Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010

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  • Acute treatment of migraine Dr Mark Weatherall London Headache Centre 2010
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  • The intangibles Doctor-patient relationship Realistic expectations Education
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  • Triggers Hormonal Dietary Psychological Environmental Sleep Drugs
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  • 10 steps to success Make the diagnosis Use the right drugs Use effective doses Treat early when the pains mild Treat associated symptoms
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  • 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
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  • Where to start? paracetamol 1 g or, aspirin 900 mg or, ibuprofen 600-800 mg +/- domperidone 10-20 mg taken as soon as possible* * i.e. as soon as the patient knows that this is a migraine if there is aura, take at the start of the headache phase
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  • Variations on a theme if early nausea, you can use: soluble aspirin suppositories*: diclofenac 75 mg domperidone 30 mg *be French!
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  • Headache response at 2 hr
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  • Problems, problems Not effective dose? timing? route? combination? Contraindications asthma, upper GI problems, renal impairment Side effects GI, CNS
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  • Codeine? is NOT a treatment for headache the WHO analgesic ladder should NOT be applied to headache management
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  • 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* * i.e. as soon as the patient knows that this is a migraine if there is aura, take at the start of the headache phase this is a race against the development of allodynia
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  • Which triptan?
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  • Headache response at 2 hr
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  • Pain freedom at 2 hr
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  • Problems, problems Ineffective dose? timing? route? switch? Headache recurrence switch? combination with NSAID? Contraindications HT, IHD SE nausea, GI, CNS, triptan chest
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  • 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
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  • 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
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