THE TREATMENT

B.- PHARMACOLOGICAL TREATMENT

The main focal points for migraine treatment are the treatment of the acute phase of the migraine or abortive treatment and prophylactic or preventive treatment.

The treatment of the acute phase is used to try to stop a migraine that has already started. If you have been diagnosed with migraine and your doctor decides to use this method, he/she will determine which are the most suitable medication options for your specific case. During a migraine attack, it is important to start the treatment as soon as possible.

According to existing data, the use of a prophylactic (preventive) treatment can be beneficial. It is estimated that more than 50% of general practitioners use diet advice and the identification of triggers as part of their preventive treatment regimen.

Treatment of the acute phase of migraine

General rules for the treatment of the acute phase of migraine:

Start the treatment early, as soon as the first warning signs appear.

Discourage the tendency of many patients to self-medicate and to take too many analgesics.

Always use the appropriate dosages.

If, after 30-60 minutes, the pain doesn't stop with the initial dose of analgesics, increase the dosage of the same drug before moving on to another analgesic.

Avoid associations of drugs in the same commercial preparation.

The use of opiates is not recommended, due to their sedative effects and the risk of addiction.

The treatment of first choice will be based on the intensity of the headache. In slight-moderate attacks, analgesics or non-steroidal anti-inflammatories are used, with or without antiemetics, and in moderate-severe attacks, triptans(a group of drugs with analgesic and abortive action against migraine attacks) are used.

In the majority of patients, migraine attacks are accompanied by gastrointestinal symptoms such as nausea. vomiting or diarrhoea.

The following are the first choice of simple analgesics used to treat slight to moderate migraines: acetylsalicylic acid (ASA) and paracetamol. A good alternative to these are other NDAIDs such as ibuprofen, naproxen or diclofenac 1.5. In Spain, metamizole and ketorolac are also widely used, although the adverse effects of ketorolac are greater than those of other NSAIDs. The most frequent side effects of ASA and NSAIDs are gastrointestinal, for which reason they are not suitable for use by patients with gastrointestinal disorders.

Triptans should be reserved for patients with moderate to severe migraine. All triptans act on the presynaptic serotonin 5-HT1 receptors in the walls of the cerebral blood vessels, inhibiting the release of vasoactive and nociceptive peptides, preventing the development and propagation of neurogenic inflammation, whilst also impeding vasodilatation in the extracerebral cranial arteries.
They improve symptoms such as nausea, vomiting, photophobia and phonophobia. If the first dose is ineffective, a second dose should not be taken, as this will not improve the results.

The profile of side effects is similar for all triptans, and the most frequent are: drowsiness, paraesthesia, dizziness, nausea, fatigue, a feeling of heaviness in the limbs and tightness in the throat and chest. They are not suitable for use in patients with severe renal or hepatic insufficiency, peripheral vascular disease, stroke or transient ischemic attack, moderate or severe arterial hypertension and slight hypertension which is not under control. They are also not indicated for concomitant administration with ergotamine and its derivatives (including methysergide), with MAOI and between them.

Prophylactic or preventive treatment of migraine:
Prophylaxisa set of measures serving to protect individuals or society against diseases. Preventive treatment of migraine should be considered in a patient if the frequency of migraine attacks is higher than 2-4 per month, or if they have fewer attacks, but they are very incapacitating, or if they present with focal neurological symptoms or have a prolonged duration.

The ideal drug for prophylaxis of migraine should completely prevent migraine attacks. To date, few drugs have had more than 50% effectiveness, and the majority of patients require treatment for acute attacks.
The pharmacological groups used are as follows: beta-blockers, calcium antagonists, serotonin antagonists, tricyclic antidepressants and anti-epileptics. The drugs from the first groups are the most commonly used.

These are considered to be the first choice treatment unless there are contraindications such as asthma or peripheral vascular disease. Propranolol (Sumial®) is the most widely used drug, and the one for which the most experience has been gleaned. The principal adverse reactions are as a consequence of beta1 blockers (bradycardia, conduction blockages and cardiac insufficiency) and beta 2 blockers (increased bronchial or vascular sounds).

These are the second treatment option. This group includes flunarizine: Flerudin®, Flurpax® and Sibelium®; whose effects have been demonstrated, and which is the most widely-used. Side effects can include drowsiness, fatigue, weight gain and digestive alterations. In prolonged treatments, depression and extrapiramidal symptoms can occur.

Pizotifen and methysergide are reserved for patients who do not respond to other types of prophylaxis. Pizotifen (Sandomigran®) is a similar compound to cyproheptadine. It has antiserotoninergic and antihistamine properties. Methysergide (not sold in Spain) is a powerful Serotoninergic antagonist, effective in prophylaxis. It can have serious side effects (inflammatory fibrosis), and should therefore be used under hospital supervision.

Naproxen is useful in the prevention of migraine related to menstruation.

The tricyclic antidepressant amitriptyline seems to have anti-migraine effects, and is especially useful in cases of tension headache and in migraine associated with tension headache. Sodium valproate can reduce migraine attacks by up to 50%, according to a series of studies carried out, and it could therefore be an alternative for patients not responding or tolerating other types of prophylaxis. Lithium and corticosteroids are used simultaneously in cases of headache.