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Canadian Headache Society Guideline: Acute Drug Therapy for Migraine Headache

Published online by Cambridge University Press:  01 July 2015

Irene Worthington
Affiliation:
Sunnybrook Health Sciences Centre, Toronto, Ontario
Tamara Pringsheim
Affiliation:
University of Calgary and the Hotchkiss Brain Institute, Calgary, Alberta
Marek J. Gawel
Affiliation:
Sunnybrook Health Sciences Centre, Toronto, Ontario Rouge Valley Health System - Centenary, Toronto, Ontario Women's College Hospital, Toronto, Ontario, Canada
Jonathan Gladstone
Affiliation:
Sunnybrook Health Sciences Centre, Toronto, Ontario Gladstone Headache Clinic, Toronto, Ontario
Paul Cooper
Affiliation:
University of Western Ontario, London, Ontario
Esma Dilli
Affiliation:
University of British Columbia, Vancouver, British Columbia
Michel Aube
Affiliation:
McGill University, Montreal, Quebec
Elizabeth Leroux
Affiliation:
University of Montreal, Montreal, Quebec
Werner J. Becker*
Affiliation:
University of Calgary and the Hotchkiss Brain Institute, Calgary, Alberta
*
Division of Neurology, 12th Floor, Foothills Hospital, 1403 29th St NW, Calgary, Alberta, T2N 2T9, Canada
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Abstract:

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Objectives:

The primary objective of this guideline is to assist the practitioner in choosing an appropriate acute medication for an individual with migraine, based on current evidence in the medical literature and expert consensus. It is focused on patients with episodic migraine (headache on < 14 days a month).

Methods:

A detailed search strategy was used to find relevant meta-analyses, systematic reviews and randomized double-blind controlled trials. Recommendations were graded with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group. In addition, a general literature review and expert consensus were used for aspects of acute therapy for which randomized controlled trials are not available.

Results:

Twelve acute medications received a strong recommendation for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four received a weak recommendation for use (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications). Strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Metoclopramide and domperidone were strongly recommended for use where necessary. Our analysis also resulted in the formulation of eight general acute migraine treatment strategies. These were grouped into: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. Additional strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation.

Conclusion:

This guideline provides evidence-based advice on acute pharmacological migraine therapy, and should be helpful to both health professionals and patients. The available medications have been organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

Type
Introduction
Copyright
Copyright © The Canadian Journal of Neurological 2014