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Recommendations for the Treatment of Migraine Attacks

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Recommendations for the Treatment of Migraine Attacks DOI: 10.1590/0004-282X20150219 CONSARTICLEENSUS Recommendations for the treatment of migraine attacks - a Brazilian consensus Recomendações para o tratamento da crise migranosa - Um consenso brasileiro Carlos Alberto Bordini1, Célia Roesler2, Deusvenir de Souza Carvalho3, Djacir Dantas P. Macedo4, Élcio Piovesan5, Eliana Meire Melhado6, Fabiola Dach1, Fernando Kowacs7, Hilton Mariano da Silva Júnior8, Jano Alves de Souza9, Jayme Antunes Maciel Jr10, João José de Freitas de Carvalho11,12, José Geraldo Speciali1, Liselotte Menke Barea7, Luiz Paulo Queiroz13, Marcelo Cedrinho Ciciarelli2, Marcelo Moraes Valença14,15, Márcia Maria Ferreira Lima16, Maurice Borges Vincent17, Mauro Eduardo Jurno18, Paulo Helio Monzillo19, Pedro Ferreira Moreira Filho8, Renan Domingues20 ABSTracT In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period. Keywords: headache, migraine, treatment, pain medication, crisis. RESUMO Neste artigo um grupo de especialistas no tratamento de cefaleia da Sociedade Brasileira de Cefaleia através de um consenso elaborou medidas estratérgicas para tratar uma crise de migrânea tanto na criança como no adulto. Uma enfase particular foi dada no tratamento da migranea na mulher, incluindo gravidez, lactação e período perimenstrual. Palavras-chave: cefaleia, enxaqueca, tratamento, analgésico, crise. 1Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, São Paulo SP, Brazil; 2Sociedade Brasileira de Cefaleia, Niterói RJ, Brazil; 3Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo SP, Brazil; 4Universidade Federal do Rio Grande do Norte, Caicó RN, Brazil; 5Universidade do Federal do Paraná, Curitiba PR, Brazil; 6Faculdade de Medicina de Catanduva, Catanduva SP, Brazil; 7Universidade Federal Ciências da Saúde de Porto Alegre, Porto Alegre RS, Brazil; 8Hospital Mário Gartti, Campinas SP, Brazil; 9Universidade Federal Fluminense, Niterói RJ, Brazil; 10Universidade Estadual de Campinas, Campinas SP, Brazil; 11Unichristus, Fortaleza CE, Brazil; 12Hospital Geral de Fortaleza, Fortaleza CE, Brazil; 13Universidade Federal de Santa Catarina, Florianópolis SC, Brazil; 14Universidade Federal de Pernambuco, Recife PE, Brazil; 15Hospital Esperança, Ilha do Leite PE, Brazil; 16Universidade Estadual Júlio de Mesquita Filho, Botucatu SP, Brazil; 17Universidade Federal do Rio de Janeiro, Rio de Janeiro RJ, Brazil; 18Faculdade de Medicina de Barbacena, Barbacena MG, Brazil; 19Santa Casa de São Paulo; São Paulo SP, Brazil; 20Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil. Correspondence: Mauro Eduardo Jurno; Faculdade de Medicina de Barbacena, Departamento de Neurologia; Rua Fernando Laguardia, 45; 36201-118 Barbacena MG, Brasil; E-mail: [email protected] Conflict of interest: There is no conflict of interest to declare. Received 03 November 2015; Accepted 27 November 2015. 262 The approach to the patient suffering from migraine NON-PHARMacOLOGIcaL MEASURES begins by the clinical history, a crucial step, once the di- agnosis is essentially clinical. Migraine diagnosis is based Simple measures such as resting in a calm, airy and low on the crisis characteristics and must meet the criteria light environment are known to be effective. To sleep during provided by the International Classification of Headache a crisis may also be a source of pain relief3. The use of cold Disorders - ICHD-3 beta. Additional tests are reserved compresses on the forehead and temples is reported by many when differential diagnosis of secondary headaches is re- to be useful. quired. It is important to identify comorbidities, among There is no conclusive evidence on the use of addition- which emotional and anxiety disorders and high blood al treatments, such as relaxation techniques, chiropractic, pressure stand out. transcutaneous electrical nerve stimulation (TENS), mas- Treatment of a migraine attack includes pharmacologi- sage and cold compresses. However, coping techniques cal and non-pharmacological measures. All migraine crisis should be encouraged. should be treated, regardless of their intensity. Studies on the use of acupuncture to treat migraine have 4 This article aims to develop a consensus with experts shown low therapeutic efficacy . There is solid evidence dem- from the Brazilian Headache Society and the Scientific onstrating the ineffectiveness of homeopathy in the treat- Department of Headache of the Brazilian Academy of ment of a crisis. Neurology on how migraine attack treatment is recommend- Recently, invasive and non-invasive neurostimulation ed. We will add some recommendations on