The Pathophysiological and Pharmacological Basis of Current Drug Treatment of Migraine Headache

Doodipala Samba Reddy

Disclosures

Expert Rev Clin Pharmacol. 2013;6(3):271-288. 

In This Article

Treatment of Migraine

It is known that certain factors can induce and/or exacerbate migraines. These factors vary among individuals, but patients should be advised to avoid these 'trigger' factors. It is important to identify and then avoid trigger factors such as dietary triggers (foods that contain tyramine such as cheese, chocolate, alcohol and red wine), chemical triggers (monosodium glutamate, nitrates and nitrites, nitroglycerin, vasodilators, tyramine, phenylethylamine, smoking and oral contraceptive use), and physiological triggers (stress, fatigue, excitement, insomnia, exposure to cold or heat and the menstrual cycle). It is also important to attempt to manage environmental factors such as glare from light, time-zone shifts, high altitude and barometric pressure changes.

Migraine treatment may be classified as prophylactic (chronic treatment of migraine), intermittent prophylaxis (only when a migraine is expected, i.e., during menstruation), or symptomatic (abortive; drugs used only during an attack). Symptomatic therapy is the mainstay of migraine management, with the goal of alleviating or decreasing symptoms.[59–61] However, recent clinical studies have shown that excessive use of symptomatic medications on a daily basis may result in chronic migraines; thus, prophylactic and symptomatic medications become ineffective. Medication overuse headache (MOH) is a major issue in headache medicine. MOH is a secondary chronic headache that is an evolution from episodic headaches as a consequence of overuse of symptomatic medications. MOH can occur in headache-prone patients when acute headache medications are taken for other indications. The diagnosis of MOH is important because patients rarely respond to preventative medications whilst overusing acute medications.

Route of administration is an important consideration for effective pain relief. Abortive drugs can be given by self-injection, by oral route or by nasal spray. Although oral preparations have the slowest onset, they are the first choice. Suppositories are useful when the patient has nausea, but are not preferred by patients; therefore, recent efforts are focused on intranasal formulations. Migraine is actually a multiorgan syndrome, which in turn prioritizes the type of therapy that should be offered; this can differ both between migraineurs and between attacks within a migraineur. Since the experience of migraine varies from person to person, therapy should be tailored to the needs of the individual patient.

There are three classes of drugs for migraine: over-the-counter NSAIDs for acute mild-to-moderate migraine, specific prescription drugs (triptans and ergot alkaloids) for acute moderate-to-severe migraine and pharmacological agents for prophylaxis of migraine. In addition, the antiemetics metochlopramide (Reglan®, Schwarz Pharma, WI, USA), prochlorperazine (Compazine®, GlaxoSmithKline, London, UK) or promethazine (Phenergan®, Sanofi, Paris, France) are used for nausea.

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