Treatment of migraine

Treatment of migraines is reduced, first of all, to the exclusion of provoking factors (smoking, drinking alcohol, lack of sleep, stress, fatigue, eating certain products, vasodilators - nitroglycerin, dipyridamole, etc.), regular physical exercises. During an attack, the condition facilitates placing the patient in a quiet dark room.

Migraine pharmacotherapy includes abortive therapy (migraine tablets that stop the attack - analgesics, extracranial vasoconstrictors, ergotamine, triptans, caffeine, zolmitriptan, sumatriptan) and preventive (aimed at preventing the attack - amitriptyline, propranol, calcium channel blockers). How to cure a migraine is decided in each case.

In the majority of patients with migraine, all treatment is reduced only to relief of seizures. Only with frequent, severe attacks and / or joining psychopathological syndromes (anxiety, depression, etc.) is shown the preventive (preventive) treatment of migraine. The main goal of prophylactic treatment of migraine is to reduce the frequency of seizures and decrease their intensity. It is impossible to completely cure migraines because of the hereditary nature of the disease. Preventative treatment of migraine is not prescribed in pregnancy or planned pregnancy.

Treatment of migraine attack

Treatment of a migraine attack begins as early as possible: with a classic migraine ( migraine with aura) - with the appearance of harbingers of an attack, with a simple migraine - with the onset of a headache. Sometimes the attack is limited only by the aura, so some patients start taking the medicine only when there is pain in the head.

Medication should be prescribed depending on the intensity of the migraine attack. If the patient has weak or moderate intensity (no more than 7 points according to the visual analogue pain scale) for a duration of not more than 1 day, it is recommended to use simple or combined analgesics (inside 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 each; there are special forms of the drug for the treatment of migraine, for example, Aspirin 1000 (effervescent tablets)], codeine + paracetamol + propyphenazone + caffeine (1-2 tablets), and codeine-containing drugs (codeine + paracetamol + caffeine, codeine + paracetamol + metamizole sodium + caffeine + phenobarbital). When prescribing drug therapy, patients should be warned about the possible risk of abusic headache (with excessive use of drugs) and addiction (with the use of codeine-containing drugs). This risk is especially high in patients who are very often suffering from migraine attacks (more than 10 times a month).

The main requirements for anti-migraine drugs are efficacy, safety, speed of action. When choosing a specific dosage form for cupping migraine attack, it is advisable to start with simpler forms (nonsteroidal anti-inflammatory drugs) and only in the absence of effect, to proceed to more targeted treatment (ergotamine drugs, serotonin agonists).

Patients who do not resort to medical care, in most cases, use simple or combined non-narcotic analgesics. These migraine tablets can also help patients with episodic headaches. But you need to remember about the inadmissibility of abuse of analgesics, because this can promote the transition of the headache to chronic forms.

Among the group of NSAIDs, cyclooxygenase inhibitors are preferred in the central nervous system or in the central nervous system and in the periphery: meloxicam, nimesulide, paracetamol, acetylsalicylic acid, ibuprofen. In seizures accompanied by nausea, it is advisable to use acetylsalicylic acid in the form of an effervescent solution, since this form better suppresses nausea. The fundamental mechanism of action of NSAIDs is associated with inhibition of the synthesis of COX, a key enzyme in the metabolism of arachidonic acid, a precursor of prostaglandins (PG). Some NSAIDs suppress the synthesis of PG very much, others are weak. At the same time, a direct connection between the degree of suppression of GH synthesis, on the one hand, and analgesic activity, on the other, has not been revealed.

Tablets from migraine, used to stop an attack

• Preparations for migraine with nonspecific mechanism of action:
  • analgesics;
  • NSAIDs;
  • combined preparations.
• Drugs with a specific mechanism of action:
  • selective agonists of 5-HT ₁ -receptors, or triptans are the drugs of choice for the treatment of migraine attacks;
  • nonselective agonists of 5-HT ₁ -receptors
  • ergotamine and others.
• Auxiliary means:
  • metoclopramide, domperidone, chlorpromazine.

