Management Of Migraine

A 27-year-old woman comes for review. She is having problems with increasingly frequent migraine attacks. She has tried a combination of paracetamol and ibuprofen to try and control the attacks but this seems to have had a limited effect. Her current medication includes paracetamol and ibuprofen as required and Cerazette( a hormonal contraceptive that contains a progestrin - Desogestrel).
What is the most appropriate medication to try and reduce the frequency of her migraine attacks?
A. Propranolol
B. Zolmitriptan
C. Topiramate
D. Amitriptyline
E. Switch Cerazette to a combined oral contraceptive pill

Answer:
A. Propranolol
(Propranolol is preferable to topiramate in women of childbearing age with migraine)

Discussion: NICE recommend either propranolol or topiramate for migraine prophylaxis. The combined oral contraceptive pill is contraindicated given her history of migraine. Zolmitriptan is useful to abort attacks but is not used for prophylaxis

Management Of Migraine Headaches:
It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines.

Acute treatment:

• First-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
• For young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
• If the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan.

Prophylaxis :

• Prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients. 
• NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives 
• If these measures fail NICE recommend 'a course of up to 10 sessions of acupuncture over 5-8 weeks' or gabapentin 
• NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.
• For women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis' 
• Pizotifen is no longer recommend. Adverse effects such as weight gain & drowsiness are common