What is the plan of care for a patient with migraines?

From the Guidelines

The plan of care for a patient with migraines should prioritize preventive therapy with beta blockers, topiramate, or candesartan as first-line medications, and consider CGRP monoclonal antibodies as third-line medications, as recommended by the most recent study 1.

Key Components of Migraine Care

• Acute treatment with NSAIDs or triptans, such as sumatriptan, at the first sign of migraine
• Preventive therapy for patients with frequent migraines (≥2 days per month) despite optimized acute treatment
• Use of beta blockers, topiramate, or candesartan as first-line medications for preventive therapy
• Consideration of CGRP monoclonal antibodies as third-line medications
• Non-pharmacological approaches, such as trigger identification and avoidance, stress management, and lifestyle modifications, as adjuncts to acute and preventive medication

Important Considerations

• Identification and management of comorbidities, as they can affect treatment choice and outcomes 1
• Adjustment of treatments according to the patient's comorbidity profile and possible interactions between drug-related adverse effects
• Regular evaluation and adjustment of the treatment plan to ensure optimal outcomes and minimize adverse effects

Lifestyle Modifications

• Regular exercise
• Adequate hydration
• Limiting caffeine
• Consistent sleep patterns and meals
• Stress management techniques, such as cognitive behavioral therapy or acupuncture These modifications can help reduce migraine frequency and improve overall quality of life.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. Patients were instructed to treat a moderate to severe headache Headache response, defined as a reduction in headache severity from moderate or severe pain to mild or no pain, was assessed up to 4 hours after dosing. A second dose of sumatriptan tablets or other medication was allowed 4 to 24 hours after the initial treatment for recurrent headache.

The plan of care for a patient with migraines includes:

• Treating moderate to severe headaches with sumatriptan tablets
• Assessing headache response up to 4 hours after dosing
• Allowing a second dose of sumatriptan tablets or other medication 4 to 24 hours after the initial treatment for recurrent headache
• Considering the use of additional treatments, such as acetaminophen, for pain relief as needed 2 Key points:
• Sumatriptan tablets are effective in the acute treatment of migraine headaches
• The efficacy of sumatriptan tablets is unaffected by the presence of aura, duration of headache prior to treatment, gender, age, or weight of the subject, relationship to menses, or concomitant use of common migraine prophylactic drugs.

From the Research

Migraine Plan of Care

The plan of care for a patient with migraines involves both acute treatment and prophylaxis.

• Acute treatment options include:
  • Analgesics like aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) 3
  • Ergotamine or dihydroergotamine, although their efficacy is inferior to that of serotonin (5-HT)1B/D-agonists (triptans) 3
  • Triptans, such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan, which are highly effective in improving headache, nausea, photo-, and phonophobia 3, 4
  • Metoclopramide, which has been shown to be effective in treating migraine attacks, especially when combined with sumatriptan 5, 6
• Prophylaxis is recommended for patients who experience more than 3 attacks per month, or if attacks do not respond to acute treatment or if side effects of acute treatment are severe 3
• Prophylactic options include:
  • Beta-blockers like metoprolol and propranolol 3
  • Calcium channel blocker flunarizine 3
  • 5-HT antagonists and amitriptyline 3
  • Antiepileptic drugs like valproic acid, gabapentin, and topiramate 3
  • Botulinum-toxin, which is still under investigation 3

Combination Therapies

Combining agents for acute migraine treatment has shown promise, particularly the combination of a triptan plus a non-steroidal anti-inflammatory drug (NSAID) 7

• The fixed combination of sumatriptan and naproxen sodium has been shown to be effective in treating migraine attacks, with improved 2-hour and 24-hour benefits over monotherapy with each option 7

Treatment Considerations

The choice of treatment should be individualized based on the patient's specific needs and characteristics, including the frequency and severity of attacks, as well as any comorbid conditions or contraindications to certain medications 3, 4