Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010

The intangibles Doctor-patient relationship Realistic expectations Education

Triggers Hormonal Dietary Psychological Environmental Sleep Drugs

10 steps to success Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms

10 steps to success Choose appropriate route of delivery Observe contraindications Use prior experience to select/reject drugs Avoid drugs with high potential for MOH Combine medications if necessary

Where to start? paracetamol 1 g or, aspirin 900 mg or, ibuprofen mg +/- domperidone mg taken as soon as possible*ª * i.e. as soon as the patient knows that this is a migraine ª if there is aura, take at the start of the headache phase

Variations on a theme if early nausea, you can use: soluble aspirin suppositories*: diclofenac 75 mg domperidone 30 mg *be French!

Headache response at 2 hr

Problems, problems… Not effective dose? timing? route? combination? Contraindications asthma, upper GI problems, renal impairment Side effects GI, CNS

Codeine…? … is NOT a treatment for headache the WHO analgesic ladder should NOT be applied to headache management

Triptans 5-HT 1B/1D receptor agonists seven different formulations options for route of delivery oral tablets or melts nasal spray subcutaneous injection taken as soon as possible*ª¹ * i.e. as soon as the patient knows that this is a migraine ª if there is aura, take at the start of the headache phase ¹ this is a race against the development of allodynia

Which triptan?

Headache response at 2 hr

Pain freedom at 2 hr

Problems, problems… Ineffective dose? timing? route? switch? Headache recurrence switch? combination with NSAID? Contraindications HT, IHD SE nausea, GI, CNS, ‘triptan chest’

Is the future ‘pants’? CGRP antagonists two with data recently published proof-of-concept trial of intravenous BIBN4096BS (now called olcagepant) was published in NEJM in 2004 phase II study of oral CGRP antagonist MK-0974 (now called telcagepant) presented at IHS 2007 and published in Neurology in 2008

multicentre phase III R-PT-PC-DB-T of oral telcagepant 150 or 300 mg vs zolmitriptan 5 mg and placebo published in The Lancet in last four weeks