Sheridan Demo

SYMPTOMS AND SIGNS

Triptans currently available

Relief – difference from placebo (mild or none at 2 hours) (% ± 95% CI) 1 hour 2 hours

Patients relapsing at 24 hours (%)

• Sumatriptan, 100 mg • Sumatriptan, 50 mg • Zolmitriptan, 2.5 mg • Naratriptan, 2.5 mg • Rizatriptan, 10 mg • Eletriptan, 40 mg • Eletriptan, 80 mg • Almotriptan, 12.5 mg • Frovatriptan, 2.5 mg

22 26 18 24 14 22 22 8

33 ± 3 33 ± 7 34 ± 7 21 ± 3

36 36 32 27 28 21 20 25 17

41 33 40 29 13

?

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intervention. It is realistic to expect patients to improve and to withdraw prophylactic treatment after 6–9 months, re-starting only if the headaches recur. This advice is particularly important for methysergide, because it is believed that discontinuing treatment after 6 months reduces the risk of retroperitoneal fibrosis. ‹ REFERENCES 1 Rasmussen B K, Jensen R, Schroll M et al. Epidemiology of headache in a general population – a prevalence study. J Clin Epidemiol 1991; 44: 1147–57. 2 Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: the utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations. Neurology 1994; 44: 1353–4. 3 Goadsby P J, Lipton R B, Ferrari M D. Migraine – current understanding and treatment. N Engl J Med 2002; 346: 257–70. 4 Silberstein S D. Seminar: migraine. Lancet 2004; 363: 381–91. 5 Management of tension type headache. Drug Ther Bull 1999; 37: 41–4. 6 Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry 1996; 61: 285–90. 7 Matharu M J, Boes C J, Goadsby P J. Management of trigeminal autonomic cephalalgias and hemicrania continua. Drugs 2003; 63 : 1637–77. 8 Van Vliet J A, Bahra A, Martin V et al. Intranasal sumatriptan in cluster headache. Neurology 2003; 60: 630–3. 9 Swannell A J. Polymyalgia rheumatica and temporal arteritis: diagnosis and management. BMJ 1997; 314: 1329–32. 10 Sist T, Filadora V, Miner M et al. Gabapentin for idiopathic trigeminal neuralgia: report of two cases. Neurology 1997; 48: 1467–71. 11 Storey J R, Calder C S, Hart D E et al. Topiramate in migraine prevention: a double-blind placebo-controlled study. Headache 2001; 41: 968–75. 12 Tronvik E, Stovner L J, Helde G et al. Prophylactic treatment of migraine with an angiotensin II receptor blocker. JAMA 2003; 289: 65–9. 13 Ferrari M D, Roon K I, Lipton R B et al. Oral triptans (serotonin 5HT 1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 2001; 358: 1668–74.

paracetamol and codeine are safe, but these drugs tend to per- petuate headache if taken daily.

Triptans: since the introduction of sumatriptan in 1991, the triptans have revolutionized acute management of migraine. The beneficial effects of ergotamine are thought to be mediated via its agonist properties at 5-HT 1B and 5-HT 1D receptors, and these drugs are pure agonists at these receptors without the other pharmacological properties (e.g. agonism at 5-HT 2 receptors) that seem to contrib- ute to the adverse side-effects of ergotamine. As a consequence, most authorities now consider ergotamine to have been almost entirely superseded. Triptans currently available are listed in Figure 7. 13 The pharmacological differences between sumatriptan, zolmitriptan, rizatriptan and probably eletriptan seem relatively small, and this is reflected in modest clinical differences, even in direct comparative trials. In contrast, naratriptan, almotriptan and perhaps frovatriptan have longer durations of action (with delayed clinical benefit in some cases), but there is a lower incidence of short-term side-effects and a lower recurrence rate. These agents should therefore be recommended for patients in whom these problems are important when they are given one of the first-line drugs. Triptans are contraindicated in patients with ischaemic heart disease. Side-effects – a few patients complain of generalized paraes- thesiae or muscular aches that pass quickly. Recurrence of the headache (usually 12–16 hours after administration) occurs in about one-third of patients treated with sumatriptan, zolmitriptan or rizatriptan, but this usually responds to a second dose. Sumatriptan and zolmitriptan are available as nasal sprays, and sumatriptan is also available as a self-administered subcutaneous injection, and as suppositories in some countries. These prepara- tions are suitable for patients in whom vomiting is a major clinical feature. Sumatriptan seems to be effective only when the patient is already in pain, and patients whose headaches are preceded by an aura should wait until the headache phase of their attack starts. Follow-up and prognosis Migrainous attacks tend to fluctuate in severity over months, and patients who have sought advice about their attacks when they are worsening often improve subsequently, independently of medical

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MEDICINE Volume 32:9

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