and prevention of migraine headaches
The guidelines were approved by the American College of Physicians (ACP) Board of Regents on 26 March 2001, and by the American Academy of Family Physicians Board of Directors on 8 August 2001.
TARGET POPULATION
The guidelines were approved by the American College of Physicians (ACP) Board of Regents on 26 March 2001, and by the American Academy of Family Physicians Board of Directors on 8 August 2001.
TARGET POPULATION
Patients with acute migraine attacks, with or without aura
Patients with migraine who are candidates for preventive drug therapy
INTERVENTIONS AND PRACTICES CONSIDERED
Treatment
Nonsteroidal anti-inflammatory drugs
· Aspirin
· Ibuprofen
· Naproxen sodium
· Tolfenamic acid
· Acetaminophen plus aspirin plus caffeine
Migraine-specific agents (triptans, dihydroergotamine [DHE])
· Oral naratriptan
· Rizatriptan
· Zolmitriptan
· Oral and subcutaneous sumatriptan
· DHE nasal spray
Antiemetics (e.g., metoclopramide) for migraines with nausea and/or vomiting
Considered but not recommended as first-line treatment: opioids (e.g., butorphanol nasal spray)
Prevention
Propranolol
Timolol
Amitriptyline
Divalproex sodium
Sodium valproate
Additional therapies include flunarizine, lisuride, pizotifen, time-released DHE, and methysergide
Education of patients in self-management
For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy.
To date, the most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, tolfenamic acid*, and the combination agent acetaminophen plus aspirin plus caffeine. There is no evidence for the use of acetaminophen alone.
To date, the most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, tolfenamic acid*, and the combination agent acetaminophen plus aspirin plus caffeine. There is no evidence for the use of acetaminophen alone.
Recommendation 2:
In patients whose migraine attack has not responded to nonsteroidal anti-inflammatory drugs, use migraine-specific agents (triptans, dihydroergotamine [DHE]).
There is good evidence for the following triptans: oral naratriptan, rizatriptan, and zolmitriptan; oral and subcutaneous sumatriptan; and DHE nasal spray. Few data in the literature demonstrate which triptans are more effective. Oral opiate combinations and butorphanol may be considered in acute migraine when sedation side effects are not a concern and the risk for abuse has been addressed.
There is good evidence for the following triptans: oral naratriptan, rizatriptan, and zolmitriptan; oral and subcutaneous sumatriptan; and DHE nasal spray. Few data in the literature demonstrate which triptans are more effective. Oral opiate combinations and butorphanol may be considered in acute migraine when sedation side effects are not a concern and the risk for abuse has been addressed.
Recommendation 3:
Select a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex. Treat nausea and vomiting with an antiemetic.
Evidence is limited, but in some patients, concomitant treatment with an antiemetic and an oral migraine medication may be appropriate. Antiemetics should not be restricted to patients who are vomiting or likely to vomit. Nausea itself is one of the most aversive and disabling symptoms of a migraine attack and should be treated appropriately.
Evidence is limited, but in some patients, concomitant treatment with an antiemetic and an oral migraine medication may be appropriate. Antiemetics should not be restricted to patients who are vomiting or likely to vomit. Nausea itself is one of the most aversive and disabling symptoms of a migraine attack and should be treated appropriately.
Recommendation 4:
Migraine sufferers should be evaluated for use of preventive therapy.
Generally accepted indications for migraine prevention include
Generally accepted indications for migraine prevention include
1) two or more attacks per month that produce disability lasting 3 or more days per month;
2) contraindication to, or failure of, acute treatments;
3) use of abortive medication more than twice per week; or
4) the presence of uncommon migraine conditions, including hemiplegic migraine, migraine with prolonged aura, or migrainous infarction.
Recommendation 5:
Recommended first-line agents for the prevention of migraine headache are
propranolol (80 to 240 mg/d),
timolol (20 to 30 mg/d),
amitriptyline (30 to 150 mg/d),
divalproex sodium (500 to 1500 mg/d), and
sodium valproate (800 to 1500 mg/d).
Recommendation 6:
Educate migraine sufferers about the control of acute attacks and preventive therapy and engage them in the formulation of a management plan. Therapy should be reevaluated on a regular basis.
