1. Infrequent migraines. Can be managed with symptomatic medication use (ie, "when headache occurs, take an analgesic medication"). These medications include acetaminophen, aspirin, NSAIDs, and a variety of combination medications (containing butalbital, caffeine, and codeine), such as Midrin and Fioricet. Triptans (eg, sumatriptan, rizatriptan, zolmitriptan, and naratriptan) can be used for infrequent headaches occurring less than once per week. Triptan medications are effective in treating migraine headache along with accompanying symptoms of nausea and vomiting. Dose can usually be repeated in 2 hours.
2. Prophylactic treatment. Various agents from many medication classes have been used to treat headaches prophylacti-cally. Choose medications based on efficacy in various headache types. Symptomatic medications are used to treat rare or occasional headaches. Most patients will not start a prophylactic headache medicine until they regularly have at least three or four headaches per month (ie, weekly).
a. The first-line prophylactic agent is often a 0-blocker; these agents should not be used in patients with asthma.
b. Anticonvulsant medications (eg, carbamazepine, sodium valproate, lamotrigine, and topiramate) are often used for migraines.
3. Other useful agents. Tricyclic antidepressants (also used for chronic daily headache and post-traumatic headache) and calcium channel blockers. Recent evidence demonstrates headache improvement with botulinum toxin type A.
4. Adverse medication effects. All medications have potential adverse effects. Triptan medications are contraindicated in patients with ischemic heart disease, hypertension, peripheral vascular disease, hemiplegic or basilar migraine, recent MAOI or ergotamine medication use, or liver failure. Routine blood testing can identify some adverse effects, but blood tests are not predictive of impending adverse effects.
5. Nonmedical interventions for recurrent headaches. These interventions include local application of heat or massage, biofeedback, relaxation techniques (meditation or yoga), psychotherapy, and acupuncture.
6. Rebound headache. Some patients have recurrent headaches because of overuse of analgesic medications, usually referred to as rebound headache. Once analgesic medications are used more than 4 days per week, for several weeks, there may be a rebound effect in which headache occurs when patient does not take analgesic medication. This is essentially a chronic, recurrent withdrawal syndrome. Patients often compensate for this by increasing the dose and frequency of their analgesic medication. This disorder is treated by withdrawal from the analgesic medication.
C. Follow-up. It is important to be able to quantify frequency and severity of headaches to determine the appropriate treatment, as well as efficacy of treatment. Patients taking prophylactic headache medications are typically followed regularly until headache-free for at least 6-12 months.
■ VI. Problem Case Diagnosis. The 12-year-old girl reported headache episodes that lasted between 2 and 10 hours. Episodes had occurred for 2 years, both at home and at school, with a frequency of one to three per month. Headaches occurred at various times of the day and were associated with nausea, photophobia, and phono-phobia, but not involuntary motor activity. Episodes began without warning and interrupted activities because of previously described symptoms. Patient's prenatal, developmental, and past medical histories were unremarkable; however, her mother and older sister had had similar symptoms when they were her age. Physical exam was unremarkable, and neurologic exam, normal. Diagnosis is migraine without aura. This disorder typically presents between the ages of 5 and 11 years (peak onset between 10 and 13 years of age). Patient's condition is not a medical emergency because the headaches have been noted for at least 2 years.
VII. Teaching Pearl: Question. How are migraines categorized?
VIII. Teaching Pearl: Answer. There are three subsets of complicated migraine: (1) basilar, with symptoms of vertigo, tinnitus, blurred or double vision, and scotoma secondary to vasoconstriction of basilar and posterior cerebral arteries; (2) ophthalmoplegic, which present with 3rd nerve palsy ipsilateral to the side of the headache; and (3) hemiplegic, in which unilateral sensory or motor signs develop during headache, including numbness, weakness, and aphasia. Although these forms of migraine are not common, keep them in mind because their presentation suggests the presence of an underlying structural lesion, thus requiring more urgent management than common migraine.
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