Migraine, along with tension headache, is one of the most common of the more than 240 types of headache and significantly limits the quality of life and daily routine of those affected. However, the complex disease is still frequently underestimated and is correspondingly under-treated. An effective therapy management as well as an optimized prophylaxis, which are mainly used in severe forms of migraine, are indicated.
In recent years, improved characterization and diagnosis of clinical features has allowed a more differentiated view of migraine as a complex disorder. One consequence of this is a better and individually tailored therapy regime. For acute therapy, analgesics are available, which alone or in combination with, for example, caffeine, can well curb mild attacks of pain. Triptans have been developed for moderate to severe pain. They mimic the function of the neurotransmitter serotonin in the brain.
Triptans for acute therapy
As a rule, tablets are prescribed as standard. However, triptans are also available as melting tablets, nasal spray of s.c. injection. Depending on the galenics, the effect occurs with varying speed and strength. To achieve effective pain relief, it should be taken as early as possible. And this is precisely where there is often a problem. It is not uncommon for migraine patients to wake up in the morning, already in the middle of the pain attack. Or accompanying symptoms such as nausea and vomiting are so severe that taking tablets is out of the question. In addition, it should be kept in mind that intestinal motility is reduced during migraine, making absorption more difficult. Studies revealed that about half of patients on oral migraine acute therapy are not pain-free two hours after taking it. An even larger percentage is not satisfied with the effect of the treatment. Here, a change to another dosage form should be considered earlier. Subcutaneous administration in particular has advantages, as it bypasses the gastrointestinal passage and enables a rapid onset of action.
Severe migraine attacks under control
Inadequate acute therapy can have far-reaching consequences. This is because it is not uncommon for overuse of pain medications to lead to painkiller-induced headaches. This phenomenon is present in 75% of all patients with chronic migraine. In this case, it is important to phase out the painkillers as a first step and then start effective prophylaxis. Preventive treatment may also be considered for patients with increased attack frequency. This should be multimodal in design and include lifestyle and behavioral changes as well as effective pharmacologic care. In addition to antidepressants, anticonvulsants, beta blockers, calcium antagonists and natural substances, CGRP antibodies have recently become available for this purpose. These are characterized by their ability to specifically address the pathophysiology of migraine. Release of excitatory neurotransmitters such as calcitonin gene-related peptide (CGRP) triggers perivascular inflammation that stimulates afferent nociceptive C-fibers. These transmit the signal back to the trigeminal nerve. A vicious circle begins. By blocking the CGRP receptors, migraine pain can be counteracted highly effectively in advance.
Source: German Pain Congress
InFo NEUROLOGY & PSYCHIATRY 2020; 18(6): 28 (published 11/28/20, ahead of print).
