What is the diagnosis and treatment for migraine (headache disorder)?

From the Guidelines

For the treatment of migraines in children and adolescents, ibuprofen should be used as the first-line treatment, with sumatriptan or other triptans considered for adolescents. When managing migraines, it is essential to take a detailed history and make a specific headache diagnosis 1. Lifestyle factors, migraine triggers, and avoidance of acute medication overuse should be discussed with patients and their families 1.

Key Treatment Considerations

• Counsel patients to treat acute migraine early in the attack 1
• Use ibuprofen to treat pain in children and adolescents, and consider sumatriptan, naproxen, zolmitriptan, or rizatriptan for adolescents 1
• If one triptan is ineffective, try another or a non-steroidal anti-inflammatory drug-triptan combination 1
• Consider preventive treatments, such as amitriptyline, topiramate, or propranolol, for children and adolescents with frequent or disabling headaches 1

Preventive Treatment

Preventive treatments aim to reduce the frequency and severity of migraine attacks. Amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol are effective options for migraine prevention 1. However, it is crucial to discuss the evidence for and side effects of these medications with patients and their families, as well as the potential teratogenic effects of topiramate and valproate 1.

Lifestyle Modifications

Lifestyle modifications are equally important in managing migraines. Identifying and avoiding personal triggers, maintaining a consistent sleep schedule, staying hydrated, and practicing stress management techniques can help reduce the frequency and severity of migraine attacks. Keeping a migraine diary can also help identify patterns and triggers. By combining pharmacologic treatment with lifestyle modifications, patients with migraines can experience significant improvements in their quality of life.

From the FDA Drug Label

Sumatriptan presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release. The primary mechanism of action of sumatriptan in treating migraine is through its agonist effects on 5-HT1B/1D receptors, leading to cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release 2.

• The therapeutic effect of sumatriptan is presumed to be a result of this mechanism.
• Migraine treatment with sumatriptan is based on its ability to bind to 5-HT1B/1D receptors.

From the Research

Acute Migraine Treatment Options

• Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, and diclofenac potassium, and triptans like sumatriptan and rizatriptan have good evidence for efficacy in treating acute migraine attacks 3, 4.
• NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics, and anti-emetics like metoclopramide and prochlorperazine are additional evidence-based options for acute migraine treatment 3, 4.
• New classes of acute treatment, including small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), have expanded available options for acute migraine treatment 5.

Treatment Strategies

• Available acute medications can be organized into four treatment strategies, including a strategy for attacks of mild to moderate severity, a triptan strategy for patients with severe attacks, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs 3, 4.
• The choice of treatment strategy should be based on patient-specific clinical features, such as usual headache intensity, nausea, vomiting, and degree of disability 3, 4.

Special Considerations

• Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine requires special consideration 3, 4, 5.
• Acetaminophen is the safest acute migraine drug during pregnancy, and sumatriptan may be an option for selected patients 4, 5.
• Medication overuse should be eliminated or avoided in patients with chronic migraine 3.

Unmet Needs and Future Directions

• Despite the availability of various treatment options, unmet acute treatment needs still exist due to lack of efficacy, unwanted side effects, or contraindication to treatment 6.
• The development of new treatments, such as neuromodulation devices and recently approved calcitonin gene-related peptide receptor antagonists, may help address these unmet needs 5, 6.