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New Treatments for Headache

Migraine affects 15% to 17% of women and 6% of men. Headaches can generally be grouped into three major categories: vascular, tension-type, and migraine.

Clinical evaluation

Migraine headaches are usually unilateral, and the acute attack typically lasts from 4 to 24 hours. Migraine headaches can occur with an aura or without an aura. Usually, the aura consists of focal neurologic symptoms starting 5 to 30 minutes before onset of an acute headache attack. Aura symptoms may continue.

The most common aura symptoms associated with migraine include scotomata (blind spots), teichopsia (fortification spectra, or the sensation of a luminous appearance before the eyes), photopsia (flashing lights), and paresthesias, as well as visual and auditory hallucinations, diplopia, ataxia, vertigo, syncope, and hyperosmia.

Features of Migraine Headache and Headache Caused by Serious Underlying Disease

Migraine headache

Headache caused by serious underlying disease

History

Chronic headache pattern similar from attack to attack

Gastrointestinal symptoms

Aura, especially visual

Prodrome or postdrome

Onset before puberty or after age 50 (tumor)

"Worst headache ever" (subarachnoid hemorrhage)

Headache occurring after exertion, sex, or bowel movement (subarachnoid hemorrhage)

Headache on rising in the morning (increased intracranial pressure, tumor)

Personality changes, seizures, alteration of consciousness (tumor)

Pain localized to temporal arteries or sudden loss of vision (giant cell arteritis)

Very localized headache (tumor, subarachnoid hemorrhage, giant cell arteritis)

Physical examination

No signs of toxicity

Normal vital signs

Normal neurologic examination

Signs of toxicity (infection, hemorrhage)

Fever (sinusitis, meningitis, or other infection)

Meningismus (meningitis)

Tenderness of temporal arteries (giant cell arteritis)

Focal neurologic deficits (tumor, meningitis, hemorrhage)

Papilledema (tumor)

Laboratory tests and neuroimaging

Normal results

Erythrocyte sedimentation rate >50 mm/hr (giant cell arteritis)

Abnormalities on lumbar puncture (meningitis, hemorrhage)

Abnormalities on CT or MRI (tumor, hemorrhage, aneurysm)

 

Tension-type headache is a steady, aching pain of mild to moderate intensity, often characterized as a band-like pain around the head. Gastrointestinal and neurologic signs and symptoms usually do

Special attention should be paid to examining the fundus of the eye, assessing neck rigidity.

Treatment of migraine

Dihydroergotamine, which can be injected subcutaneously, intramuscularly or intravenously, or sprayed intranasally.

5-HT1 Receptor Agonists ("Triptans")

Sumatriptan (Imitrex) is available for subcutaneous self-injection, an oral formulation, and as a nasal spray. A selective serotonin-receptor agonist, it appears to be more effective than ergotamine. The injection and nasal spray begin to produce relief in 10 to 15 minutes, compared to one to two hours with the tablets. A subcutaneous injection produces relief in 70-80%. Sumatriptan nasal spray.

Zolmitriptan (Zomig), naratriptan (Amerge), and rizatriptan (Maxalt). Zolmitriptan and rizatriptan may have a more rapid onset of action than oral sumatriptan. Naratriptan, which has a longer half-life.

Drugs for Treatment of Migraine and Tension Headache

Drug

Dosage

NSAIDs

Ibuprofen ( Motrin)

400-800 mg, repeat as needed in 4 hr

Naproxen sodium ( Anaprox DS)

550-825 mg, repeat as needed in 4 hr

5-HT1 Receptor Agonists ("Triptans")

Naratriptan ( Amerge)

1- or 2.5-mg tablet, can be repeated 4 hours later (max 5 mg/24 hours)

Rizatriptan ( Maxalt)

5- or 10-mg tablet or wafer (MLT); can be repeated in 2 hours (max 30 mg/24 hours)

Sumatriptan ( Imitrex)

6 mg SC; can be repeated in 1 hour (max 2 injections/24 hours)

25, 50 or 100 mg PO; can be repeated in 2 hours (max 200 mg/24 hours)

5 or 20 mg intranasally; can be repeated after 2 hours (max 40 mg/24 hours)

Zolmitriptan ( Zomig)

2.5 or 5 mg PO; can be repeated in 2 hours (max 10 mg/24 hours)

Ergot Alkaloids

Dihydroergotamine

DHE 45

Migranal Nasal Spray

1 mg IM; can be repeated twice at 1-hour intervals (max 3 mg/attack)

1 spray (0.5 mg)/nostril, repeated 15 minutes later (2 mg/dose; max 3 mg/24 hours)

Ergotamine 1 mg/caffeine 100 mg

( Ercaf, Gotamine , Wigraine)

2 tablets PO, then 1 q30min, x 4 PRN (max 6 tabs/attack)

Ergotamine ( Ergomar)

2-mg sublingual tablet, can be repeated q30min x 2 PRN (max 3 tabs/attack)

Ergotamine 2 mg/caffeine 100 mg ( Cafergot)

One rectal suppository; can be repeated once, 1 hour later

Butalbital combinations

Aspirin 325 mg, caffeine 40 mg, butalbita l 50 mg ( Fiorinal)

2 tablets, followed by 1 tablet q4-6h as needed

Acetaminophen 325 mg, caffeine 40 mg, butalbital 50 mg ( Esgic, Fioricet)

2 tablets, followed by 1 tablet q4-6h as needed

Acetaminophen 325 mg, butalbital 50 mg ( Phrenilin)

2 tablets, followed by 1 tablet as q4-6h needed

Isometheptene combination

Isometheptene 65 mg, acetaminophen 325 mg, dichloralphenazone 100 mg ( Midrin)

2 tablets, followed by 1 tablet as needed q4-6h prn

Opioid Analgesics

Butorphanol ( Stadol NS)

One spray in one nostril; can be repeated in the other nostril in 60-90 minutes; the same two-dose sequence can be repeated in 3 to 5 hours

Prophylaxis against migraine

Patients with frequent or severe migraine headaches or those refractory to symptomatic treatment may benefit from prophylaxis. Menstrual or other predictable migraine attacks may sometimes be prevented.

Beta-adrenergic blocking agents are used most commonly for continuous prophylaxis. Propranolol, timolol, metoprolol (Lopressor), nadolol (Corgard, and others) and atenolol (Tenormin).

Valproate (Depakote), an anticonvulsant, has been effective in decreasing migraine frequency. Its effectiveness was equal to that of propranolol. Adverse effects include nausea, weight gain and fatigue. Valproate taken during pregnancy.

Tricyclic antidepressants can prevent migraine and may be given concurrently with other prophylactic agents, but they often cause weight gain. Amitriptyline (Elavil) in a dosage ranging from 10 to 150 mg/day.