Migraine treatment

Treatment of migraine is primarily reduced to eliminating provoking factors (smoking, alcohol consumption, lack of sleep, stress, overwork, eating certain foods, vasodilators - nitroglycerin, dipyridamole, etc.), regular physical exercise. During an attack, the condition is alleviated by placing the patient in a quiet, dark room.

Pharmacotherapy of migraine includes abortive therapy (migraine tablets are used to stop an attack - analgesics, extracranial vasoconstrictors, ergotamine, triptans, caffeine, zolmitriptan, sumatriptan) and preventive therapy (aimed at preventing an attack - amitriptyline, propranolol, calcium channel blockers). How to cure migraine is decided in each specific case.

For most patients with migraine, all treatment is limited to stopping attacks. Only in cases of frequent, severe attacks and/or the addition of psychopathological syndromes (anxiety, depression, etc.) is prophylactic (preventive) treatment of migraine indicated. The main goal of prophylactic treatment of migraine is to reduce the frequency of attacks and decrease their intensity. It is impossible to completely cure migraine due to the hereditary nature of the disease. Prophylactic treatment of migraine is not prescribed during pregnancy or planned pregnancy.

Treatment of migraine attack

Treatment of a migraine attack begins as early as possible: for classic migraine ( migraine with aura) - when the precursors of an attack appear, for simple migraine - when the headache begins. Sometimes the attack is limited only by the aura, so some patients begin taking the medicine only when the headache appears.

Drug therapy should be prescribed depending on the intensity of the migraine attack. If the patient has attacks of mild or moderate intensity (no more than 7 points on the visual analogue pain scale), lasting no more than 1 day, it is recommended to use simple or combined analgesics (orally or in the form of suppositories): paracetamol (500 mg) or naproxen (500-1000 mg), or ibuprofen (200-400 mg), or acetylsalicylic acid [500-1000 mg; There are special forms of the drug for the treatment of migraines, such as Aspirin 1000 (effervescent tablets), codeine + paracetamol + propyphenazone + caffeine (1-2 tablets), as well as codeine-containing drugs (codeine + paracetamol + caffeine, codeine + paracetamol + metamizole sodium + caffeine + phenobarbital). When prescribing drug therapy, it is necessary to warn patients about the possible risk of abuse headaches (with excessive use of drugs) and addiction (with the use of codeine-containing drugs). This risk is especially high in patients who suffer from migraine attacks very often (more than 10 times a month).

The main requirements for anti-migraine drugs are effectiveness, safety, and speed of action. When choosing a specific dosage form to stop a migraine attack, it is advisable to start with simpler forms (non-steroidal anti-inflammatory drugs) and only if there is no effect, move on to more targeted treatment (ergotamine drugs, serotonin agonists).

Patients who do not seek medical help in most cases use simple or combined non-narcotic analgesics. These migraine pills can also help patients with episodic headaches. But it is important to remember that analgesics should not be abused, as this can contribute to the transition of headaches to chronic forms.

Among the NSAIDs, preference is given to cyclooxygenase inhibitors primarily in the CNS or in the CNS and periphery: meloxicam, nimesulide, paracetamol, acetylsalicylic acid, ibuprofen. In attacks accompanied by nausea, it is advisable to use acetylsalicylic acid in the form of an effervescent solution, since this form better relieves nausea. The fundamental mechanism of action of NSAIDs is associated with the inhibition of the synthesis of COX - a key enzyme in the metabolism of arachidonic acid, a precursor of prostaglandins (PG). Some NSAIDs suppress PG synthesis very strongly, others weakly. At the same time, no direct relationship has been found between the degree of suppression of PG synthesis, on the one hand, and analgesic activity, on the other.

Migraine tablets used to stop an attack

• Migraine drugs with a non-specific mechanism of action:
  • analgesics;
  • NSAIDs;
  • combination drugs.
• Drugs with a specific mechanism of action:
  • Selective 5-HT ₁ receptor agonists, or triptans, are the drugs of choice for treating migraine attacks;
  • non-selective 5-HT ₁ receptor agonists
  • ergotamine, etc.
• Auxiliary means:
  • metoclopramide, domperidone, chlorpromazine.