Medications for abortive migraine treatment

1. Aspirin
2. Acetaminophen
3. Nurofen, ressulid, rheumoxicam
4. Combined analgesics (Nurofen + Solpadein, Cofetamine, Cofergot, etc.)
5. Non-steroidal anti-inflammatory drugs (naproxen, ibuprofen, etc.)
6. Ergotamine preparations (ergotamine, nicergoline)
7. Selective serotonin agonists (sumatriptan and zolmitriptan, imigran, zolmigren, naramig)
8. Dihydroergotamine (dihydergot - nasal spray)
9. Adjuvant (aminazine, cerucal, droperidol, motilium)

Combined medications for the treatment of migraine - caffetin, citramone, spasmalgin, spasmoveralgin-neo, solpadane and others - have a higher analgesic effect due to the inclusion of additional components. As a rule, the composition of these drugs includes caffeine, which has a tonic effect on the 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 for the relief of migraine attacks, it is precisely the combination of paracetamol with caffeine that is effective, pure paracetamol has no such pronounced therapeutic effect. Codeine has an analgesic and sedative effect, and also potentiates the action of paracetamol. For example, the drug caffetin contains: propiphenazone 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, in the absence of effect - after 30 minutes a repeated dose is taken. The maximum daily dose is 6 tablets of caffeine.

Since the migraine attack usually stops when you fall asleep, hypnotic drugs, for example, benzodiazepine drugs or phenobarbital, which is a part of many combined preparations containing NSAIDs (selagin, pentalgin, spasmoveralgine neo) can help in part. 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 care is needed because there is a danger of developing a drug headache. It is believed that in a patient taking medication for migraine on a daily or every second day, after three months, a drug headache may form .

If the patient is not helped by NSAIDs, he can recommend ergotamine preparations. These drugs have a powerful vasoconstrictive effect, prevent neurogenic inflammation and, thus, stop the migraine attack. Ergotamine is prescribed as a monotherapy or in combination with analgesics, antiemetics and sedatives, caffeine. The effectiveness of ergotamine preparations against migraine is higher when the drug is administered, bypassing the gastrointestinal tract (rectal suppositories, nasal spray). With increased sensitivity to ergot preparations, side effects are possible: retrosternal pain, pain and paresthesia in the extremities, muscle spasms, vomiting, diarrhea. Diigidergot-nasal spray has the least side effects. Coronary heart disease, hypertension and peripheral vascular disease are contraindications for the administration of ergotamine drugs. The initial dose is 1 -2 mg ergotamine, if necessary, the reception 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 the serotonin receptors of the cerebral vessels, causing selective narrowing of the carotid arteries without significantly affecting cerebral blood flow. It is believed that the expansion of these vessels is the main mechanism of migraine development in humans. In addition, these migraine drugs inhibit trigeminal nerve activity. They are highly effective both in relation to the actual headache (stop even extremely severe migraine attacks), and with regard to nausea, vomiting. Imigran is used in tablet form (tablets of 50 mg and 100 mg) and injectable - 6 mg subcutaneously, the introduction is carried out using an autoinjector (the total dose should not exceed 12 mg / day). Side effects are usually poorly expressed: face hyperemia, fatigue, drowsiness, weakness, unpleasant sensations in the chest (in 3-5% of patients).

Such medications for migraine as serotonin agonists are also contraindicated in ischemic heart disease, hypertensive disease. Categorically, this group of drugs should not be used together with ergotamine or other vasoconstrictors.

Another mechanism of action has a drug for migraine - zolmitriptan (zolmigren). The point of application are serotonin receptors 5-HT B / D. The drug causes vasoconstriction, mainly cranial vessels, blocks the release of neuropeptides, in particular, the vasoactive intestinal peptide, which is the main effector transmitter of reflex excitation that causes vasodilation, which underlies the pathogenesis of migraine. It stops the development of a migraine attack without direct analgesic action. Along with the relief of a migraine attack, it weakens nausea, vomiting (especially with left-side attacks), photo and phonophobia. In addition to peripheral action, it affects the centers of the brain stem associated with migraine, which explains the persistent repeated effect in the treatment of a series of migraine attacks. It is highly effective in the complex treatment of migraine status - a series of several severe, sequential 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 one hour after administration. The therapeutic dose is 2.5 mg, if the headache is not completely removed after 2 hours, a further intake of 2.5 mg is possible. The maximum daily dose is 15 mg. Possible side effects may be drowsiness, a feeling of heat.

In a study of a representative of the zolmigrene triptane group, such 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 the pain syndrome and accompanying symptoms at the same frequency, in 50% of the observations - a positive effect in autonomic disorders, the severity of the asthenic syndrome.

It is important to note that during the attack of migraine in many patients expressed atony of the stomach and intestines, so the absorption of drugs taken inside, is violated. In this regard, especially in the presence of nausea and vomiting, antiemetics are shown that 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) for 30 minutes before taking analgesics.

