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French Guidelines for the Diagnosis and Management of Migraine in Adults and Children

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French Guidelines for the Diagnosis and Management of Migraine in Adults and Children French Guidelines for the Diagnosis and Management of Migraine in Adults and Children Gilles Gkraud, MD,l Michel Lank-i-Minet, MD,’ Christian Lucas, MD,3 and Dominique Valade, MD,4 on behalf of the French Society for the Study of Migraine Headache (SFEMC) lDepartment of Neurology, Rangueil Hospital, Toulouse, 2Pain Centel; Pasteur Hospital, Nice, 3Depurtment of Neurology, Sulengro Hospital, Lille, and 4Heuduche Emergency Centel; Lur-iboisi&e Hospital, Paris, France ABSTRACT Background: The French Recommendations for Clinical Practice: Diagnosis and Therapy of Migraine are guidelines concerning the overall management of patients with migraine, including diagnostic and therapeutic strategies and assessment of disability Objective: This article summarizes the guidelines as they apply to adults and children, and proposes future direction for steps toward optimal treatment of migraine in patients in France. Methods: The recommendations were categorized into 3 levels of proof (A-C) according to the National Agency for Accreditation and Evaluation in Health (ANAES) methodology and were based on a professional consensus reached among members of the Working Group and the Guidelines Review Group of the ANAES. Results: The International Headache Society diagnostic criteria for migraine should be used in routine clinical practice. Recommended agents for the treatment of migraine in adults include nonsteroidal anti-inflammatory drugs, acetylsalicylic acid (ASA) monotherapy or in combination with metoclopramide, acetaminophen monotherapy, triptans, ergotamine tartrate, and dihydroergotamine mesylate. Patients should use the medication as early as possible after the onset of migraine headache. For migraine prophylaxis in adults, the following can be used: propranolol, metoprolol, oxetorone, or amitriptyline as first-line treatment, and pizotifen, flunarizine, valproate sodium, or topiramate as second-line treatment. Migraine in children can be distinguished from that in adults by shorter duration (2-48 hours in children aged ~15 years), more frequent bilateral localization, fre- quent predominant gastrointestinal disturbances, and frequent pallor hailing the onset of the attack. The follow- ing drugs are recommended in children and adolescents: ibuprofen in children aged >6 months, diclofenac in children weighing >16 kg, naproxen in children aged >6 years or weighing >25 kg, ASA alone or in combina- tion with metoclopramide, acetaminophen alone or in combination with metoclopramide, and ergotamine tar- trate in children aged >10 years. Conclusions: These guidelines are intended to help general practitioners to manage migraine patients according to the rules of evidence-based medicine. (Clin Ther: 2004;26: 1305-13 18) Copyright 0 2004 Excerpta Medica, Inc. Key words: guidelines, migraine, diagnosis, treatment, adults, children. Accepted for publicationJuly 22, 2004. Printed in the USA. Reproduction in whole or part IS not permitted. 0149-2918/04/$19.00 Copyright@ 2004 Excerpta MedicaJnc. 1305 CLINICAL THERAPEUTICS® INTRODUCTION Level A recommendations are based on established The French Recommendations for Clinical Practice: scientific evidence with the highest level of proof. Diagnosis and Therapy of Migraine 1 are guidelines These include randomized, comparative, controlled concerning the overall management of patients with trials with high statistical power and without major migraine, including diagnostic and therapeutic strate- bias; and/or meta-analyses of randomized, comparative gies and the assessment of disability caused by controlled trials; or combinations of well-conducted migraine. The guidelines were designed for health studies. care professionals involved in the care of patients Level B recommendations are based on scientific with migraine (eg, general practitioners, specialists, evidence provided by studies with an intermediate and pharmacists). This article summarizes the guide- level of proof, such as randomized, comparative trials lines as they apply to adults and children. The com- with lower statistical power; well-conducted, nonran- plete text, with full argumentation and references, is domized trials; or cohort studies. available (in French) elsewhere. Level C recommendations are based on evidence These guidelines were developed at the request of with a lower level of proof, such as that provided by the French Society for the Study of Migraine and case-control studies or case series. Headache (Soci t fran aise d' tude des migraines et Unless specified otherwise, the recommendations des c phal es) by the National Agency for Accred- proposed were based on a professional consensus itation and