Abortive Migraine Treatment Medications

1. Aspirin
2. Acetaminophen
3. Nurofen, remesulide, revmoxicam
4. Combined analgesics (nurofen + solpadeine, caffetamin, cofergot, etc.)
5. Nonsteroidal anti-inflammatory drugs (naproxen, ibuprofen, etc.)
6. Ergotamine drugs (ergotamine, nicergoline)
7. Selective serotonin agonists (sumatriptan and zolmitriptan, imigran, zolmigren, naramig)
8. Dihydroergotamine (Digidergot - nasal spray)
9. Adjuvant agents (aminazine, cerucal, droperidol, motilium)

Combination drugs for the treatment of migraine - caffetin, citramon, spazmalgin, spazmoveralgin-neo, solpadeine and others - have a higher analgesic effect due to the inclusion of additional components. As a rule, these drugs contain caffeine, which has a tonic effect on the blood vessels of the brain, which explains its beneficial effect on migraine. In addition, caffeine enhances the venopressor effect, inhibits the activity of prostaglandin and histamine. It should be noted that the combination of paracetamol with caffeine is effective in stopping migraine attacks, pure paracetamol does not have such a pronounced therapeutic effect. Codeine has an analgesic and sedative effect, and also potentiates the effect of paracetamol. For example, the drug caffetin contains: propyphenazone - 210 mg, paracetamol - 250 mg, caffeine - 50 mg, codeine phosphate - 10 mg. Depending on the intensity of the headache, one or two tablets are taken; if there is no effect, a second dose is taken after 30 minutes. The maximum daily dose is 6 tablets of caffetin.

Since a migraine attack usually stops when falling asleep, sleeping pills, such as benzodiazepines or phenobarbital, which is part of many combination drugs containing NSAIDs (sedalgin, pentalgin, spazmoveralgin-neo), can help to some extent. It is better to take the medicine in the first minutes or hours from the onset of a migraine attack, preferably no later than 2-4 hours. With frequent use of analgesics, special caution is necessary, since there is a risk of developing a drug-induced headache. It is believed that a patient taking migraine medications daily or every other day may develop a drug-induced headache after three months.

If NSAIDs do not help the patient, he can be recommended ergotamine drugs. These drugs have a powerful vasoconstrictor effect, prevent neurogenic inflammation and, thus, stop a migraine attack. Ergotamine is prescribed as monotherapy or in combination with analgesics, antiemetics and sedatives, caffeine. The effectiveness of ergotamine drugs against migraines is higher when the drug is administered, bypassing the gastrointestinal tract (rectal suppositories, nasal spray). With increased sensitivity to ergot drugs, side effects are possible: chest pain, pain and paresthesia in the limbs, muscle spasms, vomiting, diarrhea. Digidergot nasal spray has the least side effects. Ischemic heart disease, hypertension and peripheral vascular disease are contraindications for prescribing ergotamine drugs. The initial dose is 1-2 mg of ergotamine, if necessary, the dose can be repeated after 30 minutes, while the total dose should not exceed 5 mg per attack or 10 mg per week.

Selective serotonin agonists (imigran, naramig) have a selective effect on serotonin receptors of cerebral vessels, causing selective narrowing of the carotid arteries, without having a significant effect on cerebral blood flow. It is believed that the expansion of these vessels is the main mechanism for the development of migraine in humans. In addition, these migraine drugs inhibit the activity of the trigeminal nerve. They are highly effective both in relation to headache itself (they relieve even extremely severe migraine attacks), and in relation to nausea and vomiting. Imigran is used in tablet form (tablets of 50 mg and 100 mg) and injection - 6 mg subcutaneously, the administration is carried out using an autoinjector (the total dose should not exceed 12 mg / day). Side effects are usually mild: facial flushing, fatigue, drowsiness, weakness, discomfort in the chest (in 3-5% of patients).

Migraine medications such as serotonin agonists are also contraindicated in ischemic heart disease, hypertension. It is strictly forbidden to use this group of drugs together with ergotamine or other vasoconstrictors.

