Analgesics

Analgesics are painkillers that work by reducing the person’s perception of the attack, effectively numbing the pain-affected area. Many are available over-the-counter (OTC).

Aspirin is a traditional first line painkiller. It has anti-inflammatory effects, which affect some of the mechanisms that make a migraine hurt.

Paracetamol is another common analgesic but unlike aspirin, it does not have an anti-inflammatory effect.

Combination Alalgesics are so termed because they consist of two drugs working together to attack thepain. Codeine and Caffeine are the most common combination painkillers. Anti-nausea (anti-emetic) drugs can also be used in combination with painkillers to treat migraine.

Non Steroidal Anti-Inflammatory Drugs

NSAIDs are also used, generally, for more severe attacks. They attack inflammation. Examples of NSAIDs would be nurofen, difene, naprosyn, etc.

Tips:

• The soluble forms of the drugs listed above  are usually better for people with migraine because most people experience stomach symptoms as part of their attack which can slow down the absorption of ordinary tablets.
• OTC analgesics can be dangerous if taken incorrectly. Please also note that if the migraine does not respond to the stated dose of the analgesic, taking extra doses won’t help and in fact can lead to Rebound Headache through overuse as well as stomach irritation.

Triptans

Triptans are the migraine specific, prescription-only drugs that became available in Ireland in the 1990s. These drugs target specific groups of serotonin receptors in the brain that are known to be closely involved in migraine attacks.

There are seven Triptan drugs available in Ireland and they are now considered to be the first line treatment of choice. They are:

• Almotriptan
• Frovatriptan
• Sumatriptan
• Eletriptan
• Zolmitriptan
• Naratriptan
• Rizatriptan

Studies have shown that treating the headache with triptans will resolve the pain within two hours in up to 80% of cases, but only if the drug is taken early when the pain is milder.

Some people find that the headache will recur after taking a Triptan in which case a second dose can be taken. Some of the triptans are available in non-tablet form (e.g. nasal spray or dissolving tablet). These are quicker acting and may be useful for people who experience severe nausea.

Triptans are licensed for people aged between 18 and 65, both those with and without aura. They are not suitable during pregnancy. They are also not suitable for people who have a history of any type of cardiovascular disease or high blood pressure.

Types of Migraine

Preventatives

The most commonly used migraine preventives include:

• Beta Blockers
• Anti-Epilepsy agents (Anti-Convulsants)
  • PLEASE NOTE  Sodium Valproate (Epilim), should not be used in female children, in female adolescents, in women of childbearing potential and pregnant women, this is particularly important, given the significant teratogenic (increase risk of birth defects) potential of the medicine.  If you are taking Sodium Valproate (Epilim) please ensure your read the Patient Information Leaflet .
• Calcium Channel Blockers
• Tricyclic Anti-Depressants
• 5-HT Antagonists*

Preventative

Treatments

For more information on any of the above, please call us on 1850-200-378 and request our Migraine Medications leaflet. You can also email info@migraine.ie

• Complete the course of treatment prescribed and in the manner prescribed unless otherwise agreed with your doctor
• Report any side effects back to your doctor immediately
• Always bring your medication (preventive and acute) with you wherever you go
• Use your Migraine Diary to record the effectiveness of the drug

*Update Nov 2015: Sanomigran (Pizotifen) has been discontinued in Ireland or the UK.

What should I expect after the Occipital Nerve Block?

Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anaesthetic injected. This will last only for a few hours. Your pain may return and you may have a sore head for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation from the steroid itself. You should start noticing a more lasting pain relief starting the third day or so.

What should I do after the Occipital Nerve Block?

You will rest for a while in the office. Most patients can drive themselves home. The patient to take it easy for several hours after the procedure. You may want to apply ice to the injected area. You can perform any activity you can tolerate.

Can I go to work to work the next day?

Unless there are complications, you should be able to return to work the next day. The most common thing you may feel is a sore head at the injection site.

How long does the effect of the medication last?

