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Introduction

Acute Migraine: Current Treatment and Migraine is a common primary headache


disorder
Emerging Therapies
Ranked as second most disabling disorder
Devi Ariani Sudibyo worldwide by Global Burden of Disease Study
2016
Neurology Department
Medical Faculty of Airlangga University
Dr. Soetomo General Hospital Surabaya, Indonesia Significant socioeconomic burden and
therapeutic need

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Migraine in adults: 1-year Population or community-based surveys of


Introduction prevalence >500 participants covering ages 25-60 y,
using IHS or modified IHS criteria
15.5
11.6
Lyngberg
14.7 Hagen 13.2
10.0 22.3
Patel Dahlof
Rasmussen Roh
10.2
90% of migraine sufferers 14.7
23.2 Lampl
8.4
11.7
report moderate to severe Stewart
O’Brien
13.3 Launer 9.6
Sakai

5.9
pain Schwartz
14.3 Bank
Takeshima
14.0 12.2 Steiner 16.7
Stewart
Lipton 7.7
Zivadinov

75% reporting impaired 11.6 8.5 Wang


8.5
function Lipton
13.5
Kryst
Morillo
9.0
3.0
Alders
Miranda
10.0 12.6 Tekle Haimanot 10.1
Morillo 9.3 Morillo 5.0 Deleu

33% requiring bed rest Morillo 16.3 Dent

during an attack 8.2 Wiehe

Morillo Africa 4.0 (2 studies)

5.3 Asia 10.6 (6 studies)


Jaillard Australia
7.3 Mean: 11.2
5.0 Europe 13.8 (9 studies)
Lavados
Morillo N. America 12.6 (8 studies) Median: 10.2
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S. America 9.6 (10 studies)

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Migraine in children and Population or community-based surveys of Migraine in the elderly: Population or community-based
adolescents: 1-year prevalence >500 participants covering ages 6-18 y, surveys of >500 participants
using IHS or modified IHS criteria
1-year prevalence covering age >61 y

7.0 2.7
11.0 Zwart Metsähonkala
Laurel

10.6 6.2 11.0


Abu-Arefeh
Mavromichalis 6.8 Prencipe
3.0
Wang
Raieli 4.6
Camarda
0.5 3.0
Kong Wang

3.8
Bener
11.0
9.9 Shivpuri

Barea

Africa Africa
Asia 3.7 (3 studies) Asia 7.0 (2 studies)
Australia Australia
Mean: 6.2 Mean: 7.4
Europe 6.8 (6 studies) Europe 7.8 (2 studies)
N. America Median: 6.5 N. America Median: 7.8
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S. America 9.9 (1 study) S. America

The International Classification of Headache Disorders: ICHD

The Primary Headaches

The Secondary Headaches

Painful Cranial
Neuropathies, Other Facial
Pain & Other Headaches
IHS 2013, IHS 2018

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Migraine Classification: Management of Migraine


ICHD
Migraine without aura
Acute/ Abortive : relieve a migraine attack
Migraine with aura

Chronic migraine

Complications of migraine
Preventive/ Profilaksis : reduce frequency,
Probable migraine duration & intensity of attacks

Episodic syndromes that may be associated with migraine


IHS 2013, IHS 2018
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Acute Migraine Strategies Acute Migraine Strategies

Efficacy in
clinical trials

Patient’s
Highly
clinical
Rapidly restore Minimal Avoidance of individualized
features
function recurrence side effects

Concomitant Treatment
comorbidities preferences
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Acute Migraine Strategies TREATMENT: Current Options


Goals of treatment
• Vast quantities of over-the-counter medications are taken but often
suboptimal
• There are two key branches of migraine treatment: acute & prophylactic

• Triptans: drugs of choice in the acute attack, but contraindicated in • The goals of each are distinct but complementary, with the shared objective of
patients with vascular conditions (potential vasoconstrictive symptomatic control to minimise the effect of the illness on a patient’s lifestyle
properties)

• Many studies have been developed regarding the use of Calcitonin


gene-related peptide (CGRP) receptor antagonists for acute migraine

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Non Spesific Abortive Migraine


