500mg x Twice daily (BD)

OR Tab. Diclofenac sodium 50mg (Voren, Voltral) at dose 50mg to 100mg in 23 divided doses x BD/TDS

Gastroprotective: Long term NSAIDs causes gastritis

3. Cap. Omeprazole 40mg (Risek, Ruling)

0 – 0 – I (OD)

ایک گولی روزانہ ایک بار کھانے سے 30 منٹ پہلے

 

For Prophylaxis prescription # 2

1. Cap. Flunarizine 5mg (Sibelium, Lunar) at dose 10mg (2 capsule) orally once daily at night

OR Tab. Divalproex sodium 500mg (Epival CR)

0 – 0 – I (One tablet once at nighttime)

NSAIDs may be given as adjunctive therapy for 12 weeks

2. Tab. Diclofenac Potassium 50mg (Caflam, DycloP, SofacP)

OR Tab. Aceclofenac 100mg (Acenac, Acemed, Alkeris))

I – 0 – I (BD)

Gastroprotective: Long-term NSAIDs cause gastritis

3. Cap. Esomeprazole 40mg (Esso, Nexum)

                          0 – 0 – I (OD) ایک گولی روزانہ ایک بار کھانے سے 30 منٹ پہلے

4. ± Adjunct: Tab Propranolol 10mg (Inderal, Cardinal)

               I – 0 – I (10mg x BD), 2 – 0 – 2 (20mg x BD)

Prophylaxis of chronic migraine with Monoclonal Antibodies Against Calcitonin Gene Related Peptide

Generic Name	Brand Name	Dose, Route & Duration	Possible Side Effects
Eptinezumab	Inj. Vyepti 100mg/1ml	100mg intravenously (IV) every 3 months	Hypersensitivity reaction during infusion, nasopharyngitis.
Erenumab	Inj. Aimovig 70mg/1ml	70140mg subcutaneously (SC) once x monthly	Injection site reactions, constipation, muscle cramps, antibody development.
Fremanezumab	Inj. Ajovy 225mg/1.5ml	225mg subcutaneously x (SC) once monthly	Injection site reactions, antibody development
Galcanezumab	Inj. Emgality 120mg/1ml	120mg daily x 2 doses, followed by 120mg monthly	Injection site reactions, antibody development.
Atogepant	Tab. Qulipta 10mg, 30mg and 60mg	10 to 60mg x once per day	Nausea, constipation, fatigue (low energy), and decreased appetite (anorexia)

 

6. Lifestyle measures

• Maintain a regular sleep schedule.
• Drink enough water.
• Eat meals at regular times.
• Exercise regularly as tolerated.
• Keep a headache diary to identify triggers.
• Rest in a quiet, dark room during an attack.

7. When is a migraine headache an emergency?

Seek emergency medical care if the headache:

• Starts suddenly and reaches maximum intensity within seconds to a minute.
• Occurs with weakness, facial drooping, confusion, fainting, or new difficulty speaking.
• Is accompanied by fever and a stiff neck.
• Starts after a significant head injury.
• Is new or severe during pregnancy or shortly after delivery.