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At the heart of general practice since 1960

Caring for patients with migraine

Migraine is a common and debilitating condition affecting 13 to 15 per cent of adults in the UK.1,2 The prevalence is two to three times higher in women than in men, due in part to the influence of female sexual hormones.3 Migraine is also highly age-dependent, arising usually in childhood or adolescence, peaking in prevalence at about age 40 and declining thereafter, being encountered much less frequently in older patients.

Evidence indicates that migraine is common in all racial groups, but perhaps most common in Caucasians.3 The pathogenesis and aetiology remain not fully understood, but migraine is now seen as a disease of the brain rather than of blood vessels, and it is known that stimulation of neurons in the trigeminal ganglion leads to the development of the characteristic migraine symptoms.4

Migraine sufferers are seen as having increased sensitivity in the brain to stimuli that cause migraine, such as stress, hormonal changes, irregular habits and sleep disturbances.3

Migraine is a large public health problem, affecting the sufferer, healthcare services and the economy in general. Sufferers experience episodic, disabling attacks that result in poor quality of life, even between attacks, when they are supposedly symptom-free.

Primary care services have to deal with the large numbers of migraine sufferers who seek care, although only about half visit a GP.5 Unfortunately, migraine is often under-diagnosed and under-treated, and patients frequently rely on OTC medications for migraine treatments.5

Migraine is also associated with high direct medical costs and indirect costs of lost productivity, estimated at £1.9 billion per year in the UK.6

Guidelines for migraine management have been developed by the Migraine in Primary Care Advisors (mipca.org.uk) based on the available clinical evidence, and are updated regularly.7 The latest management algorithm is shown in

figure 2.

The guidelines are based on seven principles of care that are generic in scope and involve:

• Screening

• Patient education and commitment

• Differential diagnosis

• Assessment of illness severity

• Tailoring management to the needs of the individual patient

• Proactive, long-term follow-up

• A team approach to care.

These principles can be used for all headache subtypes, with customisation of the medications prescribed.

diagnosis

Headache diagnosis is in two parts: a differential diagnosis or inclusive diagnosis is conducted for all headache patients, followed by an exclusive diagnostic procedure to confirm the migraine diagnosis.

MIPCA guidelines advocate a simple validated screening questionnaire for the inclusive diagnosis procedure (see

table 1).8 The questions are based on diagnostic criteria defined by the International Headache Society (IHS).9

This questionnaire, excludes sinister headaches before asking any of the questions (questions 1–3), and a diagnostic algorithm for sinister headaches is available if required (see figure 3).10

A high-impact headache (question 4) is indicative of migraine or chronic daily headache (CDH), whereas a low-impact headache indicates episodic tension-type headache (TTH).

Impact can be assessed by simple questioning or by using one of the available impact questionnaires: the Migraine Disability Assessment (MIDAS) Questionnaire or the Headache Impact Test (HIT).11 Episodic (less than 15 days per month), high-impact headaches are indicative of migraine.

However, if the patient has more than

15 days of headache every month, with an average duration of four hours or more, a diagnosis of CDH is indicated (question 5).

For patients with CDH, medication overuse headache (MOH) is indicated if the patient takes symptomatic medications such as analgesics, ergots or triptans on two or more days per week (question 7). Less than two days of medication use per week indicates that the headache is not due to medication overuse.

Evidence indicates that any episodic, disabling headache can be given a default diagnosis of migraine.12 However, if required, the migraine diagnosis can be confirmed using the inclusive diagnostic migraine questionnaire, a validated exclusive questionnaire.13 Patients giving a ‘yes' answer to two or three of the following questions can be given a migraine diagnosis:

• Has a headache limited your activities for a day or more in the last three months?

• Are you nauseated or sick to your stomach when you have a headache?

• Does light bother you when you have

a headache?

acute treatments

All migraine patients require acute treatments and the diagnosis and illness severity drive the choice of this. Patients with mild-to-moderate attacks can be prescribed simple analgesics (paracetamol, aspirin or NSAIDs) or combination analgesics (aspirin or paracetamol plus metoclopramide).

Those with moderate-to-severe attacks and those who have failed on

analgesic-based therapy are best given a triptan tablet of either the film-coated or orally-disintegrating tablet (ODT) type as initial therapy.7

Ergots are now generally not recommended, except for patients who obtain a good response and can use them safely.

Of the available triptans, evidence shows that sumatriptan, zolmitriptan, rizatriptan, almotriptan and eletriptan offer optimal efficacy and have similar clinical profiles. Naratriptan and frovatriptan are not as effective, but may be suitable for patients who suffer from triptan-related side-effects or who have long-lasting attacks.

