Headaches are one of the most commonly encountered problems in general practice, with migrainous headaches presenting important diagnostic and management issues. Migraines are seen with increasing frequency worldwide – approximately 18% of women and 6% of men in young adult life experience these types of headaches. The true incidence of migraines is likely to be greater than this, as many people with frequent headaches are not recognised as having migraines. Studies have been conducted, regarding criteria that the general public can use to diagnose migraines, such as the Lipton Questionnaire.
Many patients self medicate with over the counter treatments, which have not been shown to be effective in migraines. It is important that a two-stage approach be employed in management of migraines – the effectiveness of simple analgesics (eg paracetamol / aspirin / non steroidal anti-inflammatories) should not be underestimated. If these medications are not effective, then more specific medications that aim to target processes central to migraines should be considered – eg ergotamines (such as Cafergot) and triptans (eg Sumatriptan).
For the comprehensive treatment of migraines, prophylaxis must also be considered. Patients with frequent migraines (more than or equal to two episodes / month) should be started on prophylaxis. There are many prophylactic medications available, but commonly used drugs include pzotifen (Sandomigraine) and propanolol. If one drug does not work for a patient, a second or third line option should always be pursued. Effective communication between the patient and the doctor is vital to ensure that treatment regimes can be individualised and side effect profiles tailored to the patient’s specific needs. For example, propanolol should be avoided in patients with asthma.
Topamax is a newer medication that is currently being used in the treatment of migraines in Australia, working well for many patients. Topamax is not on the pharmaceutical benefits scheme (PBS) yet, thus is more costly. Its side effect profile is well tolerated – the dose used in migraine treatment is only a fraction of that used for epilepsy. Initially, a low dose should be administered, gradually titrating the medication as tolerated. There have been substantial reductions in the frequency of migraines reported by patients.
In summary, optimal management of migraines is difficult to achieve. Treatments should be used with caution and prophylaxis considered for all patients with frequent migraines. Effective communication may hold the key to successful control of this potentially debilitating cause of headaches. Listen to the full interview recording involving Professor Richard Stark, neurologist from the Alfred Hospital in Melbourne, on Drive Time medical.
|Click here to listen to an audio file ( 4.7 MB ) of an interview with Professor Richard Stark on Drivetime Medical about migraines.