Medication for Migraine - Chronic Migraine

Here's the medication for migraine that I like to choose when treating chronic migraine.

Remember the 2 most important things are:

• Stop painkillers that are causing Medication Overuse Headache
• Lead a Headache Friendly Lifestyle

Choices of Medication for Migraine (Chronic Migraine, not Episodic)

Here's how to use medication for migraine as part of a chronic migraine treatment programme:

NOTE: Migraine prophylaxis drugs need to be taken every day for several months to have an effect.

• Keep a Migraine Headache Diary for 2 Weeks
• Decide on which drug you want to use
• Remember that these are prescription only medications.

  Some carry potentially serious side-effects including risk to an unborn baby.

• The choices are:
  1. Sodium Valproate 500mg once or twice daily
  • A study of 29 patients with chronic migraine had a 77% reduction in the number of headache days per month from 22 to 5 days per month, after 3 months of Sodium Valproate.

    The group treated with placebo remained at 22 days per month of headaches.

  2. Tizanidine 12 to 24mg daily
  • Research on 71 people with migraine, treated with Tizanidine at an average dose of 18mg for 4 months found a 57% reduction in Headache Frequency and Severity (The Headache Index).
  3. Amitriptyline 40mg daily
  • A trial of 39 patients given Amitriptyline had a 45% reduction in headache intensity and frequency after 8 weeks, but about 40% took a side-effect of a dry mouth
  4. Botox 100 Units at multiple sites of the scalp
  • 60 people were recruited to this trial, but only 33 were suitable for final assessment.

    After 16 weeks, 6/18 Botox treated cases had a 50% reduction in headache days compared to 3/15 who had "dummy" injections.

    Before Botox people had an average of 23 days per month with headache, and this fell to 18 days in the 4th month.

    The people treated with the dummy injections also started at 23 days per month of headache adn theirs reduced to 21 days in the 4th month.

    This is a 14% reduction in headache days after 4 months.

  5. Topiramate 100mg daily
  • A large trial of 306 people compared topiramate to a placebo for 16 weeks.

    There was a 37% reduction in headache in the Topiramate group compared to a 26% reduction in the placebo group. This is an 11% difference between groups.

    The people on active Topiramate lost an average 5 lbs, (as high as 18lbs in some) in 16 weeks.

  6. Gabapentin 2400mg daily
  • A study of 133 people found a 9% reduction in the amount of headache after 4 months treatment

How to Start Medication and Work Out if it Helped

1. Start the Medication for Migraine (Remember this is for Chronic Migraine here!)
• Increase the dose every week until you get to the recommended dose
• If you cannot tolerate the recommended dose, stick at the highest dose you could put up with
• Continue the drug for at least 8 weeks, preferably 12 weeks
2. GET RID OF PAINKILLERS
• Once on the recommended or maximum tolerated dose GET RID OF ANY PAINKILLERS YOUR DOCTOR IDENTIFIED AS CAUSING MEDICATION OVERUSE HEADACHE
3. Consider a short course of Steroids
• It can be helpful to take a high dose of Prednisolone eg 100mg daily for the first 5 days of medication withdrawal to prevent medication withdrawal headache
4. Use an NSAID or Anti-emetic if a severe pain occurs
• If a severe headache occurs after the first week withdrawal period have a supply of an NSAID eg Naproxen 500mg to take as need to a maximum of 12 times per month

  An anti-emetic like Metoclopramide 10mg or prochlorperazine (buccal type 3mg) can also help if pain or nausea is severe

  Intravenous Aspirin 1000mg, Intravenous Chlorpromazine 12.5mg to 37.5mg or Intravenous Dihydroergotamine (up to 12mg over 96 hours) can be used if the headaches remain extremely severe during this process

5. Keep another 2 weeks of diary weeks 5 and 6
6. Keep a final diary for weeks 11 and 12
7. In each of the three diaries, add up the number of days in which any headache scored 7, 8, 9 or 10 - these are called "severe headache days"
8. Compare the number of severe headache days between the three diaries
• If the number of severe headache days reduced by any amount more than 10% you have probably achieved what is expected from research trials of chronic daily headache.

  If you were overusing medication, the chances are that the headaches may reduce by more like 50-75%.

9. If a migraine prophylaxis drug, withdrawal of overused medications, and a Headache Friendly Lifestyle has not had any impact, you are likely to need specialist help for managing your chronic migraine

Medication for migraine is important but there is also the Headache Friendly Lifestyle

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