Nasal spray formulations are best used for patients with more severe or unpredictable attacks, while the injection formulation is especially useful for particularly severe attacks, and as a rescue medication.14

Recent developments illustrate the best way to use triptans in practice and offer more flexible treatment options. Many patients have attacks of differing severity and may require more than one acute treatment, while all require rescue medications. Some will cope well with an analgesic for milder attacks and a triptan for more severe ones. Others may need two different triptans or different formulations of the same triptan, one for initial treatment and one for rescue.

Studies show that many patients who fail to respond to one triptan often do respond to a different one.14 A tablet and a nasal spray (for example zolmitriptan) can be used concurrently.

Using combinations of different triptans at the same time is generally contraindicated, but seems to work in practice. If one triptan fails consistently, the GP should provide another at

follow-up.

One very recent development is the approval of sumatriptan 50mg tablets for pharmacy prescription. Migraine sufferers frequently rely on OTC treatments, and the move to make sumatriptan available at pharmacies widens the choice of treatments. It also gives sufferers the potential to treat a migraine headache

at an early stage, avoiding the need to consult with a GP and obtaining a prescription.

Additionally, the pharmacist has the opportunity to develop their experience of managing customers with migraine and other headaches. This move has been generally welcomed by the UK headache organisations, especially as stringent safeguards have been put into operation to prevent at-risk patients from receiving the drug.

One caution with all acute medications is the potential for overuse and the development of CDH, a condition that is particularly difficult to treat. Patients should be advised not to use acute medications (analgesics, triptans or egots) on more than two days per week, and those suspected of overuse should be called in for review.7,15

Treatment involves stopping the acute medications, introducing neck exercises if there is any stiffness and adding daily preventive drugs such as amitriptyline (10mg starting dose, titrating weekly by 10mg to a target range 30–80mg) or

anti-neuropathic pain drugs (topiramate, gabapentin, pregabalin).

preventive treatments

Clear guidelines are now available for who should receive prescribed preventive treatments for migraine. Suitable patients are those with frequent, high-impact migraine attacks (more than four per month); those using an increasing number of symptomatic drugs (on more than two days per week); those for whom acute medications are ineffective or precluded by safety concerns (perhaps due to

co-morbidities); and those for whom one drug can be used to treat both the headache and a co-morbidity.7,15

In addition, preventive medications should be given to all patients with CDH and cluster headache, for whom they are the primary treatment.

Clinical evidence favours the use of a beta-blocker or the neuromodulator topiramate as first-line preventive treatments. Both these drugs result in a reduction of 50 per cent or more in the frequency of attacks in about 50 per cent of patients. It can be clearly seen from these results that acute treatments are also required to manage breakthrough attacks as they occur.

Topiramate has only recently been licensed and the GP should be aware of the side-effects to expect, including paraesthesia, headache, fatigue, dizziness, somnolence, weight loss, nausea, anorexia, insomnia, difficulty concentrating, depression, abdominal pain, nervousness, hypoaesthesia, mood changes and anxiety. However, it is contradicated for use in patients with epilepsy, and weight loss might be welcomed by some.

Propranolol is the usual beta-blocker prescribed for prevention. Clinical evidence for propranolol is more robust than for the other available beta-blockers (timolol, nadolol and metoprolol). Recent precautions for the use of beta-blockers should be taken into account, although this is not likely to affect most migraine patients.

Pizotifen is often prescribed in the UK, although its clinical profile is suboptimal. It is perhaps best used as second-line therapy, although it is the only preventive agent licensed for use in children. However, patients who respond to the drug and who tolerate it well should continue to receive it, even in the lack of clear evidence for its effectiveness.

Other preventive agents with some efficacy in migraine include complementary therapies such as feverfew, butterbur root, magnesium, riboflavin and coenzyme Q, and behavioural and physical therapies such as trigger avoidance, relaxation, biofeedback and acupuncture. None of these treatments requires a prescription, but patients should be advised to consult with accredited professionals for treatment.

Also, individual complementary therapies differ in formulation and clinical data are available only for certain of these. The patient should be encouraged to research the field and to discuss the selection of an appropriate treatment with their GP.

It is certainly true to say that even the best of the current preventive migraine treatments are suboptimal, and new and more effective treatments are needed.

hot topics

Which patients require investigations? Most migraine patients do not require investigations such as scanning procedures unless a neurological examination is abnormal. However, there is some evidence that migraine patients who are very anxious about their condition may improve if they are scanned, for emotional rather than clinical reasons. Patients who do require investigations are those with red flags and suspected sinister headaches (see

figure 3).