The anti-migraine drug zolmitriptan (zolmigren) has a different mechanism of action. The point of application is the serotonin receptors 5-HT B/D. The drug causes vasoconstriction, mainly of the cranial vessels, blocks the release of neuropeptides, in particular, vasoactive intestinal peptide, which is the main effector transmitter of reflex excitation causing vasodilation, which underlies the pathogenesis of migraine. It stops the development of a migraine attack without a direct analgesic effect. Along with stopping a migraine attack, it reduces nausea, vomiting (especially with left-sided attacks), photo- and phonophobia. In addition to the peripheral action, it affects the centers of the brain stem associated with migraine, which explains the stable repeated effect in the treatment of a series of migraine attacks. Highly effective in the complex treatment of migraine status - a series of several severe, successive migraine attacks lasting 2-5 days. Eliminates migraine associated with menstruation. The effect of the drug develops in 15-20 minutes and reaches a maximum an hour after administration. The therapeutic dose is 2.5 mg, if the headache is not completely relieved after 2 hours, a repeat dose of 2.5 mg is possible. The maximum daily dose is 15 mg. Possible side effects may include drowsiness, a feeling of warmth.

In a study of a representative of the triptan group, zolmigren, the following data were obtained: in 20% of cases - a decrease in the frequency of migraine attacks, in 10% of cases - a decrease in the severity of pain syndrome and associated symptoms with the same frequency, in 50% of observations - a positive effect on autonomic disorders, a decrease in the severity of asthenic syndrome.

It is important to note that during a migraine attack, many patients have pronounced atony of the stomach and intestines, so the absorption of drugs taken orally is impaired. In this regard, especially in the presence of nausea and vomiting, antiemetics are indicated, which simultaneously stimulate peristalsis and improve absorption: metoclopramide (2-3 teaspoons of solution - 10-20 mg orally, 10 mg intramuscularly, intravenously or in suppositories 20 mg), domperidone (10-20 mg orally) 30 minutes before taking analgesics.

In case of high pain intensity (more than 8 points on the visual analog pain scale) and significant duration of attacks (24-48 hours or more), specific therapy is indicated. The so-called triptans, agonists of serotonin receptors of the 5HT ₁ type: sumatriptan, zolmitriptan, naratriptan, eletriptan, frovatriptan, etc., are recognized as the "gold standard", i.e. the most effective means capable of relieving intense migraine pain in 20-30 minutes. These drugs act on 5-HT ₁ receptors located both in the central nervous system and on the periphery, blocking the release of pain neuropeptides and selectively constricting the vessels dilated during an attack. Along with tablets, there are other dosage forms of triptans, such as nasal spray, solution for subcutaneous injections, and suppositories. Due to the presence of certain contraindications and side effects, before starting to take triptans, the patient should carefully read the instructions for use of the drug.

Imigran (sumatriptan) is a migraine medicine. Relief of migraine attacks with or without aura. Nasal spray is especially indicated for migraine attacks accompanied by nausea and vomiting, as well as for achieving an immediate clinical effect. Release form: nasal spray 10 or 20 mg in one dose, tablets 50,100 mg No. 2. Manufacturer - GlaxoSmithKline Trading CJSC.

Ergotamine-containing drugs for migraine, which were widely used in the past and have a vasoconstrictor effect on the smooth muscles of the vascular wall, are used less and less recently.

Preventive treatment of migraine

The duration of the course of treatment should be sufficient (from 2 to 12 months, on average 4-6 months, depending on the severity of migraine).

Goals of migraine preventive treatment

• Reducing the frequency, duration and severity of migraine attacks.
• Reducing the frequency of taking medications that relieve attacks can lead to chronic headaches.
• Reducing the impact of migraine attacks on daily activities + treatment of comorbid disorders.

This therapy prevents the disease from becoming chronic and improves the quality of life of patients.

Indications for prophylactic treatment of migraine

• High frequency of attacks (three or more per month).
• Long-term attacks (3 days or more) causing significant maladaptation.
• Comorbid disorders in the interictal period that worsen the quality of life (depression, insomnia, dysfunction of the pericranial muscles, tension headaches associated with it).
• Contraindications to abortion treatment, its ineffectiveness or poor tolerability.
• Hemiplegic migraine or other headache attacks during which there is a risk of developing permanent neurological symptoms.

Preventive treatment of migraine includes migraine medications of various pharmacological groups. How to cure migraine is decided strictly individually. Each patient is prescribed migraine pills taking into account the pathogenetic mechanisms of the disease, provoking factors, the nature of emotional-personal and comorbid disorders.