The immediate effect is usually from the local anaesthetic injected. This wears off in a few hours. The steroid starts working in about three to five days and its effect can last for several days to a few months.

How many Occipital Nerve Blocks do I need to have?

It varies. The injections are done about one week apart only if needed. If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a second injection. If you respond to the injections, you may be recommended for additional injections when the symptoms return.

Can I have as many Occipital Nerve Blocks as I need?

With some exceptions, in any given six-month period, experts will generally not perform more than three occipital nerve blocks. This is because giving more injections could increase the likelihood of side effects from the steroids that are injected. Likewise, if the patient needs more frequent injections, other treatments should probably be considered.

Will the Occipital Nerve Blocks help me?

It is difficult to predict if the injection will help you or not. Generally speaking, patients who have recent onset of pain may respond much better than the ones with a longstanding pain. Usually the first injection is as much a test as a treatment. The first block will confirm that the occipital nerves are involved in the pain and be helpful. Or it will not help and the occipital nerves will not be suspected as part of the pain.

What are the risks and side effects of Occipital Nerve Blocks?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is temporary pain at the injection site. Other uncommon risks involve infection, bleeding, worsening of symptoms etc. Fortunately, serious side effects and complications are uncommon.

Who should not have an Occipital Nerve Block?

If you are allergic to any of the medications to be injected, if you are on a blood thinning medication, if you have an active infection going on, or if you have poorly controlled diabetes or heart disease, you should not have an occipital nerve block or at least consider postponing it if postponing would improve your overall medical condition.

Safety and Side-Effects

In clinical trials for chronic migraine, 26% reported side-effects after the first treatment and this declined to 11% with a second treatment. 9% reported a worsening of headache.

In general, adverse reactions occur within the first few days following injection and are not permanent or long-lasting.

Serious and/or immediate hypersensitivity reactions have been rarely reported. However, these can include anaphylaxis (severe allergic reaction), serum sickness, urticaria (hives), soft tissue oedema (fluid retention) and dyspnoea (breathlessness).

Side effects related to spread of toxin distant from the site of administration have been reported, sometimes resulting in death, which in some cases was associated with dysphagia (difficulty swallowing), pneumonia and/or significant weakness. Patients treated with therapeutic doses may experience exaggerated muscle weakness.

As with any injection, injury can occur. An injection could result in localised infection, pain, inflammation, tenderness, swelling, bleeding, bruising, etc. BOTOX may cause asthenia (lack of strength), muscle weakness, somnolence (drowsiness), dizziness and visual disturbance, which could affect driving and the operation of machinery. If there is a reaction, further injections of BOTOX should be discontinued. Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respiratory disorders arise.

The safety and effectiveness of BOTOX in the treatment of chronic migraine has not been demonstrated in children (however, chronic migraine is rare in children).

Clinical Trials

Two clinical trials involving 1,384 adults were carried out over 60 weeks (five injection cycles).

Patients were eligible for the study if they had a history of migraine and experienced fifteen or more headache days of which at least 50% were migraine or probable migraine during a 28 day ‘baseline’ period.

Two thirds of the patients had previously been treated with at least one other headache prophylactic medication and nearly two thirds of the patients were overusing acute medications.

Patients were divided into two groups – Botox and Placebo.

At baseline, patients in the BOTOX treatment group had an average of 19.1 days with migraine. Patients in the placebo treated group had an average of 18.9 days with migraine. By week 24 BOTOX treated patients averaged 8.2 fewer migraine days. Placebo had 6.2 fewer.

47.1% of BOTOX treated patients (compared to 35.1% of placebo treated patients) achieved >50% reduction in the number of headache days at week 24. After week 56, nearly 70% of BOTOX treated patients experienced ≥50% reduction in migraine days.

Patients treated with BOTOX reported more significant improvements in their quality of life scores and a greater lessening of headache related disability compared with those on placebo.

Most adverse events reported in the trials were mild to moderate and resolved without further problems. The treatment was generally well tolerated and only 3.8% of the BOTOX group stopped treatment.