There is strong consensus about the need for educating people with migraine. The physician must help the patient establish realistic expectations by discussing therapeutic options and their benefits and harms, such as medication-overuse headache. Encouraging patients to be actively involved in their own management by tracking their own progress through daily flow sheets, for example, may be especially useful. Diaries should measure attack frequency, severity, and duration; resulting disability; response to type of treatment; and adverse effects of medication. Patient input can provide the best guide to treatment selection.
There is strong consensus about the need for educating people with migraine. The physician must help the patient establish realistic expectations by discussing therapeutic options and their benefits and harms, such as medication-overuse headache. Encouraging patients to be actively involved in their own management by tracking their own progress through daily flow sheets, for example, may be especially useful. Diaries should measure attack frequency, severity, and duration; resulting disability; response to type of treatment; and adverse effects of medication. Patient input can provide the best guide to treatment selection.
Rapid and consistent treatment of acute migraine attacks may avoid headache recurrence, restore the patient’s ability to function, and minimize the use of backup and rescue medications.
Subgroups Most Likely to Benefit:
Anticonvulsants may be especially useful in patients with prolonged or atypical migraine aura.
POTENTIAL HARMS
· Adverse effects of the triptans include chest symptoms, but postmarketing data indicate that true ischemic events are rare.
· Studies have documented frequent adverse events of ergotamine or ergotamine-caffeine.
· Adverse effects reported most commonly with beta-blockers were fatigue, depression, nausea, dizziness, and insomnia. These symptoms appear to be fairly well tolerated and seldom caused premature withdrawal from trials.
· Drowsiness, weight gain, and anticholinergic symptoms were frequently reported with the tricyclic antidepressants studied, including amitriptyline.
· Adverse events with anticonvulsants are not uncommon and include weight gain, hair loss, tremor, and teratogenic potential, such as neural tube defects.
· The most commonly reported adverse events with all nonsteroidal anti-inflammatory drugs (NSAIDs) were gastrointestinal symptoms, including nausea, vomiting, gastritis, and blood in the stool.
· The most commonly reported events for all the ergot alkaloids were gastrointestinal symptoms.
· There are reports of retroperitoneal and retropleural fibrosis associated with long-term, mostly uninterrupted administration of methysergide. Other adverse events most commonly reported included gastrointestinal symptoms and leg symptoms (restlessness or pain).
· Published data on adverse events associated with lisuride are limited, and pizotifen is often associated with weight gain and drowsiness.
· Adverse events reported with flunarizine include sedation, weight gain, and abdominal pain. Depression and extrapyramidal symptoms can be observed, particularly in elderly persons.
CONTRAINDICATIONS
· Adverse effects of the triptans include chest symptoms, but postmarketing data indicate that true ischemic events are rare.
· Studies have documented frequent adverse events of ergotamine or ergotamine-caffeine.
· Adverse effects reported most commonly with beta-blockers were fatigue, depression, nausea, dizziness, and insomnia. These symptoms appear to be fairly well tolerated and seldom caused premature withdrawal from trials.
· Drowsiness, weight gain, and anticholinergic symptoms were frequently reported with the tricyclic antidepressants studied, including amitriptyline.
· Adverse events with anticonvulsants are not uncommon and include weight gain, hair loss, tremor, and teratogenic potential, such as neural tube defects.
· The most commonly reported adverse events with all nonsteroidal anti-inflammatory drugs (NSAIDs) were gastrointestinal symptoms, including nausea, vomiting, gastritis, and blood in the stool.
· The most commonly reported events for all the ergot alkaloids were gastrointestinal symptoms.
· There are reports of retroperitoneal and retropleural fibrosis associated with long-term, mostly uninterrupted administration of methysergide. Other adverse events most commonly reported included gastrointestinal symptoms and leg symptoms (restlessness or pain).
· Published data on adverse events associated with lisuride are limited, and pizotifen is often associated with weight gain and drowsiness.
· Adverse events reported with flunarizine include sedation, weight gain, and abdominal pain. Depression and extrapyramidal symptoms can be observed, particularly in elderly persons.
CONTRAINDICATIONS
Triptans are contraindicated in patients with risk for heart disease, basilar or hemiplegic migraine, or uncontrolled hypertension.
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