For #FamilyMedicine
My 2 cents on #MigraineProphylaxis
Choose the prophylactic drug by running through contraindications:
*Obese, avoid VPA
*Asthmatic, avoid Beta Blockers, etc.
Look for other comorbidities for an added benefit:
*Obese, go for Topiramate
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My 2 cents on #MigraineProphylaxis
Choose the prophylactic drug by running through contraindications:
*Obese, avoid VPA
*Asthmatic, avoid Beta Blockers, etc.
Look for other comorbidities for an added benefit:
*Obese, go for Topiramate
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*Sleep issues, anxiety…TCA
(You might have to treat separately with better drugs, and better doses than that are sufficient for migraine prophylaxis)
*Pains, neuropathy… Gabapentin "weak evidence, but it works!"
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(You might have to treat separately with better drugs, and better doses than that are sufficient for migraine prophylaxis)
*Pains, neuropathy… Gabapentin "weak evidence, but it works!"
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*Avoid Topiramate for professionals who need to be mentally sharp for work, +/- Women in child bearing age.
Once decided and selected a drug: Explain the target, and encourage compliance. We have limited options, and each one should be given a fair chance/dose/duration.
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Once decided and selected a drug: Explain the target, and encourage compliance. We have limited options, and each one should be given a fair chance/dose/duration.
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Start low and Go slow. Migraine is a lifelong brain dysfunction, and we are there for the long term. Don’t rush.
Once you reach the recommended dose, keep it for three months, then reassess.
The best is to use a migraine diary. Ask the patient to X-Mark each
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Once you reach the recommended dose, keep it for three months, then reassess.
The best is to use a migraine diary. Ask the patient to X-Mark each
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headache day, medications used, ER or not, duration, etc.
Patients can use calendars on their cellphones to register their diaries.
*At three months
1- if there is no change in headache, discontinue the prophylactic drug and start another one. Keep on using the diaries.
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Patients can use calendars on their cellphones to register their diaries.
*At three months
1- if there is no change in headache, discontinue the prophylactic drug and start another one. Keep on using the diaries.
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2- if improved by 50% or more, keep on the same dose and continue. More improvement is on the way.
3- if improved by 20-30% or so, increase the dose—more on this below.
Now, what are the doses of common prophylactic drugs?
*Amitriptyline: 10-25-100 mg at bedtime.
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3- if improved by 20-30% or so, increase the dose—more on this below.
Now, what are the doses of common prophylactic drugs?
*Amitriptyline: 10-25-100 mg at bedtime.
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*Propranolol: 80-320 mg per day
*Metoprolol: 50-200 mg per day
*Topiramate: 50-100 mg BID
*VPA: 500 to 1500 mg per day.
*Verapamil: 120-480 mg per day
Monitoring each drug when going up to the higher doses is your headache!
Combination is OK, as long as you monitor for
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*Metoprolol: 50-200 mg per day
*Topiramate: 50-100 mg BID
*VPA: 500 to 1500 mg per day.
*Verapamil: 120-480 mg per day
Monitoring each drug when going up to the higher doses is your headache!
Combination is OK, as long as you monitor for
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Efficacy and the adverse effects.
More details in Q&A
Thanks.
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More details in Q&A
Thanks.
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How long we treat?
Once you get migraine under control, keep the effective dose for 6-9 months, or even a year, then taper off slowly. If headache is back, then escalate to the previous effective dose for another 6-9 months..
Don't forget to stress the importance of regular
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Once you get migraine under control, keep the effective dose for 6-9 months, or even a year, then taper off slowly. If headache is back, then escalate to the previous effective dose for another 6-9 months..
Don't forget to stress the importance of regular
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Sleep and exercise.
Sometimes, once lifestyle issues are fixed, patients can have a long stretch without prophylactic drugs.
In severe disabling migraine, I suggest you keep the prophylactic drug longer than a year.
Remember: we use these drugs for other indications like
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Sometimes, once lifestyle issues are fixed, patients can have a long stretch without prophylactic drugs.
In severe disabling migraine, I suggest you keep the prophylactic drug longer than a year.
Remember: we use these drugs for other indications like
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Epilepsy or depression for years, without problems, as long as we monitor for the side effects.
P.S. Please avoid giving a beta blocker to a gym goer. It will fail. Fatigue usually sits in, and heart rate has a ceiling in cardio. Bad start!.
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P.S. Please avoid giving a beta blocker to a gym goer. It will fail. Fatigue usually sits in, and heart rate has a ceiling in cardio. Bad start!.
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For Peri-menstrual migraine:
Look at the second drop of estrogen as a trigger, like any other trigger. The problem is you can't avoid it.
Rx: 1-Preemptive with a triptan or a NSAID, Used from day -2 to +3.
2- Continous Combined Oral Contraceptive to prevent ovulation.
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Look at the second drop of estrogen as a trigger, like any other trigger. The problem is you can't avoid it.
Rx: 1-Preemptive with a triptan or a NSAID, Used from day -2 to +3.
2- Continous Combined Oral Contraceptive to prevent ovulation.
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Timolol, a beta blocker could be used for:
1- Prophylaxis: 10-30 mg/d, usual effective is 10 mg BID.
2- Acute abortive therapy: 0.5% eye drops. One drop each eye. May repeat in 10 minutes. Supported by one RCT. NNT 2. Effective and cheap!
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1- Prophylaxis: 10-30 mg/d, usual effective is 10 mg BID.
2- Acute abortive therapy: 0.5% eye drops. One drop each eye. May repeat in 10 minutes. Supported by one RCT. NNT 2. Effective and cheap!
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