Silicon Simplicity

“Prevention is better then cures” and in case of migraine also this is true. But the question is who should be given prophylaxis treatment for migraine?

The right candidates for prophylaxis of migraine are patients with high frequency of migraine headache or if frequency is increasing, if patient is not responding adequately to abortive treatments or if patients are not responding to abortive treatments of migraine are good candidates for prophylaxis treatment of migraine. Clinicians/doctors generally give prophylactic medication for migraine if a patient is getting 5 or more attacks of migraine headache per month. This is a rough guideline, but migraine patients may require prophylaxis with lesser number of acute attacks per month, especially if the attacks are severe.

It is important to weigh the pros and cons of prophylactic treatment of migraine, as the agents used for prophylaxis may have many side effects and some of the side effects are potentially serious. Calculation of dose for prophylaxis of migraine may also pose problem as the drugs used for prophylaxis of migraine are basically (primarily) used for other purposes (other than migraine). The basic principle that is followed in the use of the drugs for prophylaxis of migraine is to start at low dose and gradually increase the dose, till clinical benefit is achieved with acceptable side effects.

The drugs for prophylaxis of migraine need to be taken daily and it may take 2-12 weeks to achieve desired result in prevention of migraine attacks. The probability of an anti migraine drug effectively preventing attacks of migraine is approximately 50-75% and if a drug is able to prevent migraine successfully, it should be continued for approximately 6 months and gradually tapered over time. Some of the patients may be able to withdraw anti migraine drugs permanently and some may need to take again of change the drug.

Patients of migraine may have certain complications, which may cause problem in treating the patients with migraine headache. The complications that may be present in managing migraine headache are recurrence of headache, poor tolerance to common and acute treatment of migraine, very rapidly developing symptoms of migraine headache. All of these complications can pose a problem in managing patients with migraine.

What to do if there is recurrence of migraine headache even after treating the patient adequately?

If patients of migraine develop recurrence of headache even after treating the migraine headache adequately with commonly used regimens, than the regimen of treatment has to be changed. Recurrence of headache can be a difficult problem for the patient to deal. In case of recurrence of migraine headache the drugs used are ergotamine 2 mg (this is most effective if used per rectally and generally along with caffeine), naratriptan (at the dose of 2.5 mg orally), almotriptan (at the dose of 12.5 mg orally), eletriptan (at the dose of 40 mg as oral tablet) etc. Any of these can be used if there is recurrence of headache in patients of migraine.

What to do if the patient of migraine can not tolerate treatment properly?

Sometimes patients can not tolerate routinely used treatment regimens (of migraine headache) properly or tolerate treatment poorly. The problem of tolerance of treatment can pose a big problem for the treating doctor as well as the patient and makes management of the patient very difficult and complicated. In case of poor tolerance or non tolerance of the commonly prescribed treatment regimens for migraine the drugs commonly used for treatment of migraine needs to be changed. Generally better tolerating triptans like almotriptan, naratriptan etc. are used in such cases. The dose of naratriptan is 2.5 mg tablet taken once a day and that of almotriptan is 12.5 mgs per day orally.

Migraine in some patients may develop very rapidly, which need to be managed promptly. The commonly used drugs for management/treatment of migraine may not be effective in case of rapidly developing symptoms of migraine. If a patient is developing symptoms of migraine headache very fast, the treatment should be initiated as early as possible before the symptoms become severe. Prompt administration of correct drugs by correct route of administration is important in managing the patients with rapidly developing migraine.

What to do if symptoms of migraine develop very rapidly in a patient?

The symptoms of migraine may develop very rapidly in some patients and the symptoms may not be amenable to commonly used treatment regimens for migraine (acute migraine). If symptoms are developing very rapidly, the drugs used should be of fast acting to give prompt relief. The drugs commonly used in case of rapidly developing symptoms of migraine are zolmitriptan 5 mg nasal spray, sumatriptan 6 mg subcutaneously or dihydroergotamine 1 mg intramuscularly. The dose of sumatriptan is very less (in compare to oral dose, which is available 50 mgs tablets) because the effectiveness of sumatriptan is very good subcutaneously. The oral dose is high, due to incomplete absorption (which is approximately 15% only) of sumatriptan if given orally.

Incase of rapidly developing symptoms of migraine, the administered drugs should have very fast action with good clinical efficacy. For very fast action nasal spray and parenteral routes of administration are used.