Acute treatments for migraines in Lausanne

Acute-phase treatments are those that can be used by migraine sufferers during an attack of pain.

To be considered effective, these treatments must reduce or eliminate pain within two hours.

First-line treatment often begins with analgesics (paracetamol +/- non-steroidal anti-inflammatory drugs NSAIDs).

The drugs generally used as first-line treatment are (NSAIDs) such as Ibuprofen (brufen, Algifor, Advil, etc), Aspirin, Diclofenac (flactor, Voltaren), Ketoprofen, Ketorolac (tora-dol), Naproxen (Aleve, etc), indometacin (Indocide), Sulfonanilides (nimesulide), among others. These drugs have mainly gastric (ulcer) and cardiovascular (edema) side effects. The action of these drugs is against pain, fever and inflammation.

Analgesics are also widely used as first-line treatment. Paracetamol (Dafalgan) is used at the start of an attack, but most migraine sufferers consider its beneficial effects to be insufficiently effective. The side-effects of paracetamol are essentially liver toxicity if used in excess of recommended doses.

An antiemetic (an anti-vomiting medication to relieve nausea and vomiting, often associated with pain during attacks, such as Domperidone or Metoclopramide).

Anti-inflammatories and analgesics are not very effective in reducing pain during a migraine attack. These drugs are widely used because they are readily available and have tolerable side-effects if the doses used do not exceed the recommended limits. It should be noted, however, that chronic use of these drugs can cause severe side-effects and is not recommended, as they cannot provide significant relief in most cases.

Second-level analgesics are “weak” opiates or minor opioids such as Codeine or Tramal, which have a synergistic effect with lighter analgesics. In special cases, Morphine may also be considered.

Side effects of opioids include constipation, drowsiness, nausea, vomiting and respiratory depression. They are also responsible for physical dependence.

Specific drugs to treat acute migraine attacks

Specific medications for treating acute migraine attacks are Triptans or 5-HT1 serotonin agonists.

Triptans (5-HT1B/1D agonists) are the only migraine-specific medications. Triptans have a vasoconstrictive action (vasoconstrictors) and are prescribed as 2^nd-line treatment if first-line therapies have failed in migraine sufferers with intense, rapidly onset attacks, at the minimum effective dose.

Triptans can be combined with NSAIDs. The doctor chooses the triptan according to the patient’s headache type and efficacy. In patients with very intense, rather short-lived attacks (e.g., vascular pain attacks), a more rapidly absorbed route of administration (subcutaneous, nasal spray, intra-rectal or sublingual) is preferred. In patients with high recurrence rates, a long-acting triptan should be chosen.

However, a fraction of migraine sufferers is resistant to triptans. Triptans include Sumatriptan (Imigran), Eletriptan (relpax), Rizatriptan (Maxalt), Frovatriptan (Menamig), Naratriptan (Naramig), Zolitriptan (Zomig), Almotriptan (Almogran). The fastest-acting triptan is Maxalt (about 15 minutes), and the slowest are Menamig and Naramig (4h onset of action).

Current triptans are very powerful vasoconstrictors and are contraindicated in patients with ischemic heart disease, a history of ischemic stroke/TIA or poorly balanced hypertension. They should not be used in migraine aura without headache.

Side effects of triptans include: a sensation of heat, tightness or paresthesia (odd skin sensation, predominantly in the neck and chest), sedation, difficulty concentrating, and a possible cross-allergy reaction to sulfonamides (not present for Maxalt and Zomig). Unfortunately, Triptans can cause so-called drug-induced migraines if taken in excess of the maximum recommended doses. In some cases, real drug abuse situations are triggered, and patients will need to undergo weaning to enable them to improve the overall situation. One option for these patients is to assist weaning with botulinum toxin injections, reducing the frequency and intensity of migraines for 3 months.

In pregnant women, paracetamol can be used throughout pregnancy, while NSAIDs can only be prescribed during the 2^nd trimester. Triptans are contraindicated (Sumatriptan and Rizatriptan: on the basis of available data, these drugs may be used if the risks to the foetus – e.g., vomiting due to migraine – are greater than the potential risks of the molecules).

Ergot derivatives are rarely used, due to their contraindications.

For vascular algies, 100% Oxygen (10-15L/minute) is used for 15 minutes in combination with a fast-acting Triptan (e.g., Sumatriptan 6mg subcutaneous, maximum 12mg/24h and 6h interval between doses).

If, unfortunately, these drugs are not enough, if you need to take too much (more than the maximum recommended dose) or if you can't tolerate the side effects, our specialist team at Global Medical Institute will assess your case and recommend a definitive minimally invasive surgical treatment.