Chapter 015. Headache (Part 9)

Abbreviations: NSAIDs, nonsteroidal anti-inflammatory drugs; 5-HT, 5hydroxytryptamine.In general, an adequate dose of whichever agent is chosen should be used as soon as possible after the onset of an attack. If additional medication is required within 60 min because symptoms return or have not abated, the initial dose should be increased for subsequent attacks. Migraine therapy must be individualized; a standard approach for all patients is not possible. A therapeutic regimen may need to be constantly refined until one is identified that provides the patient with rapid, complete, and consistent relief with minimal side effects (Table 15-6).Table 15-6 Clinical Stratification...
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Chapter 015. Headache (Part 9) Chapter 015. Headache (Part 9) Abbreviations: NSAIDs, nonsteroidal anti-inflammatory drugs; 5-HT, 5-hydroxytryptamine. In general, an adequate dose of whichever agent is chosen should be usedas soon as possible after the onset of an attack. If additional medication is requiredwithin 60 min because symptoms return or have not abated, the initial dose shouldbe increased for subsequent attacks. Migraine therapy must be individualized; astandard approach for all patients is not possible. A therapeutic regimen may needto be constantly refined until one is identified that provides the patient with rapid,complete, and consistent relief with minimal side effects (Table 15-6). Table 15-6 Clinical Stratification of Acute Specific MigraineTreatmentsClinical Situation Treatment OptionsFailed NSAIDS/analgesics First tier Sumatriptan 50 mg or 100 mg PO Almotriptan 12.5 mg PO Rizatriptan 10 mg PO Eletriptan 40 mg PO Zolmitriptan 2.5 mg PO Slower effect/better tolerability Naratriptan 2.5 mg PO Frovatriptan 2.5 mg PO Infrequent headache Ergotamine 1–2 mg PO Dihydroergotamine nasal spray 2 mg Early nausea or difficulties Zolmitriptan 5 mg nasal spraytaking tablets Sumatriptan 20 mg nasal spray Rizatriptan 10 mg MLT wafer Headache recurrence Ergotamine 2 mg (most effective PR/usually with caffeine) Naratriptan 2.5 mg PO Almotriptan 12.5 mg PO Eletriptan 40 mg Tolerating acute treatments Naratriptan 2.5 mgpoorly Almotriptan 12.5 mg Early vomiting Zolmitriptan 5 mg nasal spray Sumatriptan 25 mg PR Sumatriptan 6 mg SC Menses-related headache Prevention Ergotamine PO at night Estrogen patches Treatment Triptans Dihydroergotamine nasal spray Very rapidly developing Zolmitriptan 5 mg nasal spraysymptoms Sumatriptan 6 mg SC Dihydroergotamine 1 mg IM