How to choose the treatment drugs for migraine in the acute phase?

*For medical professionals to read only for reference to specific drugs, non-specific drugs, precautions, and principles of medicati.

Migraine is a common chronic neurovascular disease characterized by recurrent attacks, unilateral or bilateral pulsatile Severe headaches occur mostly on the side of the head, and can be combined with autonomic nervous system dysfunction such as nausea, vomiting, photophobia, and phonophob.
About 1/3 of migraine patients may have neurological aura symptoms before the ons.
The prevalence of migraine in China is 3%, and the ratio of women to men is about 3:The World Health Organization (WHO) lists migraine as one of the top ten health diseas.
Although it is not fatal, it is recommended to seek medical attention and control it regular.
In addition to the damage caused by the disease itself, migraine can also lead to white matter lesions, cognitive decline, and asymptomatic cerebral infarction in the posterior circulati.
In addition, migraines can also coexist with a variety of diseases such as anxiety and depressi.
Pharmacological treatment of migraine includes acute treatment of headache and preventive treatment of intermittent headac.
Today, let's learn about the commonly used drugs for the acute treatment of migrai.
Medication Instructions▌ The purpose of medication is rapid, sustained analgesia, reducing headache recurrence, and restoring the patient's normal li.
▌ Commonly used criteria for the efficacy of acute treatment of migraine: ① Painless after 2 hours; ② Pain improved after 2 hours, from moderate to severe pain to mild or no pain (or VAS decreased by more than 50%); ③ The effect is repeatable, 3 times 2 or more attacks were effective; ④ There was no recurrence of headache within 24 hours after successful treatment or no need to take medicine aga.
Acute treatment of migraine non-specific drugs 1 acetaminophen Acetaminophen is an acetanilide antipyretic analges.
The mechanism of action is to inhibit the hypothalamic thermoregulatory center prostaglandin synthase and reduce the synthesis and release of the prostaglandin PGEBy inhibiting the synthesis and release of prostaglandin PGE1, bradykinin and histamine, it can increase the pain threshold and play an analgesic effe.
Acetaminophen is available in oral formulations (tablets, suspensions, suspension drops), rectal suppositories and injections, which can meet the needs of different patient populatio.
It can be used for those who are allergic, intolerant or unsuitable for aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs), and can also be used for infants and children over 3 months o.
2 Ibuprofen Ibuprofen is a class of NSAIDs, its mechanism of action is to inhibit the activity of cyclooxygenase (COX) and inhibit the synthesis of prostaglandins, thereby exerting antipyretic, analgesic and anti-inflammatory effec.

Ibuprofen is available by mouth (tablets, capsules, suspension) for children over 6 months of a.

3 Naproxen Naproxen is a class of NSAI.

Its mechanism of action is to inhibit the activity of COX, thereby inhibiting the synthesis of prostaglandins, but it has a stronger selective inhibitory effect on COX-2, so its anti-inflammatory effect is stro.

Gastrointestinal adverse reactions were min.

Naproxen is available in oral formulations, rectal suppositories and injectio.

Oral administration: 250~1000mg, rectal administration: 250mg once, intravenous administration: 275mg, can be used for children over 6 years old or weighing over 25.

4 Diclofenac Diclofenac is a kind of NSAIDs derived from phenylacetic acid, and its mechanism of action is to inhibit the activity of COX, thereby blocking the conversion of arachidonic acid to prostaglandi.
At the same time, it can also promote the combination of arachidonic acid and triglyceride, reduce the concentration of free arachidonic acid in cells, and indirectly inhibit the synthesis of leukotrien.

Diclofenac sodium is one of the most powerful NSAIDs, and its inhibitory effect on prostaglandin synthesis is stronger than that of aspirin and indomethac.

Diclofenac is available in oral formulations, rectal suppositories and injectio.

Oral absorption is rapid and complete, with rapid onset of action, preferably before mea.

Taking capsules works faster, and capsules are more effective than table.

Diclofenac can effectively improve pain and related symptoms in the treatment of acute migraine attacks (level I evidence), but should pay attention to adverse reactions such as liver damage and neutropen.

5 Aspirin Aspirin was the first NSAIDs to be us.

Aspirin is available in oral formulations, rectal suppositories and injectio.

Effervescent tablet is a new type of tablet developed and applied in recent yea.

Each tablet is 3g or
When taking it, dissolve it in 150-250ml of warm water and drink .

It is especially suitable for children, the elderly and those who have difficulty swallowing pil.

patien.

Aspirin lysine salt (Ryampirin), can be used for intravenous or intramuscular injection, each 9 ~
Children over 10 years of age can be given aspirin alone or in combination with metocloprami.

Special reminder: Be careful not to confuse it with antiplatelet low-dose aspirin (100mg or 75m.

6 Compound preparations Commonly used compound preparations include compound preparations of aspirin, acetaminophen and caffeine, compound preparations of acetaminophen and caffeine, and compound preparations of diclofenac and caffei.
Among them, caffeine can inhibit phosphodiesterase, reduce the decomposition and destruction of cAMP, and increase the intracellular cAMP, thereby exerting a wide range of pharmacological effects, including constricting cerebral blood vessels to reduce the pulsation amplitude, and strengthening the efficacy of analgesi.

It is important to note that co-administration of caffeine increases the risk of drug dependence, addiction, and overdose headach.

7 Other drugs Metoclopramide, domperidone and other antiemetic and gastric motility drugs can not only treat the accompanying symptoms, but also help the absorption of other drugs and the treatment of headac.

Benzodiazepine, barbiturate sedatives can promote sedation, sleep, and promote the disappearance of headach.

