Management of the acute migraine headache - Practical Therapeutics

Author: Glen Aukerman, William F. Miser
Date: Dec 1, 2002

Migraine headaches are a major public health problem affecting more than 28 million persons in this country. (1) Nearly 25 percent of women and 9 percent of men experience disabling migraines. (2,3) The impact of these headaches on patients and their families is tremendous, with many patients reporting frequent and significant disability. (4) The economic burden of migraine headaches in the United States is also tremendous. Persons with migraines lose an average of four to six work days each year, with an annual total loss nationwide of 64 to 150 million work days. The estimated direct and indirect costs of migraine approach $17 billion. (5,6) Despite the prevalence of migraines and the availability of multiple treatment options, this condition is often undiagnosed and untreated. (7) About one half of patients stop seeking medical care for their migraines, in part because of dissatisfaction with the therapy they have received. (4)

Patients with migraine headaches often present family physicians with diagnostic and therapeutic challenges. The aspects of migraine management that deserve careful consideration include the treatment of acute pain, the role of neuroimaging, and the management of patients who fail to respond to initial treatment. This article addresses these issues, presenting the evidence-based migraine headache treatment guidelines recently established by the U.S. Headache Consortium, a multidisciplinary team consisting of members from seven organizations, including the American Academy of Family Physicians (AAFP). The guidelines are available on the AAFP Web site. (8)

Clinical Presentation

The classification of migraines is based on the clinical features of the headache, most notably the presence or absence of a characteristic aura before the onset of pain. The aura may take many forms but usually involves visual distortions, including scotomas. Other prodromal symptoms described by many patients with migraines include nausea, food cravings, heightened sensory perceptions, and alterations in mood or behavior.

The International Headache Society's categorization of headaches is listed in Table 1. (9) Migraines can be triggered by hormonal changes, certain foods, sensory stimuli (i.e., light, smells), missed meals, or the relief of tension after stressful events.

Evaluation

The initial task in managing a patient who presents with migraine headache is to take a detailed history and perform a thorough physical and neurologic examination. Patients may present with significant expectations derived from the numerous sources of information available, especially those on the Internet. One of the most popular and authoritative Web sites is that of the National Headache Foundation (NHF) (http://www.headaches.org/). The NHF site provides patients with a "checklist" of questions that primary care physicians should ask when taking an appropriate history (Table 2). (10)

This site can be a highly useful part of patient education, but family physicians should be aware that it advises patients to seek referral to a subspecialist or headache clinic if the primary care physician does not appear to appropriately appreciate, diagnose, or treat the headache. This suggestion may raise concern in some patients about the ability of primary care physicians to appropriately manage headaches. Family physicians might ask patients about their sources of medical information.

Physicians may struggle to determine the appropriate use of neuroimaging in the patient with migraine. The American Academy of Neurology suggests that neuroimaging should be considered only in patients with migraine who have atypical headache patterns or neurologic signs (11); the U.S. Headache Consortium has developed evidence-based guidelines on the use of neuroimaging for patients with migraines.

In general, the U.S. Headache Consortium guidelines do not recommend neuroimaging if the patient is not at higher risk of a significant abnormality than the general population or if the results of the study would not change the management of the headache. Symptoms that increase the odds of positive neuroimaging results include rapidly increasing frequency of headache, a history of uncoordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep. Other "red flags" include abrupt onset of severe headache, marked change in headache pattern, or persistent headache following head trauma. The specific U.S. Headache Consortium guidelines for neuroimaging are outlined in Table 3. (12)

Electroencephalography is not useful in the routine evaluation of patients with headache but may be appropriate in those who have associated symptoms suggestive of a seizure disorder, atypical migrainous aura, or episodic loss of consciousness. (13)

Goals of Migraine Treatment

Migraine treatment depends on the duration and severity of pain, associated symptoms, degree of disability, and initial response to therapy. Management of migraines can be difficult because of the complexity of migraines and the variation of symptoms among and within patients. Some medical conditions (stroke, myocardial infarction, epilepsy, affective and anxiety disorders, and some connective tissue disorders) are more common in people with migraine. These conditions provide opportunities to treat both conditions with one medication but are also limiting because of drug interactions or contraindications. Appropriate migraine therapy should allow for consideration of the above factors. (14)

