Non-specific migraine attack treatment

The purpose of migraine attack treatment is to reduce the intensity and duration of the attack when it occurs. There are specific treatments (ie developed to treat migraine) and non-specific treatments. The main risk of the treatment of attack is (in addition to the potential toxicity) to develop migraines by drug abuse. In this case, the drug itself is the cause of headaches, the patient then enters a vicious circle which requires strict weaning. The choice of crisis treatment will be dictated by the answer to the following four questions (Géraud 2015):

• Are you significantly relieved two hours after taking it?
• Is your treatment well tolerated?
• Do you use only one medication?
• Does taking the treatment allow you to resume normal and rapid activities?

If the answer is yes to each of the questions, it is recommended not to modify the crisis treatment in the absence of excessive consumption. However, analgesics combined with caffeine and opioids (codeine, opium, Tramadol®, morphine and other strong opioids) are not recommended, as they can induce drug abuse that risks chronicizing the migraine, or even causing addiction. They are therefore reserved for patients with absolute contraindications to NSAIDs and triptans. There are two broad categories of seizure treatment: specific and non-specific.

Lasmiditan, a new specific migraine attack treatment.

Non-specific treatments are analgesics and non-steroidal anti-inflammatory drugs. So-called specific treatments are used exclusively to treat migraine: these are ergot derivatives and triptans. Other substances such as caffeine, antiemetics or psychotropics are sometimes used as adjuvants (National Agency for Accreditation and Evaluation in Health 2002).

Non-specific seizure treatments

has. paracetamol

Paracetamol is very widely used in the treatment of migraine and particularly in self-medication. For 80% of patients, it is considered harmless, but at high doses, there is however a proven hepatotoxicity. It is also at the top of the list of drug abuse inducing chronic daily headaches (Géraud 2015). It is often combined with codeine, caffeine or aspirin, and in several trials the paracetamol-aspirin-caffeine combination has been shown to be superior to placebo and even ibuprofen alone (Derry et al. 2013). However, for the moment, there is no specific marketing authorization (MA) for the treatment of migraine attacks.

b. aspirin

Aspirin or acetylsalicylic acid is the oldest and best known analgesic substance. Widespread, it is often the first and only therapy used by migraine sufferers (Kirthi, Derry, and Moore 2013). It owes its beneficial action to its three properties: analgesic, but also anti-inflammatory and anti-platelet aggregation. Its efficacy has been demonstrated for doses ranging from 500 to 1000 mg and marketing authorization has been obtained in the treatment of migraine attacks for the 900 mg aspirin combination associated with 10 mg of metoclopramide, marketed under the name Migpriv (Derry et al. 2017). Metoclopramide is an antiemetic belonging to the class of neuroleptics. It acts as a dopamine antagonist which helps prevent vomiting. The action of aspirin is based on the inhibition of cyclo-oxygenases involved in the synthesis of prostaglandins. It also inhibits platelet aggregation by blocking the synthesis of thromboxane A2 (Ornelas et al. 2017).

vs. Nonsteroidal anti-inflammatory drugs (NSAIDs) for migraine attacks

In France, there are two Marketing Authorizations for NSAIDs in the indication of migraines. These are Ketoprofen and Ibuprofen, but in other studies, various NSAIDs have also shown their superiority over placebo in the treatment of migraine attacks ; these include Naproxen and Diclofenac (Xu et al. 2016). There are few direct comparisons between NSAIDs and no one stands out from the others. There also does not seem to be any cross-efficacy between these treatments (Géraud et al. 2015).

It is therefore recommended that the patient try several to determine the most appropriate. However, there are undesirable effects, mainly at the digestive level, and must be avoided from the third trimester of pregnancy because they are likely to cause fetal malformations. In addition, women with mechanical IUDs cannot use NSAIDs because they decrease contraceptive effectiveness by reducing inflammation of the uterine lining. NSAIDs can also be used as disease-modifying therapy (Baena et al. 2017).

Their mode of action on migraine remains poorly understood but their inhibitory action, as is the case for the action of aspirin, does not seem to be the only mechanism of NSAIDs. Indomethacin, which is a powerful inhibitor of cyclo-oxygenases, has no proven preventive effect in migraine (Géraud et al. 2015). The same is true for the anti-platelet effect, because aspirin at a dose of 160 mg has no preventive efficacy in migraine, whereas for this dose, its anti-aggregation action is very significant (Buring et al. 1990). NSAIDs do not have Marketing Authorization in migraine prophylaxis, because the risk of gastritis or ulcers limits their long-term use.

d. Opiate analgesics

Despite the recommendations of the Haute Autorité de Santé which advises avoiding opioids (Codeine, Tramadol, Morphine and other strong opioids), they are still widely prescribed and used, although they often increase nausea and vomiting. They hold the second place in the list of analgesic drugs inducing chronic daily headaches (Thorlund et al. 2016). The most widely prescribed is Lamaline®, which contains 1 mg of morphine per capsule or 3 mg in a suppository (Marmura et al. 2015). Despite this very common use among migraine sufferers, no specific study has reported a beneficial effect of opiates in the treatment of migraine (National Agency for Accreditation and Evaluation in Health 2002).

See also: Treatment of migraine during pregnancy.