Chapter 015. Headache (Part 11)

ParenteralParenteral dopamine antagonists (e.g., chlorpromazine, prochlorperazine, metoclopramide) can also provide significant acute relief of migraine; they can be used in combination with parenteral 5-HT1B/1D agonists. A common intravenous protocol used for the treatment of severe migraine is the administration over 2 min of a mixture of 5 mg of prochlorperazine and 0.5 mg of dihydroergotamine.Other Medications for Acute MigraineOralThecombinationofacetaminophen,dichloralphenazone,andisometheptene, one to two capsules, has been classified by the FDA as "possibly" effective in the treatment of migraine. Since the clinical studies demonstrating theefficacy of this combination analgesic in migraine predated the clinical trial methodologies used with the triptans, it...
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Chapter 015. Headache (Part 11) Chapter 015. Headache (Part 11) Parenteral Parenteral dopamine antagonists (e.g., chlorpromazine, prochlorperazine,metoclopramide) can also provide significant acute relief of migraine; they can beused in combination with parenteral 5-HT1B/1D agonists. A common intravenousprotocol used for the treatment of severe migraine is the administration over 2 minof a mixture of 5 mg of prochlorperazine and 0.5 mg of dihydroergotamine. Other Medications for Acute Migraine Oral The combination of acetaminophen, dichloralphenazone, andisometheptene, one to two capsules, has been classified by the FDA as possiblyeffective in the treatment of migraine. Since the clinical studies demonstrating theefficacy of this combination analgesic in migraine predated the clinical trialmethodologies used with the triptans, it is difficult to compare the efficacy of thissympathomimetic compound to other agents. Nasal A nasal preparation of butorphanol is available for the treatment of acutepain. As with all narcotics, the use of nasal butorphanol should be limited to aselect group of migraineurs, as described below. Parenteral Narcotics are effective in the acute treatment of migraine. For example,intravenous meperidine (50–100 mg) is given frequently in the emergency room.This regimen works in the sense that the pain of migraine is eliminated.However, this regimen is clearly suboptimal for patients with recurrent headache.Narcotics do not treat the underlying headache mechanism; rather, they act to alterthe pain sensation. Moreover, in patients taking oral narcotics such as oxycodoneor hydrocodone, narcotic addiction can greatly confuse the treatment of migraine.Narcotic craving and/or withdrawal can aggravate and accentuate migraine.Therefore, it is recommended that narcotic use in migraine be limited to patientswith severe, but infrequent, headaches that are unresponsive to otherpharmacologic approaches. Medication-Overuse Headache Acute attack medications, particularly codeine or barbiturate-containingcompound analgesics, have a propensity to aggravate headache frequency andinduce a state of refractory daily or near-daily headache called medication-overuseheadache. This condition is likely not a separate headache entity but a reaction ofthe migraine patient to a particular medicine. Migraine patients who have two ormore headache days a week should be cautioned about frequent analgesic use (seeChronic Daily Headache, below). Preventive Treatments for Migraine Patients with an increasing frequency of migraine attacks, or with attacksthat are either unresponsive or poorly responsive to abortive treatments, are goodcandidates for preventive agents. In general, a preventive medication should beconsidered in the subset of patients with five or more attacks a month. Significantside effects are associated with the use of many of these agents; furthermore,determination of dose can be difficult since the recommended doses have beenderived for conditions other than migraine. The mechanism of action of thesedrugs is unclear; it seems likely that the brain sensitivity that underlies migraine ismodified. Patients are usually started on a low dose of a chosen treatment; thedose is then gradually increased, up to a reasonable maximum to achieve clinicalbenefit. Drugs that have the capacity to stabilize migraine are listed in Table 15-7.Drugs must be taken daily, and there is usually a lag of at least 2–12 weeks beforean effect is seen. The drugs that have been approved by the FDA for theprophylactic treatment of migraine include propranolol, timolol, sodium valproate,topiramate, and methysergide (not available in the United States). In addition, anumber of other drugs appear to display prophylactic efficacy. This group includesamitriptyline, nortriptyline, flunarizine, phenelzine, gabapentin, topiramate, andcyproheptadine. Phenelzine and methysergide are usually reserved for recalcitrantcases because of their serious potential side effects. Phenelzine is a monoamineoxidase inhibitor (MAOI); therefore, tyramine-containing foods, decongestants,and meperidine are contraindicated. Methysergide may cause retroperitoneal orcardiac valvular fibrosis when it is used for >6 months, and thus monitoring isrequired for patients using this drug; the risk of fibrosis is about 1:1500 and islikely to reverse after the drug is stopped.