Evaluation in Health (ANAES). The reached among members of the Working Group and ANAES is an official national agency that uses precise the Guidelines Review Group of the ANAES. The methodology to constitute Working and Review absence of evidence with a high level of proof does Groups, including specialists, general practitioners, not mean that the recommendations are not pertinent members of the national drug agency, and others. or useful; rather, it should be an incentive for addi- Pharmaceutical companies are not represented in the tional studies when possible. ANAES, and everyone in the Working and Review Groups must sign a form indicating no conflicts of MIGRAINE IN ADULTS interest before participating. Prevalence Headaches other than migraine are not covered in According to the diagnostic criteria described later, these guidelines except as part of the differential diag- the estimated prevalence of migraine in adults aged nosis. Other associated topics (ie, conditions associat- 18 to 65 years is 12 to 17 in 100, with a female pre- ed with migraine [apart from associated psychiatric dominance (female-male ratio, 3:1) .3# disorders], predisposing migraine factors, migraine in pregnancy, menstrual migraine, migraine and oral contraception, migraine and smoking, transformed Table I. International Headache Society classification of migraine, and rare and complicated forms of migraine migraine.* headache [International Headache Society (IHS) Codes 1.2.2-1.5, Table 12]) are not discussed in this article. Code Description In addition, a complete comparison of these guide- I.I Migraine without aurar lines with those of other national and international 1.2 Migraine with aura guidelines is beyond the scope of this article, because 1.2.1 Typical aura with migraine headache~ habits, drugs, and behaviors are different between 1.2.2 1.2.6 Other types of auras§ countries. However, as shown in the reference list, these 1.3 1.5 Rare and complicated forms of migrainell guidelines were based on evidence-based medicine and 1.6. I Probable migraine without aura, fulfilling all the diagnostic criteria~ except one used data largely from the international literature. ~Adapted with permission. 2 GRADING OF RECOMMENDATIONS ~SeeTable II2 for diagnostic criteria of migraine without aura. INTHE GUIDELINES ¢SeeTable III2 for diagnostic criteria of typical aura with migraine headache. §Includes familial and sporadic hemiplegic migraine, basilar-type migraine. The recommendations are categorized into 3 levels IIIncludes retinal migraine, chronic migraine, status migrainous, persi~ent (A-C), as follows. aura, migrainous infarction. ]306 G. G@raud et al. Clinical Diagnosis Table III. Diagnostic criteria of typical aura with migraine The recommended diagnostic criteria for migraine headache.* were established in 1988 by the IHS, based on an expert consensus} These criteria are summarized in A. >2 Attacks Fulfilling criteria B D Tables 112 and 111.2 B. Aura consisting of > I of the Following, but not motor weaknesst: Only the diagnoses of migraine without aura (Code Fully reversible visual symptoms, including positive Features (eg, 1.1), typical aura with migraine headache (Code flickering lights, spots, or lines) and/or negative Features (eg, 1.2.1), and probable migraine without aura, fulfilling loss orvision) Fully reversible sensory symptoms, including positive Features all the diagnostic criteria except one (Code 1.6.1) are (eg,"pins and needles") and/or negative Features (eg, numbness) covered in this article because the other types of Fully reversible dysphasic speech disturbance migraine (Codes 1.2.2-1.5) are rarely encountered. C. >2 of the Following: The diagnosis of migraine is based on a clinical Homonymous visual symptoms and/or unilateral sensory triad (professional consensus): symptoms _>1 Aura symptom developing gradually over _>5 minutes • Recurrent attacks separated by totally pain-free and/or different aura symptoms occurring in succession over intervals _>5 minutes • Characteristic migraine symptoms Each symptom lasts 5 60 minutes • Unremarkable clinical examination D. Headache Fulfilling criteria B D for IHS migraine classification The IHS diagnostic criteria for migraine without I. I (migraine without auraS) begins during the aura or Follows aura and for typical aura with migraine headache aura within 60 minutes E. Physical examination between attacks is unremarkable. In case of are presented in Tables 112 and 111,2 respectively. doubt, organic diseases should be ruled out using appropriate These criteria are easy to use and enable the clini- investigations cian to ask essential questions in a logical and structured manner. It is recommended to use the IHS = International HeadacheSociety. ~Adapted with permission.2 The term migraine with aura has replaced the former term, classic or accompanied migraine. tFor more details, see reference
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