Page 228 Guide to Pain Management in Low-Resource Settings

216 Arnaud Fumal and Jan Schoenen

What are the options for acute proven cost-eff ective. In severely disabled migraineurs,
migraine treatment? the effi cacy rate of injectable sumatriptan for a pain-free
outcome at 2 hours is twice that of ergot derivatives or
During the last decade, the advent of highly eff ective NSAIDs taken at high oral doses and of i.v. acetylsalicyl-
5-HT agonists, the triptans, has been a major break- ic acid lysinate. Th e therapeutic gain tends to be clearly
1B/1D
through in treatment. Triptans are able to act as vaso- lower for simple analgesics or NSAIDs, such as acet-
constrictors via vascular 5-HT receptors and to inhibit aminophen (1000 mg p.o.), eff ervescent aspirin (1000
1B
neurotransmitter release at the peripheral as well as at mg), or ibuprofen (600 mg), than for oral triptans, when
central terminal of trigeminal nociceptors via 5-HT severe attacks are considered.
1D/B
receptors. Th e site of action relevant for their effi ca- For mild and moderate attacks, however, it has
cy in migraine is still a matter of controversy; possibly proven diffi cult to show superiority of oral triptans in
their high effi cacy rate is due to their capacity of acting randomized controlled trials. Combining analgesics
at all three sites, contrary to other antimigraine drugs. or NSAIDs with an antiemetic and/or with caff eine or
Sumatriptan, the fi rst triptan, was followed by several- administering them as suppositories clearly increas-
second generation triptans (zolmi-, nara-, riza-, ele-, es their effi cacy, often up to that of oral triptans. Re-
almo-, and frovatriptan), which were thought to correct cently, combining a triptan plus an NSAID as a single
some of the shortcomings of sumatriptan. A large me- tablet for acute treatment of migraine resulted in more
ta-analysis of a number of randomized controlled trials favorable clinical benefi ts compared with either ther-
performed with triptans confi rms that the subcutane- apy used alone, with an acceptable and well-tolerated
ous auto-injectable form of sumatriptan (6 mg) has the adverse-eff ect profi le.
best effi cacy, whatever outcome measure is considered. As expected, the triptans have not solved pa-
Diff erences between oral triptans do exist for some out- tients’ problems. Th ere is room for more effi cient and
come measures, but in practice each patient has to fi nd safer oral acute migraine treatments. As triptans are con-
the triptan that gives the best satisfaction. traindicated in patients with cardiovascular disorders,
At present, the major reason for not considering non-vasoconstricting agents are the holy grail in acute
triptans as fi rst-choice treatments for migraine attacks therapy research. Serotonin 5-HT -receptor agonists
1F
is their high cost, and in some patients their cardiovas- and a novel calcitonin gene-related peptide (CGRP) an-
cular side eff ects. However, stratifying care by prescrib- tagonist are currently being investigated, with promis-
ing a triptan to the most disabled patients has been ing results. Treatment algorithms should be inspired by

Table 4
Red fl ags in the diagnosis of headache
Red Flags To Consider Possible Investigation(s)
Sudden-onset headache Subarachnoid hemorrhage, brain bleeding, Neuroimaging, lumbar puncture (after neuro-
mass lesion (especially posterior fossa) imaging)
Worsening-pattern headache Mass lesion, subdural hematoma, medica- Neuroimaging
tion overuse
Headache with systemic illness (fever, Meningitidis, encephalitis, Lyme disease, Neuroimaging, lumbar puncture, biopsy, blood
neck stiff ness, cutaneous rash) systemic infection, collagen vascular disease, tests
arteritis
Focal neurologic signs, or symptoms Mass lesion, arteriovenous malformation, Neuroimaging, collagen vascular evaluation
other than typical visual or sensory aura collagen vascular disease
Papilledema Mass lesion, pseudotumor, encephalitis, Neuroimaging, lumbar puncture (after neuro-
meningitidis imaging)
Headache triggered by cough, exertion Subarachnoid hemorrhage, mass lesion Neuroimaging, consider lumbar puncture
or Valsalva
Headache during pregnancy or post- Cortical vein/cranial sinus thrombosis, Neuroimaging
partum carotid dissection, pituitary apoplexy
New headache type in a patient with Metastasis, meningoencephalitis, opportu- For all neuroimaging and lumbar puncture
cancer, Lyme disease or HIV nistic infection
Source: Bigal ME, Lipton RB. Headache Pain 2007;8:263–72.