At a high pain intensity (more than 8 points according to visual analog pain scale) and a significant duration of attacks (24-48 hours and more), the purpose of specific therapy is indicated. "Gold standard", i.e. The most effective means, able to stop intensive migraine pain after 20-30 minutes, are the so-called triptans - serotonin receptor type 5HT ₁ agonists : sumatriptan, zolmitriptan, naratriptan, eletriptan, frevaptriptan, etc. By acting on 5-HT ₁ -receptors located both in the central nervous system and in the periphery, these drugs block the isolation of painful neuropeptides and selectively narrow the vessels dilated during the attack. Along with tableted, there are other medicinal forms of triptans, for example nasal spray, hypodermic injection, suppositories. In connection with the presence of certain contraindications and side effects before the start of triptans, the patient should carefully read the instructions for use of the drug.

Imigran (sumatriptan) is a remedy for migraine. Coping migraine attacks with an aura or without an aura. Nasal spray is especially indicated for migraine attacks accompanied by nausea and vomiting, and to achieve immediate clinical effect. Form release: nasal spray 10 or 20 mg in a single dose, tablets 50,100 mg No. 2. Producer - CJSC "GlaxoSmithKline Trading".

Widely used in the past, ergotamine-containing preparations for migraine, which have a vasoconstrictive effect on the smooth muscle of the vessel wall, have recently been used less and less.

Preventive treatment of migraine

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

Goals of preventive treatment of migraine

• Reduction of the frequency, duration and severity of migraine attacks.
• Reducing the frequency of taking medications that stop seizures, and can lead to chronic headaches.
• Weakening the impact of migraine attacks on daily activity + treatment of comorbid disorders.

Such therapy prevents the chronization of the disease and improves the quality of life of patients.

Indications for preventive treatment of migraine

• A high incidence of seizures (three or more per month).
• Prolonged seizures (3 days or more), causing significant disadaptation.
• Comorbid disorders in the interictal period, worsening the quality of life (depression, dissomnia, dysfunction of pericranial muscles, accompanying tension headache).
• Contraindications to abortive treatment, its inefficiency or poor tolerability.
• Hemiplegic migraine or other attacks of headache, during which there is a risk of permanent neurological symptoms.

Preventive treatment of migraine includes preparations from migraine of various pharmacological groups. How to cure a migraine is decided individually. Each patient is selected from migraine tablets, taking into account the pathogenetic mechanisms of the disease, provoking factors, the nature of emotional-personal and comorbid disorders.

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

1. Two or more seizures per month, causing disability for 3 or more days.
2. Symptomatic medications are contraindicated (ineffective).
3. Abortion drugs are required more than twice a week.
4. There are special circumstances, for example, seizures are rare, but cause profound and severe disorders.

Non-steroidal anti-inflammatory drugs

Side effects: nausea, vomiting, heartburn, abdominal pain, stool disorders, skin rash

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

Tricyclic, with sedative effect

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 (cytagexal) 20-40 mg / day

Beta-blockers

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

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

[1], [2], [3], [4], [5], [6], [7]

Calcium channel blockers

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

Course treatment is 2-3 months. The course of preventive treatment should be carried out in combination with drugs that directly stop the migraine attack. Apply beta-adrenoblockers, antidepressants, calcium channel blockers, antiserotonergic drugs and anticonvulsants. Treatment, as a rule, begins with beta-blockers or antidepressants. In addition to drug therapy, it is advisable to conduct rational psychotherapy, acupuncture, relaxation techniques for pericranial muscles.

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

The scheme of complex therapy of elderly patients (after 45-50 years) can include vasodilator, nootropic drugs, as well as antioxidants: piracetam + cinnarizine (two capsules 3 times a day), cinnarizine (50 mg three times daily), vinpocetine (10 mg 2-3 times a day), dihydroergocryptin + 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 daily). Although these drugs do not have a specific antimigraine effect, they can be useful for their nootropic and antioxidant effects. The presence of myofascial syndrome in pericranial muscles and muscles of the upper humeral girdle, often on the side of pain, necessitates the appointment of muscle relaxants (tizanidine 4-6 mg / day, tolperisone 150 mg 2-3 times a day, baclofen 10 mg 2-3 times per day), since excessive muscle tension can provoke a typical migraine attack.

There is evidence of the effectiveness of botulinum toxin in migraine, while many published clinical studies do not support this.

