Migraine - acute - 4

Treatment - non pharmacological

Nurse the patient in a quiet darkened room.

There is no specific treatment for the prodromal phase other than observation and antiemetics if required.

Treatment strategies

The treatment of migraine should be aimed at relieving the cause, rather than giving symptomatic relief.

This approach is hampered by
- lack of understanding about the causes of migraine
- poor quality evidence
- a high placebo response of about 20%.   
  Ask the patient what works - there are many therapeutic treatments for migraine headache and patients will often know what works best for them, with one important caveat:    
Giving pethidine to a patient with headache is not responsible medical practice.
Pethidine treats the symptoms, not the cause, and is extremely addictive: it is the drug of choice (85%) for opiate-addicted doctors:     Drug addiction in doctors

First choice - Phenothiazines

Chlorpromazine is most commonly used, at doses of 12.5mg i.v., with another dose after 20 minutes if still headache.
This is combined with intravenous fluids, which counteract the hypotension, and may be therapeutic on their own.
Cheap, safe, and effective.

It is thought that phenothiazines somehow act on the depolarisation wave, and this mediates the vascular effects.
There is some evidence to suggest that phenothiazines give a lower rebound rate than tryptans. 

Canadian recommendations for acute migraine management

First choice - i.v. normal saline

Intravenous fluid seems to have a beneficial effect on its own, whether or not other drugs are given.
It is recommended in conjunction with phenothiazines.

Unfortunately the fact that there is little money to be made in selling normal saline or chlorpromazine makes funding research in this area difficult.
Prochlorperazine, metoclopromide or haloperidol are alternatives.

Tryptans - second line

5HT1D selective agonist, giving vasoconstriction - predominantly cerebral, but may cause problems in ischaemic heart disease/cerebrovascular disease/peripheral vascular disease.

Rapidly active, but expensive. The ability of the patient to give their own medication means it is given earlier, and prevents hospital attendance.

Examples: Sumatriptan, Zoltriptan, Naratriptan.

Analgesics - third line

Should be used if analgesia necessary despite above measures.
- Morphine (i.v.)
- Ketorolac (i.v.)
- Indometacin (p.r.)    

Ergot derivatives - fourth line

Direct acting on 5HT receptors. Non-selective, so more risk of non-cerebral (e.g. cardiac) vasoconstriction than tryptans, and high incidence of gastro-intestinal side effects.

More effective if given early in the attack.

Have been superceded by the above treatments, but dihydroergotamine may have a place in intractable migraine.   

Other treatments

Intravenous or intranasal lidocaine (lignocaine), intravenous steroids have been tried with anecdotal reports of success.