Due to the addictive nature of sedatives, it is only suitable for severe patients who are ineffective in other drug treatmen.

Opioids are addictive, can cause overdose headaches and induce resistance to other drugs, so they are not routinely recommend.

It is only suitable for people with severe headaches who have not responded to other drug treatments, after weighing the pros and co.

Parenteral opioids, such as butorphanol, can be used as an emergency medication for migraine attacks and have good immediate analgesic effects (level III evidenc.

Table 1 Recommended over-the-counter analgesic drugs for acute migraine attacks in adults Migraine headac.

At present, there are sumatriptan, zolmitriptan and rizatriptan in China, while naratriptan, almotriptan, eletriptan and frotriptan have not been marketed in Chi.

Triptans are effective at any time during the headache period, but the sooner they are used, the bett.

For safety reasons, it is not recommended to use it during the au.
Compared with ergot drugs, triptans have a higher headache recurrence rate within 24 hours (15% to 40%), but if the first application is effective, it is still effective after recurren.

If it is ineffective for the first time, changing the dosage form or dose may be effecti.

Patients who do not respond to one triptan may still respond to anoth.

Sumatriptan is available in oral formulations (tablets, immediate-release formulations), subcutaneous injections, nasal sprays, and rectal suppositories, of which 100 mg tablets are the efficacy reference standard for all tripta.

Subcutaneous injection of sumatriptan 6mg, 10 minutes onset, 2 hours headache relief rate of 8
Zolmitriptan is available in 5mg and 5mg oral and nasal spra.

The drug is lipophilic, can pass through the blood-brain barrier, and has high bioavailabili.

Onset of action after oral administration of 40 to 60 minutes, nasal spray than oral onset of acti.

Rizatriptan is available in 5 mg and 10 mg oral dosage forms in plain and wafer sache.

The recommended starting dose is 10 mg, which can be repeated after 2 hours if the headache persis.

The oral action is rapid, and the disappearance of headache and the maintenance of efficacy are the most significant among all triptans, and the recurrence rate of headache is lower than that of sumatriptan, zolmitriptan and naratript.

2 Ergotamines Ergotamines have a long history of treating acute migraine attacks, but there are not many randomized controlled trials to judge their effica.

The test mostly used ergotamine caffeine mixture (2mg and 200mg or 1mg and 100mg mixture respectivel.

The comparative observation of ergotamines and triptans confirms that their efficacy is less than that of tripta.
Ergotamine has the advantages of long drug half-life and low recurrence rate of headache, and is suitable for patients with long duration of atta.

In addition, very small amounts of ergotamines can rapidly cause overdose headache, so the frequency of drug use should be limited and routine use is not recommend.

3 Calcitonin gene-related peptide (CGRP) receptor antagonists CGRP receptor antagonists (gepants) reduce migraine symptoms by restoring dilated meningeal arteries to normal without causing vasoconstricti.

Some patients who are ineffective or intolerant to triptans may respond well to gepan.

Representative drugs of this type of drugs are: Ubrogepant (approved by the US FDA), Rimegepant (75mg, orally disintegrating tablets, marketed in the EU) Atogepant (currently under review by the US FDA), Telcagepant,e.

At present, there is no CGRP receptor antagonist on the market for the treatment of migraine in China, so there is still a lack of clinical evidence for the effect on Asian populati.

4 Compound ergotamine caffeine mixture can treat some moderate to severe migraine attacks (level III evidenc.

Be aware that co-administration of caffeine increases the risk of drug dependence, addiction, and overdose headach.

Table 2 Recommendations for the selection of prescription drugs for adults with acute migraine attacks should be based on the severity of the headache, accompanying symptoms, previous drug use, and individual conditions of the patie.

The methods of drug selection are as follows: (1) Stratification method: select drugs based on the degree of headache, the degree of functional impairment and the previous response to the dr.

②Ladder therapy: Non-specific drug treatment is given first for each headache attack, and specific drug treatment is given if treatment fai.
The adverse reactions in the stratified treatment group were slightly higher than those in the stepped treatment group, but the adverse reactions were mild, and only manifested as fatigue, dizziness, paresthesia and other common triptan adverse reactio.

Precautions for drug useDrug use should be used in sufficient amounts in the early stage of headac.

Delayed use can reduce the efficacy, increase the proportion of headache recurrence and adverse reactio.

When there is severe nausea and vomiting, parenteral administration should be select.

Antiemetic and gastric motility drugs such as metoclopramide and domperidone can not only treat accompanying symptoms, but also facilitate the absorption of other drugs and the treatment of headach.

Triptans are effective at any time during the headache period, but the earlier the application, the better the effe.

For safety reasons, it is not recommended to use it during the au.

There are slight differences in efficacy and tolerability of different tripta.

For an individual patient, one triptan may not work, another triptan may work; one trip may not work, another attack may wo.

Since the efficacy and safety of triptans are better than those of ergots, ergots are only used as second-line optio.

Ergot has the characteristics of long duration of action and low recurrence rate of headache, so it is suitable for patients with long attack time or frequent recurren.

In order to prevent drug overdose headache, the use of NSAIDs alone should not exceed 15 days within a month, and the use of ergot alkaloids, triptans, and NSAIDs combined preparations should not exceed 10 da.
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Guidelines for the Prevention and Treatment of Migraine in Chi.

Pain in China Journal of Medicine, 2016, 22(10): 721-72 [2] Qian Zhi.

Pharmacology [.

Beijing: China Medical Science and Technology Press, 2009: 35 First publication of the text: Article from the Neurology Channel of the Medical Community Author: Yang Yang Review of this article: Li Tuming, Deputy Chief Physician Responsible Editor: .

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