The American Academy of Family Phys...

The American Academy of Family Physicians (AAFP) and the American body of Physicians-American Society of Internal Medicine (ACP-ASIM), working jointly and with assistance from the American Headache Society, not long ago developed guidelines for primary care physicians forward the pharmacologic management of acute migraine attacks and the prevention of migraines. The clinical guidelines were published in the November 19 2002 issue of Annals of Internal Medicine. The guidelines were based onward articles by Matchar and associates and Ramadan and colleagues (available at www.aan.com/professionals/practice/guidelines. cfm) if it were not that contain somewhat different recommendations based forward the levels of evidence necessityed to make a positive recommendation.

Diagnosis and Initial Management

Migraine is a primary headache disorder with a wide variety of manifestations. returning acute attacks may not have the same characteristics in all patients or plane in the same patient. Criteria for the diagnosis of migraine have been cause to growed by the International Headache Society. However, physicians ne to be aware that a patient can have more than single in kind headache disorder (e.g., migraine and episodic tension-type headaches).

Patient Education and Involvement

Recommendation. The patient should be educated about the sway of acute migraine attacks and preventive treatment. The patient should be involved in formulating a management plan. Regular reevaluation of therapy is important.

A discussion of the benefits and adverse results of therapeutic options can help the patient establish realistic expectations. Together, the physician and patient should decide by what means acute attacks are to be treated and whether the patient would benefit from preventive medication.

Patient input is crucial to treatment selection and evaluation. Tracking progres with a daily emanate sheet can be helpful in assessing treatment. The patient's headache diary should include the severity, common occurrence and duration of migraine attacks; the extent of disability resulting from the attacks; the answer to treatment; and adverse validitys from medication. The patient also should be encouraged to identify factors or situations that trigger migraines (eg alcohol, caffeine, meats containing tyramine or nitrates, stres fatigue, sweetness of smells fumes, glare, flickering lights).

Management of Acute Attacks

Management of acute migraine attacks extremitys to be individualized. Factors to consider include associated symptoms (eg nausea, vomiting), the commonness and severity of the attacks, and the stage of disability caused by the attacks. Comorbid conditions (eg uncontroll hypertension, heart disease, pregnancy) and previous answers to specific medications may limit treatment options.

To guard against medication-overuse headaches, experienced persons suggest limiting the use of acute treatment to no more than twice a week. Preventive migraine therapy should be considered if medication overuse is suspected or considered to be a risk.

Consideration should be given to the possibility of recoil headaches, which are associated with the withdrawal of analgesic physics or abortive migraine medications. Although universal agreement is lacking, it is generally deliberation that rebound headaches can be caused by dint of opiates, triptans, ergotamine, and analgesic medications that contain caffeine, isometheptene, or butalbital.

The physician may ne to consider the patient's use of a deliver medicine (e.g., an opioid, a unite that contains butalbital) at to one's home when other treatments for simple migraine attacks are not prosperous Appropriate situations for use should be addressed.

Recommendation. In chiefly patients with migraine, nonsteroidal anti-inflammatory remedys (NSAIDs) are first-line treatment.

Evidence for efficacy is principally consistent for these agents: aspirin, ibuprofen, naproxen sodium, tolfenamic acid (not generally available in the United States), and the acetaminophen-aspirin-caffeine combination. Acetaminophen alone is ineffective.

Recommendation. Migraine-specific agents (triptans, dihydroergotamine [DHE]) should be used in patients whose migraine attacks do not be agreeable to to NSAIDs.

Evidence for efficacy is well adapted for the following triptans (serotonin1B/1D agonists): orally administered naratriptan, rizatriptan, and zolmitriptan, and orally and subcutaneously administered sumatriptan. Triptans should not be used in a patient who has uncontroll hypertension or basilar or hemiplegic migraine or who is at risk for heart disease.

Evidence for efficacy and safety is convenient for intranasally administered DHE. There also is pious evidence for the efficacy of butorphanol nasal spray. Treatment with opioids may be considered if other medications cannot be used and if the risk of abuse has been addressed and sedation is not a concern

Recommendation. A nonoral road of administration should be preferableed when nausea or vomiting not away early as significant components of migraine attacks. Nausea should be treated with an antiemetic drug