How to manage acute migraine in a patient with known Parkinson's disease (PD)?

Management of Acute Migraine in Patients with Parkinson's Disease

For patients with Parkinson's disease experiencing acute migraine, NSAIDs should be used as first-line treatment, with careful consideration of antiemetic selection to avoid dopamine antagonists that may worsen parkinsonian symptoms. 1

First-Line Treatment Options

• NSAIDs are recommended as first-line medication for acute migraine treatment in patients with Parkinson's disease 1

  • Preferred options include:
    • Ibuprofen (400-800 mg every six hours) 1
    • Naproxen sodium (275-550 mg every two to six hours) 1
    • Aspirin (650-1,000 mg every four to six hours) 1
    • Diclofenac potassium 1

• Administer NSAIDs early in the headache phase for maximum effectiveness 1

• Acetaminophen alone is not recommended for migraine treatment, but may be effective in combination with aspirin and caffeine 1

Second-Line Treatment Considerations

• Triptans are typically second-line therapy for migraines but require special consideration in Parkinson's disease patients 1

  • Use with caution due to potential cardiovascular effects and drug interactions 2
  • Monitor for serotonin syndrome, especially if patient is taking MAO-B inhibitors for Parkinson's disease 2

• Combination therapy of triptans with fast-acting NSAIDs may be considered for patients with inadequate response to NSAIDs alone 1

Special Considerations for Parkinson's Disease

• Avoid dopamine antagonist antiemetics (such as metoclopramide and prochlorperazine) as they may worsen parkinsonian symptoms 1

  • These medications are typically used for nausea in migraine but block dopamine receptors, potentially exacerbating motor symptoms in Parkinson's disease

• Domperidone may be a safer antiemetic option if available, as it has minimal central nervous system penetration 1

• Avoid medications that can worsen cognitive symptoms or increase the risk of falls:

  • Opioids should be limited due to risk of dependency, sedation, and potential worsening of constipation which is common in Parkinson's disease 1
  • Barbiturates and medications containing butalbital should be avoided 1

Medications to Strictly Avoid

• Oral ergot alkaloids are poorly effective, potentially toxic, and should not be used 1

• Opioids and barbiturates have questionable efficacy and considerable adverse effects with risk of dependency 1

• Medications that may worsen tremor or motor symptoms in Parkinson's disease patients should be avoided 1

Alternative Approaches

• For patients with nausea and vomiting, consider non-oral routes of administration 1

  • Nasal or injectable formulations may be preferable when oral medications cannot be tolerated

• Self-administered rescue medication may be considered for severe migraine attacks not responding to first-line treatments 1

  • This should be carefully selected to avoid worsening Parkinson's symptoms

Prevention Strategies

• Consider preventive therapy if acute attacks occur frequently (≥2 per month) or cause significant disability 1

• Limit acute medication use to no more than twice weekly to prevent medication-overuse headache 1

• Beta-blockers (commonly used for migraine prevention) should be used with caution in Parkinson's disease due to potential worsening of orthostatic hypotension 1

Patient Education and Monitoring

• Educate patients about early recognition and treatment of migraine attacks 1

• Monitor for medication-overuse headache, which can develop with frequent use of acute medications 1

• Track migraine frequency, severity, and response to treatment to guide management decisions 1