The U.S. Headache Consortium identified the goals of long-term migraine treatment and successful management of acute migraine (Tables 4 and 5). (14) These goals emphasize the importance of patient education and self-participation in the management of migraines, and of establishing reasonable patient expectations and effective communication. Of note, these treatment goals are also designed to avoid "rebound" or medication-overuse headaches. Frequent use of some migraine medications (e.g., ergotamine [Ergostat], opiates, analgesics, and triptans) may cause medication-overuse headaches. Preventive therapy should be considered if the patient has more than two headaches per week. (15)

If identified early, a migraine may be aborted with pharmacologic treatment using either nonspecific or migraine-specific medications. Gastrointestinal motility is reduced during acute migraine, causing impaired drug absorption. If administration of oral medication is not possible because of nausea or if the oral agents fail, alternative methods of administration (rectal, nasal, subcutaneous or intravenous) may be used for many medications.

Nonspecific Abortive Migraine Therapy

Table 6 (4,16-18,22) lists the nonspecific treatments that may be effective for mild to moderate migraines. Non-narcotic analgesics can be used for mild to moderate migraines that are not associated with nausea and vomiting. Administration as early as possible during an attack improves efficacy. The use of these analgesics should be closely monitored because overuse may lead to rebound headaches.

Acetaminophen alone has not been shown to be beneficial in migraine treatment, but it is effective in combination with aspirin and caffeine. Ketorolac (Toradol), a parenteral nonsteroidal anti-inflammatory drug (NSAID), has a relatively rapid onset of action and a duration of approximately six hours. It is generally reserved for abortive therapy of severe migraines, and rebound headache is unlikely. Opioid analgesics such as meperidine (Demerol) and butorphanol (Stadol) are sometimes required to abort severe migraines. Narcotic use should be avoided for chronic daily headaches because it can lead to dependency, rebound headaches, and eventual loss of efficacy.

Adjunctive therapy is used to treat the associated symptoms of migraine and provide synergistic analgesia. While metoclopramide (Reglan) is sometimes recommended as a single agent in the treatment of migraine pain, its main use is for treating accompanying nausea and improving gastric motility, which may be impaired during migraine attacks. Prochlorperazine (Compazine) can effectively relieve headache pain. (19,20) Other adjunctive therapies for the abortive treatment of migraines are caffeine and sleep.

The combination of isometheptene, acetaminophen, and dichloralphenazone (Midrin) has been shown to be effective in the treatment of milder migraine headaches. (10,21) Sedatives such as the barbiturates have historically been used to induce sleep in persons with migraines. However, with the advent of effective nonsedating agents and migraine-specific therapy, sedatives are no longer widely used in migraine therapy.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

REFERENCES

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Members of various medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Medicine at Ohio State University College of Medicine and Public Health, Columbus. Guest editor of the series is Doug Knutson, M.D.

GLEN AUKERMAN, M.D., is professor in the Department of Family Medicine at Ohio State University College of Medicine and Public Health in Columbus. He received his medical degree from Ohio State University College of Medicine. Dr. Aukerman is past president of the Ohio Academy of Family Physicians and the American Academy of Family Physicians.

DOUG KNUTSON, M.D., is assistant professor in the Department of Family Medicine at Ohio State University. He received his medical degree from Ohio State University College of Medicine and completed a residency in family medicine at Riverside Methodist Hospital in Columbus, Ohio.

WILLIAM F. MISER, M.D., M.A., is associate professor in the Department of Family Medicine at Ohio State University, where he also serves as residency director. Dr. Miser received his medical degree from Ohio State University College of Medicine and completed a residency in family medicine in Augusta, Ga.

Address correspondence to Glen Aukerman, M.D., Department of Family Medicine, Ohio State University College of Medicine and Public Health, 2231 N. High St., Columbus, OH 43201 (e-mail: aukerman-1@medctr.osu.edu). Reprints are not available from the authors.

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