Migraine is a primary headache disorder associated with symptoms of throbbing, unilateral headache, nausea, vomiting and increased sensitivity to light, sound or smell. These attacks are usually disabling and affects concentration. Migraine is a broad condition with associated symptoms. Cluster headache is a variant of migraine. Please refer to international classification of headache disorders for further details.
Medications:
Management of migraine attacks:
Migraine headache for less 2 hours –
- Tab. Naxdom 500 (Naproxen 500 mg, Domperidone 10 mg) – one tablet twice a day for one day.
- Tab. Crocin Pain Relief (Paracetamol 650 mg, Caffeine 50 mg) – one tablet thrice a day for one day.
- Tab. Ultra Magnesium 200 (Elemental Magnesium 200 mg) – one tablet 4 times a day for one day.
If migrainous headache fails to improve within 1 hour –
- Tab. Almogril 12.5 (Almotriptan 12.5 mg) – one tablet as a single dose. The dose can be repeated after 2 hours. Contraindicated in – ischemic heart disease, coronary artery disease, uncontrolled hypertension, cerebrovascular accident, pregnancy, patient on MAO inhibitor or use of ergotamine within last 24 hours.
If migraine headache fails to improve within 3 hours it is advisable to refer to emergency department.
For migraine prophylaxis or management of cluster headaches:
- If patient has no underlying co-morbidity – tab. Ciplar LA 20 (Propranolol long acting 20 mg) – one tablet a day. Increase the dose till symptoms clinically improve (maximum dose – 240 mg per day). Discontinue treatment gradually if adequate response not achieved within one month.
- If patient has underlying hypertension – tab. Prolomet XL 12.5 (Metoprolol 12.5 mg) – one tablet once a day. Gradually increase till maximum dose of 400 mg per day (avoid in COPD, asthma and depression).
- If patient has underlying depression – start with tab. Nortimer 10 (Nortriptyline 10 mg) one tablet at bedtime. Gradually increase till maximum dose of 150 mg per day. Serious cardiotoxicity seen in overdosages (Serum level should be between 50 to 150 ng/ml).
- If patient has underlying neuropathy – tab. Nova 75 SR (Pregabalin sustained release 75 mg) – one tablet at bedtime. Gradually increase till maximum dose of 600 mg per day.
- If patient experiences prominent auras – tab. Calaptin 120 SR (Verapamil sustained release 120 mg) – one tablet in the morning. Gradually increase till maximum dose of 480 mg per day.
- If patient has underlying convulsions, trauma or obesity – tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 100 mg twice a day.
General advice:
- Advice application of cool packs.
- Avoid stress – spread workload evenly through the day.
- Maintain good posture – avoid bad neck postures.
- Keep a headache diary – record date, day of week, and time of day. Record precipitating and relieving factors.
- Avoid excessive fatigue and ensure good sleep cycle.
- Advice regular and healthy diet. Avoid alcohol, caffeine, opioid based analgesics.
- Consider avoiding oral contraceptives.
- Avoid excessive light, sounds or strong smells.
Investigations:
- CT Head or MRI Brain – to rule out space occupying lesion
- Lumbar Puncture – to rule out evidence of meningitis for prolonged cases
Referral:
Consider referral to neurologist if patient fails to respond or presents with additional complications. Urgent referral would be needed if patient presents with neurological deficit.