Preventive therapy should be prescribed under the following conditions (Silberstein):

1. Two or more attacks per month causing incapacity for 3 or more days.
2. Symptomatic medications are contraindicated (ineffective).
3. Requires taking abortion drugs more than twice a week.
4. There are special circumstances, for example, attacks occur rarely, but cause deep and pronounced disorders.

Nonsteroidal anti-inflammatory drugs

Side effects: nausea, vomiting, heartburn, abdominal pain, bowel disturbances, skin rash

1. Remesulide 100 mg 2 times a day.
2. Revmoxicam 7.5-15 mg 1 time/day.
3. Nurofen 200-400 mg 2-3 times a day.
4. Ketoprofen 75 mg 3 times a day.
5. Naproxen 250-500 mg 2 times a day

Tricyclic, with sedative action

Contraindicated in glaucoma, prostatic hyperplasia, cardiac conduction disorders

Amitriptyline 10-150 mg/day

Serotonin reuptake inhibitors

Side effects include nausea, diarrhea, insomnia,
anxiety, sexual dysfunction

• Fluoxetine (Prozac) 10-80 mg/day
• Citalopram (Cytahexal) 20-40 mg/day

Beta blockers

Side effects include fatigue, gastrointestinal disturbances, sleep disturbances, arterial hypotension, cold extremities, bradycardia, sexual dysfunction. Contraindicated: patients with asthma, chronic obstructive bronchitis, heart failure, atrioventricular block, insulin-dependent diabetes, peripheral vascular disease.

• Propranolol 60-160 mg/day
• Metoprolol 100-200 mg/day

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Calcium channel blockers

• Verapamil 120-480 mg/day (May cause arterial hypotension, constipation, nausea)

The course of treatment is 2-3 months. Preventive treatment courses should be carried out in combination with drugs that directly stop a migraine attack. Beta-blockers, antidepressants, calcium channel blockers, antiserotonergic agents and anticonvulsants are used. Treatment usually begins with beta-blockers or antidepressants. In addition to drug therapy, it is advisable to carry out rational psychotherapy, acupuncture, and relaxation techniques for pericranial muscles.

In recent years, the advisability of using antiepileptic drugs (anticonvulsants) for migraine prevention has been studied, due to their ability to reduce increased excitability of neurons in the brain and thereby eliminate the prerequisites for the development of an attack. Anticonvulsants are especially indicated for patients with severe frequent migraine attacks that are resistant to other types of treatment, including chronic migraine, as well as chronic tension headache. One such drug is topiramate at a dose of 100 mg per day (initial dose - 25 mg per day with an increase of 25 mg every week, the regimen is 1-2 times a day; duration of therapy is 2-6 months). Before starting treatment, the doctor should carefully read the instructions for use of the drug.

The complex therapy regimen for older patients (over 45-50 years old) may include vasodilators, nootropics, and antioxidants: piracetam + cinnarizine (two capsules 3 times a day), cinnarizine (50 mg three times a day), vinpocetine (10 mg 2-3 times a day), dihydroergocryptine + caffeine - vasobral (2 ml 2-3 times a day or 1 tablet 3 times a day), piracetam (800 mg 2-3 times a day), ethylmethylhydroxypyridine succinate (125 mg three times a day). Although these drugs do not have a specific antimigraine effect, they can be useful due to their nootropic and antioxidant effects. The presence of myofascial syndrome in the pericranial muscles and muscles of the upper shoulder girdle, more often on the side of pain, necessitates the administration of muscle relaxants (tizanidine 4-6 mg/day, tolperisone 150 mg 2-3 times a day, baclofen 10 mg 2-3 times a day), since excessive muscle tension can provoke a typical migraine attack.

There is some evidence that botulinum toxin is effective in treating migraines, although many published clinical studies do not support this.

If a patient with migraine has comorbid disorders that significantly disrupt the condition in the interictal period, treatment should be aimed not only at preventing and stopping the actual pain attacks, but also at combating these unwanted companions of migraine (treatment of depression and anxiety, normalization of sleep, prevention of autonomic disorders, impact on muscle dysfunction, treatment of gastrointestinal diseases). Only such an approach will alleviate the condition of patients in the interictal period and improve their quality of life.