TREATMENT: Current Options Treatment
Table : AAN and AHS treatment goals for acute and prophylactic therapy
Acute (Silberstein, 2000; Prophylatic (Silberstein, 2000;
Marmura et al., 2015) Silberstein, 2015)

•treat attacks rapidly and consistently •reduce frequency, duration, or severity


without recurrence of attacks
•restore the patient’s ability to function •enhance responsiveness to acute
•minimise the use of back-up and rescue therapy
medications •improve the patient’s ability to function
•optimise self-care and reduce •reduce disability
subsequent use of resources •reduce healthcare costs
•be cost-effective for overall
management
•have minimal or no adverse events. 15 ASNA Neuroinfection & 19th CNE 2018 16
1. MacGregor et al., 2010,

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Non Spesific Abortive Migraine


Spesific Abortive Migraine Treatment
Treatment

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Spesific Abortive Migraine Treatment The Guidelines

Canadian guideline, 2015

French guideline, 2016

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Acute Migraine Medications Migraine Medications

French guideline, 2012


ASNA Neuroinfection & 19th CNE 2018 Becker, 2015 21 ASNA Neuroinfection & 19th CNE 2018 22

Migraine Medications Migraine Medications

Spanish guideline, 2011


Japanese guideline, 2013

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Acute Migraine - Abortive Medications for


Migraine Medications Emergency Department & Inpatient Treatment

British guideline, 2013 French Guideline, 2016


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Prophylactic Migraine Medications Prophylactic Migraine Medications

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Acute Migraine - Abortive Medications for Acute Migraine - Abortive Medications for
Emergency Department & Inpatient Treatment Emergency Department & Inpatient Treatment

ASNA Neuroinfection & 19th CNE 2018 Rozen, 2015 29 ASNA Neuroinfection & 19th CNE 2018 Rozen, 2015 30

Acute Migraine - Abortive Medications for Migraine in Emergency


Emergency Department & Inpatient Treatment Treatment Strategy

ASNA Neuroinfection & 19th CNE 2018 Rozen, 2015 31 ASNA Neuroinfection & 19th CNE 2018 Rozen, 2015 32

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Red flags & other potential indicators of Dissatisfaction reason in Migraine Treatment
secondary headache
Only 29 % patient who satisfy with current migraine treatment
Several dissatisfaction reason with current migraine treatment

Obat tidak cepat bekerja 87

Tidak mengatasi semua nyeri 84

Tidak efektif bekerja 84

Sakit kepala kembali timbul 71

Banyak efek samping 35

0 20 40 60 80 100

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Potassium Diclofenac (Cataflam Fast) with rapid reduction of headache


Potassium Diclofenac (Cataflam Fast) with rapid onset of action

CATAFLAM FAST ® sachet memberikan onset efek analgetik pada 15 menit


CATAFLAM FAST ® sachet: Tmax tercapai dalam 14 menit(Tmax range: 5 – 22 menit)

Preferentially COX-2
Selective Inhibitor

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Potassium Diclofenac (Cataflam Fast) is more effective than Potassium Diclofenac (Cataflam Fast) reduce associate symptome
sumatriptan in migraine attack
in pain relieve Kalium diklofenak mengurangi gejala penyerta pada serangan migren setelah 2 jam

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Take home messages Take home messages


• Primary headache should treat properly & aggressively (Grade A) • Stratified management of acute migraine is recommended
• Over the counter’s analgesics (NSAID) should not consume more than • Low disability using over the counter’s analgesics (NSAID)
10 days per month to prevent Medication Overuse Headache/MOH • High disability using triptan
(Grade A)
• Headache diary is a keypoint to evaluate headache attack, frequency,
• Monotherapy is recommended for abortive treatment (Grade A) duration, severity, disability, and drug response
• Metoclopramide injection intravenously is recommended for acute
attack as anti migraine and anti nausea (Grade A)
• Attention with the extrapyramidal effect (Grade C)
• Consider using Triptan if optimal dose of over the counter’s analgesics
(NSAID) was not effective (Grade A)

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Summary
• Many recent studies had established for acute migraine treatment
• Choosing appropriate treatment should consider clinical condition,
comorbidity, pharmacodynamic and pharmacokinetic of drug
• Other modality such as lifestyle modification and prevent trigger
factor should be considered

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