In the presence of a migraine patient with comorbid disorders that significantly disrupt the condition in the interictal period, treatment should be directed not only at preventing and arresting the painful seizures themselves, but also in combating these undesirable migraine satellites (treatment of depression and anxiety, sleep normalization, prophylaxis of vegetative violations, the effect on muscle dysfunction, treatment of gastrointestinal diseases). Only such an approach will make it possible to alleviate the condition of patients in the interictal period and improve their quality of life.

Recently, to treat frequent and severe attacks of migraine, non-drug methods are increasingly being used: psychotherapy, psychological relaxation, biological feedback, progressive muscle relaxation, acupuncture. The most effective these methods have in patients with migraine with emotional-personality disorders (depression, anxiety, demonstrative and hypochondriacal tendencies, the state of chronic stress). In the presence of severe dysfunction of pericranial muscles, post-isometric relaxation, collar zone massage, manual therapy, gymnastics are shown. Apply also treatment of migraine by alternative means.

[8], [9], [10]

Treatment of severe migraine attacks

Migraine attacks with intense pain, especially accompanied by severe nausea and vomiting, may require parenteral administration of drugs. To stop such an attack, you can subcutaneously inject sumatriptan. In this case, the effect of the drug manifests itself within 30 minutes, and its effect will last up to 4 hours. Dihydroergotamine (DHE) is an ergot derivative, produced in the form for injections. It has a less pronounced vasoconstrictor effect on the peripheral arteries than ergotamine, and is able to effectively stop the attack. Dihydroergotamine can be administered subcutaneously or intravenously. With intravenous injection dihydroergotamine to a lesser degree causes nausea than ergotamine, nevertheless, before applying DHE, it is preliminary recommended to inject an antiemetic.

Ketorolac, a non-steroidal anti-migraine anti-inflammatory drug that can be administered parenterally, can be effective in alternative narcotic analgesics in those patients who do not tolerate vasoconstrictive drugs such as sumatriptan or DHE. For the treatment of severe migraine attacks, meperidine is also used, an opioid analgesic that is often prescribed intramuscularly, usually also in combination with an antiemetic. Given the availability of alternatives, parenteral use of narcotic analgesics is currently allowed only in patients with rare seizures or in cases where other drugs are contraindicated, for example, in severe lesions of peripheral or cerebral arteries, ischemic heart disease or during pregnancy.

Neuroleptics can be used in an emergency room to treat a severe or protracted headache as an alternative to mezernanu or vasoconstrictor drugs. However, the risk of hypotension and the need for intravenous administration limit the use of chlorpromazine. To prevent arterial hypotension, 500 ml of isotonic sodium chloride solution are injected intravenously before chlorpromazine is used. Chlorpromazine can be reintroduced after 1 hour. An alternative to chlorpromazine may be prochlorperazine, which can be administered intravenously without pre-infusion of an isotonic solution. Repeated administration of the drug is possible after 30 minutes.

In addition to drug therapy, in all forms of migraine, rational psychotherapy, auto-training, acupuncture, percutaneous electro-neurostimulation, and methods based on biofeedback can be used. Given the important role of the cervico-muscular "corset" in the maintenance of headaches, a special program is proposed for affecting the musculoskeletal system of the neck, head, and shoulder girdle, which includes physiotherapy, special exercises, stretching, injection into trigger points, relaxation training.

The effect of a permanent magnetic field is also transcerebral. It has been established that the transcerebral application of a permanent hemogenic magnetic field reduces the severity of migraine attacks and other vasomotor cephalges.

Surgical treatment of migraine: sympathectomy of the upper cervical sympathetic node, especially in cases with frequent ischemic complications on the basis of arterial spasm. Cryosurgery with beam migraine or with severe unilateral migraine - freezing the branches of the external carotid artery. In recent years, these methods are rarely used, given the complex genesis of migraine cephalgia and their low effectiveness.

Treatment of migraine headache 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 injection of dihydrosyrgotagon (DHE). Treatment is carried out in conditions of emergency department in the absence of contraindications, including pregnancy, angina pectoris or other forms of ischemic heart disease. DGE is administered undiluted through an intravenous system. To avoid nausea before injection of DHE, 10 mg of metoclopramide is administered intravenously, but after six doses of DHE are administered in most cases, metoclopramide can be eliminated. Patients with migraine status should find out which analgesics and in what dose he had time to take before hospitalization. Since in this case there is often an overdose of stoppers, it is necessary to closely monitor the appearance of symptoms of withdrawal of barbiturates or opioids. If the patient has not previously taken funds to prevent seizures, then after cupping the migraine status, it is recommended that he begin preventive therapy.