general and ed- therapy to treat migraine crises, such as transcranial magnet- ucational measures and to the treatment of comorbidities, ic stimulation, occipital nerve stimulation and transcutane- although they are not relate specifically to the crisis of mi- ous supraorbital therapy have been described. Although with graine, for the importance of these procedures in reducing positive results in some patients, there are no sufficient data to its recommendation5. the frequency of these episodes of pain. PHARMacOLOGIcaL MEASURES GENERAL AND EDUcaTIONAL MEASURES Treatment of migraine crises should consider individual Patients should be warned about the triggering factors of features, as migraine is known as a complex disease, involv- crises, so that they can identify these factors and thereby re- ing multiple characteristics that vary from one person to an- duce the frequency of migraine episodes, at least in part. The other and that influence the treatment outcome. triggering factors are multiple and individual. Each patient Drugs should be chosen taking into account the must check potential triggering factors for their crises with history of each patient (previous results, allergies, the assistance of the doctor. Among the most common are contraindications, comorbidities). the stress, the emotions, inconsistent sleep schedules (exces- The prescription must include all required information sive hours of sleep, sleep deprivation or sleeping outside the and be clear as to when to use, in which doses, when to re- usual time), the suppression of meals or prolonged fasting, peat or change doses. excessive regular use of caffeine, alcohol intake and specific The treatment can be done with specific and/or non- foods. The use of food lists to be avoided should not be en- specific drugs. The specific drugs are the triptans and ergot couraged, when only foods identified as crises triggering fac- derivatives. The nonspecific drugs are the simple analgesics tors should be discontinued. and the nonsteroidal anti-inflammatory drugs (NSAIDs). The Guidance on the risks of self-medication, and especial- concomitant use of antiemetic, neuroleptic and corticoste- ly on the risk of excessive use of abortive medications is of roid drugs may be required. Opioids should be avoided. 1 great importance . Triptans are agonists to the serotonin 5HT-1b, 1d-5HT Comorbidities should always be treated and, if applicable, and 5HT-1f receptors. Four medications in this class are the patient should be referred to other professionals of spe- sold in Brazil: sumatriptan, naratriptan, zolmitriptan cific areas. and rizatriptan. Use of a diary for recording crises should be encouraged Sumatriptan, a pioneer drug, is the one that comes with in order to not underestimate or overestimate the frequency, more presentation forms: 25 mg, 50 mg and 100 mg tab- intensity and duration of migraine crises. lets, 6 mg subcutaneous injection, 10 mg/dose nasal spray. Patients and their families should be clarified, in an The subcutaneous use is the one with greater efficiency and accessible language, about the neurobiological and ge- speed of action, followed by the nasal route. These two forms netic nature of the disease, the diagnosis criteria and be are particularly useful in patients showing the early symp- warned on the factors that can modify the natural course toms of nausea and vomiting appearing in the crisis. In order of the disease2. to treat the crises that allow the oral administration, a 50 mg Carlos Alberto Bordini et al. Recommendations for the treatment of migraine 263 dose should be tried. If response is unsatisfactory, it should only in the form of fixed combinations (associations with dif- made use of an administration of 100 mg. For any of the dos- ferent substances, such as dipyrone or paracetamol, caffeine age forms for an unsatisfactory response, one can repeat the or metoclopramide), which may constitute in an additional treatment after 2 hours. The maximum daily doses for each limitation. The dihydroergotamine has an erratic oral absorp- formulation are subcutaneous injection - 20 mg (two admin- tion, and it is not possible to foresee which serum concen- istrations); nasal route - 40 mg; oral route - 200 mg. tration will be achieved, also having the disadvantage of en- Naratriptan is marketed in tablets of 2.5 mg. This drug hancing nausea and vomiting in some patients. shows a disadvantage when compared to Sumatriptan, as Since triptans and ergot derivatives act in the same sero- it is less potent and has a slower onset of action, but with tonin receptors, the concomitant use of these drugs is contra- the advantage of being one of the triptans among those sold indicated.
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