ACUTE TREATMENT
Prophylaxis for Migraine
Guidance
Prophylaxis is indicated in patients with frequent migraine or if migraine causes significant disability
• These medications should be initiated at low dose to minimise side effects and the dose should be gradually titrated upwards depending on patient response and tolerability. A 3-6 month trial is required to determine efficacy.
• As a general rule only one drug should be used at a time but combination therapy can be useful in patients with difficult to control migraine. A useful combination is nortriptyline and topiramate.
• Choice may depend on co-morbid conditions and contra-indications
• First choice for adults is usually ß blockers or tricyclic
• Second choice for adults is an anti epileptic (caution in women using COP). Risk of teratogenicity should be discussed with the patient
• First choice for children ( 10%
o Paraesthesia in about 50%
o Anorexia, nausea
o Weight loss
o Fatigue
o URTI
o Diarrhoea
• Less common < 10%
o Cognitive effects such as memory, language and somnolence
o Depression and mood alteration
• Rare < 1 %
o Acute myopia secondary to angle closure glaucoma
o Choroidal effusions resulting in anterior displacement of the lens and iris
Monitoring
• Response to therapy
o Topiramate should be administered for a minimum of 12 weeks
o If effective continue for 6 months and then withdraw to establish continued need. (migraine prophylaxis should rarely be used uninterrupted for more than 12 months)
o If not effective at adequate dosage or intolerable side-effects, treatment should be withdrawn and alternative therapy considered. Cognitive effects rarely settle so treatment should be withdrawn early if there are significant problems.
• Treatment Safety
o Patients with new onset visual symptoms or signs should have their intra ocular pressure measured urgently. If it is raised they should be referred to the ophthalmology clinic immediately and the topiramate stopped as rapidly as feasible
o Patients on long term topiramate should be weighed every 8 weeks and discontinuation of treatment should be considered if weight loss is greater than 10%.
o Patients should be monitored for signs of depression and advised to seek medical help immediately if they have suicidal thoughts.
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Migraine prophylaxis indicated and medication over use headache excluded
Propranolol or TCA (Nortriptyline or Amitriptyline)
No response to either after 3 month trial at maximum tolerated dose
Consider antiepileptic
Topiramate Gabapentin [pic]Sodium valproate
Good response, consider stopping after 6-12 months
Review contraception
No response to 3 anti epileptics after 3 month trial at maximum tolerated dose
Consider referral to headache clinic
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