MIGRAINE
A migraine is usually a moderate or severe headache felt as a throbbing pain on 1 side of the head.
Migraine is a paroxysmal recurrent headache unilateral or bilateral lasting 4-72 hours, often preceded by aura and accompanied by nausea and/or vomiting. Migraine is thought to have a polygenetic and multifactorial etiology. Migraine is about three times more common in women than men.
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Diagnosis:Clinical
The International Headache Society (IHS) diagnostic criteria for migraine are as follows:
• Headache attacks last 4 to 72 hours
Headache has at least two of the following characteristics: unilateral location; pulsating quality; moderate or severe intensity; aggravation by routine physical activity
• During headache at least one of the following occurs: nausea and/or vomiting; photophobia and phonophobia
• At least five attacks occur fulfilling the above criteria. History, physical examination, and neurologic examination do not suggest any underlying organic disease
Treatment
Non-drug treatment:
• Patients should be reassured that this is a benign condition.
• They should attempt to identify foods or drinks and other situations, which precipitate the attack and try to diminish patterns of tension.
Drug Treatment:
1. Acute treatment, mild attacks:
First line
Acetylsalicylic acid, soluble, 600-900 mg P.O. once, followed by 300 mg half hourly up to a maximum dose of 1800 mg
S/Es: Dyspepsia, fatigue, nausea, and diarrhea S/Es
C/Is: Hypersensitivity, active peptic ulcer disease Dosage forms: Tablet, 100mg (soluble), 300mg, 500mg Dosage forms: (enteric coated)
Alternative
Paracetamol, 500-1000 mg P.O. 4-6 hourly, PRN Paracetamol, (For S/Es, C/Is S/Es, C/Is S/Es, C/Is anddosage forms dosage forms dosage forms)
N.B. Initiate therapy during the attack or at the very onset of the headache. If nausea and vomiting is troublesome an anti-emetic, e.g. Metoclopramide Metoclopramide, opramide, 10 mg , P.O. 10 mg 3 times TID can be used.
S/Es: drowsiness, fatigue, dizziness, weakness
C/Is: epilepsy, pheochromocytoma, and mechanical bo C/Is wel obstruction,
concomitant administration of atropine like drugs.
S/Ps: concomitant administration of phenothiazines.
S/Ps: Dosage forms: tablet, 10mg; syrup, 5mg/5ml; injecti Dosage forms: on, 5mg/ml in 2ml ampoule; drop, 0.2mg/drop.
2. More severe attacks, especially with a defined aura:
First line
Ibuprofen, 600-1,200 mg/day P.O. in 2-3 divided doses
S/Es: Gastritis, gastrointestinal bleeding
C/Is: Active peptic ulcer disease
Dosage forms: Tablet, 200mg, 400mg; capsule, 300mg; Dosage forms: syrup, 100mg/5ml.
AND/OR
Ergotamine tartrate and Caffeine , 1mg +100 mg P.O. 1-2 tablets immediately, followed by 1/2-1 tablet every 30 minutes to a maximum of 4 tables per attack or 10 tablets per week, or until vomiting occurs.
S/Es: nausea, vomiting, abdominal pain, muscle cram S/Es: ps, occasionally precordial pain, myocardial ischaemia and rarely infarction; repeated high dose may cause ergotism with gangrene and confusion
C/I : peripheral vascular disease, coronary heart d C/I : isease, hepatic or renal impairment, inadequately controlled hypertension, pregnancy, and breast feeding Dosage forms: Tablet, 1mg +100mg; suppository, 2mg +100mg.
Prophylaxis:
Prophylactic headache treatment is indicated if the headaches are frequent (>2-3/month), long lasting, or account for a significant amount of total disability. The success rate is about 60-70%.
Propranolol, 80 mg/day in divided doses; increase by 20-40 mg/dose every 3-4 weeks to a maximum of 160-240 mg/day)
(For S/Es, C/Is S/Es, C/Is S/Es, C/Is anddosage forms dosage forms dosage forms)
Alternative
Amitriptyline, 10-25 mg P.O. at bed time, titrate dose up to adequate response. It seldom requires more than 75-150 mg as a single bedtime dose
S/Es: dry mouth, sedation, blurred vision, constipa S/Es: tion, nausea, difficulty with micturition, postural hypotension, Arrythmias
C/Is: recent myocardial infarction, arrythmias, se C/Is: vere liver disease Dosage forms: Tablet, 10 mg, 25 mg, 50 mg.