Recently, non-drug methods have been increasingly used to treat frequent and severe migraine attacks: psychotherapy, psychological relaxation, biofeedback, progressive muscle relaxation, acupuncture. These methods are most effective in migraine patients with emotional and personality disorders (depression, anxiety, demonstrative and hypochondriacal tendencies, chronic stress). In the presence of severe dysfunction of the pericranial muscles, post-isometric relaxation, collar zone massage, manual therapy, and gymnastics are indicated. Folk remedies are also used to treat migraine.

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Treatment of severe migraine attacks

Migraine attacks with intense pain, especially those accompanied by severe nausea and vomiting, may require parenteral administration of drugs. To stop such an attack, sumatriptan can be administered subcutaneously. In this case, the effect of the drug appears within 30 minutes, and its effect will last up to 4 hours. Dihydroergotamine (DHE) is an ergot derivative produced in an injectable form. It has a less pronounced vasoconstrictor effect on peripheral arteries than ergotamine, and is able to effectively stop an attack. Dihydroergotamine can be administered subcutaneously or intravenously. When administered intravenously, dihydroergotamine causes less nausea than ergotamine, however, before using DHE, it is recommended to pre-administer an antiemetic.

Ketorolac, a nonsteroidal anti-inflammatory drug for migraine that can be administered parenterally, may be an effective alternative to narcotic analgesics in patients who cannot tolerate vasoconstrictor drugs such as sumatriptan or DHE. Meperidine, an opioid analgesic often administered intramuscularly, is also used to treat severe migraine attacks, usually also in combination with an antiemetic. Given the availability of alternatives, parenteral use of narcotic analgesics is currently only permitted in patients with rare attacks or in cases where other drugs are contraindicated, such as severe peripheral or cerebral arterial disease, ischemic heart disease, or pregnancy.

Neuroleptics may be used in the emergency department for the treatment of severe or prolonged headache as an alternative to meperidine or vasoconstrictor drugs. However, the risk of hypotension and the need for intravenous administration limit the use of chlorpromazine. To prevent hypotension, 500 ml of isotonic sodium chloride solution is administered intravenously before using chlorpromazine. Chlorpromazine can be repeated after 1 hour. An alternative to chlorpromazine is prochlorperazine, which can be administered intravenously without prior infusion of isotonic solution. Repeated administration of the drug is possible after 30 minutes.

In addition to drug therapy, rational psychotherapy, autogenic training, acupuncture, transcutaneous electrical neurostimulation, and methods based on biological feedback can be used for all forms of migraine. Considering the important role of the cervical-muscular "corset" in maintaining headaches, a special program of influence on the musculoskeletal system of the neck, head, and shoulder girdle is offered, including physiotherapy, special exercises, traction, injections into trigger points, and relaxation training.

The effect of a constant magnetic field is also carried out transcerebrally. It has been established that transcerebral application of a constant hemogenic magnetic field reduces the severity of migraine attacks and other vasomotor cephalgias.

Surgical treatment of migraine: sympathectomy of the superior cervical sympathetic ganglion, especially in cases with frequent ischemic complications due to arterial spasm. Cryosurgery for cluster migraine or severe unilateral migraine - freezing of branches of the external carotid artery. In recent years, these methods have been rarely used, given the complex genesis of migraine headaches and their low effectiveness.

Treatment of migraine status

If a migraine attack lasts more than 3 days or if attempts to stop it are unsuccessful, then the method of choice is intravenous dihydroergotamine (DHE). Treatment is carried out in the emergency department in the absence of contraindications, including pregnancy, angina or other forms of ischemic heart disease. DHE is administered undiluted through the intravenous system. To avoid nausea, 10 mg of metoclopramide is administered intravenously before the DHE injection, but after six doses of DHE, metoclopramide can be discontinued in most cases. In patients with migraine status, it is necessary to find out what analgesics and in what doses they managed to take before hospitalization. Since in this case an overdose of relief agents often occurs, it is necessary to carefully monitor the appearance of signs of barbiturate or opioid withdrawal syndrome. If the patient has not previously taken drugs to prevent attacks, then after relief of migraine status, he is recommended to begin preventive therapy.