What is the relationship between migraine and patent foramen ovale? Epidemiological and retrospective clinical studies indicate that migraine (especially migraine with aura) is linked to the presence of a patent foramen ovale (PFO). The presence of either condition increases the risk of the other. Small clinical studies, mostly in patients with stroke indicated that PFO closure showed improvement or resolution of the migraine in most patients.

The Migraine Intervention with Starflex Technology (MIST) Trial was recently completed and is the first prospective, randomised, double-blind, placebo-controlled study to assess PFO closure on migraine.

Patients had frequent migraine attacks that were refractory to repeated preventive treatments. Results showed that 43.3 per cent of the patient population had large right-to-left shunts (mostly large PFOs). Preliminary results showed more patients treated with PFO closure than with a sham surgical procedure had a more than 50 per cent reduction in their headache days (42 per cent versus 23 per cent), while headache resolution (the primary endpoint) was not demonstrated. There is therefore a treatment effect on migraine with aura with PFO closure, but this requires confirmation in further controlled

clinical studies.

Can botulinum toxin be used for migraine? There has been much interest in the use of botulinum toxin as a preventive treatment for migraine and other headache subtypes. Results from controlled trials to date are equivocal. The latest opinion is that the toxin is not effective in episodic migraine, while the jury is still out on its effect in CDH. However, off-label experience in my secondary-care clinic does indicate that botulinum toxin can dramatically improve some CDH patients who are refractory to treatment. As yet, it is not possible to predict the patients who will respond and further studies are required.

How can we work with the patient to improve migraine care? Migraine guidelines recommend that the patient and primary healthcare provider (who may be a GP, nurse or pharmacist) should work together in partnership through the journey of care. The professional provides education, advocacy and management skills, while the patient provides commitment and takes charge of their own management.7 For this to be successful, clear communication channels need to be in place. It is often best for the practice nurse to take charge of everyday patient contact, encouragement, education and assessments, while the GP concentrates on diagnosis and management issues.

The increased responsibilities taken on by nurses and pharmacists in the NHS today may mean that most migraine patients are managed by these healthcare professionals in the future.16,17

Sources of education for the professional are available on the MIPCA website mipca.org.uk and for the patient from the Migraine Action Association (MAA) www.migraine.org.uk. In addition, the MAA is running a specialist patient programme throughout the UK, and committed patients who wish to help other sufferers can be encouraged to take part in this valuable initiative.

References

1 Steiner TJ, Scher AI et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia 2003;23:519–27

2 Lipton RB, Bigal ME et al. The family impact of migraine: population-based studies in the USA and UK. Cephalalgia 2003;23:429–40

3 Breslau N, Rasmussen BK. The impact of migraine: Epidemiology, risk factors, and co-morbidities. Neurology 2001;56:4–12

4 Goadsby PJ. Migraine pathophysiology. Headache 2005;45:14–24

5 Lipton RB, Goadsby PJ et al. Migraine: diagnosis and assessment of disability. Rev Contemp Pharmacother 2000;11:63–73

6 Migraine: costs and consequences. Bandolier tinyurl.co.uk/fdex

7 Dowson AJ, Lipscombe S et al. New guidelines for the management of migraine in primary care. Curr Med Res Opin 2002;18:414–39

8 Dowson AJ, Turner A et al. Development and validation of the headache Diagnostic Screening Questionnaire (DSQ): a new questionnaire for the differential diagnosis of headache for use in primary care. Headache Care 2005;2:111–8

9 Headache Classification Committee of the International Headache Society. The international classification of headache disorders; 2nd Edition. Cephalalgia 2004;24:1–160

10 Dowson AJ, Sender J et al. Establishing principles of migraine management in primary care. Int J Clin Pract 2003;57:492–507.

11 Dowson AJ. Assessing the impact of migraine. Curr Med Res Opin 2001;17:298–309

12 Tepper SJ, Dahlöf CGH et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache 2004;44:856–64

13 Lipton RB, Dodick D et al. A self-administered screener for migraine in primary care: The ID Migraine validation study. Neurology 2003;61:375–82

14 Dowson AJ, Kilminster S et al. Understanding the evidence: evaluating the efficacy of migraine medications in clinical practice. Headache Care 2005;2:133–43

15 Tepper SJ, D'Amico D et al. Guidelines for prescribing prophylactic medications for migraine: a survey among headache specialist physicians in different countries. Headache Care 2004;1:267–72

16 MacBean H, Leech J et al. New guidelines for the management of migraine by nurses. Practice Nursing 2004;15:346–50

17 Glover C, Greensmith S et al. Guidelines on headache management for use by the pharmacist. Pharmaceutical J 2006; in press

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