Medications

and Migraine

Migraine Treatment

Medications

Acute Migraine
Medication
Preventative Migraine
Medication
Occipital Nerve
Block
Onabotulinum Toxin
A for Migraine

Acute Migraine Medication

Acute migraine medication attempts to relieve or stop the progression of an attack or to abort it once it has begun. Acute treatment should be taken as early as possible in the headache phase of an attack to prevent its escalation and to increase the drugs effectiveness. The two main types of acute treatments used are Analgesics and Triptans.

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.

HCP (Acute Treatment)

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.
HCP (Acute Treatment)

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.

HCP (Acute Treatment)

Preventative Migraine Medication

Preventative migraine medication is used in an attempt to reduce the frequency and severity of anticipated attacks. However, these drugs are unlikely to prevent attacks altogether and will not cure the underlying cause.

Preventative

Treatments

The goal of preventative treatments is to reduce the frequency of your migraine attacks. They are normally prescribed in one of the following circumstances:

  • If you suffer from more than two or three attacks per month
  • If your attacks are particularly severe or disabling and do not respond well to acute treatments
  • To break the cycle of attacks
  • If your attacks follow a regular pattern (e.g. around the time of menstruation)
  • If you suffer from rare forms of migraine such as basilar or hemiplegic migraine

Preventives are taken daily for a period of six to twelve months and while they rarely actually prevent attacks altogether, their success rate of about 50-60% means that it is likely you will experience at least some benefit. Preventatives will not be beneficial in treating an attack once it has started. Acute treatment is then necessary.

Some preventatives work better in one person than in another, so if one does not work well, it does not mean that another will not work.

Acute Therapy

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*
Epilim Patient Leaflet

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

Some tips for when you have been prescribed a Preventive:
  • 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.

Migraine Diary

Occipital Nerve Block

Occipital Nerve Block as a treatment for Migraine

What is an Occipital Nerve Block?

An occipital nerve block is an injection of a steroid or other medication around the greater and lesser occipital nerves that are located on the back of the head just above the neck area.

What is the purpose of an Occipital Nerve Block?

The steroid injected reduces the inflammation and swelling of tissue around the occipital nerves. This may in turn reduce pain, and other symptoms caused by inflammation or irritation of the nerves and surrounding structures. Typically, headaches over the back of the head including certain types of tension headaches and migraine headaches, may respond to occipital nerve blocks.

How long does the Occipital Nerve Block take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a local anaesthetic and a steroid medication.

Will the Occipital Nerve Block hurt?

The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, the skin and deeper tissues are numbed with a local anaesthetic using a very thin needle during the performance of the block.

Will I be “put out” for the Occipital Nerve Block?

No. This procedure is done with a small thin needle, usually without any sedation. There is local anaesthetic within the injection.

How is the Occipital Nerve Block performed?

It is done with the patient seated or lying down. The skin and hair of the back of the head are cleaned with antiseptic solution and then the injection is carried out.

Watch: Occipital Nerve Block with Dr Andrew Blumenfeld

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.

Find out More

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.

Find out More

Onabotulinum Toxin A for Migraine

Botox is now used as a preventative treatment for chronic migraine sufferers. Chronic migraine is defined as headaches on at least fifteen days per month (of which at least eight days are with migraine).

How does it work?

BOTOX blocks the release of neuro-transmitters that are linked to causing pain. Neuro-transmitters are chemicals that carry nerve impulses. To prevent headache, Botox blocks these signals from reaching the central nervous system and causing the nerves to become highly sensitive.

Botox is given by injection; divided across seven specific head/neck muscle areas. The number of injection sites start at 31, up to a maximum of 39. Half the injection sites should be on the left side of the head and half on the right. If there is a predominant pain location, further injections may be given (up to the maximum dosage). The injections should be given by trained personnel in hospital or specialist centres.

Always make sure that you see a doctor who is trained in administering botox for migraine, and not for cosmetic reasons. Training is now beginning across Ireland.

The recommended re-treatment schedule is every twelve weeks. No efficacy has been shown for BOTOX in preventing headaches in patients with episodic migraine (headaches on less than fifteen days per month).

Watch: Botox Injection for Chronic Migraine

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).

Contraindications

BOTOX is contraindicated:

  • In the presence of infection at the proposed injection site(s)
  • In individuals with a known hypersensitivity to botulinum toxin type A or to any of the other ingredients used to form ‘Botox’

It is not advised:

  • During pregnancy, unless clearly necessary
  • During lactation as there is no information on whether BOTOX is excreted in human milk

Note: Patients with underlying neurological disorders including swallowing difficulties are at increased risk of side effects. In this case, treatment should only be used if the benefit of treatment is considered to outweigh the risk.

Patients with neuromuscular disorders may be at an increased risk of more severe effects including acute dysphagia and respiratory compromise from typical doses of BOTOX.

Patients with a history of dysphagia (difficulty swallowing) and aspiration (inhaling foreign bodies, such as stomach contents, into the airways) should be treated with extreme caution.

Caution should be used when BOTOX is used in the presence of inflammation at the proposed injection site(s) or when excessive weakness is present in the target muscle.

Caution should also be exercised when BOTOX is used for treatment of patients with peripheral motor neuropathic diseases.In the absence of studies, this medicinal product should not be mixed with other medicinal products.

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.

Migraine is a

Complex

Neurological

Disorder

That Effects Different Areas of The Brain

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